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Annals of Gastroenterological Surgery logoLink to Annals of Gastroenterological Surgery
. 2020 Mar 20;4(3):250–274. doi: 10.1002/ags3.12324

Surgical outcomes in gastroenterological surgery in Japan: Report of the National Clinical Database 2011‐2018

Yoshihiro Kakeji 1,✉, Arata Takahashi 2,3, Hiroshi Hasegawa 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, Mitsukazu Gotoh 1, Hiroyuki Konno 1, Hiroyuki Yamamoto 2,3, Hiroaki Miyata 2,3, Yasuyuki Seto 1, Yuko Kitagawa 1; National Clinical Database
PMCID: PMC7240139  PMID: 32490340

Abstract

The National Clinical Database (NCD) of Japan grew rapidly, harvesting over 11 million cases of data between 2011 and 2018 from more than 5000 facilities. This is the Report of the NCD based upon gastrointestinal surgery information in 4 420 175 cases from 2011 to 2018. More than 70% of all gastrointestinal surgeries were performed at certified institutions, and the percentage of surgeries performed at certified institutions was particularly high for the esophagus (93.8% in 2018), liver (89.4%), pancreas (91.3%), and spleen (86.9%). Also, more than 70% of the surgeries were performed with the participation of the board‐certified surgeon. As the patients have been getting older, the morbidities have been increasing. However, the mortalities have been kept at a low level. The rates of endoscopic surgery have been increasing year by year, especially high in low anterior resection (67.0%) and esophagectomy (61.0%). Nationwide, this database is surely expecting to ensure the quality of board certification system and surgical outcomes in gastroenterological surgery.

Keywords: gastroenterological surgery, NCD, surgical outcome

This is the Report of the National Clinical Database (NCD) based upon gastrointestinal surgery information in 4 420 175 cases from 2011 to 2018. Nationwide this database is surely expecting to ensure the quality of the board certification system and surgical outcomes in gastroenterological surgery.

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1. INTRODUCTION

The Japanese National Clinical Database (NCD), which started its data registration in 2011, has grown into a large nationwide database covering more than 95% of the surgeries performed by regular surgeons in Japan. 1 As of the end of December 2019, 5276 facilities have enrolled in the NCD, and about 1 500 000 cases have been registered every year. 2

In the gastroenterological section of the NCD, the Japanese Society of Gastroenterological Surgery (JSGS) selected 115 gastrointestinal operative procedures as important for the board certification system, and eight main procedures 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; namely, esophagectomy, partial/total gastrectomy, right hemicolectomy, low anterior resection, hepatectomy, pancreaticoduodenectomy, and surgery for acute diffuse peritonitis. 3 , 4 Risk models of mortality 5 , 6 , 7 , 8 , 9 , 10 , 11 , 12 and morbidity 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 for these eight main procedures have been reported, which were all the first‐risk stratification studies based on a Japanese nationwide web‐based database. The risk calculator has been implemented using the risk models, which enables predictions of morbidity and mortality of patients after inputting the preoperative data. 21 To secure the reliability of data collected from the gastroenterological section of the NCD, the JSGS started data verification activity in 2016 and found a high accuracy of data entry. 22

Following the previous annual reports, 3 , 4 the Report of the NCD 2011‐2018 is based upon gastrointestinal surgery information in 4 420 175 cases of surgery performed and recorded from 2011 to 2018. It is our pleasure that this report would reflect the real world of Japanese surgical outcomes of gastroenterological surgery.

2. SUBJECTS AND METHOD

As previously reported, 3 , 4 the 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. 23 Requirements for board‐certified training institutions are 600 or more gastroenterological operations determined by the certified committee (more than 120 of which are essential major surgery) in the last 3 years. And board‐certified surgeons are required the experience performing 450 or more gastroenterological operations, and gastroenterological surgical training for more than 5 years according to the training curriculum in a board‐certified training institution authorized by the JSGS. We targeted data from 2011 to 2018, adding data of complications to data already reported in the Annual Report 2011‐2017. 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 complications defined by transfusions 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. 24 In this study, grade III (complications requiring intervention) or higher complications were defined as severe complications. Furthermore, we separated and studied the eight main operative methods that we deemed important in terms of medical standards among these 115 procedures.

We clarified the number of surgical cases and the mortality rates related to the selected 115 gastrointestinal operative procedures, and also the eight main operative procedures from 2011 to 2018. We also comparatively studied patient sex, age groups, institution groups, and the percentage contribution of certified surgeons related to the eight main operative procedures.

