Abstract
Purpose
This study examined nationwide data regarding laparoscopic and robotic surgery for colorectal cancer (CRC) in Korea.
Methods
Nationwide data concerning patients who underwent surgery for CRC from 2019 to 2023 were obtained from the Health Insurance Review and Assessment Service database.
Results
From 2019 to 2023, a total of 109,573 patients with CRC underwent surgical resection in Korea. Among these, open, laparoscopic, and robotic surgery comprised 17.2%, 71.5%, and 11.3%, respectively. Open surgery decreased from 18.3% in 2019 to 15.2% in 2023, whereas robotic surgery increased from 10.3% in 2019 to 12.7% in 2023. Regarding rectal cancer, the rate of robotic surgery increased from 23.0% in 2019 to 28.2% in 2023, and the rate of minimally invasive surgery (MIS) increased from 86.9% in 2019 to 89.2% in 2023. Patients with National Health Insurance had significantly shorter lengths of hospital stay after surgery than those with medical aid for all surgical methods (p < 0.0001). With respect to hospital size, 74,282 CRC surgeries (67.8%) were performed in tertiary general hospitals and 33,050 (30.2%) in general hospitals. By the region, 47,140 cases (43.0%) were performed in Seoul, 19,961 (18.2%) in Gyeonggi, and 7,417 (6.8%) in Daegu. Ostomy was created in 16,222 CRC surgeries (14.8%).
Conclusion
The rate of MIS adoption for CRC in Korea has increased, reaching 84.7% in 2023. The rate of laparoscopic surgery exceeded 70% and has plateaued. In contrast, the rate of robotic surgery adoption has steadily increased, particularly for rectal cancer, where it surpassed 28% in 2023.
Keywords: Colorectal surgery, Laparoscopy, Robotic surgical procedures, Big data, Korea
INTRODUCTION
Colorectal cancer (CRC) is one of the most common malignancies in Korea, with approximately 32,751 newly diagnosed cases in 2021 [1]. The crude incidence rate of CRC was 63.8 per 100,000 people (74.8 in males and 52.9 in females) in 2021 [1]. Similar to most cancers, CRC incidence increases with age, such that it was the most common cancer in women aged >75 years in 2021 [1]. The 5-year relative survival rate for CRC was 74.3% among patients diagnosed between 2017 and 2021 [1].
The laparoscopic approach has been established as the first-choice treatment for CRC, with oncologic outcomes equivalent to those of conventional open surgery [2,3]. Korea has experienced particularly rapid adoption of minimally invasive surgery (MIS) across various surgical fields [4]. Previous studies have demonstrated the successful implementation of laparoscopic surgery in Korea, where resection rates for CRC increased from 42.6% in 2008 to 64.9% in 2013 and 78.5% in 2018 [5,6]. Robotic surgery has emerged as an alternative minimally invasive approach, although its benefits for complex rectal procedures have not been fully established [7,8]. A recent nationwide study showed that the rate of robotic surgery adoption for intersphincteric resection substantially increased from < 5% in 2007 to >40% in 2014 [4]. However, because robotic surgery for CRC is not covered by health insurance in Korea, detailed nationwide data have not yet been reported.
The utilization patterns of surgical methods are expected to vary across regions and hospital settings. Additionally, an understanding of contemporary surgical trends and the identification of differences in MIS utilization based on population characteristics are crucial considerations for healthcare policy planning. This study aimed to analyze nationwide trends and regional variations in surgical approaches (open, laparoscopic, and robotic) for CRC in Korea from 2019 to 2023 using a comprehensive national database.
METHODS
Nationwide data for patients who were hospitalized and underwent surgical resection for CRC from 2019 to 2023 were requested and provided through the Health Insurance Review and Assessment Service (HIRA) (https://opendata.hira.or.kr, project number: M20241028001). Researchers with access rights can retrieve data from the HIRA database for a pre-approved period. Data are searched and analyzed using the statistical program specified in the data request. The dataset included the following information: year of surgical treatment, sex, age group (10-year intervals), main disease code, procedure fee code, number of procedures, date of procedures, type of surgery (open or laparoscopic), duration of hospital stay, type of hospital (tertiary general hospital, general hospital, hospital, or clinic), and hospital region.
As previously described [5,6], the following data collection criteria were used (Table 1): (1) Data were electronically extracted based on the day of surgical treatment covered by the National Health Insurance (NHI), Medical Aid Program (MAP), or Korean veterans’ benefits. (2) Surgical procedures included all colectomies, colorectal resections, abdominoperineal resections, and total proctocolectomies with or without lymph node dissection. The procedure fee codes searched were QA671–673, QA679, QA921–926, QA928, Q0292, Q1261–1262, Q2671–2673, Q2679, Q2921–2928, and Q0292. (3) CRC cases were classified according to the Korean Classification of Diseases and Related Health Problems, including colon cancers stratified by location, rectosigmoid junction cancer, and rectal cancer (corresponding disease codes: C18.0–18.9, C19, and C20, respectively). (4) Because robotic surgery is not covered by Korean health insurance, direct data collection was not possible. Therefore, robotic surgery was indirectly estimated using the following criteria: patients with a CRC diagnosis were presumed to have undergone robotic surgery if they (a) were hospitalized, and (b) had general anesthesia fees (L1211, L1212), (c) had histopathology examination fees for surgical resection of malignant tumor (C5605, C5606, C5607), and (d) lacked the surgical procedure fees listed above.
Table 1.
