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Annals of Gastroenterological Surgery logoLink to Annals of Gastroenterological Surgery
. 2024 Oct 17;9(1):32–59. doi: 10.1002/ags3.12868

Annual report on National Clinical Database 2021 for gastroenterological surgery in Japan

Sunao Ito 1,2, Arata Takahashi 3,4, Hideki Ueno 1,5,✉, Shuji Takiguchi 1,2, Yoshiki Kajiwara 1,5, Yoshihiro Kakeji 1,6, Susumu Eguchi 1,7, Takanori Goi 1,8, Akio Saiura 1,9, Akira Sasaki 1,10, Hiroya Takeuchi 1,11, Chie Tanaka 1,12, Masaji Hashimoto 1,13, Naoki Hiki 1,14, Akihiko Horiguchi 1,15, Satoru Matsuda 1,16, Tsunekazu Mizushima 1,17, Hiroyuki Yamamoto 4, Yuko Kitagawa 1,16, Ken Shirabe 1,18
PMCID: PMC11693552  PMID: 39759995

Abstract

Aim

The Japanese National Clinical Database, which covers more than 95% of the surgeries performed in Japan, is the largest nationwide database. This is the 2021 annual report of the Gastroenterological Section of the National Clinical Database, which aims to present the short‐term outcomes of cases registered in 2021 and discuss significant changes and insights into gastroenterological surgeries observed over the decade.

Methods

We reviewed the data of patients registered in the National Clinical Database between 2012 and 2021.

Results

In total, 5 788 093 cases, including 597 780 cases in 2021, were extracted from the National Clinical Database. The number of surgeries resumed its original trend after a uniform decrease due to the coronavirus disease 2019 pandemic. The patient population continues to age, and the proportion of female patients is steadily increasing. The trend of surgeries being conducted in certified institutions with the involvement of board‐certified surgeons is consistently rising. Moreover, the increasing trend of endoscopic surgery rate is still maintained. Although operative mortality is declining, the trend of increasing postoperative complications continues. Surgery on the esophagus, liver, and pancreas has shown substantial improvements in operative mortality, with a high participation rate of board‐certified surgeons. Surgical procedures with a high incidence of emergency surgeries are characterized by low participation rates of board‐certified surgeons, increased morbidity rates, and worse mortality outcomes.

Conclusion

This overview of surgical patients in Japan, obtained using data extracted from the National Clinical Database, may serve as a critical cornerstone for the future development of gastroenterological surgery.

Keywords: annual report, emergency surgery, gastroenterological surgery, National Clinical Database, surgical outcome

This study presents the annual report of the gastroenterological surgery of the National Clinical Database (NCD) in 2021. In total, 5 788 093 cases, including 597 780 cases in 2021, were extracted from the NCD. The patient population continues to age, and the proportion of female patients is steadily increasing. The trend of surgeries being conducted in certified institutions with the involvement of board‐certified surgeons is consistently rising.

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1. INTRODUCTION

The Japanese National Clinical Database (NCD) is the largest nationwide database, which covers more than 95% of the surgeries performed in Japan. 1 , 2 Data registration with the NCD commenced in 2011 and now includes 1.5 million cases annually from more than 5600 facilities, reaching a cumulative total of 17 million cases. 3

The Japanese Society of Gastroenterological Surgery (JSGS) is among the 10 societies involved in the establishment of the NCD and conducts numerous systems and analyses using data in the registry to benefit patients, surgeons, and enrolled facilities. First, the registered cases are used for the board certification system; 121 gastroenterological procedures are classified into three levels of difficulty, forming the basis of board certification applications. Second, nine major surgical procedures were benchmarked to improve the quality of surgical care 4 ; namely, esophagectomy, partial/total gastrectomy, right hemicolectomy, low anterior resection, hepatectomy, pancreaticoduodenectomy, surgery for acute diffuse peritonitis, and liver transplantation. Risk models for mortality 5 , 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 and morbidity 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 associated with these nine major procedures have been reported as some of the most significant findings derived from NCD. Third, feedback systems based on risk models were constructed and operated online. 4 For individual patients, a risk calculator can be used to estimate surgical risks based on preoperative clinical information. Furthermore, the NCD can provide surgical outcomes for the enrolled facilities in comparison with national real‐world data. The former can be used to obtain informed consent, whereas the latter can support risk management and performance improvements in facilities.

As mentioned above, the NCD have evolved into an indispensable framework for the advancement of gastroenterological surgery in Japan. The purpose of this report is to understand the current trends and challenges of gastroenterological surgeries and to clarify the path for future advancements, by overviewing gastroenterological surgeries registered in the NCD. Hence, we continue with previous annual reports 22 , 23 , 24 , 25 , 26 by presenting the short‐term outcomes of cases registered in the NCD in 2021 and discuss significant changes and insights into gastroenterological surgeries observed over the decade from 2012 to 2021.

2. PATIENTS AND METHODS

The included patients were those who underwent one or more of the 121 surgical procedures stipulated in the “Training Curriculum for Board‐Certified Surgeons in Gastroenterology,” and had their surgical data recorded from 2012 to 2021 in the NCD system. The clinical data of these patients were collected using the NCD system, as previously reported. 4 , 22 , 23 , 24 , 25 , 26 The number of surgeries, patient sex, age, postoperative complications, mortalities, and proportions of endoscopic and emergency surgeries for each surgical procedure were calculated. The proportion of institutions certified by the JSGS and the participation rates of anesthesiologists and board‐certified surgeons were calculated. Using these data, four main analyses were conducted: analysis of (1) each surgical procedure; (2) annual trends in surgeries by organ; (3) annual trends of endoscopic surgery rate in major surgical procedures; and (4) surgical procedures with high rates of emergency surgery.

Major requirements for board‐certified training institutions include 600 or more gastroenterological operations, as mandated by the accreditation committee, with at least 120 being essential major surgeries done over the preceding 3 years. Board‐certified surgeons are required to undergo training for over 5 years and have experience in performing more than 450 surgical cases at the aforementioned board‐certified training institutions.

When interpreting the data provided, it is necessary to consider the following factors: (a) due to the NCD's limitation of recording a maximum of eight operative procedures per case, the aggregate number of surgeries reported for each result does not accurately represent the total number of surgical cases; (b) data entries with inaccuracies in patient age, sex, and postoperative 30‐day status were omitted from the analysis; (c) postoperative complications that were grade III or more in the Clavien–Dindo (C‐D) classification were defined as severe complications 27 ; (d) the measure of postoperative 30‐day mortality encompasses all instances of death within 30 days following the surgery, irrespective of whether the patient was discharged or not, whereas operative mortality accounts for all deaths occurring during the index hospitalization, which may extend up to 90 days, as well as any deaths occurring after discharge within 30 days from the date of surgery.

3. RESULTS

3.1. Gastroenterological operative procedures in the “Training Curriculum for Board‐Certified Surgeons in Gastroenterology” in 2021

From January 1, 2021, to December 31, 2021, 597 780 patients underwent gastroenterological surgeries, as recorded in the NCD. In the analyses regarding the treated organ, the breakdown of the cases were as follows: esophagus, 8905 cases (1.5%); stomach and duodenum, 56 759 cases (9.5%); small intestine and colon, 240 448 cases (40.2%); rectum and anus, 56 536 cases (9.5%); liver, 26 250 cases (4.4%); gallbladder, 136 111 cases (22.8%); pancreas, 19 722 cases (3.3%); spleen, 1833 cases (0.3%); and others, 51 216 cases (8.5%).