The following points need to be considered in the interpretation of the data reported here: (a) since a maximum of eight operative procedures can be recorded per each case in the NCD, the total number of surgeries in “Results of the 115 gastrointestinal surgical procedures for board certification system” is not the actual total number of surgical cases; (b) cases with errors in patient age, sex, and postoperative 30‐day status were excluded; (c) cases in which several operative methods were performed simultaneously were tallied per all operative methods; (d) postoperative 30‐day mortality included all cases of mortality within 30 days of surgery regardless of pre‐ or post‐discharge status. The calculation of operative mortality included all patients who died during the index hospitalization, including hospital stays up to 90 days, and any patient who died after hospital discharge within 30 days of the operation date.

3. RESULTS

3.1. The 115 selected gastrointestinal operative procedures in the “Training Curriculum for Board Certified Surgeons in Gastroenterology“

The total number of cases represented by the 115 selected gastrointestinal surgical procedures, recorded in the NCD between 1 January and 31 December 2018 was 601 754. Based on organ involvement, 9286 cases involved the esophagus (1.5%); 65 152 cases, the stomach and duodenum (10.8%); 236 496 cases, the small intestine and colon (39.3%); 56 162 cases, the rectum and anus (9.3%); 26 531 cases, the liver (4.4%); 139 844 cases, the gall bladder (23.2%); 19 152 cases, the pancreas (3.2%); 2544 cases, the spleen (0.4%); and 46 587 cases, other organs (7.7%) (Table 1). The increase of cases, especially with malignant colorectal diseases, was remarkable, while cases of the stomach and duodenum decreased. Year by year, older patients have been increasing for procedures across all organs (Table 1).

TABLE 1.

Annual changes of surgeries by sex, age group, and organ for the selected 115 gastrointestinal operative procedures in the training curriculum for board certified surgeons in gastroenterology

Organ Year No. surgeries Percentage by sex 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
2018 9286 78.4 21.6 19.0 12.8 21.3 21.6 16.7 8.7
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
2018 65 152 66.9 33.1 16.0 9.0 16.4 18.0 17.5 23.2
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
2018 236 496 56.9 43.1 32.2 7.7 12.6 13.4 13.2 21.1
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
2018 56 162 56.9 43.1 22.2 9.8 15.9 15.8 14.6 21.6
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
2018 26 531 66.5 33.5 19.6 10.3 18.8 19.6 17.8 13.8
Gall bladder 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
2018 139 844 55.3 44.7 31.8 9.7 14.2 14.2 13.4 16.7
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
2018 19 152 58.6 41.4 16.9 9.2 18.2 21.5 20.4 13.7
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
2018 2544 56.6 43.4 32.6 9.9 15.6 16.9 13.9 11.1
Others 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
2018 46 587 54.1 45.9 26.8 8.2 14.0 14.4 14.7 21.9
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In terms of the institutional groups in which the surgeries were performed, more than 70% of all surgeries were performed at certified institutions, and the percentage of surgeries performed at certified institutions has been increasing for all organs (Table 2). Also, more than 70% of the surgeries were performed with the participation of the board‐certified surgeon. The percentage of certified surgeons that were operators was high for the esophagus (75.2% in 2018), liver (64.1%), and pancreas (66.5%). The complication rates were comparatively higher and increasing for the esophagus and the pancreas, however, the mortality rates for procedures on these organs were not so high (Table 3 and Figure 1). Tables 4, 5, 6, 7, 8, 9, 10, 11, 12 show the number of surgeries, endoscopic surgeries, and morbidity/mortality rates according to the selected 115 gastrointestinal operative procedures in 2018.

TABLE 2.

Institution and anesthesiologist and specialist participation rates by organ for the selected 115 gastrointestinal operative procedures

Organ Year No. surgeries Percentage by institution group 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
2018 9286 93.8 4.0 2.2 98.5 94.7 75.2 24.8
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
2018 65 152 80.0 14.8 5.1 95.1 81.4 43.2 56.8
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
2018 236 496 76.3 17.5 6.1 93.3 71.8 32.6 67.4
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
2018 56 162 74.1 17.9 8.0 85.2 77.2 46.7 53.3
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
2018 26 531 89.4 7.1 3.5 97.3 92.8 64.1 35.9
Gall bladder 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
2018 139 844 72.5 20.1 7.4 94.1 73.1 31.1 68.9
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
2018 19 152 91.3 6.4 2.3 97.3 93.4 66.5 33.5
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
2018 2544 86.9 9.7 3.4 95.3 84.7 49.3 50.7
Others 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
2018 46 587 80.2 14.2 5.7 93.8 71.2 33.1 66.9
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TABLE 3.

