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Annals of Gastroenterological Surgery logoLink to Annals of Gastroenterological Surgery
. 2021 Apr 9;5(5):639–658. doi: 10.1002/ags3.12462

Surgical outcomes in gastroenterological surgery in Japan: Report of the National Clinical Database 2011–2019

Shigeru Marubashi 1, Arata Takahashi 2,3, Yoshihiro Kakeji 1,✉, Hiroshi Hasegawa 1, Hideki Ueno 1, Susumu Eguchi 1, Itaru Endo 1, Takanori Goi 1, Akio Saiura 1, Akira Sasaki 1, Shuji Takiguchi 1, Hiroya Takeuchi 1, Chie Tanaka 1, Masaji Hashimoto 1, Naoki Hiki 1, Akihiko Horiguchi 1, Tadahiko Masaki 1, Kazuhiro Yoshida 1, Mitsukazu Gotoh 1, Hiroyuki Konno 1, Hiroyuki Yamamoto 2,3, Hiroaki Miyata 2,3, Yasuyuki Seto 1, Yuko Kitagawa 1; the National Clinical Database
PMCID: PMC8452469  PMID: 34585049

Abstract

Background

We aimed to present the 2019 annual report of the gastroenterological section of the National Clinical Database (NCD).

Methods

We reviewed 609,589 cases recorded in 2019 and 5,029,764 cases registered from 2011 to 2019 for the 115 selected gastroenterological surgical procedures.

Results

The main features of gastroenterological surgery in Japan were similar to those described in the 2018 annual report, namely, that 1) operative numbers gradually increased in all procedures, except gastrectomy and hepatectomy, which decreased in these years; 2) in all eight major gastroenterological surgeries, the age distribution tended toward older patients; 3) the morbidity of esophagectomy, hepatectomy, and pancreaticoduodenectomy increased, but mortality was minimized in all procedures; 4) all eight major gastroenterological procedures have increasingly been performed under laparoscopy; and 5) board‐certified surgeons were increasingly involved. These trends in recent years were more prominent in 2019.

Conclusions

Thanks to the continuous cooperation and dedication of the surgeons, medical staff, and surgical clinical reviewers who registered the clinical data into the NCD, it is possible to understand the comprehensive landscape of surgery in Japan and to disclose new evidence in this field. The Japanese Society of Gastroenterological Surgery will continue to promote the value of this database and encourage the use of feedback and clinical studies using the NCD, now and in the future. Generating further approaches to surgical quality improvement are important directions for future research.

Keywords: gastroenterological surgery, NCD, research report, surgical outcome, treatment outcome

As the annual report of NCD 2019, data of gastroenterological surgery from 2011 to 2019 in Japan were summarized, and the trends in the 115 gastroenterological procedures and eight major gastroenterological surgeries were reported.

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1. INTRODUCTION

The National Clinical Database (NCD) has been recognized as the largest and best‐organized nationwide surgical registry in Japan and has become indispensable for surgeons, patients, and the healthcare system of Japan. The NCD was established in 2010 and started its data registration in 2011.1, 2, 3, 4 As of January 14, 2021,5 5404 facilities have enrolled in the NCD and approximately 1,500,000 cases have been registered every year, constituting more than 95% of all surgical cases in Japan.2

The NCD comprises the members of surgery‐related societies5 including the Japan Surgical Society (JSS), the Japanese Society of Gastroenterological Surgery (JSGS), and the Japanese Society of Hepato‐Biliary‐Pancreatic Surgery (JSHBPS), and clinical data are stratified into three levels3: 1) basic common variables, 2) subspecialty variables such as those in 115 selected gastroenterological surgeries or eight major gastroenterological surgeries, and 3) more specialized variables such as those in the Hepato‐Biliary‐Pancreatic surgery. Data in the gastroenterological section of the NCD are based on the JSGS’s definition of the variables and include 115 gastroenterological operative procedures considered important for the board certification system. Eight major gastroenterological surgeries were selected among these 115 procedures (esophagectomy [ESO], distal/total gastrectomy [DG/TG], right hemicolectomy [RHC], low anterior resection [LAR], hepatectomy [HEP], pancreaticoduodenectomy [PD], and surgery for acute diffuse peritonitis [ADP]); data on detailed variables including preoperative laboratory findings, comorbidities, and postoperative complications were required.1, 6, 7, 8

Gastroenterological surgical procedures are also classified into three groups according to their technical difficulty; low, medium, and high degree of difficulty. Some of the newly approved high‐difficulty procedures, such as laparoscopic major hepatectomy and laparoscopic and robot‐assisted pancreatoduodenectomy, are required to be registered preoperatively in the NCD for health insurance to be authorized by the Ministry of Health, Labour and Welfare in Japan.

Thus, the importance of the NCD has been increasing rapidly as a clinical database and a means for controlling the quality of new surgical procedures. The NCD is also important as it provides medical staff and societies with rigorously collected data for quality improvement of surgery, feedback about surgical outcomes as risk calculators for morbidities9, 10, 11, 12, 13, 14, 15, 16, 17 and mortality,17, 18, 19, 20, 21, 22, 23, 24, 25 data on the comprehensive surgical landscape via the NCD website,1, 5 and data gathered from various clinical studies.

This report intends to outline the current situation and trends to understand the standpoint of and to elucidate the future directions of gastroenterological surgery in Japan using data from the gastroenterological section of the NCD. Previously, the annual reports of the NCD were published on data from 2011 to 2018, and more than 609,589 cases were newly registered in 2019. We describe the most important findings from the data about gastroenterological surgery in the NCD between 2011 and 2019.

2. SUBJECTS AND METHODS

As previously reported,6, 7, 8 the subjects were patients who collectively underwent the 115 surgical procedures stipulated by the “Training Curriculum for Board‐Certified Surgeons in Gastroenterology” and had their surgical data recorded from 2011 to 2019 in the NCD system. Data of basic and perioperative variables were collected for these cases, as described previously.1, 3, 8 Basic common variables were designed for JSS‐level data, comprising age, gender, preoperative and final diagnosis, date of procedure, surgical procedure (NCD code), operator and assistants, emergent or elective surgery, and participation of anesthesiologists. Subspecialty variables, such as the TNM classification for malignant diseases, Clavien–Dindo (C–D) classification26, 27 of postoperative complications, date of discharge or death, and 30‐day and in‐hospital mortality were collected for the 115 selected surgical procedures. Additionally, detailed laboratory data, preoperative comorbidities and functional status, and types of postoperative morbidities were recorded for the eight major gastroenterological procedures defined above.

Postoperative complications of C–D grade III or greater were defined as severe complications. Anonymous data of the board‐certified gastroenterological surgeons of the JSGS were transferred into the NCD and linked with each procedure to elucidate the participation of board‐certified surgeons.

Data were extracted in a secure system without external connection and basic statistical analysis were carried out by NCD statistic experts, and the number of surgical cases and the mortality rates related to the selected 115 gastroenterological operative procedures were calculated, as well as those for the eight major operative procedures from 2011 to 2019. The incidence of participation of board‐certified surgeons as the primary surgeons or assistants in the eight major gastroenterological surgeries was also calculated.

The NCD system is modified annually to adapt to the change in operative procedures, new surgical techniques, or fit the definition and choices of variables better. In 2019, over 50 modifications were made, including the addition of six new variables and the modification of over 40 parts in the definition and other sections of gastroenterological surgery in NCD.

The following points need to be considered in the interpretation of the data reported here: 1) As a maximum of eight operative procedures can be recorded per case in the NCD, the total number of surgeries in the results describing the 115 gastroenterological surgical procedures for the board certification system does not represent the actual number of surgical cases; 2) Cases with errors in patient age, sex, and postoperative 30‐day status were excluded; 3) Cases in which several operative methods were performed simultaneously were recorded according to all operative methods; 4) Postoperative 30‐day mortality included all cases of mortality within 30 days after surgery, regardless of pre‐ or postdischarge status. The calculation of operative mortality included all patients who died during hospitalization, including hospital stays up to 90 days, and any patient who died after hospital discharge within 30 days of the operative date.

