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Annals of Gastroenterological Surgery logoLink to Annals of Gastroenterological Surgery
. 2019 May 20;3(4):426–450. doi: 10.1002/ags3.12258

Surgical outcomes of gastroenterological surgery in Japan: Report of the National Clinical Database 2011‐2017

Hiroshi Hasegawa 1,✉, Arata Takahashi 2, Yoshihiro Kakeji 1, Hideki Ueno 1, Susumu Eguchi 1, Itaru Endo 1, Akira Sasaki 1, Shuji Takiguchi 1, Hiroya Takeuchi 1, Masaji Hashimoto 1, Akihiko Horiguchi 1, Tadahiko Masaki 1, Shigeru Marubashi 1, Kazuhiro Yoshida 1, Hiroyuki Konno 1, Mitsukazu Gotoh 1, Hiroaki Miyata 2,3, Yasuyuki Seto 1
PMCID: PMC6635689  PMID: 31346582

Abstract

Background

The Japanese National Clinical Database (NCD) is a large‐scale, nationwide, web‐based data entry system that is linked to the surgical board certification system and covers almost all surgical cases carried out in Japan.

Aim

To evaluate outcomes according to the gastroenterological section of the NCD.

Methods

The 115 surgical procedures stipulated by the “Training Curriculum for Board‐Certified Surgeons in Gastroenterology” were registered from 2011 to 2017. The number of surgeries, preoperative comorbidities, and short‐term outcomes were compared between registration periods.

Results

In total, 3 818 414 cases have been registered. More than 70% of all surgeries were carried out at certified institutions. The annual number of cases has been increasing year after year, and the aged population has also been increasing. Although the rates of preoperative comorbidities and postoperative complications have been increasing, the postoperative mortality rate has remained relatively low; in 2017, the 30‐day mortality rate was 1.0% among those who underwent esophagectomy, 0.7% among those who underwent distal gastrectomy, 1.1% among those who underwent total gastrectomy, 1.3% among those who underwent right hemicolectomy, 0.5% among those who underwent low anterior resection, 1.3% among those who underwent hepatectomy, and 1.3% among those who underwent pancreaticoduodenectomy. The annual rate of endoscopic surgery dramatically increased over 7 years between 2011 and 2017, especially for low anterior resection (29.5%‐62.6%) and esophagectomy (31.0%‐56.1%).

Conclusion

This database is expected to ensure the quality of the board‐certification system and surgical outcomes in gastroenterological surgery.

Keywords: gastroenterological surgery, National Clinical Database, surgical outcome

1. INTRODUCTION

The Japanese National Clinical Database (NCD) is a large‐scale, nationwide, web‐based data entry system linked to the surgical board certification system, and covers almost all surgical cases (90%‐95%) carried out in Japan.1 The NCD was created in April 2010 with major support from the Japan Surgical Society and the Japanese Society of Gastroenterological Surgery (JSGS).2 Fifteen professional societies joined the NCD in 2018. The NCD has collected data on more than 9 690 000 surgical cases from almost 5000 facilities from January 2011 to December 2017.

In the gastroenterological section of the NCD, the JSGS selected 115 gastrointestinal operative procedures as important for the board certification system and eight main procedures (ie, esophagectomy, distal gastrectomy, total gastrectomy, right hemicolectomy, low anterior resection, hepatectomy, pancreaticoduodenectomy, and surgery for acute diffuse peritonitis) as especially important in terms of medical standards for improvement of surgical quality. All surgical cases are registered in the NCD with input of postoperative complications for the 115 procedures, and with detailed input such as comorbidities and morbidities for the eight main procedures.3 Risk models of mortality for the eight main procedures were established using approximately 120 000 surgical cases registered in 2011.4, 5, 6, 7, 8, 9, 10, 11 Risk models of morbidity for the eight main procedures were also established using approximately 250 000 surgical cases registered in 2011 and 2012.12, 13, 14, 15, 16, 17 Using the risk models of morbidity and mortality, the risk calculator was created. The risk calculator adjusts the risks of patients, provides the predicted morbidity and mortality of patients after inputting the preoperative data, and has been available on the websites of the participating hospitals since 2015.2 To evaluate the reliability of data collection, the JSGS started data verification activity in 2016 and found high accuracy of data entry.18

Following up on the 2011‐2016 Report,3 we herein summarize the 2011‐2017 data in the NCD based on gastroenterological surgery information on 3 818 414 cases of surgeries carried out and recorded from 2011 to 2017 along with the data on perioperative complications.

2. SUBJECTS AND METHODS

Methods were the same as previously reported.3 Subjects were patients whose surgical data were recorded in the NCD, and who underwent one or more of the 115 surgical procedures stipulated by the “Training Curriculum for Board‐Certified Surgeons in Gastroenterology,” using the “New classification of surgical difficulty.” The board certification system of the JSGS consists of board‐certified training institutions and board‐certified surgeons in gastroenterological surgery.19 One requirement for board‐certified training institutions is having carried out 600 or more gastroenterological operations as determined by the certifying committee (of which more than 120 gastroenterological operations were essential major surgery) in the last 3 years. Board‐certified surgeons are required to have received gastroenterological surgical training for more than 5 years according to the training curriculum in a board‐certified training institution authorized by the JSGS and to have carried out 450 or more gastroenterological operations. We targeted data from 2011 to 2017, adding the data of complications to cases that have already been reported in the 2011‐2016 Report on the 115 gastroenterological surgical procedures. Complications included surgical site infection (SSI), wound dehiscence, anastomotic leakage, pancreatic fistula, bile leakage, pneumonia, unplanned intubation, pulmonary embolism, ventilator‐assisted respiration longer than 48 hours, progressive renal insufficiency, acute renal failure, urinary tract infection, cerebrovascular accident with neurological deficit, coma longer than 24 hours, peripheral nerve injury, cardiac arrest requiring cardiopulmonary resuscitation, myocardial infarction, bleeding complication defined as transfusion in excess of one unit of blood, deep venous thrombosis, and sepsis. Postoperative complications were categorized into six grades according to the Clavien‐Dindo (C‐D) classification.20 In this study, complications of grade III (complications requiring intervention) or higher were defined as severe complications. Furthermore, among the 115 surgical procedures, we separated and studied the eight main operative methods that we deemed important in terms of medical standards.

We clarified the number of surgical cases and the mortality rates related to the 115 selected gastroenterological operative procedures. We also clarified the changes over time in the annual number of surgical cases, preoperative morbidity rates, and mortality rates related to the eight main operative procedures from 2011 to 2017. We also comparatively studied patient gender, age groups, institution type, and percentage of surgeries carried out by certified surgeons related to the eight main operative procedures.

The following points need to be considered in the interpretation of the data reported here. (i) As a maximum of eight operative procedures can be recorded for each case in the NCD, the total number of surgeries in “Results of the 115 gastroenterological surgical procedures for board certification system” is not the actual total number of surgical cases; (ii) cases with abnormal data or missing information in patient age, gender, or 30‐day postoperative status were excluded; (iii) cases in which several operative methods were carried out simultaneously were tallied for all operative methods; (iv) postoperative 30‐day mortality included all cases of mortality within 30 days after surgery regardless of pre‐ or post‐discharge status. Calculation of operative mortality included all patients who died during the index hospitalization, including hospital stays of up to 90 days, and any patient who died after hospital discharge within 30 days of the operative date.

3. RESULTS

3.1. Analysis of cases who underwent one or more of the 115 selected gastrointestinal operative procedures in the “Training Curriculum for Board‐Certified Surgeons in Gastroenterology”

The total number of cases that underwent one or more of the 115 selected gastroenterological surgical procedures reported in the NCD between January 1, 2011 and December 31, 2017 was 3 818 414. Based on organ involvement, 61 242 cases involved the esophagus (1.6%); 507 827 cases the stomach and duodenum (13.3%); 1 409 527 cases the small intestine and colon (36.9%); 360 101 cases the rectum and anus (9.4%); 182 462 cases the liver (4.8%); 894 793 cases the gallbladder (23.4%); 117 503 cases the pancreas (3.1%); 26 135 cases the spleen (0.7%), and 258 824 cases other organs (6.8%). The annual number of surgical cases for each organ generally showed an increasing trend over time except for surgeries on the stomach and duodenum, and surgeries on the spleen. The male : female ratio was approximately 8:2 for surgeries on the esophagus, 7:3 for surgeries on the stomach and duodenum, 7:3 for surgeries on the liver, and 6:4 for surgeries on other organs. Year by year, the percentages of older patients have been increasing for all organs (Table 1).

