Annual Report of the 2022 National Clinical Database: Decade‐Long Trends and Current Status of Gastroenterological Surgery in Japan

ABSTRACT

Aim

The National Clinical Database (NCD) of Japan is the largest nationwide registry, covering over 95% of surgeries in the country. This 2022 annual report summarizes the short‐term outcomes of gastroenterological surgeries and discusses trends and insights over the past decade.

Methods

We analyzed the NCD data for gastroenterological surgeries performed between 2013 and 2022. The number of surgeries, patient demographics, surgical approaches, postoperative outcomes, and the involvement of board‐certified surgeons and anesthesiologists were examined.

Results

A total of 591 221 surgeries were recorded in 2022. Compared to 2021, the overall surgical volume remained stable, with a continued increase in minimally invasive procedures. Patient aging continued across all organ categories, with a rise in the proportion of patients aged ≥ 80 years. Board‐certified surgeon participation remained high in complex procedures, while emergency surgeries were associated with higher morbidity and mortality. Operative mortality continued to decrease, particularly in pancreatic and hepatic surgeries.

Conclusion

The 2022 NCD data provide a comprehensive overview of the current status and evolving trends in gastroenterological surgery in Japan. Continued efforts toward data‐driven quality improvement and surgical education remain essential.

1. Introduction

Established in 2011, the Japanese National Clinical Database (NCD) is a nationwide surgical registry that encompasses over 95% of all surgical procedures performed in Japan [1, 2]. As of 2022, it has accumulated over 20 million cases from more than 5600 participating facilities [3]. The NCD plays a pivotal role in surgical quality assurance, clinical governance, and credentialing of surgeons. Among the seventeen participating surgical societies, the Japanese Society of Gastroenterological Surgery (JSGS) has taken the leading role in organizing and operating the NCD for gastroenterological surgery and remains the largest and most active contributor.

Within the domain of gastroenterological surgery, the NCD is utilized in three major ways. First, it forms the core of the board certification system, which classifies 121 surgical procedures into three levels of difficulty. These procedures serve as benchmarks for the training and assessment of board‐certified surgeons. Second, nine major surgical procedures—esophagectomy [4, 5], gastrectomy (partial [6, 7]/total [8, 9]), right hemicolectomy [10, 11], low anterior resection [12, 13], hepatectomy [14, 15], pancreaticoduodenectomy [16, 17], surgery for acute diffuse peritonitis [18, 19], and liver transplantation [20]—are used for quality benchmarking and risk modeling. Third, outcome feedback systems based on risk‐adjusted models are employed to support institutional improvement and provide individualized risk assessments for patients, thereby enhancing both clinical practice and patient consent processes [21].

Annual reports based on NCD data are published to elucidate nationwide trends in surgical performance, outcomes, and evolving demographics [22, 23, 24, 25, 26, 27]. These reports serve as a valuable resource for surgeons, policymakers, and educators. Since the initial release, the annual report has contributed to the identification of key challenges in Japanese gastroenterological surgery, including the aging of the patient population, regional disparities in surgical access, and the need for standardization of endoscopic and emergency procedures.

The current report focuses on the surgical cases registered in the NCD during 2022. In continuity with previous reports, we present an overview of short‐term surgical outcomes and analyze decade‐long trends from 2013 to 2022. The analysis highlights operative characteristics, participation of board‐certified surgeons, institutional accreditation status, morbidity and mortality indicators, and changes in minimally invasive surgery and emergency surgery rates. The goal of this annual report is to facilitate the ongoing advancement of gastroenterological surgery in Japan through evidence‐based monitoring and analysis.

2. Subjects and Methods

This study analyzed data from the NCD, specifically focusing on gastroenterological surgeries performed between January 1, 2013, and December 31, 2022. The target procedures were defined according to the “Training Curriculum for Board‐Certified Surgeons in Gastroenterology,” which includes 121 operative procedures stratified into three difficulty levels: low, medium, and high. For each procedure, the following variables were examined: the number of surgeries, sex distribution, patient age (especially ≥ 70 and ≥ 80 years), proportion of endoscopic and emergency surgeries, severe postoperative complications (Clavien–Dindo classification grade ≥ III), reoperation rates, 30‐day postoperative mortality, and operative mortality [28, 29]. Data extraction and tabulation were based on standardized formats approved by the JSGS [21, 22, 23, 24, 25, 26, 27].

Several considerations should be noted when interpreting the data presented in this Annual Report: (1) In the NCD, up to eight operative procedures could be recorded per patient, and therefore, the total number of registered procedures did not necessarily correspond to the total number of surgical cases. If multiple procedures were performed simultaneously, each was counted separately in the aggregated data. (2) Cases with incomplete records regarding patient age, sex, or 30‐day postoperative status were excluded from the analysis. (3) The 30‐day mortality included all deaths within 30 days after surgery, regardless of whether the patient was discharged. Operative mortality was defined as the combination of 30‐day mortality and in‐hospital deaths occurring after 30 days postoperatively.

In addition, data on institutional certification status (JSGS‐certified, affiliated, or others), participation of anesthesiologists, and involvement of board‐certified surgeons were collected. The presence of board‐certified surgeons as the operating surgeon was separately calculated. Comparative trend analysis from 2013 through 2022 was performed across nine anatomical categories: esophagus, stomach and duodenum, small intestine and colon, rectum and anus, liver, gallbladder, pancreas, spleen, and other procedures.

3. Results

3.1. Characteristics of Gastroenterological Operative Procedures in 2022

A total of 591 221 gastroenterological surgical procedures were registered in the NCD in 2022. The distribution of procedures by anatomical region was as follows: esophagus (8758; 1.5%), stomach and duodenum (53 705; 9.1%), small intestine and colon (232 918; 39.4%), rectum and anus (53 117; 9.0%), liver (26 295; 4.4%), gallbladder (134 343; 22.7%), pancreas (18 969; 3.2%), spleen (1784; 0.3%), and others (61 332; 10.4%).