3. RESULTS

3.1. The 115 selected gastroenterological operative procedures in the “Training Curriculum for Board‐Certified Surgeons in Gastroenterology”

The total number of cases represented by the 115 selected gastroenterological surgical procedures, recorded in the NCD from January 1 to December 31, 2019, was 609,589, and 5,029,764 cases were registered between 2011 and 2019 (Figure 1). Regarding organ involvement, the stomach and duodenum decreased slightly to 63,160 (10.3% of all 115 procedures) in 2019 from 65 ,52 (10.8%) in 2018, and the rectum and anus increased slightly to 57,706 (9.5%) in 2019 from 56,162 (9.3%) in 2018. The involvement of other organs (esophagus, small intestine and colon, liver, gallbladder, pancreas, spleen, and other organs) was approximately the same as in 2018 (Table 1).

FIGURE 1.

FIGURE 1

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Annual changes in the number of surgeries, 30‐day mortality, operative mortality, and complications: Analysis of the 115 surgical procedures. Postoperative complication rate: the rate of Clavien–Dindo (C–D) classification grade III (complications requiring intervention) or higher complications

TABLE 1.

Annual changes of surgeries by sex, age group, and organ for the selected 115 gastrointestinal operative procedures in the training curriculum for board‐certified surgeons in gastroenterology

Organ Year No. surgeries Percentage by sex Percentage according to age group (years)
Male Female <60 60 to <65 65 to <70 70 to <75 75 to <80 ≥80
Esophagus 2011 7246 81.8 18.2 22.5 19.6 21.1 18.7 12.0 6.0
2012 8819 82.2 17.8 22.1 19.7 20.0 19.5 12.9 6.0
2013 8642 81.5 18.5 20.8 17.5 21.0 20.6 13.2 6.9
2014 9021 81.5 18.4 20.8 16.5 21.4 20.9 13.8 6.6
2015 8943 80.8 19.2 19.6 15.3 22.4 22.5 13.1 7.1
2016 9212 79.6 20.4 20.1 14.4 22.9 20.5 14.5 7.5
2017 9359 80.0 20.0 19.3 13.4 24.4 19.4 15.5 8.0
2018 9286 78.4 21.6 19.0 12.8 21.3 21.6 16.7 8.7
2019 9224 78.6 21.4 18.8 13.1 19.4 22.8 17.3 8.6
Stomach and duodenum 2011 66 740 68.0 32.0 20.1 14.4 14.0 17.1 16.4 18.0
2012 76 186 68.3 31.7 18.9 14.4 14.5 17.1 16.4 18.6
2013 75 583 67.9 32.1 18.6 13.1 15.5 17.2 16.9 18.7
2014 74 920 67.6 32.4 17.9 12.1 16.0 17.8 16.7 19.5
2015 73 877 67.8 32.2 17.4 11.1 17.1 17.8 16.6 19.9
2016 72 234 67.8 32.2 17.0 10.2 18.1 17.1 16.6 21.0
2017 68 287 67.2 32.8 16.3 9.9 17.5 17.3 17.2 21.8
2018 65 152 66.9 33.1 16.0 9.0 16.4 18.0 17.5 23.2
2019 63 610 66.5 33.5 15.6 8.8 15.0 19.0 18.5 23.2
Small intestine and colon 2011 151 143 56.7 43.3 37.4 10.9 10.5 12.1 12.2 16.9
2012 184 810 56.7 43.3 36.4 10.7 10.7 12.2 12.5 17.4
2013 198 677 56.9 43.1 35.6 10.1 11.3 12.7 12.4 17.8
2014 206 857 56.9 43.1 34.7 9.4 12.0 13.1 12.4 18.4
2015 214 453 57.1 42.9 34.0 8.9 12.9 13.1 12.3 18.7
2016 218 228 57.3 42.7 33.7 8.4 13.6 12.5 12.4 19.3
2017 235 359 56.7 43.3 32.7 8.0 13.2 12.7 12.9 20.5
2018 236 496 56.9 43.1 32.2 7.7 12.6 13.4 13.2 21.1
2019 239 612 56.3 43.7 32.1 7.4 11.7 13.9 13.5 21.2
Rectum and anus 2011 41 061 59.1 40.9 22.0 16.1 14.6 15.4 14.2 17.7
2012 49 704 58.3 41.7 22.3 14.8 14.6 15.5 14.3 18.5
2013 49 980 58.0 42.0 20.9 13.9 15.2 16.1 14.6 19.3
2014 51 454 58.3 41.7 20.4 13.1 16.0 16.4 14.2 19.9
2015 56 092 57.8 42.2 22.3 11.8 16.7 15.7 14.0 19.4
2016 55 666 57.3 42.7 22.0 11.1 17.9 15.0 13.6 20.4
2017 56 144 56.7 43.3 22.2 10.2 17.3 15.1 14.2 21.0
2018 56 162 56.9 43.1 22.2 9.8 15.9 15.8 14.6 21.6
2019 57 706 56.3 43.7 22.5 9.5 14.8 16.5 14.9 21.9
Liver 2011 22 855 67.3 32.7 22.2 16.5 16.3 18.7 17.2 9.2
2012 26 288 66.3 33.7 22.1 15.7 16.7 18.0 17.4 10.2
2013 25 814 66.1 33.9 21.3 14.6 17.6 18.7 17.3 10.5
2014 26 518 66.3 33.7 21.5 13.7 18.1 19.8 16.6 10.3
2015 26 378 65.7 34.3 20.8 12.8 18.9 19.4 16.5 11.5
2016 27 212 66.4 33.6 20.3 11.5 20.5 18.6 17.0 12.1
2017 27 397 65.8 34.2 20.1 11.0 20.2 18.8 17.2 12.7
2018 26 531 66.5 33.5 19.6 10.3 18.8 19.6 17.8 13.8
2019 26 582 66.3 33.7 19.4 10.1 16.5 21.1 18.6 14.2
Gall bladder 2011 103 183 54.5 45.4 34.3 14.0 12.2 13.8 12.8 13.0
2012 122 513 55.2 44.8 32.9 13.8 12.4 13.9 13.2 13.8
2013 129 162 55.3 44.7 32.6 12.9 13.0 14.2 13.2 14.0
2014 131 182 55.6 44.4 32.1 11.8 13.9 14.5 13.2 14.5
2015 133 126 55.6 44.4 32.0 11.2 15.0 14.1 13.0 14.8
2016 137 360 55.4 44.6 32.6 10.6 15.5 13.1 12.9 15.3
2017 138 267 55.6 44.4 32.2 10.2 15.1 13.5 13.2 15.8
2018 139 844 55.3 44.7 31.8 9.7 14.2 14.2 13.4 16.7
2019 140 214 55.4 44.6 31.6 9.6 13.3 14.7 13.9 16.9
Pancreas 2011 13 477 59.9 40.1 20.0 15.6 16.9 19.7 17.7 10.2
2012 15 550 60.0 40.0 19.8 15.2 17.0 19.5 18.2 10.3
2013 16 380 59.7 40.3 19.1 13.6 18.0 20.7 17.7 10.9
2014 17 313 59.5 40.5 18.4 12.4 19.0 21.0 18.2 11.1
2015 17 407 59.1 40.9 18.2 11.3 19.4 21.6 18.1 11.4
2016 18 238 58.9 41.1 18.2 10.4 19.9 20.4 19.0 12.2
2017 19 138 59.2 40.8 17.7 9.9 19.5 19.9 20.1 12.9
2018 19 152 58.6 41.4 16.9 9.2 18.2 21.5 20.4 13.7
2019 19 703 58.3 41.7 17.0 9.2 16.5 21.6 21.1 14.6
Spleen 2011 3609 61.3 38.7 35.3 15.6 14.7 14.8 11.9 7.8
2012 4142 61.4 38.6 32.9 16.3 15.0 15.1 12.9 7.8
2013 4509 61.8 38.2 30.8 14.9 15.9 16.5 13.1 8.7
2014 4272 61.8 38.2 29.9 13.0 17.3 17.0 13.8 9.1
2015 3568 60.4 39.6 29.7 11.4 17.3 16.6 14.1 10.8
2016 3171 57.3 42.7 31.9 11.7 17.7 15.7 12.5 10.5
2017 2864 58.7 41.3 31.6 11.0 18.1 16.0 13.3 10.0
2018 2544 56.6 43.4 32.6 9.9 15.6 16.9 13.9 11.1
2019 2413 55.2 44.8 31.3 10.5 16.8 15.8 13.1 12.5
Others 2011 23 218 55.0 45.0 32.0 11.9 11.3 13.3 13.8 17.6
2012 28 779 55.4 44.6 31.1 11.7 11.7 13.8 13.7 18.0
2013 36 363 53.1 46.9 28.3 10.9 12.7 14.1 14.8 19.1
2014 39 854 53.7 46.3 28.1 10.1 13.1 14.5 14.4 19.8
2015 41 465 53.2 46.8 27.4 9.4 14.0 14.5 14.2 20.6
2016 43 523 54.0 46.0 27.5 9.2 14.6 13.5 14.0 21.2
2017 45 622 54.1 45.9 27.0 8.2 14.7 13.5 14.6 21.9
2018 46 587 54.1 45.9 26.8 8.2 14.0 14.4 14.7 21.9
2019 50 525 54.8 45.2 27.0 8.1 12.7 15.3 15.0 21.9
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Most cases were performed in the certified or related institutions of JSGS and included a notably high number of operations involving the esophagus (certified 94.3%, related 3.8%), liver (certified 89.7%, related 6.8%), and pancreas (certified 91.9%, related 6.2%), indicating that very few cases, fewer than 2–4%, underwent these surgeries in nonrelated or noncertified institutions in Japan.