Table 1.

Annual changes in percentage of surgeries by gender and age group for 115 selected GI operative procedures in the training curriculum for board‐certified surgeons in gastroenterology classified according to target organ

Organ Year No. of surgeries Percentage by gender Percentage according to age group (y)
Male Female <60 60 to <65 65 to <70 70 to <75 75 to <80 ≥80
Esophagus 2011 7246 81.8 18.2 22.5 19.6 21.1 18.7 12.0 6.0
2012 8819 82.2 17.8 22.1 19.7 20.0 19.5 12.9 6.0
2013 8642 81.5 18.5 20.8 17.5 21.0 20.6 13.2 6.9
2014 9021 81.5 18.4 20.8 16.5 21.4 20.9 13.8 6.6
2015 8943 80.8 19.2 19.6 15.3 22.4 22.5 13.1 7.1
2016 9212 79.6 20.4 20.1 14.4 22.9 20.5 14.5 7.5
2017 9359 80.0 20.0 19.3 13.4 24.4 19.4 15.5 8.0
Stomach and duodenum 2011 66 740 68.0 32.0 20.1 14.4 14.0 17.1 16.4 18.0
2012 76 186 68.3 31.7 18.9 14.4 14.5 17.1 16.4 18.6
2013 75 583 67.9 32.1 18.6 13.1 15.5 17.2 16.9 18.7
2014 74 920 67.6 32.4 17.9 12.1 16.0 17.8 16.7 19.5
2015 73 877 67.8 32.2 17.4 11.1 17.1 17.8 16.6 19.9
2016 72 234 67.8 32.2 17.0 10.2 18.1 17.1 16.6 21.0
2017 68 287 67.2 32.8 16.3 9.9 17.5 17.3 17.2 21.8
Small intestine and colon 2011 151 143 56.7 43.3 37.4 10.9 10.5 12.1 12.2 16.9
2012 184 810 56.7 43.3 36.4 10.7 10.7 12.2 12.5 17.4
2013 198 677 56.9 43.1 35.6 10.1 11.3 12.7 12.4 17.8
2014 206 857 56.9 43.1 34.7 9.4 12.0 13.1 12.4 18.4
2015 214 453 57.1 42.9 34.0 8.9 12.9 13.1 12.3 18.7
2016 218 228 57.3 42.7 33.7 8.4 13.6 12.5 12.4 19.3
2017 235 359 56.7 43.3 32.7 8.0 13.2 12.7 12.9 20.5
Rectum and anus 2011 41 061 59.1 40.9 22.0 16.1 14.6 15.4 14.2 17.7
2012 49 704 58.3 41.7 22.3 14.8 14.6 15.5 14.3 18.5
2013 49 980 58.0 42.0 20.9 13.9 15.2 16.1 14.6 19.3
2014 51 454 58.3 41.7 20.4 13.1 16.0 16.4 14.2 19.9
2015 56 092 57.8 42.2 22.3 11.8 16.7 15.7 14.0 19.4
2016 55 666 57.3 42.7 22.0 11.1 17.9 15.0 13.6 20.4
2017 56 144 56.7 43.3 22.2 10.2 17.3 15.1 14.2 21.0
Liver 2011 22 855 67.3 32.7 22.2 16.5 16.3 18.7 17.2 9.2
2012 26 288 66.3 33.7 22.1 15.7 16.7 18.0 17.4 10.2
2013 25 814 66.1 33.9 21.3 14.6 17.6 18.7 17.3 10.5
2014 26 518 66.3 33.7 21.5 13.7 18.1 19.8 16.6 10.3
2015 26 378 65.7 34.3 20.8 12.8 18.9 19.4 16.5 11.5
2016 27 212 66.4 33.6 20.3 11.5 20.5 18.6 17.0 12.1
2017 27 397 65.8 34.2 20.1 11.0 20.2 18.8 17.2 12.7
Gallbladder 2011 103 183 54.5 45.4 34.3 14.0 12.2 13.8 12.8 13.0
2012 122 513 55.2 44.8 32.9 13.8 12.4 13.9 13.2 13.8
2013 129 162 55.3 44.7 32.6 12.9 13.0 14.2 13.2 14.0
2014 131 182 55.6 44.4 32.1 11.8 13.9 14.5 13.2 14.5
2015 133 126 55.6 44.4 32.0 11.2 15.0 14.1 13.0 14.8
2016 137 360 55.4 44.6 32.6 10.6 15.5 13.1 12.9 15.3
2017 138 267 55.6 44.4 32.2 10.2 15.1 13.5 13.2 15.8
Pancreas 2011 13 477 59.9 40.1 20.0 15.6 16.9 19.7 17.7 10.2
2012 15 550 60.0 40.0 19.8 15.2 17.0 19.5 18.2 10.3
2013 16 380 59.7 40.3 19.1 13.6 18.0 20.7 17.7 10.9
2014 17 313 59.5 40.5 18.4 12.4 19.0 21.0 18.2 11.1
2015 17 407 59.1 40.9 18.2 11.3 19.4 21.6 18.1 11.4
2016 18 238 58.9 41.1 18.2 10.4 19.9 20.4 19.0 12.2
2017 19 138 59.2 40.8 17.7 9.9 19.5 19.9 20.1 12.9
Spleen 2011 3609 61.3 38.7 35.3 15.6 14.7 14.8 11.9 7.8
2012 4142 61.4 38.6 32.9 16.3 15.0 15.1 12.9 7.8
2013 4509 61.8 38.2 30.8 14.9 15.9 16.5 13.1 8.7
2014 4272 61.8 38.2 29.9 13.0 17.3 17.0 13.8 9.1
2015 3568 60.4 39.6 29.7 11.4 17.3 16.6 14.1 10.8
2016 3171 57.3 42.7 31.9 11.7 17.7 15.7 12.5 10.5
2017 2864 58.7 41.3 31.6 11.0 18.1 16.0 13.3 10.0
Other 2011 23 218 55.0 45.0 32.0 11.9 11.3 13.3 13.8 17.6
2012 28 779 55.4 44.6 31.1 11.7 11.7 13.8 13.7 18.0
2013 36 363 53.1 46.9 28.3 10.9 12.7 14.1 14.8 19.1
2014 39 854 53.7 46.3 28.1 10.1 13.1 14.5 14.4 19.8
2015 41 465 53.2 46.8 27.4 9.4 14.0 14.5 14.2 20.6
2016 43 523 54.0 46.0 27.5 9.2 14.6 13.5 14.0 21.2
2017 45 622 54.1 45.9 27.0 8.2 14.7 13.5 14.6 21.9
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Abbreviation: GI, gastrointestinal.

In terms of the type of institution in which the surgeries were carried out, more than 70% of all surgeries were carried out at certified institutions, and the percentage of surgeries carried out at certified institutions was particularly high in 2017 for surgeries on the esophagus (92.7%) and pancreas (90.4%). The percentage of surgeries with participation of an anesthesiologist was more than 90% for almost all organs, except 84.8% for the rectum and anus. More than 70% of surgeries on most organs were carried out with the participation of a board‐certified surgeon. In 2017, the percentage of surgeries in which a certified surgeon was the operator was high for surgeries on the esophagus (71.8%), liver (62.5%), and pancreas (63.9%; Table 2). Postoperative complications, operative mortality rates, and 30‐day postoperative mortality rates are shown in Table 3. Complication rates were comparatively higher in 2017 for surgeries on the esophagus (20.7%) and the pancreas (21.3%); however, the mortality rates for procedures on these organs were not so high. Figure 1 shows the number of surgeries, rates of complications and mortality rates among cases who underwent the 115 gastroenterological surgical procedures according to organ involvement. Tables 4, 5, 6, 7, 8, 9, 10, 11, 12 show the number of surgeries carried out using each of the 115 gastroenterological surgical procedures, according to recording year and organ.

Table 2.