HIRA database search conditions
| Period | January 1, 2019 to December 31, 2023 |
|---|---|
| Patient | Medical inpatients |
| Health insurance | National Health Insurance, Medical Aid, Veterans’ benefits |
| Type of hospital | Tertiary general hospital, General hospital, Hospital, Clinic, Health care center |
| Location of hospital | All in Korea |
| Disease code | Main disease: C18, C19, C20 |
| Procedure code, operation | Hemicolectomy: QA671, Q2671 Subtotal colectomy: Q1261, Q1262 Total colectomy: QA672, Q2672 Segmental resection: QA673, Q2673 Hartmann procedure: QA679, Q2679 Anterior resection: QA921, Q2921 Low anterior resection: Q2927, QA922, Q2922 Intersphincteric resection: Q0292 Ultra low anterior resection: QA928, Q2928 Abdominoperineal resection: QA923, Q2923 Pull-through operation: QA924, Q2924 Total proctocolectomy with ileostomy: QA925, Q2925 Total proctocolectomy with IPAA: QA926, Q2926 |
| Laparoscopy material cost | N0031001 |
| Procedure code, anesthesia | L1211, L1212 |
| Procedure code, pathology | C5605, C5606, C5607 |
| Procedure code, ostomy | Q2791, Q2792, Q2793, Q2794 |
HIRA, Health Insurance Review and Assessment Service; IPAA, ileal pouch-anal anastomosis.
In this study, SAS version 9.4 (SAS Institute) was used for data search and analysis. Analysis of variance and the Bonferroni post hoc test were used to analyze statistical differences in the mean length of hospital stay after CRC surgery.
RESULTS
Among patients who were diagnosed with CRC and hospitalized from 2019 to 2023, 109,573 underwent colorectal resection surgery in Korea (Table 2). Of these, 78,349 (71.5%) underwent laparoscopic surgery and 12,367 (11.3%) underwent robotic surgery. Over the 5-year period, the number and proportion of open surgeries gradually decreased, laparoscopic surgery remained stable without substantial changes, and robotic surgery gradually increased. When tumor location was categorized as left colon, right colon, or rectum, the proportion of open surgery was highest in the right colon and lowest in the rectum. The proportion of robotic surgery was highest in the rectum. In 2020, the rate of open surgery temporarily increased, whereas the rates of laparoscopic and robotic surgery decreased before increasing again. According to tumor location, the proportion of rectal cancer surgeries was 28.2%, and the most frequently operated colon cancer sites were, in descending order, the sigmoid colon, ascending colon, and rectosigmoid colon (Table 3). The age and sex distributions of patients who underwent CRC surgery were examined (Table 4). In total, 64,954 CRC surgeries (59.3%) were performed in male patients and 44,619 were performed in female patients. The highest frequencies of CRC surgeries occurred in men in their 60s, and women in their 70s.
Table 2.
Annual number and proportion of surgery for colorectal cancer from 2019 to 2023 in Korea
| Location | Type of surgery | Year | Total | ||||
|---|---|---|---|---|---|---|---|
| 2019 | 2020 | 2021 | 2022 | 2023 | |||
| All of the colon and rectum | Open | 3,991 (18.3) | 3,984 (18.9) | 3,896 (17.0) | 3,715 (16.6) | 3,271 (15.2) | 18,857 (17.2) |
| Laparoscopic | 15,569 (71.3) | 14,901 (70.8) | 16,422 (71.7) | 16,003 (71.5) | 15,454 (72.0) | 78,349 (71.5) | |
| Robotic | 2,247 (10.3) | 2,149 (10.2) | 2,590 (11.3) | 2,652 (11.9) | 2,729 (12.7) | 12,367 (11.3) | |
| Total | 21,807 | 21,034 | 22,908 | 22,370 | 21,454 | 109,573 | |
| Right colona) | Open | 1,299 (21.9) | 1,364 (23.6) | 1,340 (21.0) | 1,309 (21.0) | 1,086 (18.1) | 6,398 (21.1) |
| Laparoscopic | 4,375 (73.9) | 4,196 (72.6) | 4,757 (74.5) | 4,641 (74.5) | 4,650 (77.4) | 22,619 (74.6) | |
| Robotic | 246 (4.2) | 222 (3.8) | 288 (4.5) | 279 (4.5) | 272 (4.5) | 1,307 (4.3) | |
| Total | 5,920 | 5,782 | 6,385 | 6,229 | 6,008 | 30,324 | |
| Left colonb) | Open | 1,611 (18.7) | 1,630 (19.3) | 1,538 (17.0) | 1,440 (16.4) | 1,305 (15.8) | 7,524 (17.4) |
| Laparoscopic | 6,509 (75.4) | 6,311 (74.7) | 6,911 (76.6) | 6,741 (76.9) | 6,309 (76.2) | 32,781 (76.0) | |
| Robotic | 508 (5.9) | 513 (6.1) | 576 (6.4) | 586 (6.7) | 668 (8.1) | 2,851 (6.7) | |
| Total | 8,628 | 8,454 | 9,025 | 8,767 | 8,282 | 43,156 | |
| Rectum | Open | 806 (13.2) | 767 (13.2) | 796 (12.3) | 752 (11.8) | 665 (10.8) | 3,786 (12.2) |
| Laparoscopic | 3,915 (63.9) | 3,739 (64.1) | 4,068 (63.0) | 3,881 (61.1) | 3,751 (61.0) | 19,354 (62.6) | |
| Robotic | 1,408 (23.0) | 1,323 (22.7) | 1,597 (24.7) | 1,717 (27.0) | 1,731 (28.2) | 7,776 (25.2) | |
| Total | 6,129 | 5,829 | 6,461 | 6,350 | 6,147 | 30,916 | |
Values are presented as number only or number (%).