Regarding the surgeons’ credentials, it was clear that an increased number of board‐certified surgeons participated in the surgeries; these were in the esophagus (94.2%), stomach and duodenum (83.8%), small intestine and colon (74.0%), liver (94.1%), gallbladder (75.7%), pancreas (95.1%), spleen (86.8%), and other organs (74.0%) (Table 2). Meanwhile, the rate of surgeries by nonboard‐certified surgeons decreased slightly but remained at more than 50% in the gallbladder (67.7%), small intestine and colon (66.8%), stomach and duodenum (53.9%), and rectum and anus (51.1%), while they were below 35% in the liver (33.6%), pancreas (30.8%), and esophagus (23.6%).

TABLE 2.

Institution and anesthesiologist and specialist participation rates by organ for the selected 115 gastrointestinal operative procedures

Organ Year No. surgeries Percentage by institution group Anesthesiologist Prticipation (%) Board‐certified surgeon participation (%) Medical practitioners (%)
Certified institution Related institution Other Board‐certified Surgeons Nonboard‐certified surgeons
Esophagus 2011 7246 93.5 5.9 0.6 97.0 87.0 62.8 37.2
2012 8819 78.1 5.9 16.0 97.4 87.0 62.7 37.3
2013 8642 90.6 7.1 2.4 97.3 88.4 64.4 35.6
2014 9021 91.1 6.1 2.8 97.9 90.1 67.6 32.4
2015 8943 91.5 6.0 2.5 97.9 91.1 69.4 30.6
2016 9212 92.4 5.0 2.6 98.2 91.2 70.0 30.0
2017 9359 92.7 4.0 3.3 97.9 92.5 71.8 28.2
2018 9286 93.8 4.0 2.2 98.5 94.7 75.2 24.8
2019 9224 94.3 3.8 1.9 98.4 94.2 76.4 23.6
Stomach and duodenum 2011 66 740 80.2 17.3 2.6 92.8 69.3 35.1 64.9
2012 76 186 63.5 15.6 20.9 93.5 70.3 35.6 64.4
2013 75 583 76.3 19.3 4.4 93.3 73.5 37.7 62.3
2014 74 920 77.0 18.2 4.8 93.6 75.9 39.2 60.8
2015 73 877 77.1 18.3 4.6 93.9 76.1 39.2 60.8
2016 72 234 79.6 16.1 4.3 94.6 78.7 41.0 59.0
2017 68 287 79.6 15.3 5.1 94.8 79.7 41.8 58.2
2018 65 152 80.0 14.8 5.1 95.1 81.4 43.2 56.8
2019 63 610 81.3 14.2 4.5 95.4 83.8 46.1 53.9
Small intestine and colon 2011 151 143 76.8 20.2 2.9 88.1 59.2 25.1 74.9
2012 184 810 60.6 18.2 21.2 88.9 59.9 25.4 74.6
2013 198 677 72.6 22.2 5.2 89.6 62.7 26.6 73.4
2014 206 857 73.0 21.4 5.6 90.8 65.4 28.1 71.9
2015 214 453 73.8 20.7 5.5 91.6 66.3 28.5 71.5
2016 218 228 75.6 19.0 5.5 92.4 68.1 29.5 70.5
2017 235 359 76.0 18.0 6.0 92.9 70.1 31.1 68.9
2018 236 496 76.3 17.5 6.1 93.3 71.8 32.6 67.4
2019 239 612 77.1 17.1 5.8 94.1 74.0 33.2 66.8
Rectum and anus 2011 41 061 76.9 19.0 4.1 86.3 68.3 36.9 63.1
2012 49 704 60.4 18.2 21.4 85.7 68.6 37.6 62.4
2013 49 980 72.9 21.7 5.4 87.3 71.2 39.4 60.6
2014 51 454 73.5 20.9 5.6 87.9 73.7 41.6 58.4
2015 56 092 72.5 20.8 6.7 84.9 73.5 41.5 58.5
2016 55 666 74.1 19.4 6.6 85.7 74.7 42.1 57.9
2017 56 144 73.8 18.2 8.0 84.8 76.1 43.9 56.1
2018 56 162 74.1 17.9 8.0 85.2 77.2 46.7 53.3
2019 57 706 74.9 17.3 7.8 86.0 80.1 48.9 51.1
Liver 2011 22 855 89.3 9.7 1.1 95.6 85.2 55.2 44.8
2012 26 288 74.2 9.2 16.7 95.4 85.7 57.4 42.6
2013 25 814 86.3 10.7 2.9 96.3 87.5 57.1 42.9
2014 26 518 86.3 10.0 3.7 96.4 89.0 59.6 40.4
2015 26 378 87.3 9.5 3.2 96.6 89.1 59.1 40.9
2016 27 212 88.4 8.8 2.9 96.8 90.0 59.6 40.4
2017 27 397 89.0 7.8 3.1 97.1 91.8 62.5 37.5
2018 26 531 89.4 7.1 3.5 97.3 92.8 64.1 35.9
2019 26 582 89.7 6.8 3.6 97.3 94.1 66.4 33.6
Gall bladder 2011 103 183 73.9 22.5 3.6 91.8 61.9 26.4 73.6
2012 122 513 57.5 19.6 22.9 92.1 62.8 26.3 73.7
2013 129 162 69.9 24.1 5.9 92.2 65.4 27.3 72.7
2014 131 182 70.3 23.3 6.4 92.3 67.4 28.1 71.9
2015 133 126 70.8 22.8 6.4 92.9 68.4 28.1 71.9
2016 137 360 72.4 21.3 6.3 93.5 69.4 28.9 71.1
2017 138 267 72.6 20.1 7.3 93.7 71.4 29.9 70.1
2018 139 844 72.5 20.1 7.4 94.1 73.1 31.1 68.9
2019 140 214 73.5 19.4 7.1 94.4 75.7 32.3 67.7
Pancreas 2011 13 477 88.1 10.8 1.2 95.8 85.2 57.7 42.3
2012 15 550 72.8 8.7 18.5 96.3 86.5 59.9 40.1
2013 16 380 86.5 11.0 2.4 95.9 87.6 60.2 39.8
2014 17 313 86.9 9.9 3.3 96.2 89.1 61.3 38.7
2015 17 407 88.4 9.1 2.4 96.4 90.3 61.6 38.4
2016 18 238 89.8 8.0 2.3 96.8 91.1 62.4 37.6
2017 19 138 90.4 7.1 2.5 97.2 92.3 63.9 36.1
2018 19 152 91.3 6.4 2.3 97.3 93.4 66.5 33.5
2019 19 703 91.9 6.2 1.9 97.2 95.1 69.2 30.8
Spleen 2011 3609 87.0 11.6 1.4 94.6 75.2 44.9 55.1
2012 4142 70.5 9.5 20.0 81.7 75.8 44.4 55.6
2013 4509 83.2 13.8 3.0 95.2 75.4 43.3 56.7
2014 4272 85.4 11.5 3.1 94.6 77.5 45.2 54.8
2015 3568 85.6 12.3 2.1 94.8 78.9 45.5 54.5
2016 3171 86.8 10.1 3.1 95.7 80.5 48.0 52.0
2017 2864 87.4 9.3 3.3 95.3 82.3 49.1 50.9
2018 2544 86.9 9.7 3.4 95.3 84.7 49.3 50.7
2019 2413 88.1 8.7 3.2 96.2 86.8 54.0 46.0
Others 2011 23 218 80.2 17.0 2.8 90.3 60.4 27.2 72.8
2012 28 779 65.7 15.2 19.1 91.0 61.1 27.6 72.4
2013 36 363 76.1 19.3 4.6 91.5 63.4 28.5 71.5
2014 39 854 76.6 18.2 5.1 91.9 64.9 29.7 70.3
2015 41 465 78.0 17.2 4.8 92.4 65.6 29.4 70.6
2016 43 523 79.4 15.8 4.8 92.7 67.3 30.3 69.7
2017 45 622 80.1 14.8 5.1 93.1 69.7 32.3 67.7
2018 46 587 80.2 14.2 5.7 93.8 71.2 33.1 66.9
2019 50 525 80.9 13.9 5.3 94.3 74.0 35.2 64.8
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The rate of postoperative complications and 30‐ and 90‐day mortalities are described in Table 3. The rate of complications in the esophagus, stomach and duodenum, pancreas, and spleen increased slightly toward 2019, while the mortality decreased in these organ groups. The rate of complications and 30‐ 90‐day mortality in the rest of the organs were approximately the same as before.