Table 1 summarizes the characteristics of gastroenterological surgical procedures in 2022. Regarding incidence, the largest number of procedures involved the small intestine and colon, followed by the gallbladder and stomach/duodenum. The proportion of elderly patients aged ≥ 80 years has steadily increased across most organ categories, reflecting the aging surgical population in Japan. Anesthesiologist and board‐certified surgeon participation exceeded 95% in most procedures, although rates remained lower in certain emergency or minor operations, such as anal surgery, external cholecystostomy, and hepatic trauma surgery.

TABLE 1.

Characteristics of each operative procedures of the “Training Curriculum for Board‐Certified Surgeons in Gastroenterology” in 2022.

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	36	88.9	11.1	97.2	94.4	72.2	27.8
	Med	Esophageal suture (perforation, injury)	185	79.5	11.4	94.6	90.3	68.1	31.9
	Med	Thoracic periesophageal abscess drainage	20	90.0	20.0	95.0	95.0	85.0	15.0
	Med	Esophageal foreign body extraction	25	60.0	40.0	96.0	84.0	56.0	44.0
	Med	Esophageal diverticulum resection	49	46.9	12.2	95.9	95.9	77.6	22.4
	Med	Benign esophageal tumor removal	54	53.7	1.9	100.0	98.1	77.8	22.2
	Med	Esophageal resection (removal only)	532	81.4	19.7	97.9	91.9	76.5	23.5
	Med	Esophageal reconstruction (gastric tube reconstruction)	484	84.3	10.3	99.4	98.3	86.2	13.8
	Med	Esophageal fistula construction	190	83.2	19.5	97.4	97.9	86.3	13.7
	Med	Esophagocardioplasty	299	32.1	30.1	97.3	86.0	56.9	43.1
	Med	Achalasia surgery	190	57.9	7.9	97.9	67.4	43.7	56.3
	High	Esophagectomy	6053	79.4	9.7	99.0	98.9	87.0	13.0
	High	Esophageal reconstruction (colon reconstruction)	29	79.3	10.3	96.6	93.1	65.5	34.5
	High	Esophageal bypass	117	81.2	11.1	97.4	98.3	70.1	29.9
	High	Bronchoesophageal fistula surgery	3	33.3	33.3	100.0	100.0	100.0	0.0
	High	Secondary esophageal reconstruction	360	86.1	16.4	99.4	96.7	75.3	24.7
Stomach and duodenum	Low	Gastrostomy and suture gastrorrhaphy	61	62.3	34.4	96.7	83.6	37.7	62.3
	Low	Diverticulectomy, polypectomy (excluding endoscopic resection)	98	60.2	18.4	95.9	90.8	63.3	36.7
	Low	Truncal vagotomy	0	—	—	—	—	—	—
	Low	Gastroenterostomy (including duodenal jejunostomy)	5859	62.8	29.0	96.2	88.8	44.6	55.4
	Low	Gastric fistula construction (excluding PEG)	1447	69.2	26.2	94.5	82.2	47.0	53.0
	Low	Gastric pyloroplasty	110	74.5	8.2	96.4	62.7	26.4	73.6
	Low	Gastric volvulus surgery and rectopexy	69	27.5	55.1	88.4	87.0	49.3	50.7
	Low	Gastric suture (including gastric suture for gastric rupture, Suture closure for gastroduodenal perforation, omental implantation and omental transposition)	5553	62.3	28.0	94.5	79.0	33.1	66.9
	Low	Local gastrectomy (including wedge resection)	4896	48.8	14.6	97.0	93.1	55.4	44.6
	Med	Gastrectomy (including distal, pylorus preserving and segmental)	27 883	66.4	28.2	96.6	93.0	60.7	39.3
	Med	Selective vagotomy	5	80.0	20.0	100.0	100.0	80.0	20.0
	High	Total gastrectomy (including proximal gastrectomy)	9028	73.8	23.2	96.4	92.8	60.8	39.2
	High	Left upper abdominal exenteration	1	100.0	0.0	100.0	100.0	100.0	0.0
Small intestine and colon	Low	Enterotomy and enterorrhaphy	4297	55.4	27.8	94.2	81.9	42.9	57.1
	Low	Disinvagination (invasive)	152	52.6	23.0	96.7	82.2	35.5	64.5
	Low	Partial small bowel resection (benign)	9039	55.9	31.6	95.2	82.1	39.7	60.3
	Low	Ileocecal resection (benign)	4752	58.4	18.5	95.7	84.0	38.7	61.3
	Low	Partial colectomy and sigmoid colectomy (benign)	8367	62.4	26.2	95.6	83.5	40.2	59.8
	Low	Appendectomy	52 611	54.4	6.8	93.7	72.0	26.8	73.2
	Low	Enterostomy and closure (without enterectomy)	27 871	62.7	20.3	96.2	86.2	49.4	50.6
	Med	Small bowel resection (malignant)	3608	57.9	19.9	96.2	89.6	48.6	51.4
	Med	Ileocecal resection (malignant)	15 786	45.2	34.0	96.7	89.5	44.4	55.6
	Med	Partial colectomy and sigmoid colectomy (malignant)	29 793	56.7	25.2	96.5	89.2	51.9	48.1
	Med	Right hemicolectomy	21 223	50.1	35.3	95.9	88.1	48.8	51.2
	Med	Left hemicolectomy	5982	58.9	24.6	95.5	89.1	53.0	47.0
	Med	Total colectomy	1502	56.7	20.9	96.3	86.3	56.6	43.4
	Med	Intestinal obstruction surgery (with enterectomy)	25 971	48.9	39.4	94.6	80.3	36.8	63.2
	Med	Enterostomy and closure (with enterectomy)	22 347	62.9	17.7	96.2	86.5	45.6	54.4
	High	Proctocolectomy and ileoanal (canal) anastomosis	371	63.6	0.8	97.8	96.8	80.1	19.9
Rectum	Low	Transanal rectal tumor resection	3373	50.3	13.9	40.2	64.0	43.9	56.1
	Low	Proctocele surgery (transanal)	2296	12.0	68.0	59.2	69.3	42.1	57.9
	Med	Abdominoperineal resection (benign)	936	60.3	19.9	94.2	86.1	54.9	45.1
	Med	High anterior resection	11 624	58.0	19.8	96.8	91.5	58.3	41.7
	Med	Hartmann's procedure	6447	55.1	39.3	95.9	85.7	42.7	57.3