Institution type, anesthesiologist and specialist participation rates in the 115 selected GI operative procedures that were classified according to target organ

Organ Year No. of surgeries Percentage by institution type Anesthesiologist participation (%) Board‐certified surgeon participation (%) Medical practitioners (%)
Certified institution Related institution Other Board‐certified surgeons Non‐board‐certified surgeons
Esophagus 2011 7246 93.5 5.9 0.6 97.0 87.0 62.8 37.2
2012 8819 78.1 5.9 16.0 97.4 87.0 62.7 37.3
2013 8642 90.6 7.1 2.4 97.3 88.4 64.4 35.6
2014 9021 91.1 6.1 2.8 97.9 90.1 67.6 32.4
2015 8943 91.5 6.0 2.5 97.9 91.1 69.4 30.6
2016 9212 92.4 5.0 2.6 98.2 91.2 70.0 30.0
2017 9359 92.7 4.0 3.3 97.9 92.5 71.8 28.2
Stomach and duodenum 2011 66 740 80.2 17.3 2.6 92.8 69.3 35.1 64.9
2012 76 186 63.5 15.6 20.9 93.5 70.3 35.6 64.4
2013 75 583 76.3 19.3 4.4 93.3 73.5 37.7 62.3
2014 74 920 77.0 18.2 4.8 93.6 75.9 39.2 60.8
2015 73 877 77.1 18.3 4.6 93.9 76.1 39.2 60.8
2016 72 234 79.6 16.1 4.3 94.6 78.7 41.0 59.0
2017 68 287 79.6 15.3 5.1 94.8 79.7 41.8 58.2
Small intestine and colon 2011 151 143 76.8 20.2 2.9 88.1 59.2 25.1 74.9
2012 184 810 60.6 18.2 21.2 88.9 59.9 25.4 74.6
2013 198 677 72.6 22.2 5.2 89.6 62.7 26.6 73.4
2014 206 857 73.0 21.4 5.6 90.8 65.4 28.1 71.9
2015 214 453 73.8 20.7 5.5 91.6 66.3 28.5 71.5
2016 218 228 75.6 19.0 5.5 92.4 68.1 29.5 70.5
2017 235 359 76.0 18.0 6.0 92.9 70.1 31.1 68.9
Rectum and anus 2011 41 061 76.9 19.0 4.1 86.3 68.3 36.9 63.1
2012 49 704 60.4 18.2 21.4 85.7 68.6 37.6 62.4
2013 49 980 72.9 21.7 5.4 87.3 71.2 39.4 60.6
2014 51 454 73.5 20.9 5.6 87.9 73.7 41.6 58.4
2015 56 092 72.5 20.8 6.7 84.9 73.5 41.5 58.5
2016 55 666 74.1 19.4 6.6 85.7 74.7 42.1 57.9
2017 56 144 73.8 18.2 8.0 84.8 76.1 43.9 56.1
Liver 2011 22 855 89.3 9.7 1.1 95.6 85.2 55.2 44.8
2012 26 288 74.2 9.2 16.7 95.4 85.7 57.4 42.6
2013 25 814 86.3 10.7 2.9 96.3 87.5 57.1 42.9
2014 26 518 86.3 10.0 3.7 96.4 89.0 59.6 40.4
2015 26 378 87.3 9.5 3.2 96.6 89.1 59.1 40.9
2016 27 212 88.4 8.8 2.9 96.8 90.0 59.6 40.4
2017 27 397 89.0 7.8 3.1 97.1 91.8 62.5 37.5
Gallbladder 2011 103 183 73.9 22.5 3.6 91.8 61.9 26.4 73.6
2012 122 513 57.5 19.6 22.9 92.1 62.8 26.3 73.7
2013 129 162 69.9 24.1 5.9 92.2 65.4 27.3 72.7
2014 131 182 70.3 23.3 6.4 92.3 67.4 28.1 71.9
2015 133 126 70.8 22.8 6.4 92.9 68.4 28.1 71.9
2016 137 360 72.4 21.3 6.3 93.5 69.4 28.9 71.1
2017 138 267 72.6 20.1 7.3 93.7 71.4 29.9 70.1
Pancreas 2011 13 477 88.1 10.8 1.2 95.8 85.2 57.7 42.3
2012 15 550 72.8 8.7 18.5 96.3 86.5 59.9 40.1
2013 16 380 86.5 11.0 2.4 95.9 87.6 60.2 39.8
2014 17 313 86.9 9.9 3.3 96.2 89.1 61.3 38.7
2015 17 407 88.4 9.1 2.4 96.4 90.3 61.6 38.4
2016 18 238 89.8 8.0 2.3 96.8 91.1 62.4 37.6
2017 19 138 90.4 7.1 2.5 97.2 92.3 63.9 36.1
Spleen 2011 3609 87.0 11.6 1.4 94.6 75.2 44.9 55.1
2012 4142 70.5 9.5 20.0 81.7 75.8 44.4 55.6
2013 4509 83.2 13.8 3.0 95.2 75.4 43.3 56.7
2014 4272 85.4 11.5 3.1 94.6 77.5 45.2 54.8
2015 3568 85.6 12.3 2.1 94.8 78.9 45.5 54.5
2016 3171 86.8 10.1 3.1 95.7 80.5 48.0 52.0
2017 2864 87.4 9.3 3.3 95.3 82.3 49.1 50.9
Other 2011 23 218 80.2 17.0 2.8 90.3 60.4 27.2 72.8
2012 28 779 65.7 15.2 19.1 91.0 61.1 27.6 72.4
2013 36 363 76.1 19.3 4.6 91.5 63.4 28.5 71.5
2014 39 854 76.6 18.2 5.1 91.9 64.9 29.7 70.3
2015 41 465 78.0 17.2 4.8 92.4 65.6 29.4 70.6
2016 43 523 79.4 15.8 4.8 92.7 67.3 30.3 69.7
2017 45 622 80.1 14.8 5.1 93.1 69.7 32.3 67.7
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Abbreviation: GI, gastrointestinal.

Table 3.

No. of surgeries, postoperative complication rates and mortality rates in the 115 selected GI operative procedures that were classified according to target organ

Organ Year No. of surgeries No. of postoperative complicationsa/rate (%) No. of postoperative 30‐d mortalities/rate (%) No. of postoperative 90‐d mortalities/rate (%)
Esophagus 2011 7246 1294/17.9 87/1.2 279/3.9
2012 8819 1653/18.7 117/1.3 315/3.6
2013 8642 1593/18.4 121/1.4 327/3.8
2014 9021 1679/18.6 115/1.3 289/3.2
2015 8943 1709/19.1 103/1.2 304/3.4
2016 9212 1805/19.6 100/1.1 238/2.6
2017 9359 1938/20.7 108/1.2 208/2.2
Stomach and duodenum 2011 66 740 5354/8.0 992/1.5 2183/3.3
2012 76 186 6447/8.5 1085/1.4 2381/3.1
2013 75 583 6380/8.4 1059/1.4 2269/3.0
2014 74 920 6328/8.4 1064/1.4 2174/2.9
2015 73 877 6418/8.7 1007/1.4 2110/2.9
2016 72 234 6413/8.9 1066/1.5 2016/2.8
2017 68 287 6455/9.5 1046/1.5 1863/2.7
Small intestine and colon 2011 151 143 12 184/8.1 2943/1.9 5390/3.6
2012 184 810 15 395/8.3 3564/1.9 6583/3.6
2013 198 677 16 709/8.4 3723/1.9 6803/3.4
2014 206 857 17 776/8.6 3822/1.9 6961/3.4
2015 214 453 18 372/8.6 4019/1.9 7092/3.3
2016 218 228 19 020/8.7 3933/1.8 6621/3.0
2017 235 359 21 854/9.3 4588/1.9 7118/3.0
Rectum and anus 2011 41 061 3584/8.7 395/1.0 676/1.6
2012 49 704 4488/9.0 462/0.9 802/1.6
2013 49 980 4684/9.4 517/1.0 858/1.7
2014 51 454 4711/9.2 449/0.9 792/1.5
2015 56 092 4986/8.9 519/0.9 824/1.5
2016 55 666 5194/9.3 503/0.9 766/1.4
2017 56 144 5600/10.0 556/1.0 829/1.5
Liver 2011 22 855 1933/8.5 309/1.4 590/2.6
2012 26 288 2454/9.3 310/1.2 605/2.3
2013 25 814 2549/9.9 275/1.1 575/2.2
2014 26 518 2466/9.3 246/0.9 481/1.8
2015 26 378 2537/9.6 234/0.9 451/1.7
2016 27 212 2543/9.3 222/0.8 382/1.4
2017 27 397 2724/9.9 214/0.8 364/1.3
Gallbladder 2011 103 183 3473/3.4 483/0.5 946/0.9
2012 122 513 4587/3.7 531/0.4 1082/0.9
2013 129 162 4982/3.9 546/0.4 1130/0.9
2014 131 182 5020/3.8 569/0.4 1097/0.8
2015 133 126 5231/3.9 541/0.4 1036/0.8
2016 137 360 5320/3.9 559/0.4 980/0.7
2017 138 267 5761/4.2 576/0.4 968/0.7
Pancreas 2011 13 477 1994/14.8 175/1.3 386/2.9
2012 15 550 2595/16.7 213/1.4 437/2.8
2013 16 380 2917/17.8 211/1.3 482/2.9
2014 17 313 2966/17.1 195/1.1 423/2.4
2015 17 407 3229/18.6 185/1.1 379/2.2
2016 18 238 3543/19.4 185/1.0 390/2.1
2017 19 138 4076/21.3 219/1.1 365/1.9
Spleen 2011 3609  400/11.1 83/2.3 137/3.8
2012 4142 528/12.7 84/2.0 138/3.3
2013 4509 575/12.8 79/1.8 139/3.1
2014 4272 549/12.9 88/2.1 137/3.2
2015 3568 543/15.2 88/2.5 144/4.0
2016 3171 449/14.2 76/2.4 117/3.7
2017 2864 434/15.2 65/2.3 89/3.1
Others 2011 23 218 3494/15.0 1163/5.0 1887/8.1
2012 28 779 4388/15.2 1399/4.9 2293/8.0
2013 36 363 4712/13.0 1401/3.9 2346/6.5
2014 39 854 5176/13.0 1521/3.8 2489/6.2
2015 41 465 5380/13.0 1541/3.7 2545/6.1
2016 43 523 5975/13.7 1760/4.0 2684/6.2
2017 45 622 6539/14.3 1909/4.2 2699/5.9
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Abbreviation: GI, gastrointestinal.