Colons, of any site, overlapping lesions, and unspecified lesions were excluded from the right or left colon.
a)Includes cecum, appendix, ascending, hepatic flexure, and transverse colon. b)Includes splenic flexure, descending, sigmoid, and rectosigmoid colon.
Table 3.
Tumor locations and annual number of surgeries for colorectal cancer from 2019 to 2023 in Korea
| Location | Disease code | Year | Total | ||||
|---|---|---|---|---|---|---|---|
| 2019 | 2020 | 2021 | 2022 | 2023 | |||
| Colon, any site | C18 | 0 | 0 | 1 | 0 | 0 | 1 |
| Cecum | C18.0 | 708 | 803 | 858 | 901 | 898 | 4,168 |
| Appendix | C18.1 | 231 | 216 | 259 | 272 | 289 | 1,267 |
| Ascending colon | C18.2 | 3,219 | 3,067 | 3,389 | 3,242 | 2,988 | 15,905 |
| Hepatic flexure | C18.3 | 684 | 660 | 695 | 711 | 735 | 3,485 |
| Transverse colon | C18.4 | 1,078 | 1,036 | 1,184 | 1,103 | 1,098 | 5,499 |
| Splenic flexure | C18.5 | 192 | 168 | 185 | 192 | 200 | 937 |
| Descending colon | C18.6 | 764 | 821 | 791 | 771 | 732 | 3,879 |
| Sigmoid colon | C18.7 | 5,526 | 5,305 | 5,948 | 5,684 | 5,328 | 27,791 |
| Colon, overlapping lesion | C18.8 | 111 | 60 | 59 | 62 | 60 | 352 |
| Colon, unspecified | C18.9 | 1,029 | 909 | 977 | 962 | 957 | 4,834 |
| Rectosigmoid colon | C19 | 2,146 | 2,160 | 2,101 | 2,120 | 2,022 | 10,549 |
| Rectum | C20 | 6,129 | 5,829 | 6,461 | 6,350 | 6,147 | 30,916 |
| Total | 21,807 | 21,034 | 22,908 | 22,370 | 21,454 | 109,573 | |
Table 4.
Surgery for colorectal cancer by age and sex in Korea from 2019 to 2023
| Age (yr) | Male | Female | Total | |||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 2019 | 2020 | 2021 | 2022 | 2023 | Total | 2019 | 2020 | 2021 | 2022 | 2023 | Total | |||
| 10–19 | 5 | 5 | 5 | 4 | 3 | 22 | 0 | 2 | 1 | 4 | 2 | 9 | 31 | |
| 20–29 | 49 | 44 | 63 | 47 | 69 | 272 | 35 | 30 | 30 | 33 | 46 | 174 | 446 | |
| 30–39 | 208 | 238 | 204 | 236 | 214 | 1,100 | 196 | 184 | 196 | 183 | 173 | 932 | 2,032 | |
| 40–49 | 838 | 809 | 877 | 796 | 699 | 4,019 | 816 | 770 | 799 | 751 | 702 | 3,838 | 7,857 | |
| 50–59 | 2,878 | 2,766 | 2,749 | 2,614 | 2,576 | 13,583 | 1,714 | 1,683 | 1,765 | 1,701 | 1,707 | 8,570 | 22,153 | |
| 60–69 | 4,140 | 4,033 | 4,581 | 4,502 | 4,485 | 21,741 | 2,107 | 2,067 | 2,263 | 2,218 | 2,120 | 10,775 | 32,516 | |
| 70–79 | 3,395 | 3,216 | 3,453 | 3,450 | 3,122 | 16,636 | 2,464 | 2,214 | 2,413 | 2,304 | 2,092 | 11,487 | 28,123 | |
| 80–89 | 1,331 | 1,307 | 1,511 | 1,557 | 1,494 | 7,200 | 1457 | 1,458 | 1,751 | 1,747 | 1,700 | 8,113 | 15,313 | |
| ≥90 | 66 | 73 | 77 | 71 | 94 | 381 | 108 | 135 | 170 | 152 | 156 | 721 | 1,102 | |
| Total | 12,910 | 12,491 | 13,520 | 13,277 | 12,756 | 64,954 | 8,897 | 8,543 | 9,388 | 9,093 | 8,698 | 44,619 | 109,573 | |
The length of hospital stay after CRC surgery is shown (Table 5). The mean length of hospital stay after surgery over the 5-year period was 12.8 ± 7.8 days. Stratified by surgical approach, the mean lengths of hospital stay after open, laparoscopic, and robotic surgery during the study period were 15.4, 12.4, and 11.3 days, respectively. Open surgery resulted in a significantly longer hospital stay than the other two surgical approaches (vs. laparoscopy, p < 0.0001; vs. robotic surgery, p < 0.0001), and robotic surgery resulted in a significantly shorter hospital stay than laparoscopic surgery (p < 0.0001). These differences were maintained in year-by-year comparisons. Over the 5-year period, the length of stay after laparoscopic surgery remained stable, whereas the lengths of stay after open and robotic surgery tended to gradually decrease.
Table 5.