	Med	Proctocele surgery (abdominoperineal)	2471	11.1	59.0	93.6	87.5	54.9	45.1
	Med	Malignant anorectal tumor excision (transanal)	605	50.1	26.3	77.2	80.7	55.9	44.1
	Med	Anal sphincteroplasty (by tissue replacement)	3078	53.2	11.3	23.5	53.4	39.1	60.9
	High	Abdominoperineal resection (malignant)	4924	64.5	22.1	97.1	93.4	71.2	28.8
	High	Low anterior resection	20 205	64.1	14.6	96.6	92.8	69.8	30.2
	High	Total pelvic exenteration	446	71.3	7.0	98.2	97.5	81.2	18.8
	High	Anorectal malignant tumor excision (posterior approach)	31	35.5	12.9	77.4	93.5	64.5	35.5
Liver	Low	Hepatorrhaphy	53	71.7	22.6	90.6	86.8	50.9	49.1
	Low	Liver abscess drainage (excluding percutaneous procedures)	41	51.2	36.6	92.7	87.8	31.7	68.3
	Low	Hepatic cyst resection, Suture, Drainage	961	25.6	21.7	96.8	88.8	47.3	52.7
	Low	Liver biopsy (excluding percutaneous procedures)	246	47.6	5.7	90.7	92.7	51.6	48.4
	Low	Liver coagulo‐necrotic therapy (excluding percutaneous procedures)	374	74.6	17.9	97.3	93.9	72.5	27.5
	Med	Partial hepatectomy	12 247	66.8	16.1	98.1	96.6	73.4	26.6
	Med	Lateral segmentectomy	1324	63.5	18.6	97.1	96.8	71.6	28.4
	Med	Esophageal and gastric varix surgery	30	56.7	13.3	86.7	63.3	46.7	53.3
	High	Surgery for hepatic trauma (excluding drainage only)	353	72.2	17.3	77.3	69.7	36.3	63.7
	High	Hepatectomy (segmentectomy or more; excluding lateral segmentectomy)	6134	67.8	16.6	98.2	98.2	81.9	18.1
	High	Subsegmentectomy	2708	71.7	17.5	98.7	98.1	79.7	20.3
	High	Liver transplantation	790	49.7	0.3	99.7	99.0	75.8	24.2
	High	Hepatopancreatoduodenectomy	143	69.9	7.0	97.9	100.0	85.3	14.7
Gall bladder	Low	Cholangiotomy	37	54.1	32.4	97.3	89.2	43.2	56.8
	Low	Cholecystolithotomy	79	73.4	43.0	94.9	86.1	51.9	48.1
	Low	Cholecystectomy	126 763	54.8	18.1	95.4	83.3	37.8	62.2
	Low	External cholecystostomy	110	59.1	41.8	71.8	72.7	44.5	55.5
	Low	Cystoenteric anastomosis	33	66.7	36.4	93.9	84.8	42.4	57.6
	Med	Choledocholithotomy	1816	59.8	40.7	94.2	89.3	53.1	46.9
	Med	Biliary tract reconstruction	273	62.6	22.7	97.1	97.1	71.8	28.2
	Med	Biliary bypass	910	119.3	28.4	95.4	94.3	59.7	40.3
	Med	Cholangioplasty	136	64.0	30.9	97.1	97.1	66.9	33.1
	Med	Duodenal papilloplasty	19	63.2	31.6	89.5	100.0	68.4	31.6
	Med	Choledocal dilatation	253	24.1	1.6	98.4	94.5	71.5	28.5
	Med	Biliary fistula closure	37	59.5	21.6	94.6	78.4	45.9	54.1
	High	Surgery for bile duct trauma (excluding drainage only)	183	63.4	25.7	93.4	85.2	49.2	50.8
	High	Malignant gallbladder tumor surgery (excluding simple cholecystectomy)	1096	50.4	23.1	98.1	95.7	65.1	34.9
	High	Malignant bile duct tumor surgery	1029	65.6	22.0	97.7	97.6	81.1	18.9
	High	Biliary atresia surgery	22	27.3	0.0	100.0	54.5	27.3	72.7
Pancreas	Low	External pancreatic cyst drainage	3	33.3	33.3	66.7	66.7	66.7	33.3
	Low	External pancreatic duct drainage	16	68.8	18.8	81.3	87.5	81.3	18.8
	Med	Pancreatorrhaphy	8	62.5	12.5	87.5	87.5	50.0	50.0
	Med	Partial pancreatic resection	130	50.8	6.9	98.5	97.7	77.7	22.3
	Med	Distal pancreatectomy (benign)	1392	44.3	8.3	97.1	97.0	77.2	22.8
	Med	Pancreatic cyst‐enterostomy	12	91.7	8.3	100.0	100.0	83.3	16.7
	Med	Pancreatic (duct) enterostomy	289	72.0	12.8	92.0	99.3	75.1	24.9
	Med	Acute pancreatitis surgery	45	77.8	20.0	93.3	80.0	53.3	46.7
	Med	Pancreatolithiasis surgery	17	82.4	0.0	88.2	100.0	64.7	35.3
	Med	Plexus pancreaticus capitalis resection	0	—	—	—	—	—	—
	High	Surgery for pancreatic trauma (excluding drainage only)	66	65.2	12.1	90.9	87.9	53.0	47.0
	High	Pancreaticoduodenectomy	11 637	59.7	17.9	98.2	97.7	77.2	22.8
	High	Distal pancreatectomy (malignant)	5318	54.6	19.6	98.1	97.9	79.0	21.0
	High	Total pancreatectomy	612	54.2	12.4	99.3	99.0	83.3	16.7
	High	Duodenum preserving pancreas head resection	28	64.3	10.7	100.0	96.4	71.4	28.6
	High	Segmental pancreatic resection	151	45.7	7.9	97.4	98.7	80.1	19.9
	High	Pancreas transplantation	48	29.2	0.0	100.0	95.8	81.3	18.8
Spleen	Low	Splenorrhaphy	35	71.4	17.1	85.7	77.1	42.9	57.1
	Med	Splenectomy	1692	56.0	13.3	96.6	93.4	63.1	36.9
	Med	Partial splenectomy	23	52.2	8.7	95.7	78.3	43.5	56.5
Other	Low	Localized intra‐abdominal abscess surgery	2162	60.0	21.6	91.2	80.6	41.5	58.5
	Low	Exploratory laparotomy	13 433	59.7	20.7	94.5	85.1	46.4	53.6
	Med	Acute diffuse peritonitis surgery	15 883	58.1	29.0	95.3	83.5	38.4	61.6
	Med	Ventral hernia surgery	14 306	47.2	21.7	94.1	78.6	41.8	58.2
	Med	Diaphragm suture	268	60.1	22.4	95.9	85.1	54.5	45.5
	Med	Esophageal hiatus hernia surgery	1216	29.6	40.0	97.5	93.4	65.9	34.1
	Med	Retroperitoneal tumor surgery	1398	47.7	8.3	97.6	87.6	62.8	37.2
	Med	Abdominal wall/mesenteric/omental tumor resection	1936	48.2	12.3	96.4	86.9	52.0	48.0
	Med	Gastrointestinal perforation closure	350	59.4	26.0	93.7	75.7	40.6	59.4
	High	Diaphragmatic hiatus hernia surgery	62	61.3	16.1	95.2	87.1	56.5	43.5