Characteristics of the operative procedures outlined in the “Training Curriculum for Board‐Certified Surgeons in Gastroenterology” for 2021 are detailed in Table 1. Although anesthesiologists participated in most surgical procedures, with a rate exceeding 95%, there were notable exceptions. These included anal surgeries, such as anal sphincteroplasty (23.3%), transanal rectal tumor resection (39.1%), proctocele surgery (55.9%), esophageal and gastric varix surgery (62.0%), external cholecystostomy (63.3%), external pancreatic duct drainage (73.7%), and surgery for hepatic trauma (excluding drainage only) (75.1%), which had participation rates below 80%. Although the participation rates of board‐certified surgeons vary, they generally exceed 90% in highly difficult procedures for each organ. However, even among the surgeries performed in more than 100 cases annually, procedures such as anal sphincteroplasty (53.7%), transanal rectal tumor resection (56.9%), achalasia surgery (53.4%), gastric pyloroplasty (57.5%), and surgery for hepatic trauma (excluding drainage only) (58.6%) had less than 60% participation by board‐certified surgeons.

TABLE 1.

Characteristics of each operative procedure of the “Training Curriculum for Board‐Certified Surgeons in Gastroenterology” in 2021.

Organ Difficulty level Operative procedure No. of surgeries Sex male (%) Age ≥80 (%) Anesthesiologist participation (%) Board‐certified surgeon participation (%) Operating surgeon (%)
Board‐certified surgeon Non‐board‐certified surgeon
Esophagus Low Cervical periesophageal abscess drainage 32 68.8 9.4 87.5 96.9 71.9 28.1
Med Esophageal suture (perforation, injury) 183 77.6 15.8 95.1 86.9 57.9 42.1
Med Thoracic periesophageal abscess drainage 23 78.3 13.0 100.0 100.0 73.9 26.1
Med Esophageal foreign body extraction 27 40.7 44.4 96.3 85.2 55.6 44.4
Med Esophageal diverticulum resection 41 63.4 9.8 95.1 95.1 78.0 22.0
Med Benign esophageal tumor removal 70 61.4 0.0 98.6 97.1 74.3 25.7
Med Esophageal resection (removal only) 606 81.2 15.3 97.4 91.4 75.6 24.4
Med Esophageal reconstruction (gastric tube reconstruction) 516 82.2 7.2 99.0 95.5 78.5 21.5
Med Esophageal fistula construction 186 77.4 12.9 96.8 96.2 83.9 16.1
Med Esophagocardioplasty 305 38.7 25.9 97.4 82.3 56.1 43.9
Med Achalasia surgery 189 52.9 7.9 96.3 53.4 38.1 61.9
High Esophagectomy 6193 80.3 8.4 99.2 98.6 83.5 16.5
High Esophageal reconstruction (colon reconstruction) 36 88.9 5.6 100.0 91.7 63.9 36.1
High Esophageal bypass 117 80.3 7.7 98.3 100.0 66.7 33.3
High Bronchoesophageal fistula surgery 7 57.1 0.0 85.7 100.0 100.0 0.0
High Secondary esophageal reconstruction 374 81.6 11.8 98.9 96.8 72.5 27.5
Stomach and duodenum Low Gastrostomy and suture gastrorrhaphy 64 60.9 21.9 96.9 82.8 40.6 59.4
Low Diverticulectomy, polypectomy (excluding endoscopic resection) 128 53.9 19.5 96.1 92.2 50.0 50.0
Low Truncal vagotomy 0 ‐ ‐ ‐ ‐ ‐ ‐
Low Gastroenterostomy (including duodenal jejunostomy) 5944 62.8 28.8 97.0 86.4 41.9 58.1
Low Gastric fistula construction (excluding PEG) 1460 63.9 28.0 93.1 79.9 45.5 54.5
Low Gastric pyloroplasty 106 79.2 3.8 96.2 57.5 28.3 71.7
Low Gastric volvulus surgery and rectopexy 64 20.3 48.4 95.3 84.4 46.9 53.1
Low Gastric suture (including gastric suture for gastric rupture, suture closure for gastroduodenal perforation, omental implantation and omental transposition) 5327 65.1 25.6 93.6 75.1 30.0 70.0
Low Local gastrectomy (including wedge resection) 4878 50.7 14.6 96.6 89.2 49.8 50.2
Med Gastrectomy (including distal, pylorus preserving, and segmental) 28 771 66.6 26.7 96.4 90.7 55.9 44.1
Med Selective vagotomy 3 66.7 0.0 100.0 66.7 33.3 66.7
High Total gastrectomy (including proximal gastrectomy) 10 010 73.8 22.6 96.5 89.4 55.6 44.4
High Left upper abdominal exenteration 4 100.0 0.0 100.0 100.0 75.0 25.0
Small intestine and colon Low Enterotomy and enterorrhaphy 4268 55.5 26.5 93.7 78.9 40.4 59.6
Low Disinvagination (invasive) 152 45.4 29.6 96.7 76.3 21.7 78.3
Low Partial small bowel resection (benign) 9017 57.5 30.9 95.0 78.9 36.6 63.4
Low Ileocecal resection (benign) 4970 58.6 18.4 94.6 79.0 34.4 65.6
Low Partial colectomy and sigmoid colectomy (benign) 8536 62.2 25.9 95.0 80.8 37.3 62.7
Low Appendectomy 56 071 55.1 6.6 93.1 68.3 24.3 75.7
Low Enterostomy and closure (without enterectomy) 28 205 62.8 20.4 96.0 83.3 45.0 55.0
Med Small bowel resection (malignant) 3620 56.8 20.4 97.1 85.2 42.1 57.9
Med Ileocecal resection (malignant) 15 488 46.2 33.6 96.1 86.0 37.3 62.7
Med Partial colectomy and sigmoid colectomy (malignant) 30 536 57.2 24.9 96.3 87.1 46.8 53.2
Med Right hemicolectomy 22 027 51.0 33.9 95.8 85.3 44.1 55.9
Med Left hemicolectomy 6018 57.6 24.9 95.9 85.9 49.2 50.8
Med Total colectomy 1546 58.2 21.8 96.2 84.0 49.9 50.1
Med Intestinal obstruction surgery (with enterectomy) 26 275 49.2 37.9 94.4 76.6 33.8 66.2
Med Enterostomy and closure (with enterectomy) 23 231 62.9 18.5 95.9 82.7 42.2 57.8
High Proctocolectomy and ileoanal (canal) anastomosis 440 61.8 1.4 99.3 95.7 77.0 23.0
Rectum Low Transanal rectal tumor resection 3527 49.6 12.6 39.1 56.9 36.1 63.9
Low Proctocele surgery (transanal) 2396 14.2 66.0 55.9 63.1 37.9 62.1
Med Abdominoperineal resection (benign) 1056 59.8 21.2 93.7 82.1 48.3 51.7
Med High anterior resection 11 841 58.1 18.3 96.7 89.1 54.3 45.7
Med Hartmann's procedure 6408 55.9 38.5 96.3 83.1 39.4 60.6