a

Complications with Clavien‐Dindo grades IIIa to V.

Figure 1.

Figure 1

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Annual changes in the number of surgeries, postoperative complication rate, operative mortality rate, and 30‐d postoperative mortality rate: analysis of the 115 selected surgical procedures that were classified according to the involved organ. Postoperative complication rate: the rate of complications with Clavien‐Dindo (C‐D) classification of grade III (complications requiring intervention) or higher

Table 4.

Changes in the annual number of surgeries among the GI operative procedures on the esophagus

Organ Degree of difficulty Procedure No. of surgeries
2011 2012 2013 2014 2015 2016 2017
Esophagus Low Cervical periesophageal abscess drainage 23 27 34 42 37 43 39
Med Esophageal suture (perforation, injury) 156 204 198 185 199 215 202
Med Thoracic periesophageal abscess drainage 22 23 18 27 27 21 21
Med Esophageal foreign body extraction 19 21 26 25 30 32 35
Med Esophageal diverticulum resection 27 32 35 48 41 34 47
Med Benign esophageal tumor removal 61 69 66 68 52 64 73
Med Esophageal resection (removal only) 388 506 580 570 571 721 720
Med Esophageal reconstruction: reconstruction only (gastric tube reconstruction) 699 844 888 799 848 772 828
Med Esophageal fistula construction 97 106 128 126 125 162 176
Med Esophagocardioplasty 321 418 392 398 362 365 366
Med Achalasia surgery 77 109 84 118 101 210 208
High Esophagectomy 4916 5946 5694 6091 6060 6041 6100
High Esophageal reconstruction: reconstruction only (colon reconstruction) 65 56 63 77 51 40 41
High Esophageal bypass 93 110 137 143 152 130 154
High Bronchoesophageal fistula surgery 6 5 9 12 7 13 5
High Secondary esophageal reconstruction 276 343 290 292 280 349 344
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Abbreviation: GI, gastrointestinal; Med, medium.

Table 5.

Changes in the annual number of surgeries among the GI operative procedures on the stomach and duodenum

Organ Degree of difficulty Procedure No. of surgeries
2011 2012 2013 2014 2015 2016 2017
Stomach and duodenum Low Gastrostomy and suture gastrorrhaphy 52 69 74 66 65 77 64
Low Diverticulum, polypectomy (excluding endoscopic resection) 156 186 231 247 226 202 230
Low Truncal vagotomy 3 6 6 2 6 3 4
Low Gastroenterostomy (including duodenal jejunostomy) 4651 5330 5571 5893 5636 5633 5867
Low Gastric fistula construction (excluding PEG) 1717 1698 1633 1722 1790 1748 1695
Low Gastric pyloroplasty 116 129 115 126 100 69 82
Low Gastric volvulus (volvulus) surgery and rectopexy 40 38 39 0 47 42 56
Low Gastric suture (including gastric suture for gastric rupture, suture closure for gastroduodenal perforation, omental implantation and omental transposition) 4707 5738 5669 5837 5858 6164 5847
Low Local gastrectomy (including wedge resection) 2466 3108 3233 3354 3625 3766 4076
Med Gastrectomy (including distal gastrectomy, pylorus‐preserving gastrectomy and segmental [transverse] gastrectomy) 34 160 38 750 39 957 38 584 37 819 36 852 35 517
Med Selective vagotomy 8 8 10 7 6 4 6
High Total gastrectomy (including fundusectomy) 18 652 21 122 19 035 19 071 18 695 17 670 14 840
High Left upper abdominal exenteration 12 4 10 11 4 4 3
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Abbreviations: GI, gastrointestinal; PEG, percutaneous endoscopic gastrostomy.

Table 6.

Changes in the annual number of surgeries among the GI operative procedures on the small intestine and colon

Organ Degree of difficulty Procedure No. of surgeries
2011 2012 2013 2014 2015 2016 2017
Small intestine and colon Low Enterotomy and enterorrhaphy 2982 3505 4025 4362 4412 4311 4378
Low Disinvagination (invasive) 172 250 234 239 209 242 221
Low Partial enterectomy (benign) 5792 7602 8564 8938 9449 9591 9465
Low Ileocecal resection (benign) 3238 4104 4313 4472 4523 4675 4643
Low Partial colectomy and sigmoid colectomy (benign) 4946 6239 6626 7358 7583 7971 8115
Low Appendectomy 43 437 51 316 54 421 54 319 54 897 55 168 55 261
Low Enterostomy and closure (without enterectomy) 15 192 19 371 21 600 23 425 24 666 25 458 26 795
Med Enterectomy (malignant) 2448 2703 3016 3082 3320 3360 3671
Med Ileocecal resection (malignant) 5492 9274 10 327 11 368 12 224 12 872 13 133
Med Partial colectomy and sigmoid colectomy (malignant) 25 034 29 863 31 495 32 092 33 518 33 936 32 986
Med Right hemicolectomy 17 890 21 034 21 814 22 446 22 850 22 829 22 543
Med Left hemicolectomy 5241 5347 5644 5763 6119 6178 5991
Med Total colectomy 2846 3131 1892 1701 1752 1735 1789
Med Intestinal obstruction surgery (with bowel resection) 5117 6496 7412 7775 7912 7898 24 142a
Med Enterostomy and closure (with enterectomy) 11 008 14 162 16 853 19 049 20 520 21 525 21 774
High Proctocolectomy and ileoanal (canal) anastomosis 308 413 441 468 499 479 452
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Abbreviation: GI, gastrointestinal.

a

2011‐2016: Intestinal obstruction surgery with bowel resection, 2017: Intestinal obstruction surgery with or without bowel resection.

Table 7.

Changes in the annual number of surgeries among the GI operative procedures on the rectum and anus

Organ Degree of difficulty Procedure No. of surgeries
2011 2012 2013 2014 2015 2016 2017
Rectum and anus Low Transanal rectal tumor removal 2483 3300 1657 1513 3690 3651 3761
Low Proctocele surgery (transanal) 1802 2461 2488 2602 2773 2805 2810
Med Rectectomy (benign) 300 386 2196 2060 1914 1688 1491
Med High anterior resection 7053 8920 8985 9496 9934 10 477 10 546
Med Hartmann's procedure 3562 4614 4865 5194 5650 5755 6034
Med Proctocele surgery (abdominoperineal) 659 996 1119 1181 1411 1538 1771
Med Malignant anorectal tumor excision (transanal) 1517 1037 898 864 821 778 735
Med Anal sphincteroplasty (by tissue replacement) 969 1378 1721 1718 2132 2045 2520
High Rectectomy (malignant) 5308 5828 4474 4531 4825 5096 5082
High Low anterior resection 16 984 20 321 21 096 21 861 22 493 21 387 20 879
High Pelvic evisceration 359 389 412 374 385 402 456
High Anorectal malignant tumor excision (posterior approach) 65 74 69 60 64 44 59
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Abbreviation: GI, gastrointestinal.