Table 2 details the short‐term outcomes of these procedures. Regarding operative mortality, high‐risk emergency operations such as surgery for hepatic trauma (operative mortality 27.8%), gastrointestinal perforations (14.6%), and esophageal fistula (12.6%) showed the highest operative mortality. These high‐risk emergency procedures were also associated with increased complication rates in comparison to procedures generally conducted electively. In contrast, more common and less invasive operations, such as laparoscopic achalasia surgery and local gastrectomy, demonstrated near‐zero operative mortality and very low complication rates.

TABLE 2.

Number of surgeries and short‐term outcome of each operative procedures of the “Training Curriculum for Board‐Certified Surgeons in Gastroenterology” in 2022.

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	36	27.8	75.0	27.8	11.1	0.0	5.6
	Med	Esophageal suture (perforation, injury)	185	17.3	75.7	40.0	10.3	5.4	10.3
	Med	Thoracic periesophageal abscess drainage	20	30.0	90.0	55.0	25.0	0.0	0.0
	Med	Esophageal foreign body extraction	25	12.0	92.0	12.0	4.0	4.0	8.0
	Med	Esophageal diverticulum resection	49	28.6	2.0	4.1	0.0	0.0	0.0
	Med	Benign esophageal tumor removal	54	81.5	0.0	7.4	3.7	0.0	0.0
	Med	Esophageal resection (removal only)	532	67.5	9.4	21.6	18.2	2.4	5.6
	Med	Esophageal reconstruction (gastric tube reconstruction)	484	73.3	0.4	24.6	6.2	1.7	3.5
	Med	Esophageal fistula construction	190	54.2	36.3	37.9	34.2	7.4	12.6
	Med	Esophagocardioplasty	299	78.9	3.3	6.4	3.7	0.7	2.3
	Med	Achalasia surgery	190	90.5	0.0	1.1	1.1	0.0	0.0
	High	Esophagectomy	6053	79.7	0.4	21.4	5.5	0.8	1.7
	High	Esophageal reconstruction (colon reconstruction)	29	44.8	0.0	27.6	13.8	6.9	13.8
	High	Esophageal bypass	117	26.5	0.0	26.5	11.1	2.6	7.7
	High	Bronchoesophageal fistula surgery	3	66.7	0.0	33.3	0.0	33.3	33.3
	High	Secondary esophageal reconstruction	360	18.1	4.2	35.3	14.7	1.9	5.3
Stomach and duodenum	Low	Gastrostomy and suture gastrorrhaphy	61	16.4	68.9	16.4	6.6	1.6	9.8
	Low	Diverticulectomy, polypectomy (excluding endoscopic resection)	98	10.2	18.4	9.2	2.0	1.0	2.0
	Low	Truncal vagotomy	0	—	—	—	—	—	—
	Low	Gastroenterostomy (including duodenal jejunostomy)	5859	35.8	10.3	15.3	4.8	4.6	8.3
	Low	Gastric fistula construction (excluding PEG)	1447	23.2	15.8	20.5	5.9	5.7	9.3
	Low	Gastric pyloroplasty	110	32.7	40.9	8.2	4.5	0.9	0.9
	Low	Gastric volvulus surgery and rectopexy	69	65.2	33.3	8.7	2.9	1.4	2.9
	Low	Gastric suture (including gastric suture for gastric rupture, Suture closure for gastroduodenal perforation, omental implantation and omental transposition)	5553	38.6	90.9	18.3	4.9	5.8	8.0
	Low	Local gastrectomy (including wedge resection)	4896	72.3	3.2	3.0	1.2	0.3	0.5
	Med	Gastrectomy (including distal, pylorus preserving and segmental)	27 883	59.9	1.8	7.3	2.3	0.8	1.4
	Med	Selective vagotomy	5	40.0	0.0	0.0	0.0	0.0	0.0
	High	Total gastrectomy (including proximal gastrectomy)	9028	38.1	1.8	12.2	3.8	1.1	1.8
	High	Left upper abdominal exenteration	1	0.0	0.0	0.0	0.0	0.0	0.0
Small intestine and colon	Low	Enterotomy and enterorrhaphy	4297	20.1	31.2	18.8	8.4	4.3	8.0
	Low	Disinvagination (invasive)	152	35.5	77.6	7.2	3.3	4.6	5.9
	Low	Partial small bowel resection (benign)	9039	22.2	63.0	19.6	10.2	6.5	9.2
	Low	Ileocecal resection (benign)	4752	46.9	49.3	9.9	3.8	2.2	3.1
	Low	Partial colectomy and sigmoid colectomy (benign)	8367	35.7	45.8	14.7	6.6	3.6	4.8
	Low	Appendectomy	52 611	75.4	64.8	1.8	0.8	0.1	0.2
	Low	Enterostomy and closure (without enterectomy)	27 871	44.2	28.4	15.8	7.1	3.6	5.9
	Med	Small bowel resection (malignant)	3608	32.9	17.6	11.4	4.2	2.5	4.0
	Med	Ileocecal resection (malignant)	15 786	67.8	4.9	5.0	1.9	0.7	1.0
	Med	Partial colectomy and sigmoid colectomy (malignant)	29 793	67.4	3.8	6.2	3.2	0.6	0.9
	Med	Right hemicolectomy	21 223	58.6	8.5	7.5	3.4	1.6	2.1
	Med	Left hemicolectomy	5982	59.3	8.8	9.5	4.5	1.8	2.6
	Med	Total colectomy	1502	33.0	34.6	25.8	10.1	9.2	11.9
	Med	Intestinal obstruction surgery (with enterectomy)	25 971	27.2	69.5	10.0	4.1	2.4	3.4
	Med	Enterostomy and closure (with enterectomy)	22 347	20.2	20.8	12.9	4.8	2.9	4.2
	High	Proctocolectomy and ileoanal (canal) anastomosis	371	59.3	6.2	10.5	3.8	0.0	0.0
Rectum	Low	Transanal rectal tumor resection	3373	3.2	1.5	0.4	0.5	0.1	0.1
	Low	Proctocele surgery (transanal)	2296	1.2	1.6	1.9	1.7	0.1	0.3
	Med	Abdominoperineal resection (benign)	936	15.6	20.8	18.5	5.4	3.3	4.8
	Med	High anterior resection	11 624	75.4	3.9	5.4	2.9	0.5	0.8
	Med	Hartmann's procedure	6447	25.1	59.2	19.4	6.1	5.3	6.8
