OBJECTIVE: To describe outcome after pancreatic surgery in the first six years of a mandatory nationwide audit. BACKGROUND: Within the Dutch Pancreatic Cancer Group, efforts have been made to improve outcome after pancreatic surgery. These include collaborative projects, clinical auditing, and implementation of an algorithm for early recognition and management of postoperative complications. However, nationwide changes in outcome over time have not yet been described. METHODS: This nationwide cohort study included consecutive patients after pancreatoduodenectomy and distal pancreatectomy from the mandatory Dutch Pancreatic Cancer Audit (January 2014-December 2019). Patient, tumor, and treatment characteristics were compared between three time periods (2014-2015, 2016-2017, and 2018-2019). Short-term surgical outcome was investigated using multilevel multivariable logistic regression analyses. Primary endpoints were failure to rescue and in-hospital mortality. RESULTS: Overall, 5345 patients were included, of whom 4227 after pancreatoduodenectomy and 1118 after distal pancreatectomy. After pancreatoduodenectomy, failure to rescue improved from 13% to 7.4% (OR 0.64, 95%CI 0.50-0.80, P<0.001) and in-hospital mortality decreased from 4.1% to 2.4% (OR 0.68, 95%CI 0.54-0.86, P=0.001), despite operating on more patients with age >75 years (18% to 22%, P=0.006), ASA score ≥3 (19% to 31%, P<0.001) and Charlson comorbidity score ≥2 (24% to 34%, P<0.001). The rates of textbook outcome (57% to 55%, P=0.283) and major complications remained stable (31% to 33%, P=0.207), whereas complication-related intensive care admission decreased (13% to 9%, P=0.002). After distal pancreatectomy, improvements in failure to rescue from 8.8% to 5.9% (OR 0.65, 95%CI 0.30-1.37, P=0.253) and in-hospital mortality from 1.6% to 1.3% (OR 0.88, 95%CI 0.45-1.72, P=0.711) were not statistically significant. CONCLUSIONS: During the first six years of a nationwide audit, in-hospital mortality and failure to rescue after ...