The length of hospital stay after CRC surgery from 2019 to 2023 in Korea
| Year | Length of hospital stay after surgery (day) | p-value | ||||||
|---|---|---|---|---|---|---|---|---|
| Open | Lap | Robot | Total | Open vs. Lap | Open vs. Robot | Lap vs. Robot | ||
| 2019 | 16.8 ± 10.2 | 12.6 ± 6.7 | 12.1 ± 7.9 | 13.3 ± 7.8 | <0.0001 | <0.0001 | 0.0047 | |
| 2020 | 15.8 ± 10.6 | 12.4 ± 6.5 | 12.0 ± 8.2 | 13.0 ± 7.8 | <0.0001 | <0.0001 | 0.0227 | |
| 2021 | 15.2 ± 11.5 | 12.4 ± 6.5 | 11.5 ± 7.8 | 12.8 ± 7.8 | <0.0001 | <0.0001 | <0.0001 | |
| 2022 | 14.0 ± 11.3 | 12.2 ± 6.5 | 10.8 ± 6.9 | 12.3 ± 7.6 | <0.0001 | <0.0001 | <0.0001 | |
| 2023 | 15.0 ± 12.3 | 12.3 ± 6.8 | 10.6 ± 6.4 | 12.5 ± 8.0 | <0.0001 | <0.0001 | <0.0001 | |
| Total | 15.4 ± 11.2 | 12.4 ± 6.6 | 11.3 ± 7.4 | 12.8 ± 7.8 | <0.0001 | <0.0001 | <0.0001 | |
Values are presented as mean ± standard deviation.
Open, open surgery; Lap, laparoscopic surgery; Robot, robotic surgery.
Surgical approaches according to the Korean healthcare system type are shown (Table 6). In total, 101,476 CRC surgeries (92.6%) were covered by the NHI. The rates of laparoscopic surgery among patients with NHI ranged from 71.1% to 72.1% over 5 years. The open surgery rate decreased, whereas the robotic surgery rate increased. The proportions of patients with MAP and veterans’ benefits were small (7.2% and 0.2%, respectively), making direct comparison difficult. However, the rates of surgeries among patients with MAP remained stable during the study period. Overall, among patients with NHI, the open surgery rate tended to be lower and the robotic surgery rate tended to be higher, compared with the other groups. The laparoscopic surgery rate remained similar regardless of medical insurance type. The lengths of hospital stay after surgery, stratified by medical insurance type are shown (Table 7). Among patients with NHI, the mean lengths of hospital stay were 15.1 days, 12.2 days, and 11.2 days for open, laparoscopic, and robotic surgery, respectively. These were significantly shorter than the lengths of stay among patients with MAP for all surgical approaches (p < 0.0001).
Table 6.
Surgical approach for colorectal cancer by type of healthcare system in Korea from 2019 to 2023
| Type of insurance | Type of surgery | Year | Total | ||||
|---|---|---|---|---|---|---|---|
| 2019 | 2020 | 2021 | 2022 | 2023 | |||
| National Health Insurance | Open | 3,633 (17.9) | 3,607 (18.5) | 3,519 (16.6) | 3,354 (16.2) | 2,916 (14.7) | 17,029 (16.8) |
| Laparoscopic | 14,470 (71.5) | 13,838 (71.1) | 15,239 (71.8) | 14,822 (71.5) | 14,281 (72.1) | 72,650 (71.6) | |
| Robotic | 2,140 (10.6) | 2,029 (10.4) | 2,477 (11.7) | 2,541 (12.3) | 2,610 (13.2) | 11,797 (11.6) | |
| Total | 20,243 | 19,474 | 21,235 | 20,717 | 19,807 | 101,476 | |
| Medical Aid Program | Open | 344 (22.8) | 359 (24.0) | 368 (22.6) | 353 (21.9) | 353 (21.6) | 1,777 (22.6) |
| Laparoscopic | 1,058 (70.2) | 1,021 (68.3) | 1,154 (70.9) | 1,147 (71.3) | 1,168 (71.4) | 5,548 (70.5) | |
| Robotic | 105 (7.0) | 115 (7.7) | 105 (6.5) | 109 (6.8) | 115 (7.0) | 549 (7.0) | |
| Total | 1,507 | 1,495 | 1,627 | 1,609 | 1,636 | 7,874 | |
| Veterans’ benefits | Open | 14 (24.6) | 18 (27.7) | 9 (19.6) | 8 (18.2) | 2 (18.2) | 51 (22.9) |
| Laparoscopic | 41 (71.9) | 42 (64.6) | 29 (63.0) | 34 (77.3) | 5 (45.5) | 151 (67.7) | |
| Robotic | 2 (3.5) | 5 (7.7) | 8 (17.4) | 2 (4.5) | 4 (36.4) | 21 (9.4) | |
| Total | 57 | 65 | 46 | 44 | 11 | 223 | |
| Total | 21,807 | 21,034 | 22,908 | 22,370 | 21,454 | 109,573 | |
Values are presented as number only or number (%).
Table 7.