Med Proctocele surgery (abdominoperineal) 2198 10.7 58.9 91.9 83.9 51.5 48.5
Med Malignant anorectal tumor excision (transanal) 706 52.5 30.3 80.0 79.7 56.1 43.9
Med Anal sphincteroplasty (by tissue replacement) 2603 54.9 11.6 23.3 53.7 37.2 62.8
High Abdominoperineal resection (malignant) 4909 63.5 21.3 96.7 91.2 66.1 33.9
High Low anterior resection 20 403 62.8 14.1 96.3 90.7 65.9 34.1
High Total pelvic exenteration 454 71.8 4.8 98.5 92.7 73.6 26.4
High Anorectal malignant tumor excision (posterior approach) 35 54.3 20.0 80.0 88.6 48.6 51.4
Liver Low Hepatorrhaphy 63 55.6 27.0 87.3 69.8 27.0 73.0
Low Liver abscess drainage (excluding percutaneous procedures) 40 67.5 27.5 85.0 95.0 45.0 55.0
Low Hepatic cyst resection, suture, drainage 966 24.0 18.5 97.0 88.5 43.7 56.3
Low Liver biopsy (excluding percutaneous procedures) 351 49.0 2.6 91.2 88.0 39.0 61.0
Low Liver coagulo‐necrotic therapy (excluding percutaneous procedures) 439 72.9 19.1 98.4 92.9 66.3 33.7
Med Partial hepatectomy 12 492 66.7 15.7 98.0 95.7 69.5 30.5
Med Lateral segmentectomy 1382 65.9 20.3 97.7 94.9 64.5 35.5
Med Esophageal and gastric varix surgery 50 62.0 10.0 62.0 40.0 32.0 68.0
High Surgery for hepatic trauma (excluding drainage only) 394 67.3 19.3 75.1 58.6 27.4 72.6
High Hepatectomy (segmentectomy or more; excluding lateral segmentectomy) 6491 67.8 15.4 98.2 97.6 80.2 19.8
High Subsegmentectomy 2656 70.8 16.8 97.3 97.0 79.0 21.0
High Liver transplantation 791 51.2 0.3 99.1 98.9 77.2 22.8
High Hepatopancreatoduodenectomy 135 67.4 5.2 96.3 99.3 88.9 11.1
Gall bladder Low Cholangiotomy 63 57.1 33.3 98.4 90.5 47.6 52.4
Low Cholecystolithotomy 64 62.5 37.5 92.2 84.4 45.3 54.7
Low Cholecystectomy 129 693 55.0 17.7 95.0 80.0 34.9 65.1
Low External cholecystostomy 139 60.4 47.5 63.3 65.5 36.0 64.0
Low Cystoenteric anastomosis 36 52.8 52.8 97.2 86.1 55.6 44.4
Med Choledocholithotomy 2015 60.4 38.5 94.1 85.5 48.2 51.8
Med Biliary tract reconstruction 295 57.6 20.3 96.9 96.3 70.2 29.8
Med Biliary bypass 967 125.9 26.8 97.2 94.1 57.5 42.5
Med Cholangioplasty 96 #REF! 21.9 92.7 91.7 63.5 36.5
Med Duodenal papilloplasty 29 58.6 27.6 82.8 93.1 72.4 27.6
Med Choledocal dilatation 278 25.9 2.2 97.8 91.0 66.2 33.8
Med Biliary fistula closure 16 50.0 43.8 93.8 87.5 31.3 68.8
High Surgery for bile duct trauma (excluding drainage only) 235 58.7 25.5 95.7 90.2 53.6 46.4
High Malignant gallbladder tumor surgery (excluding simple cholecystectomy) 1039 51.9 23.1 98.5 94.9 61.2 38.8
High Malignant bile duct tumor surgery 1108 69.4 23.1 96.9 97.3 81.3 18.7
High Biliary atresia surgery 38 39.5 0.0 100.0 50.0 21.1 78.9
Pancreas Low External pancreatic cyst drainage 4 100.0 0.0 100.0 25.0 25.0 75.0
Low External pancreatic duct drainage 19 73.7 10.5 73.7 78.9 73.7 26.3
Med Pancreatorrhaphy 4 100.0 25.0 100.0 75.0 75.0 25.0
Med Partial pancreatic resection 145 46.9 5.5 98.6 95.2 77.2 22.8
Med Distal pancreatectomy (benign) 1422 46.8 9.1 97.3 94.4 74.0 26.0
Med Pancreatic cyst‐enterostomy 20 70.0 15.0 95.0 85.0 55.0 45.0
Med Pancreatic (duct) enterostomy 280 70.4 8.2 94.6 97.5 69.3 30.7
Med Acute pancreatitis surgery 50 64.0 8.0 94.0 80.0 54.0 46.0
Med Pancreatolithiasis surgery 14 78.6 7.1 100.0 85.7 71.4 28.6
Med Plexus pancreaticus capitalis resection 0 ‐ ‐ ‐ ‐ ‐ ‐
High Surgery for pancreatic trauma (excluding drainage only) 59 69.5 13.6 93.2 74.6 50.8 49.2
High Pancreaticoduodenectomy 11 764 60.2 16.7 98.1 97.4 75.5 24.5
High Distal pancreatectomy (malignant) 5091 55.6 17.8 97.8 96.5 75.3 24.7
High Total pancreatectomy 635 54.3 12.1 98.7 98.7 81.3 18.7
High Duodenum preserving pancreas head resection 38 47.4 5.3 97.4 89.5 60.5 39.5
High Segmental pancreatic resection 153 50.3 5.2 98.7 99.3 76.5 23.5
High Pancreas transplantation 23 60.9 0.0 100.0 100.0 95.7 4.3
Spleen Low Splenorrhaphy 24 62.5 16.7 91.7 66.7 25.0 75.0
Med Splenectomy 1789 55.9 12.7 96.4 91.2 61.3 38.7
Med Partial splenectomy 20 45.0 10.0 95.0 45.0 20.0 80.0
Other Low Localized intra‐abdominal abscess surgery 2243 60.5 17.9 92.0 75.8 34.5 65.5
Low Exploratory laparotomy 13 325 60.6 18.6 94.8 82.5 42.8 57.2
Med Acute diffuse peritonitis surgery 15 776 58.8 28.0 95.1 80.3 34.4 65.6
Med Ventral hernia surgery 14 399 46.5 21.1 94.4 74.4 37.4 62.6
Med Diaphragm suture 285 56.5 22.1 96.8 83.2 51.6 48.4
Med Esophageal hiatus hernia surgery 1231 31.0 41.0 96.2 89.7 61.7 38.3
Med Retroperitoneal tumor surgery 1425 49.0 9.9 97.4 88.8 60.3 39.7
Med Abdominal wall/mesenteric/omental tumor resection 2085 50.3 10.2 96.5 82.4 46.8 53.2
Med Gastrointestinal perforation closure 391 65.7 26.3 92.8 80.3 38.1 61.9
High Diaphragmatic hiatus hernia surgery 56 57.1 23.2 96.4 92.9 55.4 44.6
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The short‐term outcomes of the operative procedures outlined in the “Training Curriculum for Board‐Certified Surgeons in Gastroenterology” in 2021 are presented in Table 2. Among the procedures performed in more than 100 cases annually, those with high surgical mortality rates (>10%) included surgery for hepatic trauma (excluding drainage only) (26.6%), closure of gastrointestinal perforations (16.2%), surgery for acute diffuse peritonitis (11.5%), esophageal bypass (11.1%), esophageal fistula construction (10.8%), and external cholecystostomy (10.1%). These procedures predominantly involved emergency surgeries, and a high proportion of patients experienced palliative or symptomatic relief.