TABLE 3.

Number of surgeries and mortality rates according to organ treated using the selected 115 gastrointestinal operative procedures

Organ Year No. surgeries Number of postoperative complicationsa/rate (%) Number of postoperative 30‐day mortalities/rate (%) Number of postoperative 90‐day mortalities/rate (%)
Esophagus 2011 7246 1294/17.9 87/1.2 279/3.9
2012 8819 1653/18.7 117/1.3 315/3.6
2013 8642 1593/18.4 121/1.4 327/3.8
2014 9021 1679/18.6 115/1.3 289/3.2
2015 8943 1709/19.1 103/1.2 304/3.4
2016 9212 1805/19.6 100/1.1 238/2.6
2017 9359 1938/20.7 108/1.2 208/2.2
2018 9286 2065/22.2 108/1.2 246/2.6
2019 9224 2035/22.1 119/1.3 246/2.7
Stomach and duodenum 2011 66 740 5354/8.0 992/1.5 2183/3.3
2012 76 186 6447/8.5 1085/1.4 2381/3.1
2013 75 583 6380/8.4 1059/1.4 2269/3.0
2014 74 920 6328/8.4 1064/1.4 2174/2.9
2015 73 877 6418/8.7 1007/1.4 2110/2.9
2016 72 234 6413/8.9 1066/1.5 2016/2.8
2017 68 287 6455/9.5 1046/1.5 1863/2.7
2018 65 152 6228/9.6 1048/1.6 1833/2.8
2019 63 610 6159/9.7 1022/1.6 1826/2.9
Small intestine and colon 2011 151 143 12184/8.1 2943/1.9 5390/3.6
2012 184 810 15395/8.3 3564/1.9 6583/3.6
2013 198 677 16709/8.4 3723/1.9 6803/3.4
2014 206 857 17776/8.6 3822/1.9 6961/3.4
2015 214 453 18372/8.6 4019/1.9 7092/3.3
2016 218 228 19020/8.7 3933/1.8 6621/3.0
2017 235 359 21854/9.3 4588/1.9 7118/3.0
2018 236 496 21881/9.3 4452/1.9 7116/3.0
2019 239 612 22061/9.2 4671/1.9 7298/3.0
Rectum and anus 2011 41 061 3584/8.7 395/1.0 676/1.6
2012 49 704 4488/9.0 462/0.9 802/1.6
2013 49 980 4684/9.4 517/1.0 858/1.7
2014 51 454 4711/9.2 449/0.9 792/1.5
2015 56 092 4986/8.9 519/0.9 824/1.5
2016 55 666 5194/9.3 503/0.9 766/1.4
2017 56 144 5600/10.0 556/1.0 829/1.5
2018 56 162 5622/10.0 522/0.9 803/1.4
2019 57 706 5573/9.7 563/1.0 839/1.5
Liver 2011 22 855 1933/8.5 309/1.4 590/2.6
2012 26 288 2454/9.3 310/1.2 605/2.3
2013 25 814 2549/9.9 275/1.1 575/2.2
2014 26 518 2466/9.3 246/0.9 481/1.8
2015 26 378 2537/9.6 234/0.9 451/1.7
2016 27 212 2543/9.3 222/0.8 382/1.4
2017 27 397 2724/9.9 214/0.8 364/1.3
2018 26 531 2737/10.3 189/0.7 372/1.4
2019 26 582 2624/9.9 201/0.8 334/1.3
Gall bladder 2011 103 183 3473/3.4 483/0.5 946/0.9
2012 122 513 4587/3.7 531/0.4 1082/0.9
2013 129 162 4982/3.9 546/0.4 1130/0.9
2014 131 182 5020/3.8 569/0.4 1097/0.8
2015 133 126 5231/3.9 541/0.4 1036/0.8
2016 137 360 5320/3.9 559/0.4 980/0.7
2017 138 267 5761/4.2 576/0.4 968/0.7
2018 139 844 5964/4.3 584/0.4 954/0.7
2019 140 214 5748/4.1 565/0.4 935/0.7
Pancreas 2011 13 477 1994/14.8 175/1.3 386/2.9
2012 15 550 2595/16.7 213/1.4 437/2.8
2013 16 380 2917/17.8 211/1.3 482/2.9
2014 17 313 2966/17.1 195/1.1 423/2.4
2015 17 407 3229/18.6 185/1.1 379/2.2
2016 18 238 3543/19.4 185/1.0 390/2.1
2017 19 138 4076/21.3 219/1.1 365/1.9
2018 19 152 4309/22.5 178/0.9 325/1.7
2019 19 703 4522/23.0 199/1.0 335/1.7
Spleen 2011 3609 400/11.1 83/2.3 137/3.8
2012 4142 528/12.7 84/2.0 138/3.3
2013 4509 575/12.8 79/1.8 139/3.1
2014 4272 549/12.9 88/2.1 137/3.2
2015 3568 543/15.2 88/2.5 144/4.0
2016 3171 449/14.2 76/2.4 117/3.7
2017 2864 434/15.2 65/2.3 89/3.1
2018 2544 418/16.4 69/2.7 104/4.1
2019 2413 380/15.7 71/2.9 97/4.0
Others 2011 23 218 3494/15.0 1163/5.0 1887/8.1
2012 28 779 4388/15.2 1399/4.9 2293/8.0
2013 36 363 4712/13.0 1401/3.9 2346/6.5
2014 39 854 5176/13.0 1521/3.8 2489/6.2
2015 41 465 5380/13.0 1541/3.7 2545/6.1
2016 43 523 5975/13.7 1760/4.0 2684/6.2
2017 45 622 6539/14.3 1909/4.2 2699/5.9
2018 46 587 6645/14.3 1865/4.0 2710/5.8
2019 50 525 7750/15.3 2221/4.4 3220/6.4
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a

Complications were defined by Clavien–Dindo grade Ⅲa–Ⅴ.

Among the procedures performed in over 50 cases in 2019 in 115 gastroenterological procedures, those with the highest 90‐day mortality rate were 1) acute pancreatitis surgery (23.2%), 2) esophagus bypass (13.5%), 3) esophageal fistula construction (12.8%), 4) gastrointestinal perforation surgery (11.9%), 5) ADP surgery (11.4%), 6) total colectomy (11.7%), 7) gastric fistula construction (excluding PEG) (11.6%), 8) external cholecystectomy (10.6%), and 9) hepatorrhaphy (10.0%). Among these nine procedures, the degree of difficulty was high in one procedure (esophagus bypass) and either moderate or low in the other eight Tables S1‐1–9).

3.2. Eight major operative procedures

The number of surgeries carried out annually for the eight major operative procedures, the percentage by gender, and the percentage according to age group between 2011 and 2019 are shown in Table 4 (Figure 2).