The length of hospital stay (day) after CRC surgery by type of healthcare system in Korea from 2019 to 2023
| Type of surgery | Type of insurance | Year | p-valuea) | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| 2019 | 2020 | 2021 | 2022 | 2023 | Total | NHI vs. MAP | NHI vs. veterans | MAP vs. veterans | |||
| Open | NHI | 16.5 ± 9.9 | 15.5 ± 10.5 | 14.9 ± 11.4 | 13.8 ± 11.2 | 14.7 ± 12.1 | 15.1 ± 11.0 | <0.0001 | >0.9999 | 0.8566 | |
| MAP | 19.9 ± 12.4 | 18.7 ± 11.6 | 17.5 ± 11.9 | 16.0 ± 12.2 | 17.2 ± 13.7 | 17.9 ± 12.4 | |||||
| Veterans | 11.7 ± 8.0 | 16.4 ± 6.7 | 17.4 ± 8.5 | 19.8 ± 5.7 | 24.5 ± 7.8 | 16.2 ± 7.7 | |||||
| Total | 16.8 ± 10.2 | 15.8 ± 10.6 | 15.2 ± 11.5 | 14.0 ± 11.3 | 15.0 ± 12.3 | 15.3 ± 11.2 | |||||
| Laparoscopic | NHI | 12.4 ± 6.5 | 12.3 ± 6.4 | 12.2 ± 6.3 | 12.0 ± 6.3 | 12.1 ± 6.7 | 12.2 ± 6.4 | <0.0001 | <0.0001 | 0.8542 | |
| MAP | 15.5 ± 8.6 | 14.9 ± 8.0 | 14.9 ± 9.2 | 14.5 ± 8.9 | 14.5 ± 7.5 | 14.8 ± 8.5 | |||||
| Veterans | 15.2 ± 6.7 | 14.4 ± 5.1 | 15.3 ± 6.7 | 16.8 ± 6.7 | 16.8 ± 7.4 | 15.4 ± 6.3 | |||||
| Total | 12.6 ± 6.7 | 12.4 ± 6.5 | 12.4 ± 6.5 | 12.2 ± 6.5 | 12.3 ± 6.8 | 12.4 ± 6.6 | |||||
| Robotic | NHI | 11.9 ± 7.8 | 11.7 ± 7.5 | 11.3 ± 7.4 | 10.7 ± 6.8 | 10.5 ± 6.3 | 11.2 ± 7.1 | <0.0001 | 0.0353 | >0.9999 | |
| MAP | 14.8 ± 10.0 | 16.2 ± 16.5 | 15.6 ± 12.6 | 13.8 ± 8.3 | 13.3 ± 9.2 | 14.7 ± 11.8 | |||||
| Veterans | 16.0 ± 2.8 | 13.4 ± 6.2 | 17.4 ± 5.4 | 16.5 ± 6.4 | 12.3 ± 3.8 | 15.2 ± 5.2 | |||||
| Total | 12.1 ± 7.9 | 12.0 ± 8.2 | 11.5 ± 7.8 | 10.8 ± 6.9 | 10.6 ± 6.4 | 11.3 ± 7.4 | |||||
Values are presented as mean ± standard deviation.
NHI, National Health Insurance; MAP, Medical Aid Program; Veterans, Veterans’ benefits.
a)Obtained by comparing the mean lengths of stay in the total column.
The numbers of surgeries for CRC according to hospital size are shown (Table 8). Overall, 74,282 CRC surgeries (67.8%) were performed in tertiary general hospitals, and 33,050 (30.2%) were performed in general hospitals. The number of CRC surgeries performed in hospitals (with 30 to 100 beds) gradually decreased over the 5-year period. In tertiary general hospitals, the number and proportion of open surgeries gradually decreased, whereas in general hospitals, the proportion of open surgeries tended to increase. Laparoscopic and robotic surgeries were performed at similar rates in tertiary and general hospitals during the study period. The numbers of CRC surgeries by hospital region are shown (Table 9). Of the total surgeries, 47,140 (43.0%) were performed in Seoul, 19,961 (18.2%) in Gyeonggi, 7,417 (6.8%) in Daegu, and 7,190 (6.6%) in Busan.
Table 8.
Surgery for colorectal cancer by hospital size in Korea from 2019 to 2023
| Type of surgery | Hospital size | Year | Total | ||||
|---|---|---|---|---|---|---|---|
| 2019 | 2020 | 2021 | 2022 | 2023 | |||
| Total | Total | 21,807 | 21,034 | 22,908 | 22,370 | 21,454 | 109,573 |
| Tertiary GH | 14,890 (68.3) | 14,087 (67.0) | 15,675 (68.4) | 15,040 (67.2) | 14,590 (68.0) | 74,282 (67.8) | |
| GH | 6,357 (29.2) | 6,491 (30.9) | 6,792 (29.6) | 6,909 (30.9) | 6,501 (30.3) | 33,050 (30.2) | |
| Hospitala) | 555 (2.5) | 446 (2.1) | 440 (1.9) | 421 (1.9) | 355 (1.7) | 2,217 (2.0) | |
| Clinicb) | 5 (0.0) | 10 (0.0) | 1 (0.0) | 0 (0) | 8 (0.0) | 24 (0.0) | |
| Open | Total | 3,991 | 3,984 | 3,896 | 3,715 | 3,271 | 18,857 |
| Tertiary GH | 2,496 (62.5) | 2,407 (60.4) | 2,247 (57.7) | 1,985 (53.4) | 1,765 (54.0) | 10,900 (57.8) | |
| GH | 1,466 (36.7) | 1,532 (38.5) | 1,635 (42.0) | 1,706 (45.9) | 1,491 (45.6) | 7,830 (41.5) | |
| Hospital | 27 (0.7) | 39 (1.0) | 14 (0.4) | 24 (0.6) | 14 (0.4) | 118 (0.6) | |
| Clinic | 2 (0.1) | 6 (0.2) | 0 (0) | 0 (0) | 1 (0.0) | 9 (0.0) | |
| Laparoscopic | Total | 15,569 | 14,901 | 16,422 | 16,003 | 15,454 | 78,349 |
| Tertiary GH | 10,551 (67.8) | 9,961 (66.8) | 11,228 (68.4) | 10,882 (68.0) | 10,575 (68.4) | 53,197 (67.9) | |
| GH | 4,499 (28.9) | 4,544 (30.5) | 4,773 (29.1) | 4,736 (29.6) | 4,539 (29.4) | 23,091 (29.5) | |
| Hospital | 518 (3.3) | 392 (2.6) | 420 (2.6) | 385 (2.4) | 334 (2.2) | 2,049 (2.6) | |
| Clinic | 1 (0.0) | 4 (0.0) | 1 (0.0) | 0 (0) | 6 (0.0) | 12 (0.0) | |
| Robotic | Total | 2,247 | 2,149 | 2,590 | 2,652 | 2,729 | 12,367 |
| Tertiary GH | 1,843 (82.0) | 1,719 (80.0) | 2,200 (84.9) | 2,173 (81.9) | 2,250 (82.4) | 10,185 (82.4) | |
| GH | 392 (17.4) | 415 (19.3) | 384 (14.8) | 467 (17.6) | 471 (17.3) | 2,129 (17.2) | |
| Hospital | 10 (0.4) | 15 (0.7) | 6 (0.2) | 12 (0.5) | 7 (0.3) | 50 (0.4) | |
| Clinic | 2 (0.1) | 0 (0) | 0 (0) | 0 (0) | 1 (0.0) | 3 (0.0) | |
Values are presented as number only or number (%).