	Med	Proctocele surgery (abdominoperineal)	2471	65.2	0.7	1.7	1.2	0.3	0.4
	Med	Malignant anorectal tumor excision (transanal)	605	17.9	7.1	4.8	3.1	1.0	1.2
	Med	Anal sphincteroplasty (by tissue replacement)	3078	0.6	2.0	0.7	1.2	0.1	0.1
	High	Abdominoperineal resection (malignant)	4924	76.9	1.2	12.1	4.4	0.6	1.1
	High	Low anterior resection	20 205	77.8	1.3	9.8	5.8	0.4	0.6
	High	Total pelvic exenteration	446	37.9	1.1	25.3	5.6	1.1	1.6
	High	Anorectal malignant tumor excision (posterior approach)	31	29.0	0.0	12.9	6.5	0.0	0.0
Liver	Low	Hepatorrhaphy	53	26.4	71.7	35.8	22.6	11.3	15.1
	Low	Liver abscess drainage (excluding percutaneous procedures)	41	41.5	58.5	14.6	2.4	0.0	0.0
	Low	Hepatic cyst resection, suture, drainage	961	81.3	4.3	4.9	1.7	0.4	0.8
	Low	Liver biopsy (excluding percutaneous procedures)	246	13.0	24.0	4.5	5.7	0.0	0.0
	Low	Liver coagulo‐necrotic therapy (excluding percutaneous procedures)	374	28.6	0.8	7.2	1.6	0.8	1.1
	Med	Partial hepatectomy	12 247	48.1	0.7	6.3	1.9	0.4	0.6
	Med	Lateral segmentectomy	1324	46.0	1.1	3.3	1.6	0.3	0.3
	Med	Esophageal and gastric varix surgery	30	26.7	33.3	33.3	20.0	10.0	20.0
	High	Surgery for hepatic trauma (excluding drainage only)	353	6.5	85.3	49.0	51.3	22.9	27.8
	High	Hepatectomy (segmentectomy or more; excluding lateral segmentectomy)	6134	20.8	0.5	14.8	2.3	1.2	1.9
	High	Subsegmentectomy	2708	40.0	0.3	9.1	1.8	0.4	0.7
	High	Liver transplantation	790	1.4	16.3	21.1	11.0	2.5	3.5
	High	Hepatopancreatoduodenectomy	143	0.7	0.7	55.2	7.0	2.8	7.7
Gall bladder	Low	Cholangiotomy	37	10.8	27.0	16.2	2.7	2.7	2.7
	Low	Cholecystolithotomy	79	22.8	21.5	16.5	5.1	3.8	3.8
	Low	Cholecystectomy	126 763	75.0	16.2	3.4	1.0	0.4	0.6
	Low	External cholecystostomy	110	18.2	61.8	28.2	12.7	15.5	18.2
	Low	Cystoenteric anastomosis	33	24.2	3.0	9.1	3.0	0.0	3.0
	Med	Choledocholithotomy	1816	36.6	14.0	9.0	2.7	1.4	2.0
	Med	Biliary tract reconstruction	273	3.3	2.6	20.9	3.7	0.7	1.5
	Med	Biliary bypass	910	5.7	11.1	15.3	3.6	2.2	4.0
	Med	Cholangioplasty	136	11.0	19.1	15.4	2.9	0.7	2.2
	Med	Duodenal papilloplasty	19	10.5	21.1	21.1	15.8	10.5	10.5
	Med	Choledocal dilatation	253	37.9	2.4	12.3	4.0	0.0	0.4
	Med	Biliary fistula closure	37	32.4	54.1	13.5	2.7	10.8	10.8
	High	Surgery for bile duct trauma (excluding drainage only)	183	30.1	44.8	23.0	6.0	3.3	5.5
	High	Malignant gallbladder tumor surgery (excluding simple cholecystectomy)	1096	20.4	1.1	10.1	1.7	0.6	1.0
	High	Malignant bile duct tumor surgery	1029	1.6	0.6	29.8	4.7	3.9	5.2
	High	Biliary atresia surgery	22	45.5	9.1	18.2	4.5	0.0	18.2
Pancreas	Low	External pancreatic cyst drainage	3	0.0	0.0	0.0	0.0	0.0	0.0
	Low	External pancreatic duct drainage	16	12.5	75.0	37.5	12.5	18.8	18.8
	Med	Pancreatorrhaphy	8	0.0	75.0	62.5	12.5	12.5	12.5
	Med	Partial pancreatic resection	130	35.4	0.0	23.1	5.4	0.0	0.0
	Med	Distal pancreatectomy (benign)	1392	57.0	4.0	19.4	2.0	0.6	1.2
	Med	Pancreatic cyst‐enterostomy	12	8.3	16.7	8.3	0.0	8.3	8.3
	Med	Pancreatic (duct) enterostomy	289	1.7	6.2	22.8	3.5	0.7	1.4
	Med	Acute pancreatitis surgery	45	2.2	60.0	48.9	17.8	8.9	15.6
	Med	Pancreatolithiasis surgery	17	0.0	0.0	23.5	5.9	0.0	0.0
	Med	Plexus pancreaticus capitalis resection	0	—	—	—	—	—	—
	High	Surgery for pancreatic trauma (excluding drainage only)	66	7.6	77.3	36.4	16.7	7.6	9.1
	High	Pancreaticoduodenectomy	11 637	6.7	0.6	24.8	3.4	1.0	1.6
	High	Distal pancreatectomy (malignant)	5318	40.3	0.4	18.7	2.0	0.5	0.8
	High	Total pancreatectomy	612	2.3	3.6	13.1	4.4	2.0	2.9
	High	Duodenum preserving pancreas head resection	28	3.6	0.0	32.1	10.7	3.6	7.1
	High	Segmental pancreatic resection	151	13.9	2.0	41.1	3.3	0.7	0.7
	High	Pancreas transplantation	48	0.0	77.1	22.9	20.8	2.1	2.1
Spleen	Low	Splenorrhaphy	35	2.9	71.4	42.9	37.1	20.0	22.9
	Med	Splenectomy	1692	32.7	11.3	15.8	6.4	2.7	3.7
	Med	Partial splenectomy	23	73.9	8.7	8.7	4.3	0.0	0.0
Other	Low	Localized intra‐abdominal abscess surgery	2162	38.5	67.7	15.6	6.4	3.3	4.7
	Low	Exploratory laparotomy	13 433	52.1	30.4	15.2	13.1	5.6	7.6
	Med	Acute diffuse peritonitis surgery	15 883	24.8	93.6	26.8	7.9	8.2	11.3
	Med	Ventral hernia surgery	14 306	34.3	12.1	3.4	1.5	0.4	0.7
	Med	Diaphragm suture	268	34.7	42.5	15.7	9.0	3.0	5.6
	Med	Esophageal hiatus hernia surgery	1216	71.4	9.3	7.6	2.7	1.6	2.4
	Med	Retroperitoneal tumor surgery	1398	11.7	1.1	8.1	3.3	0.4	0.6
	Med	Abdominal wall/mesenteric/omental tumor resection	1936	32.2	14.4	8.5	5.2	1.2	1.9
	Med	Gastrointestinal perforation closure	350	15.1	94.6	34.3	14.0	9.7	14.6
	High	Diaphragmatic hiatus hernia surgery	62	35.5	51.6	8.1	6.5	3.2	3.2