TABLE 2.

Number of surgeries and short‐term outcome of each operative procedure of the “Training Curriculum for Board‐Certified Surgeons in Gastroenterology” in 2021.

Organ Difficulty level Operative procedure No. of surgeries Endoscopic surgeries (%) Emergency surgeries (%) Postoperative complications (%) a Re‐operations (%) Postoperative 30‐day mortalities (%) Operative mortalities (%) b
Esophagus Low Cervical periesophageal abscess drainage 32 21.9 59.4 28.1 9.4 3.1 3.1
Med Esophageal suture (perforation, injury) 183 19.1 74.9 36.6 13.7 3.3 4.9
Med Thoracic periesophageal abscess drainage 23 17.4 91.3 21.7 30.4 4.3 8.7
Med Esophageal foreign body extraction 27 22.2 88.9 22.2 0.0 0.0 3.7
Med Esophageal diverticulum resection 41 34.1 0.0 12.2 4.9 0.0 0.0
Med Benign esophageal tumor removal 70 81.4 0.0 0.0 2.9 0.0 0.0
Med Esophageal resection (removal only) 606 63.5 8.7 20.1 16.5 1.5 3.8
Med Esophageal reconstruction (gastric tube reconstruction) 516 71.7 1.2 21.5 5.0 1.0 3.1
Med Esophageal fistula construction 186 49.5 26.9 39.8 31.2 2.2 10.8
Med Esophagocardioplasty 305 76.7 2.6 4.6 2.0 1.0 1.0
Med Achalasia surgery 189 91.5 0.0 0.0 0.0 0.0 0.0
High Esophagectomy 6193 74.8 0.9 23.0 5.7 0.7 1.4
High Esophageal reconstruction (colon reconstruction) 36 55.6 0.0 25.0 16.7 2.8 2.8
High Esophageal bypass 117 12.0 2.6 32.5 9.4 6.0 11.1
High Bronchoesophageal fistula surgery 7 14.3 14.3 57.1 14.3 0.0 0.0
High Secondary esophageal reconstruction 374 15.2 2.1 32.9 10.4 0.8 2.4
Stomach and duodenum Low Gastrostomy and suture gastrorrhaphy 64 14.1 62.5 10.9 3.1 0.0 0.0
Low Diverticulectomy, polypectomy (excluding endoscopic resection) 128 16.4 23.4 13.3 5.5 1.6 2.3
Low Truncal vagotomy 0 ‐ ‐ ‐ ‐ ‐ ‐
Low Gastroenterostomy (including duodenal jejunostomy) 5944 33.6 9.7 15.1 5.2 5.0 8.5
Low Gastric fistula construction (excluding PEG) 1460 15.4 16.5 20.5 4.7 6.3 9.8
Low Gastric pyloroplasty 106 17.0 43.4 4.7 5.7 0.9 0.9
Low Gastric volvulus surgery and rectopexy 64 71.9 20.3 14.1 4.7 1.6 1.6
Low Gastric suture (including gastric suture for gastric rupture, suture closure for gastroduodenal perforation, omental implantation and omental transposition) 5327 38.6 91.5 17.7 5.7 5.7 7.5
Low Local gastrectomy (including wedge resection) 4878 71.3 3.1 3.1 1.4 0.3 0.5
Med Gastrectomy (including distal, pylorus preserving and segmental) 28 771 56.3 1.8 7.5 2.5 0.7 1.1
Med Selective vagotomy 3 66.7 0.0 0.0 0.0 0.0 0.0
High Total gastrectomy (including proximal gastrectomy) 10 010 33.8 1.9 12.5 3.9 1.3 2.2
High Left upper abdominal exenteration 4 0.0 0.0 75.0 25.0 0.0 0.0
Small intestine and colon Low Enterotomy and enterorrhaphy 4268 18.6 29.7 17.0 7.7 4.5 7.5
Low Disinvagination (invasive) 152 29.6 80.3 5.3 2.0 2.6 3.3
Low Partial small bowel resection (benign) 9017 21.1 62.5 20.4 10.4 6.7 9.1
Low Ileocecal resection (benign) 4970 44.7 49.1 10.3 4.1 2.2 3.0
Low Partial colectomy and sigmoid colectomy (benign) 8536 35.6 45.3 15.5 6.3 4.1 5.6
Low Appendectomy 56 071 73.9 67.6 1.8 1.0 0.1 0.2
Low Enterostomy and closure (without enterectomy) 28 205 40.7 28.4 16.0 7.6 3.5 5.7
Med Small bowel resection (malignant) 3620 32.2 17.4 12.1 4.8 2.8 4.2
Med Ileocecal resection (malignant) 15 488 65.2 5.7 4.9 2.2 0.6 0.9
Med Partial colectomy and sigmoid colectomy (malignant) 30 536 64.8 3.6 6.3 3.6 0.5 0.9
Med Right hemicolectomy 22 027 56.9 8.2 7.4 3.4 1.4 2.1
Med Left hemicolectomy 6018 56.1 9.2 10.1 4.8 2.0 2.9
Med Total colectomy 1546 33.1 33.4 23.9 9.5 7.9 9.8
Med Intestinal obstruction surgery (with enterectomy) 26 275 25.7 68.3 10.2 4.4 2.4 3.4
Med Enterostomy and closure (with enterectomy) 23 231 19.4 21.2 13.6 5.3 3.2 4.5
High Proctocolectomy and ileoanal (canal) anastomosis 440 52.7 7.7 10.5 4.3 0.9 1.1
Rectum Low Transanal rectal tumor resection 3527 2.4 1.4 0.7 0.8 0.1 0.1
Low Proctocele surgery (transanal) 2396 0.8 1.3 1.9 2.5 0.2 0.2
Med Abdominoperineal resection (benign) 1056 13.1 19.3 18.4 6.6 2.5 3.8
Med High anterior resection 11 841 74.9 3.4 5.6 3.5 0.4 0.6
Med Hartmann's procedure 6408 23.3 58.6 20.8 6.0 5.6 7.5
Med Proctocele surgery (abdominoperineal) 2198 58.6 0.7 2.2 1.6 0.2 0.4
Med Malignant anorectal tumor excision (transanal) 706 19.5 7.4 7.2 3.8 1.0 1.4
Med Anal sphincteroplasty (by tissue replacement) 2603 1.8 2.2 0.8 1.2 0.0 0.1