Table 8.

Changes in the annual number of surgeries among the GI operative procedures on the liver

Organ Degree of difficulty Procedure No. of surgeries
2011 2012 2013 2014 2015 2016 2017
Liver Low Hepatorrhaphy 172 202 161 196 147 161 64
Low Liver abscess drainage (excluding percutaneous procedures) 42 47 54 44 59 55 51
Low Hepatic cyst resection. Suture. Drainage 425 535 606 695 695 741 861
Low Partial hepatectomy 9431 10 919 10 708 11 598 12 063 12 604 12 847
Low Liver biopsy (excluding percutaneous procedures) 122 264 176 165 175 126 138
Low Liver coagulonecrotic therapy (excluding percutaneous procedures) 1958 2122 1083 1069 939 854 811
Med Lateral segmentectomy of the liver 1390 1632 1773 1807 1666 1704 1598
Med Esophageal and gastric varix surgery 94 109 67 61 46 67 52
High Hepatectomy (segmented or more; excluding lateral segments) 7434 8239 7937 7666 7439 7610 7698
High Systematic subsegmentectomy 996 1353 2374 2257 2221 2367 2391
High Liver transplant 692 775 757 848 790 800 748
High Hepatopancreatoduodenectomy 99 91 118 112 138 123 138
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Abbreviation: GI, gastrointestinal.

Table 9.

Changes in the annual number of surgeries among the GI operative procedures on the gallbladder

Organ Degree of difficulty Procedure No. of surgeries
2011 2012 2013 2014 2015 2016 2017
Gallbladder Low Cholangiotomy 142 163 174 139 141 132 106
Low Cysticolithectomy 1094 1093 750 641 611 571 63
Low Cholecystectomy 93 665 112 048 119 455 122 026 124 267 128 809 130 570
Low External cholecystostomy 104 119 127 124 109 146 143
Low Cystoenteric anastomosis 70 73 61 61 67 59 54
Med Cysticolithectomy 3682 4117 3880 3574 3342 3057 2962
Med Biliary tract reconstruction 150 162 265 315 362 347 332
Med Biliary bypass 1594 1751 1765 1686 1613 1490 1300
Med Cholangioplasty 201 180 192 168 156 176 128
Med Duodenal papilloplasty 66 68 50 33 31 37 30
Med Choledochal dilatation 217 240 254 242 248 291 264
Med Biliary fistula closure 43 42 42 37 40 34 39
High Malignant gallbladder tumor surgery (excluding simple cholecystectomy) 869 1013 929 963 969 948 1027
High Malignant bile duct tumor surgery 1268 1426 1202 1153 1155 1245 1232
High Biliary atresia surgery 18 18 16 20 15 18 17
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Abbreviation: GI, gastrointestinal.

Table 10.

Changes in the annual number of surgeries among the GI operative procedures on the pancreas

Organ Degree of difficulty Procedure No. of surgeries
2011 2012 2013 2014 2015 2016 2017
Pancreas Low External pancreatic cyst drainage 29 27 13 21 8 13 15
Low External pancreatic duct drainage 17 20 26 28 22 34 13
Med Pancreatorrhaphy 22 17 21 34 27 17 5
Med Partial pancreatic resection 126 148 202 182 165 177 187
Med Distal pancreatectomy (benign) 1018 1398 1372 1557 1477 1536 1568
Med Pancreatoenteric anastomosis 81 71 59 49 44 39 35
Med Pancreatic (duct) anastomosis 223 295 309 388 280 269 328
Med Acute pancreatitis surgery 94 117 104 103 90 132 76
Med Pancreatolithiasis surgery 17 17 14 35 31 29 22
Med Plexus pancreaticus capitalis resection 1 1 2 0 1 1 0
High Pancreaticoduodenectomy 8305 9329 10 068 10 400 10 576 11 028 11 580
High Distal pancreatectomy (malignant) 2861 3344 3483 3750 3930 4173 4508
High Total pancreatectomy 348 408 423 496 503 545 561
High Duodenum‐preserving pancreas head resection 201 193 111 85 63 49 50
High Segmental pancreatic resection 131 163 138 165 162 169 155
High Distal pancreatectomy 3 2 35 20 28 27 35
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Abbreviation: GI, gastrointestinal.

Table 11.

Changes in the annual number of surgeries among the GI operative procedures on the spleen

Organ Degree of difficulty Procedure No. of surgeries
2011 2012 2013 2014 2015 2016 2017
Spleen Low Splenorrhaphy 22 35 26 24 17 30 32
Med Splenectomy 3564 4063 4457 4215 3525 3117 2811
Med Partial splenic resection 23 44 26 33 26 24 21
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Abbreviation: GI, gastrointestinal.

Table 12.

Changes in the annual number of surgeries among the GI operative procedures on other organs

Organ Degree of difficulty Procedure No. of surgeries
2011 2012 2013 2014 2015 2016 2017
Other Low Localized intra‐abdominal abscess surgery 2526 2944 3231 3262 2942 2764 2630
Low Exploratory laparotomy 5036 6852 7532 8271 8982 9629 10 416
Med Acute diffuse peritonitis surgery 7753 9177 10 447 12 085 13 030 13 981 14 423
Med Ventral hernia surgery 5053 6095 11 387 12 298 12 494 12 896 13 663
Med Diaphragm suture 183 218 246 213 257 253 313
Med Esophageal hiatus hernia surgery 511 602 725 757 800 842 981
Med Retroperitoneal tumor surgery 622 837 806 805 807 850 829
Med Abdominal wall/mesenteric/omental tumor resection 979 1398 1402 1509 1506 1707 1767
Med Gastrointestinal perforation closure 504 576 522 589 587 549 530
High Diaphragmatic hiatus hernia surgery 51 80 65 65 60 52 70
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Abbreviation: GI, gastrointestinal.

3.2. Eight main operative procedures

The number of surgeries carried out annually for the eight main operative procedures, the percentage by gender, and the percentage according to age group between 2011 and 2017 are shown in Table 13. The percentage of patients who were ≥80 years has been increasing for all eight main procedures. Regarding the institution type in which the surgeries were carried out, more than 75% of the surgeries were carried out at certified institutions and the percentage of surgeries done at certified institutions was particularly high in 2017 for esophagectomy (95.3%), hepatectomy (non‐lateral segments; 91.2%), and pancreaticoduodenectomy (90.5%). The percentage of surgeries with participation of an anesthesiologist was more than 90% for all eight procedures. Approximately 95% of esophagectomy, hepatectomy (non‐lateral segments), and pancreaticoduodenectomy procedures involved participation of a board‐certified surgeon, whereas the percentages of right hemicolectomy and acute diffuse peritonitis surgeries with participation of a board‐certified surgeon were 76.4% and 69.0% in 2017, respectively (Table 14).

Table 13.

Changes in the annual percentage of surgeries by gender and age group for the eight main operative procedures

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

Institution type, anesthesiologist and specialist participation rates in the eight main operative procedures