Abbreviation: PEG, percutaneous endoscopic gastrostomy.

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

^b Operative mortality was defined as the rate combining 30‐day mortality and in‐hospital deaths occurring beyond postoperative day 30.

3.2. Annual Trends in Organ‐Specific Surgical Procedures

Figure 1 illustrates the annual changes in the number of gastroenterological surgeries, patient demographics, and institutional factors from 2013 to 2022. Over the decade, the total number of surgeries has continued to rise steadily, except for a transient decline in 2020 due to the COVID‐19 pandemic. This overall increase, however, was not uniform across all organ systems: surgeries for the stomach, liver, and spleen showed a gradual decline, whereas the number of surgeries for the colon, rectum, and pancreas consistently increased. In 2022, surgical volume remained stable compared to 2021, reflecting recovery from the pandemic. Among organ systems, surgeries involving the small intestine and colon, rectum and anus, pancreas, and the “others” category showed a consistent upward trend. In contrast, surgeries for the stomach and duodenum, liver, and spleen gradually decreased. Esophageal surgery volume remained relatively constant.

FIGURE 1.

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. †Operative mortality was defined as the rate combining 30‐day mortality and in‐hospital deaths occurring beyond postoperative day 30.

Table 3 summarizes changes in sex and age distribution. The proportion of female patients increased across all organ categories over the past 10 years, with notable rises in spleen, esophageal, and gastric surgeries. Aging of the patient population continued in 2022: the percentage of patients aged ≥ 70 years increased in all organ systems, and those aged ≥ 80 years now account for over 20% of cases in gastric surgery, but remained below 20% in hepatic and pancreatic surgery. Conversely, the proportion of patients aged < 60 years decreased in all organ systems, with rectal and anal surgery being the only exception, where this proportion slightly increased over the decade.

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 to 69	70 to 74	75 to 79	≥ 80
Esophagus	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
	2022	8626	77.7	22.3	18.9	12.1	17.2	24.1	16.1	11.7
Stomach and duodenum	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
	2022	55 010	65.3	34.7	14.9	7.6	12.1	21.1	18.2	26.2
Small intestine and colon	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
	2022	233 672	55.5	44.5	31.1	7.3	9.9	15.6	13.3	22.9
Rectum and anus	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
	2022	56 436	55.8	44.2	22.9	8.7	12.0	18.5	14.6	23.2
Liver	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
	2022	25 404	65.3	34.7	20.7	9.6	13.2	22.5	17.8	16.1
Gall bladder	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
	2022	132 796	55.0	45.0	31.5	9.3	11.2	16.3	13.2	18.6
Pancreas	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
	2022	19 772	57.1	42.9	16.3	8.7	13.4	23.8	20.5	17.2
Spleen	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
	2022	1750	56.2	43.8	33.9	10.3	12.9	17.1	12.4	13.3
Others	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
	2022	51 014	54.3	45.7	26.4	7.9	10.6	17.0	14.6	23.4