High Abdominoperineal resection (malignant) 4909 73.9 0.8 12.3 4.7 0.6 0.8
High Low anterior resection 20 403 75.3 1.3 10.4 6.1 0.5 0.6
High Total pelvic exenteration 454 33.0 1.5 32.4 8.8 0.9 1.8
High Anorectal malignant tumor excision (posterior approach) 35 14.3 0.0 11.4 5.7 0.0 0.0
Liver Low Hepatorrhaphy 63 11.1 85.7 34.9 23.8 11.1 12.7
Low Liver abscess drainage (excluding percutaneous procedures) 40 32.5 42.5 20.0 2.5 5.0 5.0
Low Hepatic cyst resection, suture, drainage 966 79.3 5.5 2.8 1.2 0.2 0.2
Low Liver biopsy (excluding percutaneous procedures) 351 13.7 26.2 4.0 7.4 0.6 1.4
Low Liver coagulo‐necrotic therapy (excluding percutaneous procedures) 439 33.5 0.5 3.4 2.1 0.2 0.9
Med Partial hepatectomy 12 492 43.9 0.7 6.4 1.9 0.4 0.5
Med Lateral segmentectomy 1382 41.6 1.5 5.2 2.1 0.4 0.7
Med Esophageal and gastric varix surgery 50 48.0 20.0 6.0 14.0 2.0 2.0
High Surgery for hepatic trauma (excluding drainage only) 394 5.3 82.0 48.5 49.0 22.8 26.6
High Hepatectomy (segmentectomy or more; excluding lateral segmentectomy) 6491 17.7 0.5 15.1 2.5 1.3 2.1
High Subsegmentectomy 2656 34.4 0.3 7.4 1.3 0.3 0.4
High Liver transplantation 791 0.6 10.1 23.1 12.6 2.1 3.5
High Hepatopancreatoduodenectomy 135 0.0 0.7 51.1 8.9 4.4 8.9
Gall bladder Low Cholangiotomy 63 11.1 22.2 15.9 3.2 1.6 1.6
Low Cholecystolithotomy 64 28.1 15.6 10.9 4.7 0.0 0.0
Low Cholecystectomy 129 693 72.9 16.3 3.6 1.1 0.4 0.6
Low External cholecystostomy 139 28.8 51.8 24.5 14.4 4.3 10.1
Low Cystoenteric anastomosis 36 11.1 5.6 22.2 5.6 5.6 11.1
Med Choledocholithotomy 2015 34.9 14.0 9.1 0.1 1.2 1.9
Med Biliary tract reconstruction 295 5.8 3.1 20.7 4.7 1.7 3.1
Med Biliary bypass 967 4.9 10.9 16.9 5.2 2.0 3.4
Med Cholangioplasty 96 12.5 18.8 25.0 2.1 2.1 2.1
Med Duodenal papilloplasty 29 13.8 3.4 10.3 10.3 3.4 3.4
Med Choledocal dilatation 278 26.3 1.8 9.0 3.2 0.4 0.4
Med Biliary fistula closure 16 31.3 43.8 31.3 12.5 6.3 18.8
High Surgery for bile duct trauma (excluding drainage only) 235 22.1 52.8 27.2 11.1 5.1 6.8
High Malignant gallbladder tumor surgery (excluding simple cholecystectomy) 1039 7.6 0.7 11.8 1.8 0.3 0.5
High Malignant bile duct tumor surgery 1108 0.8 0.5 33.6 5.6 3.2 5.7
High Biliary atresia surgery 38 47.4 28.9 21.1 10.5 0.0 0.0
Pancreas Low External pancreatic cyst drainage 4 0.0 25.0 0.0 25.0 0.0 0.0
Low External pancreatic duct drainage 19 0.0 63.2 57.9 31.6 5.3 21.1
Med Pancreatorrhaphy 4 0.0 100.0 75.0 25.0 0.0 25.0
Med Partial pancreatic resection 145 35.9 0.7 16.6 2.1 0.0 0.7
Med Distal pancreatectomy (benign) 1422 52.3 4.1 16.8 2.3 0.7 0.9
Med Pancreatic cyst‐enterostomy 20 5.0 10.0 25.0 5.0 10.0 10.0
Med Pancreatic (duct) enterostomy 280 0.0 7.5 18.6 4.6 2.1 3.6
Med Acute pancreatitis surgery 50 16.0 58.0 52.0 14.0 6.0 16.0
Med Pancreatolithiasis surgery 14 0.0 0.0 0.0 0.0 0.0 0.0
Med Plexus pancreaticus capitalis resection 0 ‐ ‐ ‐ ‐ ‐ ‐
High Surgery for pancreatic trauma (excluding drainage only) 59 5.1 78.0 44.1 25.4 8.5 13.6
High Pancreaticoduodenectomy 11 764 5.2 0.7 24.1 3.3 0.9 1.6
High Distal pancreatectomy (malignant) 5091 33.4 0.8 20.0 2.1 0.3 0.7
High Total pancreatectomy 635 1.9 3.5 15.7 4.6 1.9 3.0
High Duodenum preserving pancreas head resection 38 0.0 0.0 26.3 2.6 2.6 5.3
High Segmental pancreatic resection 153 8.5 1.3 34.0 2.0 0.7 0.7
High Pancreas transplantation 23 0.0 73.9 34.8 43.5 0.0 4.3
Spleen Low Splenorrhaphy 24 16.7 87.5 29.2 29.2 8.3 8.3
Med Splenectomy 1789 29.9 1.2 14.6 5.5 2.6 3.7
Med Partial splenectomy 20 35.0 20.0 10.0 15.0 0.0 0.0
Other Low Localized intra‐abdominal abscess surgery 2376 32.7 70.5 14.6 6.6 2.2 3.2
Low Exploratory laparotomy 12 401 49.3 30.3 16.8 13.2 6.2 9.0
Med Acute diffuse peritonitis surgery 15 542 22.1 92.6 27.3 7.8 8.0 11.5
Med Ventral hernia surgery 14 136 32.0 11.4 3.9 2.0 0.6 0.9
Med Diaphragm suture 294 34.0 40.5 19.7 9.5 4.4 6.5
Med Esophageal hiatus hernia surgery 1217 62.8 7.9 8.0 4.1 1.4 2.2
Med Retroperitoneal tumor surgery 1551 10.9 2.1 9.2 3.5 0.3 0.5
Med Abdominal wall/mesenteric/omental tumor resection 2054 31.3 15.3 7.7 4.3 0.9 1.9
Med Gastrointestinal perforation closure 421 11.9 90.5 35.4 14.0 11.6 16.2
High Diaphragmatic hiatus hernia surgery 56 37.5 42.9 12.5 3.6 10.7 12.5
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a