Procedure Year No. of surgeries Percentage by institution type Anesthesiologist participation (%) Board‐certified surgeon participation (%) Medical practitioners (%)
Certified institution Related institution Other Board‐certified surgeons Non‐board‐certified surgeons
Esophagectomy 2011 4916 94.2 5.3 0.5 97.6 88.4 63.5 36.5
2012 5946 78.3 4.9 16.8 98.1 89.0 64.8 35.2
2013 5694 92.9 5.9 1.2 98.0 90.8 66.6 33.4
2014 6091 93.6 4.7 1.7 98.6 92.6 70.2 29.8
2015 6060 93.6 4.6 1.8 98.5 93.5 72.1 27.9
2016 6041 94.5 3.8 1.7 98.8 93.7 73.2 26.8
2017 6100 95.3 3.1 1.7 98.8 94.8 74.7 25.3
Gastrectomy (distal) 2011 34 160 81.1 16.6 2.3 93.2 71.3 37.0 63.0
2012 38 750 64.5 15.2 20.3 93.9 72.5 37.9 62.1
2013 39 957 76.6 19.2 4.1 93.6 76.1 40.6 59.4
2014 38 584 77.7 17.8 4.5 94.0 78.4 42.1 57.9
2015 37 819 77.3 18.3 4.4 94.1 78.1 41.3 58.7
2016 36 852 80.2 15.9 4.0 95.0 81.8 43.8 56.2
2017 35 517 80.2 14.9 4.8 95.4 82.4 45.2 54.8
Total gastrectomy 2011 18 652 80.9 16.8 2.3 93.9 71.6 37.4 62.6
2012 21 122 63.0 15.3 21.7 94.3 72.1 38.0 62.0
2013 19 035 77.2 18.9 3.9 94.2 75.0 39.5 60.5
2014 19 071 77.8 17.9 4.3 94.4 77.7 41.7 58.3
2015 18 695 77.9 17.9 4.1 94.5 78.2 42.6 57.4
2016 17 670 80.0 15.9 4.0 95.0 81.4 45.0 55.0
2017 14 840 79.3 15.8 4.9 95.0 80.7 44.3 55.7
Right hemicolectomy 2011 17 890 75.7 21.2 3.1 92.7 66.0 30.5 69.5
2012 21 034 60.0 18.3 21.7 93.0 67.1 30.8 69.2
2013 21 814 72.1 22.3 5.6 92.9 69.7 32.6 67.4
2014 22 446 71.2 23.1 5.7 93.4 71.9 33.6 66.4
2015 22 850 72.1 22.0 5.9 94.1 72.4 33.5 66.5
2016 22 829 73.8 20.1 6.1 94.5 74.2 34.3 65.7
2017 22 543 75.0 18.4 6.6 94.7 76.4 37.1 62.9
Low anterior resection 2011 16 984 79.4 17.7 2.9 93.4 72.7 41.6 58.4
2012 20 321 64.0 16.2 19.7 93.8 73.0 42.3 57.7
2013 21 096 76.3 19.5 4.2 93.7 75.5 44.3 55.7
2014 21 861 76.2 19.0 4.9 94.4 78.2 47.2 52.8
2015 22 493 76.9 18.3 4.8 94.6 79.2 47.7 52.3
2016 21 387 79.0 16.4 4.7 95.0 81.0 48.8 51.2
2017 20 879 79.3 15.6 5.1 95.2 83.1 51.2 48.8
Hepatectomy (non‐lateral segments) 2011 7434 91.1 8.0 0.8 96.4 88.9 61.5 38.5
2012 8239 75.9 7.9 16.3 96.8 89.3 64.0 36.0
2013 7937 88.1 9.7 2.2 96.9 91.0 65.2 34.8
2014 7666 88.2 8.7 3.1 96.7 92.3 66.6 33.4
2015 7439 89.2 8.6 2.2 97.2 92.3 66.6 33.4
2016 7610 90.7 7.1 2.1 97.1 93.3 67.7 32.3
2017 7698 91.2 6.6 2.2 97.7 95.1 72.3 27.7
Pancreaticoduodenectomy 2011 8305 87.8 11.0 1.2 95.9 85.7 58.7 41.3
2012 9329 72.4 8.8 18.8 96.6 87.2 60.9 39.1
2013 10 068 85.9 11.7 2.4 96.0 87.9 60.5 39.5
2014 10 400 86.4 10.4 3.3 96.4 90.3 62.2 37.8
2015 10 576 88.5 9.2 2.4 96.9 90.9 62.1 37.9
2016 11 028 89.4 8.3 2.3 97.1 91.7 63.3 36.7
2017 11 580 90.5 7.2 2.3 97.3 93.0 65.0 35.0
Acute diffuse peritonitis surgery 2011 7753 80.6 16.9 2.4 90.0 58.5 23.5 76.5
2012 9177 65.2 16.4 18.4 90.4 59.4 22.7 77.3
2013 10 447 77.7 18.1 4.2 91.2 62.4 23.9 76.1
2014 12 085 77.7 17.2 5.1 91.9 63.3 25.1 74.9
2015 13 030 79.8 15.9 4.3 92.2 64.5 24.9 75.1
2016 13 981 82.2 13.8 4.0 93.0 66.8 26.1 73.9
2017 14 423 83.1 13.0 3.8 93.3 69.0 27.2 72.8
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The rate of preoperative chemotherapy within 90 days increased over time and was 50.9% for esophagectomy in 2017. Although the rates of preoperative chemotherapy in patients who underwent total gastrectomy, low anterior resection, or pancreaticoduodenectomy were relatively low (<10%), the rates of preoperative chemotherapy in patients who underwent these procedures showed an increasing trend over time (Table 15).

Table 15.

Changes in the annual number of surgeries in patients who received preoperative chemotherapy or radiation prior to the eight main operative procedures

  Year No. of surgeries No. with preoperative chemotherapy within 30 d/rate (%) No. with preoperative chemotherapy within 90 d/rate (%) No. with preoperative radiotherapy within 90 d/rate (%)
Esophagectomy 2011 4914 928/18.9 –/– 235/4.8
2012 5947 1131/19.0  2476/41.6 432/7.3
2013 5694 982/17.2 2386/41.9 374/6.6
2014 6092 1145/18.8 2733/44.9 435/7.1
2015 6058 1153/19.0 2842/46.9 416/6.9
2016 6041 1150/19.0 2955/48.9 398/6.6
2017 6100 1103/18.1 3103/50.9 400/6.6
Gastrectomy (distal) 2011 32 241 469/1.5 –/– 47/0.1
2012 36 715 502/1.4 902/2.5 45/0.1
2013 39 094 516/1.3 1028/2.6 51/0.1
2014 37 718 479/1.3 1002/2.7 36/0.1
2015 37 082 492/1.3 990/2.7 50/0.1
2016 36 197 481/1.3 1070/3.0 36/0.1
2017 34 861 462/1.3 1073/3.1 46/0.1
Total gastrectomy 2011 18 046 814/4.5 –/– 33/0.2
2012 20 467 835/4.1 1540/7.5 31/0.2
2013 18 777 656/3.5 1364/7.3 48/0.3
2014 17 962 713/4.0 1002/5.6 48/0.3
2015 17 385 638/3.7 1452/8.4 38/0.2
2016 16 188 583/3.6 1366/8.4 34/0.2
2017 14 840 566/3.8 1385/9.3 28/0.2
Right hemicolectomy 2011 17 884 157/0.9 –/– 24/0.1
2012 21 027 184/0.9 317/1.5 32/0.2
2013 21 816 187/0.9 363/1.7 0.1
2014 22 444 192/0.9 370/1.6 29/0.1
2015 22 851 204/0.9 409/1.8 53/0.2
2016 22 829 256/1.1 438/1.9 56/0.2
2017 22 543 192/0.9 416/1.8 46/0.2
Low anterior resection 2011 16 982 355/2.1 –/– 293/1.7
2012 20 319 481/2.4 1131/5.6 484/2.4
2013 21 097 477/2.3 1273/6.0 523/2.5
2014 21 854 531/2.4 1533/7.0 641/2.9
2015 22 496 565/2.5 1721/7.7 599/2.7
2016 21 387 507/2.4 1682/7.9 627/2.9
2017 20 879 526/2.5 1759/8.4 665/3.2
Hepatectomy (non‐lateral segments) 2011 7439 420/5.6 –/– 31/0.4
2012 8242 508/6.2 1290/15.7 38/0.5
2013 7937 454/5.7 1293/16.3 36/0.5
2014 7663 419/5.5 1170/15.3 32/0.4
2015 7439 358/4.8 1152/15.5 25/0.3
2016 7610 350/4.6 1121/14.7 46/0.6
2017 7698 326/4.2 1137/14.8 64/0.8
Pancreaticoduodenectomy 2011 8306 227/2.7 –/– 88/1.1
2012 9336 229/2.5 440/4.7 155/1.7
2013 10 069 291/2.9 584/5.8 213/2.1
2014 10 395 304/2.9 631/6.1 214/2.1
2015 10 577 339/3.2 766/7.2 272/2.6
2016 11 028 374/3.4 850/7.7 268/2.4
2017 11 580 410/3.5 907/7.8 240/2.1
Acute diffuse peritonitis surgery 2011 7751 277/3.6 –/– 47/0.6
2012 9182 352/3.8 463/5.0 61/0.7
2013 10 452 412/3.9 573/5.5 62/0.6
2014 12 085 396/3.3 570/4.7 60/0.5
2015 13 030 483/3.7 669/5.1 76/0.6
2016 13 981 511/3.7 732/5.2 88/0.6
2017 14 423 553/3.8 762/5.3 82/0.6
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‐/‐ indicates lack of data

The number and rate of comorbidities and American Society of Anesthesiologists (ASA) score in patients who underwent the eight main procedures are shown in Table 16. The annual rates of diabetes mellitus and hypertension increased over time for all eight procedures.