TABLE 4.

Annual changes of surgeries by sex, age group, and organ for eight main operative procedures

Procedure Year No. surgeries Percentage by sex Percentage according to age group (years)
Male Female <60 60 to <65 65 to <70 70 to <75 75 to <80 ≥80
Esophagectomy 2011 4916 84.1 15.9 20.4 20.8 22.5 19.4 12.2 4.7
2012 5946 84.4 15.6 19.7 21.3 20.7 20.3 13.1 4.9
2013 5694 83.6 16.4 18.3 18.3 22.6 21.3 13.8 5.8
2014 6091 84.0 16.0 18.7 17.8 22.8 22.0 13.4 5.2
2015 6060 82.9 17.1 17.9 16.3 23.6 23.5 13.1 5.7
2016 6041 81.7 18.3 17.8 15.8 25.3 21.6 14.3 5.2
2017 6100 82.3 17.7 17.0 14.6 25.6 20.6 15.8 6.3
2018 6207 80.5 19.5 17.2 14.2 22.6 22.8 16.8 6.5
2019 6298 81.0 19.0 17.0 13.9 20.7 24.1 17.2 7.0
Gastrectomy (distal) 2011 34 160 66.6 33.4 18.1 15.0 14.2 17.4 16.8 18.5
2012 38 750 66.9 33.1 16.9 14.8 15.0 17.8 16.5 18.8
2013 39 957 66.7 33.3 16.3 13.5 15.8 17.8 17.6 19.0
2014 38 584 66.4 33.6 15.7 12.4 16.6 18.4 17.3 19.5
2015 37 819 66.6 33.4 14.8 11.3 17.5 18.2 17.5 20.6
2016 36 852 66.6 33.4 14.5 10.4 18.5 17.6 17.4 21.6
2017 35 517 66.8 33.2 13.4 9.9 18.0 18.1 18.0 22.6
2018 33 988 66.6 33.4 12.9 9.1 16.9 19.0 18.1 24.0
2019 33 177 66.5 33.5 12.2 8.6 15.3 20.4 19.3 24.3
Total gastrectomy 2011 18 652 73.7 26.3 16.6 14.7 16.0 19.7 18.0 15.0
2012 21 122 74.2 25.8 15.5 14.8 15.7 19.2 18.5 16.3
2013 19 035 74.0 26.0 14.7 13.5 16.9 19.4 19.2 16.3
2014 19 071 73.7 26.3 14.0 12.3 17.2 20.1 18.9 17.5
2015 18 695 74.5 25.5 13.7 11.1 18.9 20.8 18.2 17.4
2016 17 670 74.4 25.6 12.6 10.3 19.6 19.5 19.0 19.0
2017 14 840 74.2 25.8 12.2 9.9 19.0 19.6 19.8 19.5
2018 13 223 74.4 25.6 10.8 9.1 18.0 20.6 20.6 20.9
2019 12 188 74.3 25.7 10.7 9.0 16.9 21.4 21.5 20.6
Right hemicolectomy 2011 17 890 50.5 49.5 12.8 11.6 13.1 17.3 18.8 26.5
2012 21 034 50.3 49.7 13.1 10.9 13.1 17.0 19.0 26.9
2013 21 814 50.6 49.4 13.0 10.0 13.4 17.6 18.9 27.1
2014 22 446 50.6 49.4 12.0 9.2 13.8 18.2 18.6 28.2
2015 22 850 50.5 49.5 11.5 8.6 14.6 18.1 18.1 29.1
2016 22 829 51.3 48.7 11.4 7.7 15.9 16.7 18.5 29.8
2017 22 543 50.9 49.1 11.3 7.4 14.9 16.3 19.3 30.8
2018 22 610 51.4 48.6 10.7 6.9 13.9 17.7 19.6 31.2
2019 22 410 51.5 48.5 11.0 6.6 12.9 17.7 19.7 32.1
Low anterior resection 2011 16 984 64.8 35.2 24.1 18.5 16.5 16.2 12.9 11.7
2012 20 321 64.8 35.2 24.2 17.6 16.5 16.6 13.1 12.0
2013 21 096 64.2 35.8 23.8 16.5 17.4 16.9 13.5 11.8
2014 21 861 64.8 35.2 23.1 15.7 18.3 17.9 13.1 11.9
2015 22 493 64.4 35.6 23.5 14.2 19.6 17.1 13.6 12.0
2016 21 387 64.4 35.6 23.4 13.6 20.7 16.8 13.2 12.2
2017 20 879 64.2 35.8 23.2 12.6 20.9 16.7 13.5 13.2
2018 20 636 64.9 35.1 22.9 12.5 19.3 18.0 14.4 12.9
2019 21 262 63.9 36.1 23.3 11.6 18.4 18.6 14.6 13.5
Hepatectomy (nonlateral segments) 2011 7434 70.4 29.6 20.1 16.4 16.5 20.4 18.0 8.7
2012 8239 69.5 30.5 19.8 16.1 17.4 19.5 18.5 8.8
2013 7937 69.4 30.6 19.4 14.2 18.0 20.3 18.2 9.9
2014 7666 69.2 30.8 18.5 13.8 18.5 21.5 17.6 10.0
2015 7439 68.9 31.1 18.7 12.5 19.3 20.9 17.6 11.1
2016 7610 68.7 31.3 18.0 11.9 21.1 20.4 17.5 11.1
2017 7698 69.5 30.5 17.2 11.3 20.5 20.4 18.7 11.9
2018 7192 69.5 30.5 17.2 9.6 19.1 21.4 19.4 13.3
2019 7018 69.2 30.8 16.7 9.2 16.8 22.6 20.9 13.8
Pancreaticoduodenectomy 2011 8305 61.9 38.1 16.1 16.0 17.3 20.9 18.8 10.9
2012 9329 62.0 38.0 14.7 15.8 18.0 20.6 20.2 10.6
2013 10 068 60.9 39.1 14.0 12.6 19.6 22.5 19.4 11.8
2014 10 400 59.5 40.5 18.4 12.4 19.0 21.0 18.2 11.1
2015 10 576 60.7 39.3 14.2 11.7 20.0 22.9 19.3 12.0
2016 11 028 61.1 38.9 14.2 10.3 20.6 21.8 20.3 12.7
2017 11 580 61.1 38.9 13.8 9.8 20.4 20.8 21.6 13.6
2018 11 626 60.3 39.7 13.3 9.1 18.9 22.2 22.0 14.6
2019 11 813 60.7 39.3 13.1 9.1 17.4 22.6 22.1 15.6
Acute diffuse peritonitis surgery 2011 7753 60.0 40.0 31.4 11.2 9.7 11.7 13.2 22.9
2012 9177 61.0 39.0 30.3 11.2 10.1 11.6 13.4 23.4
2013 10 447 60.1 39.9 29.1 10.3 11.5 11.8 13.1 24.1
2014 12 085 61.2 38.8 28.4 9.5 12.2 12.3 12.9 24.7
2015 13 030 59.4 40.6 28.2 8.9 12.5 13.1 12.3 25.0
2016 13 981 60.2 39.8 27.4 8.6 13.4 12.4 12.3 26.0
2017 14 423 59.4 40.6 26.5 7.8 13.0 12.0 13.6 27.1
2018 14 835 59.2 40.8 26.1 7.7 12.7 13.1 13.5 26.9
2019 15 765 59.2 40.8 25.2 7.7 11.6 13.6 14.1 27.7
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FIGURE 2.

FIGURE 2

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Annual changes in the number of surgeries, 30‐day mortality, operative mortality, and complications: Analysis of the eight major surgical procedures. Postoperative complication rate: the rate of Clavien–Dindo (C–D) classification grade III or higher complications

The number of procedures increased in RHC, LAR, and PD and decreased in DG, TG, and HEP.

The age distributions mirrored the tendency in recent years to shift toward older patients, and the percentage of cases with the age >70 years in 2019 (increase from 2011) was 48.3% (+12.0%), 64.0% (+12.3%), 63.5% (+10.8%), 69.5% (+7.1%), 46.7% (+5.9%), 57.3% (+10.2%), 60.3% (+9.7%), 55.4% (+7.6%) in ESO, DG, TG, RHC, LAR, HEP, PD, and ADP, respectively.