GH, general hospital.
a)30 to 100 beds, b)less than 30 beds.
Table 9.
Surgery for colorectal cancer by the region in Korea from 2019 to 2023
| Region | Year | Total | ||||
|---|---|---|---|---|---|---|
| 2019 | 2020 | 2021 | 2022 | 2023 | ||
| Seoul | 9,879 | 9,031 | 9,796 | 9,390 | 9,044 | 47,140 (43.0) |
| Busan | 1,482 | 1,442 | 1,514 | 1,424 | 1,328 | 7,190 (6.6) |
| Incheon | 977 | 987 | 1,031 | 900 | 956 | 4,851 (4.4) |
| Daegu | 1,467 | 1,398 | 1,541 | 1,545 | 1,466 | 7,417 (6.8) |
| Gwangju | 184 | 188 | 194 | 224 | 199 | 989 (0.9) |
| Daejeon | 657 | 694 | 693 | 709 | 683 | 3,436 (3.1) |
| Ulsan | 242 | 216 | 260 | 242 | 279 | 1,239 (1.1) |
| Gyeonggi | 3,648 | 3,694 | 4,285 | 4,276 | 4,058 | 19,961 (18.2) |
| Gangwon | 483 | 556 | 566 | 540 | 469 | 2,614 (2.4) |
| Chungcheongbuk-do | 217 | 236 | 237 | 251 | 245 | 1,186 (1.1) |
| Chungcheongnam-do | 298 | 313 | 339 | 357 | 376 | 1,683 (1.5) |
| Jeonbuk | 511 | 521 | 556 | 550 | 547 | 2,685 (2.5) |
| Jeollanam-do | 715 | 680 | 734 | 772 | 744 | 3,645 (3.3) |
| Gyeongsangbuk-do | 119 | 114 | 128 | 126 | 116 | 603 (0.6) |
| Gyeongsangnam-do | 791 | 792 | 847 | 867 | 761 | 4,058 (3.7) |
| Jeju | 136 | 165 | 159 | 165 | 149 | 774 (0.7) |
| Sejong | 1 | 7 | 28 | 32 | 34 | 102 (0.1) |
| Total | 21,807 | 21,034 | 22,908 | 22,370 | 21,454 | 109,573 |
Values are presented as number only or number (%).
The inclusion or exclusion of ostomy surgery during the main surgical resection for CRC was examined (Table 10). The timing of ostomy surgery in the data search was classified as before the main surgery, at the same time as the main surgery, within 30 days after the main surgery, and 30 days after the main surgery. Overall, ostomy was created in 16,222 of all CRC surgeries (14.8%). The proportions of ostomy surgeries in open, laparoscopic, and robotic surgery were 3,436 (18.2%), 10,818 (13.8%), and 1,968 (15.9%), respectively. Over the 5-year period, an increasing trend was observed in the number of ostomy surgeries performed before the main surgery, whereas the number performed after 30 days after the main surgery continued to decrease. The number and rate of ostomy surgery are shown by tumor location (Table 11). The overall rate of ostomy surgery for rectal tumors was 36.7% over the 5-year period.
Table 10.
