This issue of the Journal includes 2 clinically highly useful and intriguing articles regarding the National Clinical Database (NCD) system in Japan. The NCD in Japan, which was launched in 2010 and started patient registration in January 2011, is a nationwide prospective registry linked to the surgical board‐certification system.1, 2 The NCD is being developed based on the National Surgical Quality Improvement Program of the American College of Surgeons (ACS‐NSQIP) in the USA. The NCD methodically gathers veracious data to develop a standardized surgical database for the purpose of quality improvement and health‐care quality evaluation. In addition, registering cases to the NCD is a requirement for all member institutions of the surgical society, because only registered cases can be used for board certification. Now, the NCD covers more than 90% of the general clinical practice data relating to surgery and surveys the operative risks and complications of approximately 1.2 million cases from more than 4000 institutions per year. In the gastrointestinal surgery section, all surgical cases are registered and require detailed input items for 8 procedures representing the performance of surgery in each specialty. To date, using the NCD data, detailed analyses of surgical risks and postoperative complications have been conducted for the aforementioned 8 surgical procedures including esophagectomy,3 total gastrectomy,4 distal gastrectomy,5 low anterior resection,6 right hemicolectomy,7 hepatectomy,8 pancreaticoduodenectomy,9 and surgery for acute diffuse peritonitis.10 Importantly, any surgeons in Japan can access these risk models and use them for benchmark performance and decision‐making by themselves as well as for informed consent for patients.
In this issue of the Journal, Kakeji and colleagues report the data of gastrointestinal surgery for more than 3 200 000 cases which were registered in the NCD from 2011 to 2016. The number of registered surgeries has been increasing year by year; the increase of cases especially with malignant colorectal diseases is remarkable. Furthermore, the authors focus attention on the significance of the board‐certification system of the Japanese Society of Gastroenterological Surgery (JSGS) for the purpose of the maintenance of surgical quality. The board‐certification system of JSGS consists of board‐certified training institutions and board‐certified surgeons. For certification as board‐certified training institutions, 600 or more gastroenterological operations determined by the certified committee are required in the previous 3 years. Board‐certified surgeons are required to experience 450 or more gastroenterological operations and to gain gastroenterological surgical training for more than 5 years according to the training curriculum in a board‐certified training institution. The authors showed that approximately 70% of all gastrointestinal surgeries were carried out at certified institutions, and the frequency of surgeries carried out at certified institutions was especially high for the esophagus, liver, pancreas, and spleen. The authors have stated that the mortality rates for all of the procedures seem to be acceptable as a nationwide outcome, as they are satisfactorily lower than those reported from other countries. Finally, the authors concluded that these favorable results might be explained by the high participation rate of board‐certified surgeons.
In the article that accompanies this editorial, Yoshida and colleagues present surgical outcomes of laparoscopic distal gastrectomy (LDG) compared to open distal gastrectomy (ODG), by using the propensity score‐matched method. In Japan, LDG has been increasingly part of general practice for patients with gastric cancer, especially for early‐stage cancer, and the number of LDG cases carried out in 2013 increased 6 times compared to that of 2001. Nonetheless, the quality and outcomes of LDG which is being done at various types of hospitals all over Japan have not been fully validated. To illustrate this concern, the authors used the NCD for 70 346 patients with gastric cancer and compared surgical outcomes between LDG and ODG in stage I patients and stage II–IV patients, respectively. Given the indication bias for LDG and ODG, they adjusted possible confounding factors by using precise propensity score matching and found no significant difference in mortality rates between LDG and ODG at any stages. Regarding morbidities, the incidences of surgical site infection and pneumonia were frequent in ODG patients, whereas the incidence of pancreatic fistula was common in LDG patients with stage I cancer. Taken together, the authors concluded that LDG in general practice might be a feasible therapeutic option in patients with both early gastric cancer and those with advanced gastric cancer in Japan.
The importance of NCD in Japan cannot be emphasized strongly enough. First, these 2 results based on the NCD can represent the whole current condition and surgical outcomes for gastrointestinal diseases in Japan, because the large amounts of data in NCD were systematically registered at various types of institutions (ie university hospital, cancer center, municipal hospital) throughout Japan. Second, I strongly believe that the international collaboration between NCD and ACS‐NSQIP may be important to compare the quality and outcome of surgery for gastrointestinal disease in Japan with those of other countries. I expect various clinical questions concerning surgical outcome and quality to be conclusively verified using the NCD in the future.
DISCLOSURE
Conflicts of Interest: Authors declare no conflicts of interest for this article.
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