The rate of involvement of board‐certified surgeons for the 115 procedures remained the same as in 2018, and the rates have been continuously increasing in recent years; these were approximately as follows: ESO (96.4%), HEP (96.3%), and PD (95.5%), and the lower rates ranged from 73.3–86.8% in DG/TG, RHC, LAR, and ADP (Table 5).

TABLE 5.

Institution and anesthesiologist and specialist participation rates by organ for eight main operative procedures

Procedure Year No. surgeries Percentage by institution group Anesthesiologist participation (%) Board‐certified Surgeon participation (%) Medical practitioners (%)
Certified institution Related institution Other Board‐certified Surgeons Nonboard‐certified surgeons
Esophagectomy 2011 4916 94.2 5.3 0.5 97.6 88.4 63.5 36.5
2012 5946 78.3 4.9 16.8 98.1 89.0 64.8 35.2
2013 5694 92.9 5.9 1.2 98.0 90.8 66.6 33.4
2014 6091 93.6 4.7 1.7 98.6 92.6 70.2 29.8
2015 6060 93.6 4.6 1.8 98.5 93.5 72.1 27.9
2016 6041 94.5 3.8 1.7 98.8 93.7 73.2 26.8
2017 6100 95.3 3.1 1.7 98.8 94.8 74.7 25.3
2018 6207 95.9 2.7 1.4 99.1 96.6 78.8 21.2
2019 6298 96.3 2.3 1.5 98.9 96.4 80.6 19.4
Gastrectomy (distal) 2011 34 160 81.1 16.6 2.3 93.2 71.3 37.0 63.0
2012 38 750 64.5 15.2 20.3 93.9 72.5 37.9 62.1
2013 39 957 76.6 19.2 4.1 93.6 76.1 40.6 59.4
2014 38 584 77.7 17.8 4.5 94.0 78.4 42.1 57.9
2015 37 819 77.3 18.3 4.4 94.1 78.1 41.3 58.7
2016 36 852 80.2 15.9 4.0 95.0 81.8 43.8 56.2
2017 35 517 80.2 14.9 4.8 95.4 82.4 45.2 54.8
2018 33 988 80.7 14.4 4.8 95.6 84.2 46.6 53.4
2019 33 177 82.4 13.5 4.0 95.7 86.4 50.1 49.9
Total gastrectomy 2011 18 652 80.9 16.8 2.3 93.9 71.6 37.4 62.6
2012 21 122 63.0 15.3 21.7 94.3 72.1 38.0 62.0
2013 19 035 77.2 18.9 3.9 94.2 75.0 39.5 60.5
2014 19 071 77.8 17.9 4.3 94.4 77.7 41.7 58.3
2015 18 695 77.9 17.9 4.1 94.5 78.2 42.6 57.4
2016 17 670 80.0 15.9 4.0 95.0 81.4 45.0 55.0
2017 14 840 79.3 15.8 4.9 95.0 80.7 44.3 55.7
2018 13 223 79.6 15.5 4.9 95.4 82.6 46.2 53.8
2019 12 188 80.0 15.5 4.4 95.7 85.5 49.2 50.8
Right hemicolectomy 2011 17 890 75.7 21.2 3.1 92.7 66.0 30.5 69.5
2012 21 034 60.0 18.3 21.7 93.0 67.1 30.8 69.2
2013 21 814 72.1 22.3 5.6 92.9 69.7 32.6 67.4
2014 22 446 71.2 23.1 5.7 93.4 71.9 33.6 66.4
2015 22 850 72.1 22.0 5.9 94.1 72.4 33.5 66.5
2016 22 829 73.8 20.1 6.1 94.5 74.2 34.3 65.7
2017 22 543 75.0 18.4 6.6 94.7 76.4 37.1 62.9
2018 22 610 74.8 19.0 6.2 94.7 77.8 38.2 61.8
2019 22 410 75.8 18.1 6.1 95.6 80.1 39.2 60.8
Low anterior resection 2011 16 984 79.4 17.7 2.9 93.4 72.7 41.6 58.4
2012 20 321 64.0 16.2 19.7 93.8 73.0 42.3 57.7
2013 21 096 76.3 19.5 4.2 93.7 75.5 44.3 55.7
2014 21 861 76.2 19.0 4.9 94.4 78.2 47.2 52.8
2015 22 493 76.9 18.3 4.8 94.6 79.2 47.7 52.3
2016 21 387 79.0 16.4 4.7 95.0 81.0 48.8 51.2
2017 20 879 79.3 15.6 5.1 95.2 83.1 51.2 48.8
2018 20 636 80.9 14.3 4.8 95.2 84.5 54.4 45.6
2019 21 262 81.2 14.1 4.6 95.6 86.8 58.3 41.7
Hepatectomy (nonlateral segments) 2011 7434 91.1 8.0 0.8 96.4 88.9 61.5 38.5
2012 8239 75.9 7.9 16.3 96.8 89.3 64.0 36.0
2013 7937 88.1 9.7 2.2 96.9 91.0 65.2 34.8
2014 7666 88.2 8.7 3.1 96.7 92.3 66.6 33.4
2015 7439 89.2 8.6 2.2 97.2 92.3 66.6 33.4
2016 7610 90.7 7.1 2.1 97.1 93.3 67.7 32.3
2017 7698 91.2 6.6 2.2 97.7 95.1 72.3 27.7
2018 7192 92.8 5.2 2.0 97.7 95.8 72.8 27.2
2019 7018 92.7 5.2 2.1 97.8 96.3 74.2 25.8
Pancreaticoduodenectomy 2011 8305 87.8 11.0 1.2 95.9 85.7 58.7 41.3
2012 9329 72.4 8.8 18.8 96.6 87.2 60.9 39.1
2013 10 068 85.9 11.7 2.4 96.0 87.9 60.5 39.5
2014 10 400 86.4 10.4 3.3 96.4 90.3 62.2 37.8
2015 10 576 88.5 9.2 2.4 96.9 90.9 62.1 37.9
2016 11 028 89.4 8.3 2.3 97.1 91.7 63.3 36.7
2017 11 580 90.5 7.2 2.3 97.3 93.0 65.0 35.0
2018 11 626 91.4 6.4 2.2 97.4 94.0 67.6 32.4
2019 11 813 92.0 6.2 1.9 97.2 95.5 69.6 30.4
Acute diffuse peritonitis surgery 2011 7753 80.6 16.9 2.4 90.0 58.5 23.5 76.5
2012 9177 65.2 16.4 18.4 90.4 59.4 22.7 77.3
2013 10 447 77.7 18.1 4.2 91.2 62.4 23.9 76.1
2014 12 085 77.7 17.2 5.1 91.9 63.3 25.1 74.9
2015 13 030 79.8 15.9 4.3 92.2 64.5 24.9 75.1
2016 13 981 82.2 13.8 4.0 93.0 66.8 26.1 73.9
2017 14 423 83.1 13.0 3.8 93.3 69.0 27.2 72.8
2018 14 835 83.4 12.4 4.2 93.6 70.4 28.7 71.3
2019 15 765 83.8 12.2 4.0 94.6 73.7 29.8 70.2
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The morbidities and mortalities of these eight major gastroenterological procedures remained relatively constant in all procedures. The morbidities increased in ESO, HEP, and PD compared to those in 2016 or 2017; in contrast, the mortalities decreased in these procedures. In the other five procedures, the rate of morbidities and mortalities remained approximately the same from 2011 to 2019 (Table 6).

TABLE 6.