Table 4 shows trends in the types of institutions and the involvement of certified professionals. The proportion of surgeries performed in JSGS‐certified or affiliated institutions continues to increase annually for all organ systems. However, a slight decrease was observed in certified institution rates for spleen and liver surgeries in 2022. The participation of anesthesiologists remained high overall, though still lower for rectal and anal procedures (approximately 87%). Board‐certified surgeon participation continues to rise, particularly in high‐complexity surgeries involving the esophagus, pancreas, and liver, where participation exceeds 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	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
	2022	8626	96.3	2.1	1.6	98.7	96.9	82.8	17.2
Stomach and duodenum	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
	2022	55 010	82.5	13.0	4.5	96.3	90.8	55.3	44.7
Small intestine and colon	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
	2022	233 672	78.6	15.8	5.6	95.4	82.9	41.6	58.4
Rectum and anus	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
	2022	56 436	76.8	16.4	6.8	87.4	86.5	59.2	40.8
Liver	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
	2022	25 404	91.0	5.5	3.5	97.7	96.4	74.3	25.7
Gall bladder	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
	2022	132 796	74.7	18.6	6.7	95.4	83.7	38.9	61.1
Pancreas	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
	2022	19 772	93.8	4.5	1.7	98.0	97.7	77.7	22.3
Spleen	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
	2022	1750	90.0	6.7	3.3	96.3	92.9	62.4	37.6
Others	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
	2022	51 014	82.7	12.5	4.8	94.8	82.9	43.6	56.4

Table 5 presents changes in complication and mortality rates over the decade. Operative mortality decreased across almost all organ categories. The most substantial absolute reductions in operative mortality between 2013 and 2022 were observed in pancreatic surgery (−1.5 percentage points), esophageal surgery (−1.1 percentage points), and hepatic surgery (−1.0 percentage points). However, the incidence of postoperative complications (Clavien–Dindo grade ≥ III) has remained stable or slightly increased, suggesting that while fatal outcomes have decreased, the burden of morbidity remains a clinical concern. The postoperative complication rates have increased in esophageal, pancreatic, and splenic surgeries. The proportion of reoperations remained unchanged for most procedures.

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	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)
	2022	8626	1896	(22.0)	109	(1.3)	235	(2.7)
Stomach and duodenum	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)
	2022	55 010	5520	(10.0)	1027	(1.9)	1641	(3.0)
Small intestine and colon	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)
	2022	233 672	20 772	(8.9)	4489	(1.9)	6668	(2.9)
Rectum and anus	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)
	2022	56 436	4889	(8.7)	568	(1.0)	787	(1.4)
Liver	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)
	2022	25 404	2512	(9.9)	260	(1.0)	381	(1.5)
Gall bladder	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)
	2022	132 796	5252	(4.0)	577	(0.4)	892	(0.7)
Pancreas	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)
	2022	19 772	4473	(22.6)	175	(0.9)	283	(1.4)
Spleen	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)
	2022	1750	284	(16.2)	53	(3.0)	70	(4.0)
Others	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)
	2022	51 014	7646	(15.0)	2278	(4.5)	3154	(6.2)

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

^b Operative mortality was defined as the rate combining 30‐day mortality and in‐hospital deaths occurring beyond postoperative day 30.

3.3. Trends in Endoscopic Surgery Rates in Major Procedures

Figure 2 displays the annual trends in endoscopic (i.e., laparoscopic or thoracoscopic) surgery rates for eight major gastroenterological procedures.

FIGURE 2.

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.

Across all procedures, endoscopic surgery rates have continued to rise steadily over the past decade. In 2022, this upward trend persisted, with an approximate annual increase of 2%–4% in most procedures. Notably, esophagectomy showed the most remarkable growth in endoscopic adoption, increasing from under 20% in 2013 to nearly 80% in 2022. Similarly, distal gastrectomy and right hemicolectomy exceeded 70% endoscopic implementation, indicating widespread adoption of minimally invasive techniques in these procedures.

Although hepatectomy and pancreaticoduodenectomy have been slower to adopt endoscopic application due to their complexity, both procedures demonstrated a slow but steady increase in endoscopic rates, reaching over 20% and 15%, respectively, by 2022. These changes reflect improvements in surgical training, device technology, and institutional infrastructure supporting advanced laparoscopic surgery.

In contrast, surgery for acute diffuse peritonitis remained predominantly open, with minimal increase in endoscopic rates. This is likely attributable to the urgent and non‐selective nature of such procedures, which are often performed under unstable clinical conditions.

4. Discussion

This 2022 annual report based on the NCD provides a comprehensive overview of gastroenterological surgeries in Japan. The analysis includes over 590 000 surgical procedures and highlights ongoing trends in surgical practice, short‐term outcomes, institutional participation, and demographic shifts. The results confirm both the maturity of the NCD as a national data infrastructure and the evolving challenges in surgical care amid Japan's aging population and increasing demand for minimally invasive and emergency procedures.

One of the most notable findings is the continued rise in the proportion of elderly patients undergoing surgery. The percentage of patients aged ≥ 80 years increased across all organ systems, particularly in gastric, pancreatic, and hepatobiliary procedures. This reflects Japan's demographic trajectory and poses challenges for perioperative management, complication prevention, and functional recovery [30, 31]. Although operative mortality has decreased substantially over the past decade, the stable or slightly increasing complication rates suggest that morbidity management in elderly surgical patients remains a clinical priority.

The observed increase in complications in esophageal, pancreatic, and splenic surgeries may be attributable to the rising proportion of elderly patients and the broader application of technically complex operations. Specifically, proactive preventive measures, such as perioperative nutritional optimization and skeletal/respiratory muscle rehabilitation to improve physical and cognitive function, should more widely be implemented.

Although anesthesiologist participation exceeded 95% overall, it was relatively low in certain emergency and minor procedures such as anal surgery, external cholecystostomy, and hepatic trauma surgery. These findings highlight the importance of ensuring anesthesiologist involvement in all surgical procedures, particularly in emergency settings, to further improve patient safety. The high mortality observed in emergency surgeries underscores the importance of further educational initiatives and the reinforcement of multidisciplinary team‐based approaches to improve outcomes in these settings.

Minimally invasive surgery continues to expand across gastroenterological procedures. According to Table 4, the proportion of endoscopic surgeries exceeded 70% in low anterior resection and approached 80% in esophagectomy, while the rates in distal gastrectomy and right hemicolectomy remained around 60%. These trends are attributable to technical advancements, institutional adaptation, and broader training opportunities. In addition, the dissemination of evidence‐based guidelines recommending laparoscopic approaches has contributed to the broader adoption of minimally invasive surgery [32, 33, 34]. Notably, the rise in endoscopic esophagectomy is particularly striking, reflecting not only improved surgeon proficiency but also better dissemination of operative techniques and favorable oncological outcomes reported in recent domestic studies [35]. On the other hand, endoscopic application in procedures such as pancreaticoduodenectomy and hepatectomy remains limited, likely due to anatomical complexity, the long and challenging learning curves, and lack of consensus on oncological equivalence in malignancies.