Table 16.

Changes in the annual number of surgeries in patients with preoperative comorbidities among patients who underwent the eight main operative procedures

  Year No. of surgeries No. with diabetes mellitus/rate (%) No. with dyspnea within 30 d/rate (%) No. with COPD/rate (%) No. with hypertension within 30 d/rate (%) No. with myocardial infarction within 6 mo/rate (%) No. receiving dialysis within 14 d/rate (%) Percentage according to ASA score (%)
1 2 3 4 5
Esophagectomy 2011 4914 628/12.8 102/2.1 302/6.1 1531/31.2 8/0.2 13/0.3 39.5 52.9 7.4 0.1 0.0
2012 5947 773/13.0 92/1.5 374/6.3 1881/31.6 22/0.4 12/0.2 31.8 61.0 6.8 0.2 0.2
2013 5694 737/12.9 98/1.7 360/6.3 1944/34.1 17/0.3 16/0.3 29.5 62.5 7.7 0.2 0.1
2014 6092 824/13.5 100/1.6 497/8.2 2144/35.2 17/0.3 8/0.1 27.6 64.7 7.5 0.2 0.1
2015 6058 895/14.8 82/1.4 527/8.7 2200/36.3 13/0.2 22/0.4 24.3 67.6 7.8 0.2 0.1
2016 6041 895/14.8 76/1.3 501/8.3 2233/37.0 12/0.2 23/0.4 19.7 71.7 8.4 0.1 0.1
2017 6100 941/15.4 72/1.2 469/7.7 2357/38.6 11/0.2 20/0.3 16.5 72.4 10.9 0.1 0.1
Gastrectomy (distal) 2011 32 250 5079/15.7 737/2.3 1182/3.7 11 192/34.7 185/0.6 271/0.8 40.5 49.7 9.2 0.4 0.2
2012 36 689 6143/16.7 772/2.1 1316/3.6 13 397/36.5 249/0.7 294/0.8 35.2 54.0 10.1 0.5 0.2
2013 39 094 6742/17.2 740/1.9 1639/4.2 14 665/37.5 211/0.5 331/0.8 31.7 57.1 10.6 0.4 0.2
2014 37 719 6652/17.6 702/1.9 1754/4.7 14 677/38.9 161/0.4 290/0.8 28.7 59.8 11.0 0.4 0.1
2015 37 083 6830/18.4 649/1.8 1833/4.9 15 023/40.5 174/0.5 279/0.8 25.7 62.2 11.7 0.4 0.1
2016 36 197 6791/18.8 627/1.7 1890/5.2 14 910/41.2 175/0.5 295/0.8 23.1 63.9 12.4 0.4 0.1
2017 34 862 6580/18.9 563/1.6 1693/4.9 14 631/42.0 159/0.5 283/0.8 19.9 66.4 13.2 0.4 0.1
Total gastrectomy 2011 18 048 2951/16.4 448/2.5 796/4.4 5983/33.2 125/0.7 95/0.5 38.0 52.2 9.2 0.4 0.2
2012 20 462 3424/16.7 482/2.4 868/4.2 7335/35.8 166/0.8 125/0.6 33.0 56.2 10.0 0.5 0.3
2013 18 775 3304/17.6 368/2.0 880/4.7 6999/37.3 98/0.5 116/0.6 28.8 59.8 10.8 0.4 0.2
2014 17 963 3332/18.5 346/1.9 922/5.1 6850/38.1 81/0.5 105/0.6 25.6 62.4 11.4 0.4 0.1
2015 17 387 3178/18.3 341/2.0 915/5.3 6761/38.9 65/0.4 109/0.6 23.3 64.5 11.6 0.4 0.2
2016 16 191 3117/19.3 322/2.0 917/5.7 6535/40.4 79/0.5 94/0.6 20.8 65.8 12.8 0.5 0.1
2017 14 840 2875/19.4 271/1.8 784/5.3 6046/40.7 71/0.5 98/0.7 17.4 68.7 13.2 0.5 0.1
Right hemicolectomy 2011 17 885 3073/17.2 518/2.9 526/2.9 6495/36.3 125/0.7 182/1.0 31.8 53.8 13.0 1.0 0.4
2012 21 022 3564/17.0 573/2.7 586/2.8 7830/37.2 155/0.7 210/1.0 29.2 56.0 13.3 1.1 0.4
2013 21 816 3802/17.4 470/2.2 614/2.8 8431/38.6 112/0.5 223/1.0 26.4 58.3 13.8 1.0 0.4
2014 22 444 4230/18.8 514/2.3 684/3.0 9048/40.3 118/0.5 226/1.0 23.1 61.3 14.4 0.9 0.3
2015 22 851 4355/19.1 471/2.1 705/3.1 9419/41.2 121/0.5 216/0.9 21.0 62.3 15.5 0.9 0.4
2016 22 829 4484/19.6 477/2.1 721/3.2 9575/41.9 88/0.4 247/1.1 19.0 63.3 16.4 1.0 0.3
2017 22 543 4481/19.9 447/2.0 715/3.2 9535/42.3 105/0.5 274/1.2 16.4 64.7 17.4 1.1 0.4
Low anterior resection 2011 16 981 2908/17.1 259/1.5 443/2.6 5321/31.3 72/0.4 80/0.5 42.1 50.3 7.5 0.1 0.0
2012 20 306 3421/16.8 300/1.5 524/2.6 6533/32.2 102/0.5 102/0.5 38.7 52.7 8.3 0.2 0.1
2013 21 097 3505/16.6 241/1.1 597/2.8 6965/33.0 75/0.4 112/0.5 35.5 55.7 8.4 0.3 0.1
2014 21 854 3836/17.6 277/1.3 851/3.9 7634/34.9 90/0.4 105/0.5 32.1 58.7 8.9 0.2 0.1
2015 22 496 4013/17.8 263/1.2 755/3.4 7917/35.2 101/0.4 116/0.5 29.9 60.8 8.9 0.2 0.1
2016 21 387 3855/18.0 221/1.0 797/3.7 7693/36.0 68/0.3 104/0.5 27.5 62.5 9.7 0.2 0.1
2017 20 879 3885/18.6 236/1.1 720/3.4 7512/36.0 67/0.3 108/0.5 24.2 65.4 10.1 0.3 0.1
Hepatectomy (non‐lateral segments) 2011 7439 1852/24.9 125/1.7 202/2.7 2728/36.7 39/0.5 60/0.8 33.9 55.7 9.9 0.3 0.1
2012 8242 2061/25.0 100/1.2 235/2.9 3112/37.8 36/0.4 63/0.8 28.1 61.0 10.4 0.3 0.2
2013 7937 1975/24.9 79/1.0 253/3.2 3155/39.8 28/0.4 71/0.9 23.4 65.0 11.2 0.2 0.1
2014 7663 1968/25.7 100/1.3 290/3.8 3066/40.0 28/0.4 55/0.7 20.2 68.3 11.0 0.4 0.1
2015 7439 1973/26.5 90/1.2 299/4.0 3059/41.1 27/0.4 71/1.0 17.9 69.3 12.3 0.4 0.1
2016 7610 2026/26.6 78/1.0 293/3.9 3269/43.0 16/0.2 66/0.9 15.6 72.6 11.4 0.3 0.1
2017 7698 2153/28.0 79/1.0 308/4.0 3418/44.4 20/0.3 67/0.9 13.7 73.2 12.9 0.1 0.1
Pancreaticoduodenectomy 2011 8306 2280/27.5 95/1.1 227/2.7 2819/33.9 36/0.4 50/0.6 34.3 56.5 8.9 0.2 0.2
2012 9331 2660/28.5 113/1.2 247/2.6 3297/35.3 38/0.4 49/0.5 28.1 62.3 9.2 0.3 0.1
2013 10 069 2830/28.1 84/0.8 269/2.7 3729/37.0 45/0.4 60/0.6 24.9 64.4 10.4 0.2 0.1
2014 10 395 3011/29.0 88/0.8 362/3.5 3973/38.2 34/0.3 58/0.6 22.6 66.2 10.9 0.2 0.0
2015 10 577 3057/28.9 92/0.9 385/3.6 4150/39.2 36/0.3 48/0.5 19.1 69.3 11.3 0.2 0.1
2016 11 028 3321/30.1 112/1.0 443/4.0 4380/39.7 31/0.3 62/0.6 16.7 70.3 12.6 0.2 0.1
2017 11 580 3517/30.4 97/0.8 416/3.6 4712/40.7 36/0.3 66/0.6 14.6 72.8 12.4 0.1 0.1
Acute diffuse peritonitis surgery 2011 7751 1063/13.7 655/8.5 264/3.4 2252/29.1 49/0.6 306/3.9 20.7 35.3 29.0 9.9 5.1
2012 9179 1253/13.7 737/8.0 300/3.3 2799/30.5 70/0.8 341/3.7 19.3 36.6 30.2 9.6 4.3
2013 10 452 1422/13.6 731/7.0 348/3.3 3306/31.6 63/0.6 411/3.9 17.3 36.5 33.7 8.8 3.7
2014 12 085 1745/14.4 758/6.3 416/3.4 3913/32.4 65/0.5 444/3.7 16.0 37.6 34.4 9.2 2.8
2015 13 030 1862/14.3 732/5.6 366/2.8 4338/33.3 62/0.5 466/3.6 13.9 40.4 33.9 9.0 2.8
2016 13 981 2113/15.1 765/5.5 441/3.2 4811/34.4 79/0.6 517/3.7 13.2 40.0 34.5 9.7 2.7
2017 14 423 2259/15.7 724/5.0 386/2.7 5118/35.5 63/0.4 496/3.4 11.4 40.6 36.3 9.2 2.5
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Abbreviations: ASA, American Society of Anesthesiologists; COPD, chronic obstructive pulmonary disease.