Number of surgeries and mortality rates according to organ treated using the eight main operative procedures

Procedure Year No. surgeries No. postoperative complicationsa/rate (%) No. re‐operation/rate (%) No. postoperative No. postoperative
30‐day mortalities/rate (%) 90‐day mortalities/rate (%)
Esophagectomy 2011 4916 879/17.9 310/6.3 55/1.1 158/3.2
2012 5946 1135/19.1 345/5.8 63/1.1 183/3.1
2013 5694 1067/18.7 375/6.6 67/1.2 161/2.8
2014 6091 1178/19.3 367/6.0 49/0.8 140/2.3
2015 6060 1171/19.3 392/6.5 57/0.9 166/2.7
2016 6041 1240/20.5 357/5.9 49/0.8 109/1.8
2017 6100 1374/22.5 355/5.8 61/1.0 108/1.8
2018 6207 1420/22.9 367/5.9 53/0.9 115/1.9
2019 6298 1435/22.8 353/5.6 54/0.9 120/1.9
Gastrectomy (distal) 2011 34 160 1774/5.2 709/2.1 208/0.6 451/1.3
2012 38 750 2205/5.7 849/2.2 232/0.6 516/1.3
2013 39 957 2450/6.1 892/2.2 239/0.6 542/1.4
2014 38 584 2356/6.1 941/2.4 264/0.7 523/1.4
2015 37 819 2325/6.1 851/2.3 222/0.6 452/1.2
2016 36 852 2314/6.3 825/2.2 249/0.7 473/1.3
2017 35 517 2445/6.9 859/2.4 253/0.7 437/1.2
2018 33 988 2327/6.8 737/2.2 227/0.7 393/1.2
2019 33 177 2361/7.1 739/2.2 253/0.8 427/1.3
Total gastrectomy 2011 18 652 1716/9.2 634/3.4 177/0.9 427/2.3
2012 21 122 2135/10.1 758/3.6 224/1.1 503/2.4
2013 19 035 1831/9.6 642/3.4 169/0.9 428/2.2
2014 19 071 1840/9.6 698/3.7 185/1.0 379/2.0
2015 18 695 1907/10.2 654/3.5 178/1.0 387/2.1
2016 17 670 1835/10.4 638/3.6 174/1.0 336/1.9
2017 14 840 1702/11.5 514/3.5 161/1.1 293/2.0
2018 13 223 1529/11.6 487/3.7 148/1.1 265/2.0
2019 12 188 1406/11.5 427/3.5 136/1.1 258/2.1
Right hemicolectomy 2011 17 890 1150/6.4 588/3.3 213/1.2 410/2.3
2012 21 034 1470/7.0 677/3.2 263/1.3 471/2.2
2013 21 814 1527/7.0 721/3.3 280/1.3 538/2.5
2014 22 446 1544/6.9 771/3.4 287/1.3 530/2.4
2015 22 850 1607/7.0 769/3.4 301/1.3 534/2.3
2016 22 829 1510/6.6 791/3.5 253/1.1 449/2.0
2017 22 543 1648/7.3 785/3.5 296/1.3 450/2.0
2018 22 610 1679/7.4 740/3.3 276/1.2 424/1.9
2019 22 410 1666/7.4 713/3.2 306/1.4 449/2.0
Low anterior resection 2011 16 984 1616/9.5 1213/7.1 75/0.4 136/0.8
2012 20 321 2092/10.3 1413/6.9 88/0.4 149/0.7
2013 21 096 2059/9.8 1473/7.0 80/0.4 175/0.8
2014 21 861 2098/9.6 1546/7.1 70/0.3 152/0.7
2015 22 493 2210/9.8 1550/6.9 95/0.4 156/0.7
2016 21 387 2306/10.8 1492/7.0 68/0.3 126/0.6
2017 20 879 2376/11.4 1330/6.4 96/0.5 148/0.7
2018 20 636 2454/11.9 1424/6.9 90/0.4 142/0.7
2019 21 262 2320/10.9 1346/6.3 73/0.3 119/0.6
Hepatectomy (nonlateral segments) 2011 7434 886/11.9 203/2.7 155/2.1 303/4.1
2012 8239 1146/13.9 248/3.0 142/1.7 293/3.6
2013 7937 1135/14.3 226/2.8 130/1.6 290/3.7
2014 7666 1052/13.7 242/3.2 94/1.2 208/2.7
2015 7439 1049/14.1 213/2.9 87/1.2 182/2.4
2016 7610 1046/13.7 220/2.9 96/1.3 178/2.3
2017 7698 1160/15.1 221/2.9 97/1.3 169/2.2
2018 7192 1137/15.8 211/2.9 83/1.2 163/2.3
2019 7018 1058/15.1 189/2.7 94/1.3 143/2.0
Pancreaticoduodenectomy 2011 8305 1285/15.5 299/3.6 97/1.2 238/2.9
2012 9329 1654/17.7 365/3.9 137/1.5 281/3.0
2013 10 068 1853/18.4 407/4.0 142/1.4 307/3.0
2014 10 400 1847/17.8 374/3.6 111/1.1 267/2.6
2015 10 576 2025/19.1 378/3.6 120/1.1 247/2.3
2016 11 028 2242/20.3 393/3.6 98/0.9 232/2.1
2017 11 580 2539/21.9 413/3.6 145/1.3 232/2.0
2018 11 626 2716/23.4 402/3.5 111/1.0 204/1.8
2019 11 813 2854/24.2 402/3.4 119/1.0 210/1.8
Acute diffuse peritonitis surgery 2011 7753 2022/26.1 634/8.2 697/9.0 1096/14.1
2012 9177 2456/26.8 685/7.5 785/8.6 1289/14.0
2013 10 447 2652/25.4 786/7.5 861/8.2 1408/13.5
2014 12 085 2966/24.5 937/7.8 927/7.7 1472/12.2
2015 13 030 3126/24.0 1051/8.1 943/7.2 1551/11.9
2016 13 981 3445/24.6 1068/7.6 1052/7.5 1572/11.2
2017 14 423 3756/26.0 1125/7.8 1152/8.0 1575/10.9
2018 14 835 3943/26.6 1183/8.0 1117/7.5 1617/10.9
2019 15 765 4367/27.7 1247/7.9 1233/7.8 1795/11.4
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a

Complications were defined by Clavien–Dindo grade IIIa–V.

The rate of laparoscopic surgery in 2019 continuously increased from 2011 in LAR (70.3%, +40.8%), ESO (66.8%, +34.8%), RHC (52.5%, +25.4%), DG (51.9%, +20.3%), TG (27.5%, +15.4%), HEP (nonlateral segment) (12.9%, +9.6%), and ADP (21.2%, +14.9%), with the exception of PD, which remained low at 2.6% (+1.8%) (Table 7, Figure 3).

TABLE 7.

Annual changes of endoscopic surgeries for eight main operative procedures

Procedure Year No. surgeries Endoscopic surgery %Endoscopic surgery
Esophagectomy 2011 4916 1525 31.0
2012 5946 2200 37.0
2013 5694 2315 40.7
2014 6091 2569 42.2
2015 6060 2659 43.9
2016 6041 2961 49.0
2017 6100 3424 56.1
2018 6207 3788 61.0
2019 6298 4209 66.8
Gastrectomy (distal) 2011 34 160 10 801 31.6
2012 38 750 13 098 33.8
2013 39 957 16 507 41.3
2014 38 584 14 432 37.4
2015 37 819 14 357 38.0
2016 36 852 15 333 41.6
2017 35 517 15 696 44.2
2018 33 988 16 355 48.1
2019 33 177 17 205 51.9
Total gastrectomy 2011 18 652 2258 12.1
2012 21 122 3060 14.5
2013 19 035 3669 19.3
2014 19 071 3620 19.0
2015 18 695 3707 19.8
2016 17 670 4007 22.7
2017 14 840 3347 22.6
2018 13 223 3344 25.3
2019 12 188 3351 27.5
Right hemicolectomy 2011 17 890 4842 27.1
2012 21 034 6954 33.0
2013 21 814 9124 41.8
2014 22 446 8269 36.8
2015 22 850 8755 38.3
2016 22 829 9622 42.1
2017 22 543 10 341 45.9
2018 22 610 11 165 49.4
2019 22 410 11 769 52.5
Low anterior resection 2011 16 984 5018 29.5
2012 20 321 7649 37.6
2013 21 096 10 814 51.3
2014 21 861 11 298 51.7
2015 22 493 12 080 53.7
2016 21 387 12 478 58.3
2017 20 879 13 064 62.6
2018 20 636 13 825 67.0
2019 21 262 14 950 70.3
Hepatectomy (nonlateral segments) 2011 7434 242 3.3
2012 8239 389 4.7
2013 7937 567 7.1
2014 7666 392 5.1
2015 7439 127 1.7
2016 7610 433 5.7
2017 7698 712 9.2
2018 7192 791 11.0
2019 7018 904 12.9
Pancreaticoduodenectomy 2011 8305 67 0.8
2012 9329 121 1.3
2013 10 068 156 1.5
2014 10 400 124 1.2
2015 10 576 53 0.5
2016 11 028 118 1.1
2017 11 580 188 1.6
2018 11 626 194 1.7
2019 11 813 308 2.6
Acute diffuse peritonitis surgery 2011 7753 488 6.3
2012 9177 652 7.1
2013 10 447 1070 10.2
2014 12 085 1381 11.4
2015 13 030 1638 12.6
2016 13 981 2164 15.5
2017 14 423 2478 17.2
2018 14 835 2820 19.0
2019 15 765 3341 21.2
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FIGURE 3.