Ostomy surgery for colorectal cancer resection in Korea from 2019 to 2023
| Type of surgery | Category | Total | Year | ||||
|---|---|---|---|---|---|---|---|
| 2019 | 2020 | 2021 | 2022 | 2023 | |||
| Total | No. of surgery | 109,573 | 21,807 | 21,034 | 22,908 | 22,370 | 21,454 |
| Ostomy, total | 16,222 (14.8) | 3,173 (14.6) | 3,181 (15.1) | 3,434 (15.0) | 3,320 (14.8) | 3,114 (14.5) | |
| Before | 2,136 | 168 | 349 | 431 | 599 | 589 | |
| Simultaneously | 12,911 | 2,674 | 2520 | 2748 | 2,543 | 2426 | |
| Within 30 days | 252 | 46 | 55 | 44 | 51 | 56 | |
| After 30 days | 923 | 285 | 257 | 211 | 127 | 43 | |
| Open | No. of surgery | 18,857 | 3,991 | 3,984 | 3,896 | 3,715 | 3,271 |
| Ostomy, total | 3,436 (18.2) | 707 (17.7) | 696 (17.5) | 720 (18.5) | 685 (18.4) | 628 (19.2) | |
| Before | 917 | 72 | 146 | 176 | 252 | 271 | |
| Simultaneously | 2,283 | 552 | 489 | 493 | 405 | 344 | |
| Within 30 days | 29 | 8 | 8 | 2 | 4 | 7 | |
| After 30 days | 207 | 75 | 53 | 49 | 24 | 6 | |
| Laparoscopic | No. of surgery | 78,349 | 15,569 | 14,901 | 16,422 | 16,003 | 15,454 |
| Ostomy, total | 10,818 (13.8) | 2,145 (13.8) | 2,063 (13.8) | 2,276 (13.9) | 2,203 (13.8) | 2,131 (13.8) | |
| Before | 693 | 67 | 107 | 137 | 203 | 179 | |
| Simultaneously | 9,544 | 1,932 | 1,808 | 2,000 | 1,905 | 1,899 | |
| Within 30 days | 151 | 21 | 33 | 32 | 31 | 34 | |
| After 30 days | 430 | 125 | 115 | 107 | 64 | 19 | |
| Robotic | No. of surgery | 12,367 | 2,247 | 2,149 | 2,590 | 2,652 | 2,729 |
| Ostomy, total | 1,968 (15.9) | 321 (14.3) | 422 (19.6) | 438 (16.9) | 432 (16.3) | 355 (13.0) | |
| Before | 526 | 29 | 96 | 118 | 144 | 139 | |
| Simultaneously | 1,084 | 190 | 223 | 255 | 233 | 183 | |
| Within 30 days | 72 | 17 | 14 | 10 | 16 | 15 | |
| After 30 days | 286 | 85 | 89 | 55 | 39 | 18 | |
Values are presented as number only or number (%).
Table 11.
Ostomy surgery for colorectal cancer resection by tumor location in Korea from 2019 to 2023
| Location | Category | Total | Year | ||||
|---|---|---|---|---|---|---|---|
| 2019 | 2020 | 2021 | 2022 | 2023 | |||
| Colon, any site | No. of surgery | 1 | 0 | 0 | 1 | 0 | 0 |
| Ostomy | 0 | 0 | 0 | 0 | 0 | 0 | |
| Cecum | No. of surgery | 4,168 | 708 | 803 | 858 | 901 | 898 |
| Ostomy | 132 (3.2) | 28 (4.0) | 33 (4.1) | 30 (3.5) | 23 (2.6) | 18 (2.0) | |
| Appendix | No. of surgery | 1,267 | 231 | 216 | 259 | 272 | 289 |
| Ostomy | 51 (4.0) | 5 (2.2) | 13 (6.0) | 15 (5.8) | 9 (3.3) | 9 (3.1) | |
| Ascending colon | No. of surgery | 15,905 | 3,219 | 3,067 | 3,389 | 3242 | 2,988 |
| Ostomy | 460 (2.9) | 95 (3.0) | 102 (3.3) | 99 (2.9) | 95 (2.9) | 69 (2.3) | |
| Hepatic flexure | No. of surgery | 3,485 | 684 | 660 | 695 | 711 | 735 |
| Ostomy | 110 (3.2) | 21 (3.1) | 20 (3.0) | 21 (3.0) | 20 (2.8) | 28 (3.8) | |
| Transverse colon | No. of surgery | 5,499 | 1,078 | 1,036 | 1,184 | 1,103 | 1,098 |
| Ostomy | 232 (4.2) | 46 (4.3) | 55 (5.3) | 35 (3.0) | 48 (4.4) | 48 (4.4) | |
| Splenic flexure | No. of surgery | 937 | 192 | 168 | 185 | 192 | 200 |
| Ostomy | 77 (8.2) | 14 (7.3) | 13 (7.7) | 21 (11.4) | 19 (9.9) | 10 (5.0) | |
| Descending colon | No. of surgery | 3,879 | 764 | 821 | 791 | 771 | 732 |
| Ostomy | 279 (7.2) | 62 (8.1) | 64 (7.8) | 60 (7.6) | 49 (6.4) | 44 (6.0) | |
| Sigmoid colon | No. of surgery | 27,791 | 5,526 | 5,305 | 5,948 | 5,684 | 5,328 |
| Ostomy | 1,773 (6.4) | 363 (6.6) | 328 (6.2) | 383 (6.4) | 382 (6.7) | 317 (5.9) | |
| Colon, overlapping | No. of surgery | 342 | 101 | 60 | 59 | 62 | 60 |
| Ostomy | 38 (11.1) | 13 (12.9) | 8 (13.3) | 7 (11.9) | 6 (9.7) | 4 (6.7) | |
| Colon, unspecified | No. of surgery | 4,834 | 1,029 | 909 | 977 | 962 | 957 |
| Ostomy | 437 (9.0) | 99 (9.6) | 77 (8.5) | 101 (10.3) | 85 (8.8) | 75 (7.8) | |
| Rectosigmoid colon | No. of surgery | 10,549 | 2,146 | 2160 | 2,101 | 2,120 | 2,022 |
| Ostomy | 1,277 (12.1) | 265 (12.3) | 249 (11.5) | 279 (13.3) | 254 (12.0) | 230 (11.4) | |
| Rectum | No. of surgery | 30,916 | 6,129 | 5,829 | 6,461 | 6,350 | 6,147 |
| Ostomy | 11,356 (36.7) | 2,162 (35.3) | 2,219 (38.1) | 2,383 (36.9) | 2,330 (36.7) | 2,262 (36.8) | |
Values are presented as number only or number (%).