Table 17 and Figure 2 show the morbidity and mortality rates of the eight main operative procedures. Other than for acute diffuse peritonitis surgery, the operative mortality rates for the procedures were 0.6%‐4.1%, and the postoperative 30‐day mortality rates were 0.3%‐2.1%. The operative mortality rate and the 30‐day postoperative mortality rate for acute diffuse peritonitis surgery were 10.9% and 8.0% in 2017, respectively. The annual numbers of cases of gastrectomy and total gastrectomy have been decreasing, and those of pancreaticoduodenectomy and acute diffuse peritonitis surgery have been increasing over time. Although there were differences in the incidences of complications and mortality according to the procedure, the annual postoperative complication rate of the eight main procedures generally increased and operative mortality rate generally decreased over time.

Table 17.

Annual number of surgeries and mortality rates among patients who underwent the eight main operative procedures

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

Complications with Clavien‐Dindo grades IIIa to V are shown.

Figure 2.

Figure 2

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

The increase in the incidence of endoscopic surgery over time is shown in Figure 3 and Table 18. The annual percentage of surgeries carried out by endoscopic surgery is greatly increasing in low anterior resection and esophagectomy over time. In contrast, laparoscopic hepatectomy and pancreaticoduodenectomy have been carried out in a limited number of institutions.

Figure 3.

Figure 3

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Annual changes in the percentage of surgeries carried out by endoscopic surgery: analysis of the eight major surgical procedures

Table 18.

Changes in the annual percentage of surgeries carried out by endoscopic surgery for the eight main operative procedures

Procedure Year No. of surgeries Endoscopic surgery % Endoscopic surgery
Esophagectomy 2011 4917 1525 31.0
2012 5948 2200 37.0
2013 5694 2315 40.7
2014 6091 2569 42.2
2015 6060 2659 43.9
2016 6041 2961 49.0
2017 6100 3424 56.1
Gastrectomy (distal) 2011 34 198 10 801 31.6
2012 38 774 13 098 33.8
2013 39 959 16 507 41.3
2014 38 584 14 432 37.4
2015 37 819 14 357 38.0
2016 36 852 15 333 41.6
2017 35 517 15 696 44.2
Total gastrectomy 2011 18 674 2258 12.1
2012 21 139 3060 14.5
2013 19 038 3669 19.3
2014 19 071 3620 19.0
2015 18 695 3707 19.8
2016 17 670 4007 22.7
2017 14 840 3347 22.6
Right hemicolectomy 2011 17 899 4842 27.1
2012 21 047 6954 33.0
2013 21 816 9124 41.8
2014 22 446 8269 36.8
2015 22 850 8755 38.3
2016 22 829 9622 42.1
2017 22 543 10 341 45.9
Low anterior resection 2011 16 996 5018 29.5
2012 20 333 7649 37.6
2013 21 098 10 814 51.3
2014 21 861 11 298 51.7
2015 22 493 12 080 53.7
2016 21 387 12 478 58.3
2017 20 879 13 064 62.6
Hepatectomy (non‐lateral segments) 2011 7440 242 3.3
2012 8246 389 4.7
2013 7938 567 7.1
2014 7666 392 5.1
2015 7439 127 1.7
2016 7610 433 5.7
2017 7698 712 9.2
Pancreaticoduodenectomy 2011 8310 67 0.8
2012 9340 121 1.3
2013 10 069 156 1.5
2014 10 400 124 1.2
2015 10 576 53 0.5
2016 11 028 118 1.1
2017 11 580 188 1.6
Acute diffuse peritonitis surgery 2011 7767 488 6.3
2012 9189 652 7.1
2013 10 452 1070 10.2
2014 12 085 1381 11.4
2015 13 030 1638 12.6
2016 13 981 2164 15.5
2017 14 423 2478 17.2
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4. DISCUSSION

Since the start of NCD registration in 2011, a robust nationwide database has been constructed as a result of the work of data managers and surgeons at the participating hospitals. We can see the real clinical status of surgical outcomes in Japan. The gastroenterological section of the NCD database shows three features: aging of the population, low mortality rate, and increase in endoscopic surgery.

The Japanese Ministry of Internal Affairs and Communications reported that the percentage of senior citizens aged 65 years or over among the Japanese population was 27.7% and the percentage of those aged 75 years or over was 13.8% in 2017, and these are the highest percentages in the world.21 It has been estimated that aging of the population will progress and the percentage aged ≥65 years will increase to a little less than 40% in 2050. Our data showed that 50% of right hemicolectomies and 40% of gastrectomies were carried out in patients aged 75 years or over in 2017. With the increase in the aging population, the annual rates of preoperative comorbidities such as diabetes mellitus and hypertension also increased. Age category was reported as a risk factor for operative mortality in all eight main procedures.2

In spite of the high population of aged patients, the mortality rates for all of the procedures seemed to be acceptable as a nationwide outcome, as they are satisfactorily lower than those reported from other countries.22, 23 These results may be explained by the high participation rate of board‐certified surgeons in gastroenterological surgeries (BCS‐Gs). The association between the participation of BCS‐Gs and mortality was evaluated using 250 012 surgical cases registered in 2011 and 2012. The participation of BCS‐Gs contributed to favorable outcomes especially for distal gastrectomy and pancreaticoduodenectomy.19 From 2011 to 2017, the annual percentage of surgeries with participation of a board‐certified surgeon in the eight procedures gradually increased and the operative mortality was kept at a low level. Centralization of the surgical center may also be important for improving surgical outcomes. The operative mortality rate after distal gastrectomy definitively decreased as both surgeon volume and hospital volume increased.24 After risk adjustment for surgeon and hospital volume and patient characteristics, hospital volume (≥52 cases per year) was significantly associated with low operative mortality.24 As for esophagectomy, high‐volume hospitals (≥30 cases per year) had a lower risk‐adjusted mortality rate compared with low‐volume hospitals (≤10 cases).25

Although the postoperative mortality was kept at a low level, the annual rate of postoperative complications with C‐D classification of grade III or higher gradually increased over time. The reason for this increase in complications may be related to the aging population with increased comorbidities. The factors causing these phenomena should be investigated for each procedure. To improve short‐term surgical outcomes in aged patients, minimally invasive surgery might play a pivotal role. The annual rate of endoscopic surgery dramatically increased from 2011 to 2017. Studies using the NCD data showed that the length of hospital stay was significantly shorter in patients who underwent endoscopic surgery.26, 27

The NCD is currently estimated to contain data on approximately 95% of all surgical cases in Japan.28 The NCD provides transparency of surgical outcomes.2 Using the NCD, many studies have been conducted and other studies are in progress to improve surgical outcomes.

DISCLOSURE

Conflicts of Interest: Authors declare no conflicts of interest for this article.

ACKNOWLEDGEMENTS

We thank all the data managers and hospitals participating in this NCD project for their efforts in entering the data.

Hasegawa H, Takahashi A, Kakeji Y, et al. Surgical outcomes of gastroenterological surgery in Japan: Report of the National Clinical Database 2011‐2017. Ann Gastroenterol Surg. 2019;3:426–450. 10.1002/ags3.12258

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