FIGURE 3

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Annual changes in the percentage of surgeries performed endoscopically: analysis of the eight major surgical procedures

4. DISCUSSION

Data of gastroenterological surgery in Japan using the gastroenterological section of the NCD were summarized, and the trends in the 115 gastroenterological procedures and eight major gastroenterological surgeries were reported. The numbers, demography, morbidities, and mortalities of the procedures comprised the main contents of this report, summarized as follows: 1) Operative numbers gradually increased in all procedures except for gastrectomy and hepatectomy, which decreased in these years; 2) age distributions shifted toward older patients in all eight major gastroenterological surgeries; 3) morbidities of ESO, HEP, and PD increased, but the mortalities were minimized in all procedures; 4) laparoscopic procedures have been increasing in all eight major gastroenterological procedures; and 5) the involvement of board‐certified surgeons increased. These trends in recent years were more prominent in 2019.

The 30‐ and 90‐day mortalities have been steadily decreasing in these years, while the postoperative morbidities classified as C–D grade III or higher remained almost unchanged in the gallbladder, rectum, and anus (LAR) and ADP surgery and increased slightly in the esophagus (ESO), stomach and duodenum (DG/TG), small intestine and colon (RHC), liver (HEP), and pancreas (PD). The reason for the discrepancy between postoperative morbidities and mortalities was unclear, but possible reasons include an improved “failure to rescue ratio,”28, 29 reduction in severe morbidities with higher mortality risk, and more accurate registration of postoperative morbidities into the NCD system than before. These possibilities should be further evaluated in future studies.

The rate of laparoscopic surgeries, including robotic surgeries, demonstrated their rapid increase, reflecting the current trends in gastroenterological surgeries, although the usage rate of laparoscopy varied greatly. Among the major GE procedures, LAR and ESO had the highest rate (more than two‐thirds), while PD had the lowest laparoscopic rate of only 2.6%. Detailed analyses including the safety and other outcomes of laparoscopic procedures should be performed in future studies.

Seven of the eight major gastroenterological surgeries, apart from ADP, can be divided into two categories: 1) basic gastroenterological surgeries (DG/TG, RHC, and LAR) and 2) advanced gastroenterological surgeries (ESO, HEP, and PD). Postoperative complications and mortalities were higher, and the rate of involvement of board‐certified surgeons as the primary surgeons was higher in advanced than in basic gastroenterological surgeries. It is not difficult to imagine that young, noncertified surgeons initially performed basic surgeries and improved their skills, thereafter proceeding to advanced surgeries. Further detailed analyses of the NCD data would clarify this point in the future.

Among the procedures performed in over 50 cases in 2019 in 115 gastroenterological procedures, nine procedures had a mortality of over 10%, and most of these were low‐difficulty procedures, indicating that the causes of mortality were more likely not technical problems but rather the poor general conditions of the patients. In this report, the NCD data between 2011 and 2019 were utilized. It is important to maintain accurate clinical data for analysis and interpretation. To ensure accuracy, systematic audits comparing the registered data and corresponding clinical charts in 20 cases per facility were initiated, and members of the JSGS committee and its subcommittee for NCD database quality improvement investigated 5% of all JSGS‐certified hospitals (about 40 facilities), which were randomly selected every year. This will be continued by the JSGS database committee. The reports of these audits have so far revealed the high accuracy of the NCD data in the JSGS section.30, 31

The usage of the NCD for clinical studies has been also expanding. JSGS leads the joint council for the society‐specific registries since 2009 and has promoted clinical studies using the NCD. The joint council currently consists of 16 societies as of January 2021; JSGS, JSS, JSHBPS, The Japan Esophageal Society, Japanese Gastric Cancer Association, Japan Pancreas Society, Japan Society for Endoscopic Surgery, Japanese Society of Abdominal Emergency Medicine, Japanese Hernia Society, The Japanese Society for Treatment of Obesity, The Japanese Association for Thoracic Surgery, Japanese Liver Transplantation Society, The Japanese Society for Cancer of the Colon and Rectum, Liver Cancer Study Group of Japan, Endoscopic Liver Surgery Study Group, and Japanese Society for Endoscopic and Robotic Pancreatic Surgery.

The JSGS approved 77 studies from 2013 to 2020 with regard to the joint council, and many high‐impact articles have been published so far. Fifteen articles were accepted and published in 2020, where preoperative risk models for postgastrectomy intraabdominal infectious complications related to gastric cancer,32 morbidities after total pancreatectomy,33 bile leakage after hepatectomies for hepatocellular carcinoma,34 and emergency surgery for gastrointestinal cancer35 were reported. The importance of board‐certified surgeons was reported in RHC36 and PD.37 The Endoscopic Surgical Skill Qualification System certification by the Japan Society for Endoscopic Surgery did not affect the postoperative mortality following laparoscopic DG and LAR.38 Additionally, hospital volume affected postoperative mortality after TG39 and PD,40 and laparoscopic liver resection was safely developed with a low mortality and complication rate relative to open liver resection in Japan.41 A geriatric surgery pilot study was conducted from 2017 to 2020, and the specific variables and outcome predictors in geriatric surgery were implemented in the NCD system in 2021.42 Thus, in the NCD, a robust nationwide registry on surgical outcomes is important to elucidate the performance of surgeries, to provide tools for future studies, and to improve the surgical outcomes.

The database itself is only a result of the clinical treatment, but it is important for establishing the four pillars of surgical quality improvement that the American College of Surgeons–National Surgical Quality Improvement Program (ACS‐NSQIP) has identified.43 These four pillars are setting standards, creating the infrastructure required to achieve these standards, commitment to measuring performance against those standards and remaining accountable for those measurements, and agreeing to a peer review against those standards. The JSGS and ACS‐NSQIP have collaborated since the foundation of the NCD in 2010, and collaborative studies are ongoing.3, 44 Rigorous data collection is required with respect to the third pillar. While the other pillars are important, establishing standards could be the essential step.

Besides the data presented in this annual report, many other variables were also available, and future studies are expected to elucidate the current situation and implications for the future. Further active clinical studies will discover new evidence using the assets of the NCD data, which all surgeons, medical staff, and surgical clinical reviewers contributed to, in most facilities in Japan. We continuously take care to promote the value of the database and to encourage the usage of feedback and clinical studies using the NCD now and in the future.

ETHICAL APPROVAL

The protocol for this research project has been approved by the Ethics Committee of the NCD as of November 18, 2020, and it conforms to the provisions of the Declaration of Helsinki as revised in Fortaleza, Brazil, October 2013. The opt‐out method to obtain patient consent was utilized at each institution.

DISCLOSURE

Funding: The department is a social collaboration department supported by grants from the National Clinical Database, Johnson & Johnson KK, and Nipro Co.

CONFLICT OF INTEREST

Arata Takahashi, Hiroyuki Yamamoto, and Hiroaki Miyata are affiliated with the Department of Healthcare Quality Assessment at the University of Tokyo. The other authors have no conflicts of interest.

Supporting information

Table S1

Click here for additional data file. (56.4KB, docx)

ACKNOWLEDGMENTS

We thank all the medical staff, surgical clinical reviewers, and hospitals for their continued efforts in participating and entering the data for this NCD. We also thank Mr. Keita Shimoakasho in JSGS and Ms. Hitomi Okamoto in the NCD for their generous cooperation and providing important information for this article.

Marubashi S, Takahashi A, Kakeji Y, et al; the National Clinical Database . Surgical outcomes in gastroenterological surgery in Japan: Report of the National Clinical Database 2011–2019. Ann Gastroenterol Surg. 2021;5:639–658. 10.1002/ags3.12462

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Supplementary Materials

Table S1

Click here for additional data file. (56.4KB, docx)

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