Board‐certified surgeon participation remained high, especially in technically demanding procedures. Over 95% of esophagectomies, pancreaticoduodenectomies, and liver resections were performed with board‐certified surgeons either participating or acting as the lead surgeon. This high level of specialist involvement is a strength of the Japanese surgical system and contributes to improved outcomes and standardization of care. However, procedures with high emergency rates, such as surgery for hepatic trauma or gastrointestinal perforations, continued to show relatively lower board‐certified surgeon participation. This disparity reflects the fact that emergency surgeries are often performed after hours, when access to board‐certified surgeons, anesthesiologists, and full institutional resources is limited, thereby contributing to worse outcomes. Given that these procedures are also associated with significantly higher mortality and complication rates, it is essential to promote structured training and allocate human resources to improve emergency surgical quality.

The number of surgeries performed in JSGS‐certified or affiliated institutions continued to increase, suggesting consolidation of surgical care in higher‐level facilities. This centralization is likely contributing to better outcomes, particularly in complex surgeries. However, slight decreases in the proportion of certified institution involvement were observed in spleen and liver surgeries. These findings may indicate regional disparities or limitations in surgical workforce distribution that merit further investigation.

The divergent trends in mortality reduction between esophageal and gastric cancer surgeries may illustrate this phenomenon in practice. Esophagectomy has increasingly been centralized to high‐volume centers with multidisciplinary expertise. This centralization has led to substantial improvements in perioperative outcomes such as shorter hospital stays, enhanced postoperative recovery, and better nutritional management as reported in previous studies despite rising complication rates [35, 36, 37, 38, 39]. In contrast, gastric cancer surgery remains widely performed across a broad range of institutions. This dispersion may limit the extent of mortality reduction, highlighting the need for further centralization or standardized care pathways to achieve similar improvements across all major procedures.

A particularly important observation from the 2022 data is the divergence between mortality and morbidity trends. While operative mortality steadily declined, complication rates did not show a corresponding decrease. This indicates improvements in perioperative monitoring, intensive care unit support, and salvage procedures that may mitigate the consequences of complications, but also highlights a plateau in efforts to prevent complications altogether. Strategies such as enhanced recovery programs, prehabilitation, and perioperative nutritional interventions may be required to reduce complication incidence further.

The strength of this report lies in the comprehensiveness of the NCD, covering over 95% of all gastroenterological surgeries performed in Japan. However, it is important to acknowledge several limitations inherent in this analysis. First, the data are descriptive and not adjusted for risk factors or comorbidities, which limits causal inference. Second, because up to eight procedures can be recorded for a single patient, cases involving multiple simultaneous procedures may be counted more than once in aggregated data, potentially leading to overestimation of the total number of surgeries. Third, certain key indicators, such as cancer stage, functional outcomes, and long‐term survival, are not captured, restricting detailed oncological or quality‐of‐life assessments. Finally, some procedural categories include heterogeneous cases (e.g., enterostomy with or without enterectomy), which may introduce variability in outcome interpretation.

Despite these limitations, the NCD continues to function as a critical infrastructure for surgical quality improvement in Japan. The findings of this report reaffirm trends toward safe, standardized, and minimally invasive gastroenterological surgery, while also drawing attention to persistent challenges such as postoperative morbidity and the need for improved emergency care systems. Future directions should include integration of risk‐adjusted analytics, enhanced real‐time feedback to institutions, and the expansion of data collection into longer‐term outcomes.

5. Conclusion

This nationwide analysis of gastroenterological surgeries performed in 2022, based on the NCD, provides valuable insights into current surgical practices in Japan. The continued decrease in operative mortality, expansion of minimally invasive techniques, and high participation of board‐certified surgeons reflect positive trends in surgical quality. At the same time, persistent postoperative morbidity and the challenges associated with emergency procedures highlight areas for improvement. This report serves as a vital resource to advance surgical education, promote quality assurance, and inform evidence‐based policy‐making in gastroenterological surgery.

Author Contributions

Koshi Kumagai: conceptualization, methodology, writing – original draft. Arata Takahashi: methodology, data curation, writing – review and editing. Hideki Ueno: conceptualization, methodology, project administration, writing – review and editing, supervision. Naoki Hiki: writing – review and editing, supervision, writing – original draft, conceptualization. Yoshiki Kajiwara: methodology, data curation, writing – review and editing. Tomoki Ebata: writing – review and editing, conceptualization. Takao Otsuka: conceptualization, writing – review and editing. Taro Oshikiri: conceptualization, writing – review and editing. Yoshihiro Kakeji: conceptualization, writing – review and editing, supervision. Takanori Goi: conceptualization, writing – review and editing. Akio Saiura: conceptualization, writing – review and editing. Hiroshi Saeki: conceptualization, writing – review and editing. Chie Tanaka: conceptualization, writing – review and editing. Masanori Tokunaga: conceptualization, writing – review and editing. Tsutomu Fujii: conceptualization, writing – review and editing. Satoru Matsuda: conceptualization, writing – review and editing. Tsunekazu Mizushima: conceptualization, writing – review and editing. Hiroyuki Yamamoto: conceptualization, writing – review and editing, supervision, data curation. Yuko Kitagawa: supervision, writing – review and editing, conceptualization, project administration. Ken Shirabe: conceptualization, supervision, writing – review and editing, project administration.

Funding

The authors have nothing to report.

Ethics Statement

The authors have nothing to report.

Conflicts of Interest

Yuko Kitagawa is Editor‐in‐Chief and Hideki Ueno, Naoki Hiki, and Hiroshi Saeki are Associate Editors of Annals of Gastroenterological Surgery. Yoshihiro Kakeji, Takanori Goi, Akio Saiura, Chie Tanaka, Satoru Matsuda, Tsunekazu Mizushima, Tsutomu Fujii 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. The other authors declare no conflicts of interest.