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

b

Operative mortality was a rate that combined 30‐day mortality and hospitalization death in 31–90 days after surgery.

3.2. Annual trends in organ‐specific surgical procedures

Figure 1 illustrates the trends in the number of gastroenterological surgeries and key outcomes in Japan from 2012 to 2021. Long‐term trends indicate an increasing trend in the number of surgeries for five regions: the small intestine and colon, rectum and anus, gallbladder, pancreas, and the “others” classification. Conversely, the number of surgeries for the esophagus and liver remained stable, while those for the stomach and duodenum, and spleen showed decreasing trends. Notably, from a short‐term perspective, there was a decrease in the number of surgeries across all areas in 2020; however, the numbers rebounded, except for that of surgeries for the stomach and duodenum, liver, and spleen.

FIGURE 1.

FIGURE 1

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Annual changes in the number of surgeries, 30‐day and operative mortality rates, and complication rates of each organ. †Postoperative complication was defined as grades IIIa–V in the Clavien–Dindo classification.

Table 3 summarizes the sex ratio and age distribution by organ in surgeries performed over a decade. The proportion of female patients increased in all organs, with the most significant increases observed in the spleen, esophagus, stomach, and duodenum. Across all organs, there has been an increase in the proportion of patients aged ≥70 years, particularly those >80 years. Conversely, the proportion of patients <60 years of age generally decreased, except for surgeries for the rectum and anus, wherein the proportion slightly increased.

TABLE 3.

Annual changes in surgeries of each organ by sex and age of patients.

Organ Year No. of surgeries Sex (%) Age (%)
Male Female <60 60 to 64 65–69 70–74 75–79 ≥80
Esophagus 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
2020 8713 79.0 21.0 18.4 13.5 18.3 23.5 16.5 9.8
2021 8905 78.0 22.0 19.0 12.5 17.8 24.4 16.5 9.8
Stomach and duodenum 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
2020 57 171 66.6 33.4 15.3 8.2 13.8 20.1 18.5 24.1
2021 56 759 65.9 34.1 15.7 7.7 12.6 20.9 18.1 25.0
Small intestine and colon 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
2020 238 631 56.2 43.8 32.6 7.3 10.7 14.6 13.4 21.5
2021 240 448 56.0 44.0 31.9 7.3 10.3 15.5 12.7 22.3
Rectum and anus 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
2020 55 536 56.2 43.8 22.7 9.2 13.7 17.6 14.7 22.1
2021 56 536 55.7 44.3 23.1 9.0 12.8 18.7 14.1 22.3
Liver 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
2020 26 614 66.0 34.0 20.6 9.5 15.1 21.7 18.7 14.4
2021 26 250 65.2 34.8 20.8 9.9 14.1 22.4 17.3 15.5
Gall bladder 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
2020 134 332 55.9 44.1 31.3 9.1 12.2 15.6 14.0 17.8
2021 136 111 55.2 44.8 31.7 9.1 11.5 16.6 13.0 18.2
Pancreas 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
2020 19 947 58.1 41.9 16.7 8.4 14.6 22.8 21.9 15.6
2021 19 722 57.9 42.1 17.0 8.4 13.7 24.2 20.8 15.9
Spleen 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
2020 2096 54.4 45.6 32.8 11.4 12.6 16.7 14.1 12.4
2021 1833 55.9 44.1 32.0 9.8 13.4 17.5 14.7 12.7
Others 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
2020 50 048 54.5 45.5 27.2 7.9 11.9 16.0 14.9 22.1
2021 51 216 54.6 45.4 27.6 7.8 11.3 17.1 14.0 22.2
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Table 4 compiles the data on the institutions where surgeries were performed and the participation rates of anesthesiologists and board‐certified surgeons. Long‐term trends indicate that surgeries for all organs are increasingly being performed at certified or affiliated institutions. However, in 2021, there was a slight decrease in the number of spleen and liver surgeries performed at these institutions. The participation rates of anesthesiologists and board‐certified surgeons in surgery increased annually across all areas. Notably, the participation rate of anesthesiologists in rectal and anal surgeries was approximately 87%, which was approximately 10% lower than that in other areas. Furthermore, the involvement of board‐certified surgeons in surgeries of the esophagus, liver, and pancreas is exceptionally high, exceeding 95%.

TABLE 4.

Annual changes in surgeries of each organ by institution type and specialist participation rate.

Organ Year No. of surgeries Institution type (%) Anesthesiologist participation (%) Board‐certified surgeon participation (%) Operating surgeon (%)
Certified institution Affiliated institution Others Board‐certified surgeon Non‐board‐ certified surgeon
Esophagus 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
2020 8713 95.2 3.2 1.5 98.9 95.7 78.3 21.7
2021 8905 95.9 2.7 1.4 98.7 96.0 79.2 20.8
Stomach and duodenum 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
2020 57 171 80.8 14.8 4.4 95.7 85.4 47.6 52.4
2021 56 759 81.3 14.2 4.4 96.2 88.1 51.1 48.9
Small intestine and colon 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
2020 238 631 76.5 17.9 5.6 94.5 75.9 34.2 65.8
2021 240 448 77.5 16.9 5.6 95.1 79.5 37.6 62.4
Rectum and anus 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
2020 55 536 74.5 18.6 6.8 86.7 81.7 51.0 49.0
2021 56 536 75.8 17.6 6.6 87.4 84.0 55.2 44.8
Liver 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
2020 26 614 89.6 7.2 3.1 97.4 94.7 67.7 32.3
2021 26 250 90.6 6.1 3.3 97.4 95.2 70.9 29.1
Gall bladder 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
2020 134 332 72.9 20.2 6.9 94.8 77.7 33.8 66.2
2021 136 111 73.4 19.7 6.9 95.1 80.5 36.1 63.9
Pancreas 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
2020 19 947 91.9 6.3 1.8 97.6 95.7 70.4 29.6
2021 19 722 92.8 5.4 1.8 97.9 96.8 75.3 24.7
Spleen 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
2020 2096 88.6 9.2 2.2 96.5 88.3 55.7 44.3
2021 1833 88.3 8.8 2.8 96.3 90.3 60.3 39.7
Others 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
2020 50 048 80.4 14.7 4.9 94.3 76.1 37.0 63.0
2021 51 216 82.1 13.4 4.5 94.9 79.6 39.5 60.5
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Table 5 presents the temporal changes in the complication and mortality rates. Operative mortality decreased across all areas compared to a decade ago, with the most significant reductions observed in surgeries involving the pancreas (−46.4%), esophagus (−41.7%), and liver (−34.8%). However, the surgical complications slowly increased or remained stable. A modest decline was observed after experiencing minor peaks over the past 2–3 years.

TABLE 5.

Annual changes in surgeries of each organ by complication and mortality rates.

Organ Year No. of surgeries No. of postoperative complications (%) a No. of postoperative 30‐day mortalities (%) No. of operative mortalities (%) b
Esophagus 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)
2020 8713 1963 (22.5) 95 (1.1) 212 (2.4)
2021 8905 2011 (22.6) 84 (0.9) 183 (2.1)
Stomach and duodenum 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)
2020 57 171 5849 (10.2) 977 (1.7) 1679 (2.9)
2021 56 759 5741 (10.1) 1047 (1.8) 1612 (2.8)
Small intestine and colon 2012 184 810 15 395 (8.3) 3564 (1.9) 6583 (3.6)
2013 198 677 16 709 (8.4) 3723 (1.9) 6803 (3.4)
2014 206 857 17 776 (8.6) 3822 (1.9) 6961 (3.4)
2015 214 453 18 372 (8.6) 4019 (1.9) 7092 (3.3)
2016 218 228 19 020 (8.7) 3933 (1.8) 6621 (3.0)
2017 235 359 21 854 (9.3) 4588 (1.9) 7118 (3.0)
2018 236 496 21 881 (9.3) 4452 (1.9) 7116 (3.0)
2019 239 612 22 061 (9.2) 4671 (1.9) 7298 (3.0)
2020 238 631 22 344 (9.4) 4791 (2.0) 7261 (3.0)
2021 240 448 21 581 (9.0) 4609 (1.9) 6730 (2.8)
Rectum and anus 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)
2020 55 536 5383 (9.7) 555 (1.0) 797 (1.4)
2021 56 536 5250 (9.3) 577 (1.0) 798 (1.4)
Liver 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)
2020 26 614 2804 (10.5) 338 (1.3) 475 (1.8)
2021 26 250 2573 (9.8) 271 (1.0) 390 (1.5)
Gall bladder 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)
2020 134 332 5888 (4.4) 620 (0.5) 978 (0.7)
2021 136 111 5702 (4.2) 612 (0.4) 930 (0.7)
Pancreas 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)
2020 19 947 4520 (22.7) 205 (1.0) 345 (1.7)
2021 19 722 4415 (22.4) 164 (0.8) 290 (1.5)
Spleen 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)
2020 2096 313 (14.9) 63 (3.0) 87 (4.2)
2021 1833 270 (14.7) 49 (2.7) 69 (3.8)
Others 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)
2020 50 048 7838 (15.7) 2267 (4.5) 3284 (6.6)
2021 51 216 7697 (15.0) 2293 (4.5) 3173 (6.2)
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a

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

b

Operative mortality was a rate that combined 30‐day mortality and hospitalization death in 31–90 days after surgery.