DISCUSSION
This study investigated nationwide data regarding surgery for CRC from 2019 to 2023, using the approach described in previous studies [5,6]. In those studies, only a limited set of predetermined data was provided by HIRA. However, in the present study, a considerably larger dataset was accessed via direct retrieval from the HIRA database. Newly included in this study were differences in surgical volume according to region and hospital size, variations in surgical approach by medical insurance type, and comparisons of hospital stay length by surgical method. Notably, nationwide data regarding robotic surgery for CRC, which is not covered by health insurance in Korea, were included. The data search conditions described above are expected to provide the most accurate estimate of the actual number of robotic surgeries performed in Korea.
From 2019 to 2023, the rate of laparoscopic surgery stabilized, whereas robotic surgery increased from 10.3% to 12.7%, and the rate of open surgery gradually declined. The rate of open surgery was highest at 18.9% in 2020 and then decreased to 15.2% in 2023, and such a trend was also observed in both the left and right colons. In contrast, a temporary decline in the number of laparoscopic and robotic surgeries was observed in 2020, which may be associated with the coronavirus disease 2019 pandemic. For example, Choi et al. [9] reported that the rate of MIS for CRC decreased and combined resection increased in 2020, the first year of the pandemic. They noted that patients were reluctant to undergo surgery due to the pandemic, leading to surgeries for more advanced and complex cancers [9]. It should be addressed whether this trend was unique to Korea or consistent with global patterns during the pandemic. The rate of MIS for CRC reached nearly 85% in 2023. The average rates of laparoscopic and robotic surgery in the right colon, left colon, and rectum were 74.6% and 4.3%, 76.0% and 6.7%, and 62.6% and 25.2%, respectively. The adoption of robotic surgery for rectal cancer exceeded 28% in 2023 and has been gradually increasing throughout the colon.
Differences in surgical approach and length of hospital stay were observed according to medical insurance status. The higher rate of open surgery among patients with medical aid may be related to the presence of more advanced cancer and possible economic factors. Because the length of hospital stay after CRC surgery was significantly longer across all surgical approaches among patients with medical aid, these patients may have had more advanced cancer or undergone more aggressive surgery, resulting in a prolonged recovery period. On the other hand, the relative lack of post-discharge care among patients with medical aid may contribute to these differences. However, because tumor stage, oncological outcomes, and complications are not included in the HIRA data, the exact cause remains unknown. If future studies supplement this analysis with data regarding the age distribution, the proportion of metastatic disease, and the ratio of postoperative chemotherapy among patients with medical aid, a more precise explanation may be inferred.
To our knowledge, this study is the first to collect nationwide Korean data regarding the number of CRC surgeries according to hospital size and region. Overall, 67.8% of CRC surgeries were performed in tertiary general hospitals, whereas 30.2% were performed in general hospitals. Although the proportion of CRC surgeries performed in hospitals with 30 to 100 beds was quite small, the average rate of laparoscopic surgery in these hospitals was 92.4% (2,049 of 2,217 cases), indicating that MIS for CRC is widely adopted even in smaller hospitals. For open surgery, the number and rate continued to decrease in tertiary general hospitals but increased in general hospitals over the 5-year period. The rates of robotic surgery were 13.7% (10,185 of 74,282 cases) in tertiary general hospitals and 6.9% (2,129 of 33,050 cases) in general hospitals; the rates of open surgery were 14.7% (10,900 of 74,282 cases) and 23.7% (7,830 of 33,050 cases), respectively. Compared with general hospitals, tertiary general hospitals had a similar rate of laparoscopic surgery, twice the number of robotic surgeries, and a lower rate of open surgery. Overall, 65.7% of CRC surgeries in Korea were performed in the metropolitan area (Seoul, Gyeonggi, and Incheon), 18.5% were performed in the five metropolitan cities (Busan, Daegu, Gwangju, Daejeon, and Ulsan), and 15.8% were performed in nine local regions including special cities and provinces. This concentration of surgeries in the metropolitan area should be addressed through government policy.
Lastly, there is a possibility that some ostomy surgeries during robotic surgery were not included in the HIRA data. In other words, since the cost of robotic surgery is not covered by Korean health insurance, there is a possibility that no additional cost for ostomy surgery was charged during robotic surgery in some cases.
In conclusion, our analysis of HIRA nationwide data confirmed that the rate of MIS for CRC in Korea has continued to increase, reaching 84.7% in 2023. The rate of laparoscopic surgery exceeded 70%, has plateaued, and remained similar between tertiary general hospitals and general hospitals. In contrast, the rate of robotic surgery has continued to increase, particularly in rectal cancer, where it exceeded 28% in 2023.
Acknowledgments
The authors would like to thank Su Jin Jeong from Statistics Support Team of Kyung Hee University Hospital for assistance with data retrieval and statistical analysis.
Notes
Ethics statement
This study was reviewed and granted an exemption by the Institutional Review Board of Kyung Hee University Hospital (No. KHUH 2024-10-029).
Authors’ contributions
Conceptualization: SJP
Formal Analysis: EJP, SJP
Supervision: KYL, SHL
Writing–original draft: EJP, SJP
Writing–review & editing: HGL, YYP, KYL, SHL
All authors read and approved the final manuscript.
Conflict of interest
Sun Jin Park, the Editor-in-Chief and Youn Young Park, the Deputy Editor of Journal of Minimally Invasive Surgery did not participate in the review process of this article. No other potential conflicts of interest relevant to this article were reported.
Funding/support
None.
Data availability
The data presented in this study are available upon reasonable request to the corresponding author.
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