3.3. Endoscopic surgery rate in major surgical procedures

Figure 2 presents the trends in the endoscopic surgery rates across eight major surgical procedures. Within these procedures, established as benchmarks for improving surgical quality, the rates of endoscopic surgery have maintained their trend in recent years, still increasing by approximately 3% annually. Particularly, esophagectomy has exhibited the most significant increase in endoscopic surgery since 2016.

FIGURE 2.

FIGURE 2

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Annual changes in the rate of endoscopic surgery in the eight major surgical procedures. † including pylorus‐preserving gastrectomy and segmental gastrectomy, ‡ including proximal gastrectomy, § segmentectomy or more; excluding lateral segmentectomy.

3.4. Operative procedures with high rates of emergency surgeries

Table 6 lists the top 20 procedures with the highest rates of emergency surgery among those performed in more than 100 cases annually, out of 80 applicable procedures. The list predominantly includes procedures related to abdominal trauma, acute abdomen, and oncology emergencies. Compared to the remaining 60 procedures, these 20 procedures have a lower participation rate of board‐certified surgeons (median, 80.0% vs. 90.9%), and notably higher rates of postoperative complications (18.7% vs. 12.0%), re‐operations (7.8% vs. 3.9%), postoperative 30‐day mortalities (4.5% vs. 0.9%), and operative mortalities (7.2% vs. 1.4%).

TABLE 6.

Top 20 operative procedures with the highest rates of emergency surgery.

Order Organ/difficulty level Operative procedure No. of surgeries Emergency surgeries (%) Board‐certified surgeon participation (%) Postoperative complications (%) a Re‐operations (%) Postoperative 30‐day mortalities (%) Operative mortalities (%) b
1 Ot/med Acute diffuse peritonitis surgery 15 542 92.6 80.3 27.3 7.8 8.0 11.5
2 St/low Gastric suture c 5327 91.5 75.1 17.7 5.7 5.7 7.5
3 Ot/med Gastrointestinal perforation closure 421 90.5 80.3 35.4 14.0 11.6 16.2
4 Li/high Surgery for hepatic trauma d 394 82.0 58.6 48.5 49.0 22.8 26.6
5 In/low Disinvagination (invasive) 152 80.3 76.3 5.3 2.0 2.6 3.3
6 Es/med Esophageal suture (perforation, injury) 183 74.9 86.9 36.6 13.7 3.3 4.9
7 Ot/low Localized intra‐abdominal abscess surgery 2376 70.5 75.8 14.6 6.6 2.2 3.2
8 In/med Intestinal obstruction surgery (with enterectomy) 26 275 68.3 76.6 10.2 4.4 2.4 3.4
9 In/low Appendectomy 56 071 67.6 68.3 1.8 1.0 0.1 0.2
10 In/low Partial small bowel resection (benign) 9017 62.5 78.9 20.4 10.4 6.7 9.1
11 Re/med Hartmann's procedure 6408 58.6 83.1 20.8 6.0 5.6 7.5
12 Gb/high Surgery for bile duct trauma e 235 52.8 90.2 27.2 11.1 5.1 6.8
13 Gb/low External cholecystostomy 139 51.8 65.5 24.5 14.4 4.3 10.1
14 In/low Ileocecal resection (benign) 4970 49.1 79.0 10.3 4.1 2.2 3.0
15 In/low Partial colectomy and sigmoid colectomy (benign) 8536 45.3 80.8 15.5 6.3 4.1 5.6
16 St/low Gastric pyloroplasty 106 43.4 57.5 4.7 5.7 0.9 0.9
17 Ot/med Diaphragm suture 294 40.5 83.2 19.7 9.5 4.4 6.5
18 In/med Total colectomy 1546 33.4 84.0 23.9 9.5 7.9 9.8
19 Ot/low Exploratory laparotomy 12 401 30.3 82.5 16.8 13.2 6.2 9.0
20 In/low Enterotomy and enterorrhaphy 4268 29.7 78.9 17.0 7.7 4.5 7.5
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Abbreviations: Es, esophagus; Gb, gall bladder; In, small intestine and colon; Li, liver; Ot, others; Re, rectum; St, stomach and duodenum.

a

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

b

Operative mortality was a rate that combined 30‐day mortality and hospitalization death in 31 to 90 days after surgery.

c

Gastric suture includes gastric suture for gastric rupture, suture closure for gastroduodenal perforation, and omental implantation and omental transposition.

d

Surgery for hepatic trauma excludes drainage only.

e

Surgery for bile duct trauma excludes drainage only.

4. DISCUSSION

By comprehensively reviewing data from actual clinical practices in Japan registered in the NCD, this section addresses the following: the number of surgeries, patient demographics, surgical environments, endoscopic surgery, and surgical outcomes, particularly for the esophagus, liver, pancreas, and Acute Care Surgery (ACS), and highlights studies focusing on the gender of surgeons.

The impact of the coronavirus disease 2019 pandemic has led to a decrease in surgeries across all areas, 28 with an overall reduction of 2.7%. 26 However, the data suggest a return to the original trends by 2021. This result indicates that surgical care was gradually returning to normalcy as treatments and the healthcare system for the coronavirus disease 2019 were organized, clarifying appropriate measures for surgical patients. Upon closer examination, it appears that the increase in surgical procedures in the small intestine, colon, rectum and anus, gallbladder, pancreas, and others may be attributed to improved diagnostic capabilities for diseases and the growing older adult population. Conversely, the decrease in the number of stomach and duodenum, and spleen surgeries may be influenced by a reduction in disease incidence rates and the development of alternative treatment methods. 29 , 30

Consistent with earlier reports, there was a clear trend towards aging in patients undergoing surgery. Notably, there has been a significant increase in the proportion of patients ≥80 years, which is likely attributable to the rise in the aging population 31 and the extension of healthy life expectancy. 32 However, the proportion of patients <60 years undergoing surgery for rectal and anal issues has exhibited a slight increase, likely due to the westernization of diets, stress, and decreased physical activity, contributing to the incidence of rectal tumors. 33 While the proportion of male patients remained high in all areas, the last decade has generally demonstrated a shift towards an increasing ratio of female patients. This trend can be attributed to the growing aging population and the higher proportion of women in the older adult population. 31

The trend of surgeries being conducted in certified institutions under the management of anesthesiologists, with the involvement of board‐certified surgeons, is becoming consistently stronger despite some variations across different organs. Receiving surgical training in a well‐equipped environment is beneficial for trainee surgeons, and most importantly, maintaining a high surgical standard is advantageous and desirable for patients. 34

The trend of increasing endoscopic surgery is expected to persist in the foreseeable future. This trend has been significantly influenced by the widespread adoption of robotic surgery into daily practice, in addition to laparoscopic and thoracoscopic surgeries. As the advantages of robotic surgery become increasingly apparent, particularly in procedures where endoscopic surgery is relatively less common, the proportion of endoscopic surgeries is likely to further increase. Moreover, there is considerable anticipation regarding the performance and innovative features of surgical robots that will emerge in the future.

General trends in surgical outcomes remained consistent. The most significant observation was the uniform decline in operative mortality across all areas. There is substantial significance in maintaining these results as the number of surgeries and the proportion of older adult patients continue to increase. This reflects the tangible efforts of Japanese gastrointestinal surgeons to improve outcomes. However, an increase in complications, diverging from the trend in operative mortality, has been noted previously, making the control of complications an ongoing challenge.

We further focus on the surgical outcomes of two critical issues: the first concerns surgeries involving the esophagus, liver, and pancreas, and the second pertains to ACS. The esophagus, liver, and pancreas share the common outcome of substantial improvements in operative mortality in recent years. A distinguishing characteristic is the limited number of surgeries compared to other areas, with a relatively high proportion of these being high‐difficulty surgeries. However, what appears most crucial is the notably high participation rate of board‐certified surgeons, which can be interpreted as contributing to favorable outcomes. While the importance of board‐certified surgeons in surgeries has already been reported in some quarters, 35 , 36 the matter at hand involves devising ways to train more board‐certified surgeons and enhance their engagement across a broader range of organ specialties.

The second issue is how to improve ACS outcomes. The traditional pillars of ACS encompass trauma, emergency general surgery, and surgical critical care, 37 with surgical rescue being recently added to these core areas. 38 These are characterized by a lower participation rate of board‐certified surgeons compared to other procedures, as well as higher rates of complications, re‐operations, and notably worse morbidities. Unlike elective surgeries that pursue curative treatment from an anatomical perspective, the formulation of treatment strategies for time‐sensitive surgeries requires a different approach. Merely increasing the participation rate of board‐certified surgeons may not be sufficient to improve ACS outcomes significantly. To improve surgical outcomes for severe traumas, including hepatic trauma which exhibited the highest operative mortality in this data set, it may be necessary to establish specialized institutions, such as trauma centers and ACS centers, to a certain extent, and consolidate cases similar to practices in Western countries. 39

Enhancing the education of gastroenterological surgeons in the field of ACS and strengthening their collaboration with acute care surgeons could further accelerate the development of gastroenterological surgery. Notably, the Japanese ACS Society became an associate member of the NCD in 2021, suggesting the establishment of a cooperative environment in both clinical and research aspects.

Between 2013 and 2022, 98 research projects in the field of gastroenterological surgery that use big data from the NCD were approved and reported on a rolling basis in scholarly papers. Among them, 12 papers were published in 2022, covering topics such as high‐complexity esophageal 40 , 41 , 42 and pancreatic 43 , 44 cancer surgery, coronavirus disease 2019‐related issues, 45 , 46 and surgeon's sex‐related aspects, 47 , 48 which indicates a heightened interest in these areas.

Given that this is the first large‐scale study on the surgeon's sex in the field of gastroenterological surgery, an overview is provided here. One of the two studies compared the surgical experience available to surgeons of different sexes, while the other compared surgical outcomes based on the sex of gastroenterological surgeons. The first study found that female surgeons had less surgical experience than male surgeons in Japan, and this gap tended to widen with an increase in years of experience, especially for medium‐ and high‐difficulty procedures. 47 The second study found that female gastrointestinal surgeons were more frequently responsible for patients with comorbid conditions, although they performed fewer surgeries than their male counterparts. Despite these disadvantages, no significant differences were observed in the risk of surgical mortality between male and female surgeons. 48 Both studies yield important conclusions that suggest addressing these gender gaps could further advance the field of gastroenterological surgery.

In summary, we presented the short‐term outcomes of 2021 and the surgical trends of the decade based on the NCD, along with the latest research findings. It is evident that the NCD will continue to be a critical cornerstone for the future development of gastroenterological surgery.

AUTHOR CONTRIBUTIONS

Sunao Ito: Conceptualization; project administration; writing – original draft. Arata Takahashi: Data curation; investigation; methodology; resources; software. Hideki Ueno: Conceptualization; project administration; supervision; writing – review and editing. Shuji Takiguchi: Conceptualization; project administration; writing – original draft. Yoshiki Kajiwara: Conceptualization; data curation; formal analysis; project administration; writing – original draft; writing – review and editing. Yoshihiro Kakeji: Conceptualization; supervision; writing – review and editing. Susumu Eguchi: Conceptualization; supervision; writing – review and editing. Takanori Goi: Conceptualization; supervision; writing – review and editing. Akio Saiura: Conceptualization; supervision; writing – review and editing. Akira Sasaki: Conceptualization; supervision; writing – review and editing. Hiroya Takeuchi: Conceptualization; supervision; writing – review and editing. Chie Tanaka: Conceptualization; supervision; writing – review and editing. Masaji Hashimoto: Conceptualization; supervision; writing – review and editing. Naoki Hiki: Conceptualization; supervision; writing – review and editing. Akihiko Horiguchi: Conceptualization; supervision; writing – review and editing. Satoru Matsuda: Conceptualization; supervision; writing – review and editing. Tsunekazu Mizushima: Conceptualization; supervision; writing – review and editing. Hiroyuki Yamamoto: Conceptualization; data curation; formal analysis; investigation; methodology; resources; supervision; writing – review and editing. Yuko Kitagawa: Conceptualization; project administration; supervision; writing – review and editing. Ken Shirabe: Conceptualization; project administration; supervision; writing – review and editing.

CONFLICT OF INTEREST STATEMENT

Yuko Kitagawa is Editor‐in‐Chief and Hideki Ueno, Hiroya Takeuchi, Naoki Hiki, and Akihiko Horiguchi are Associate Editors of Annals of Gastroenterological Surgery. Shuji Takiguchi, Yoshihiro Kakeji, Susumu Eguchi, Takanori Goi, Akio Saiura, Chie Tanaka, Satoru Matsuda, Tsunekazu Mizushima, and Ken Shirabe are editorial board members of Annals of Gastroenterological Surgery. Arata Takahashi and Hiroyuki Yamamoto are affiliated with the Department of Healthcare Quality Assessment at the University of Tokyo that is a social collaboration department supported by grants from the National Clinical Database, Johnson & Johnson K.K., and Nipro Co and Intuitive Surgical Sàrl. Other authors have no conflicts of interest.

ETHICS STATEMENT

Approval of the research protocol by an Institutional Reviewer Board: N/A.

Informed Consent: N/A.

Registry and the Registration No. of the study/trial: N/A.

Animal Studies: N/A.

ACKNOWLEDGMENTS

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

Ito S, Takahashi A, Ueno H, Takiguchi S, Kajiwara Y, Kakeji Y, et al. Annual report on National Clinical Database 2021 for gastroenterological surgery in Japan. Ann Gastroenterol Surg. 2025;9:32–59. 10.1002/ags3.12868

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