Number of surgeries and mortality rates according to organ treated using the selected 115 gastrointestinal operative procedures

Organ Year No. surgeries Number of postoperative complicationsa/rate (%) Number of postoperative 30‐d mortalities/rate (%) Number 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
2018 9286 2065/22.2 108/1.2 246/2.6
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
2018 65 152 6228/9.6 1048/1.6 1833/2.8
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
2018 236 496 21 881/9.3 4452/1.9 7116/3.0
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
2018 56 162 5622/10.0 522/0.9 803/1.4
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
2018 26 531 2737/10.3 189/0.7 372/1.4
Gall bladder 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
2018 139 844 5964/4.3 584/0.4 954/0.7
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
2018 19 152 4309/22.5 178/0.9 325/1.7
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
2018 2544 418/16.4 69/2.7 104/4.1
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
2018 46 587 6645/14.3 1865/4.0 2710/5.8
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a

Complications were defined by Clavien‐Dindo gradeⅢa‐Ⅴ.

FIGURE 1.

FIGURE 1

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Annual changes of number of surgeries, 30‐Day mortality, operative mortality, and complications: Analysis of 115 surgical procedures. Postoperative complication rate: the rate of Clavien–Dindo (C–D) classification grade III (complications requiring intervention) or higher complications

TABLE 4.

Number of surgeries, endoscopic surgery, and mortality rates according to the selected 115 gastrointestinal operative procedures in 2018 (esophagus)

Organ Degree of difficulty Procedure No. surgeries No. Endoscopic surgeries/ rate (%) No. postoperative complications*/rate (%) No. postoperative 30‐d mortalities /rate (%) No. postoperative 30‐d mortalities/rate (%)
Esophagus Low Cervical periesophageal abscess drainage 40 5/12.5 13/32.5 2/5.0 2/5.0
Med Esophageal suture (perforation, injury) 211 22/10.4 81/38.4 9/4.3 12/5.7
Med Thoracic periesophageal abscess drainage 27 1/3.7 15/55.6 1/3.7 3/11.1
Med Esophageal foreign body extraction 36 2/5.6 9/25.0 1/2.8 2/5.6
Med Esophageal diverticulum resection 53 26/49.1 2/3.8 0/0.0 0/0
Med Benign esophageal tumor removal 76 48/63.2 5/6.6 0/0 1/1.3
Med Esophageal resection (removal only) 687 403/58.7 102/14.8 12/1.7 31/4.5
Med Esophageal reconstruction: reconstruction only (gastric tube reconstruction) 647 372/57.5 157/24.3 7/1.1 15/2.3
Med Esophageal fistula construction 192 69/35.9 56/29.2 11/5.7 22/11.5
Med Esophagocardioplasty 306 210/68.6 19/6.2 2/0.7 2/0.7
Med Achalasia surgery 232 162/69.8 2/0.9 0/0 0/0
High Esophagectomy 6207 3788/61.0 1420/22.9 53/0.9 115/1.9
High Esophageal reconstruction: reconstruction only (colon reconstruction) 31 15/48.4 10/32.3 0/0 2/6.5
High Esophageal bypass 152 18/11.8 55/36.2 6/3.9 18/11.8
High Bronchoesophageal fistula surgery 3 1/33.3 2/66.7 0/0 0/0
High Secondary esophageal reconstruction 386 39/10.1 117/30.3 4/1.0 21/5.4
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TABLE 5.

Number of surgeries, endoscopic surgery, and mortality rates according to the selected 115 gastrointestinal operative procedures in 2018 (stomach and duodenum）

Organ Degree of difficulty Procedure No. surgeries No. Endoscopic surgeries/ rate (%) No. postoperative complications*/rate (%) No. postoperative 30‐d mortalities/rate (%) No. postoperative 90‐d mortalities/rate (%)
Stomach and duodenum Low Gastrostomy and suture gastrorrhaphy 61 9/14.8 3/4.9 3/4.9 3/4.9
Low Diverticulum, polypectomy (excluding endoscopic resection) 169 19/11.2 19/11.2 2/1.2 3/1.8
Low Truncal vagotomy 4 2/50.0 1/25.0 1/25.0 1/25.0
Low Gastroenterostomy (Including duodenal jejunostomy) 5882 1406/23.9 974/16.6 300/5.1 615/10.5
Low Gastric fistula construction (Excluding PEG) 1560 244/15.6 303/19.4 98/6.3 162/10.4
Low Gastric pyloroplasty 66 12/18.2 8/12.1 1/1.5 2/3.0
Low Gastric volvulus (volvulus) surgery and rectopexy 53 29/54.7 4/7.5 0/0 0/0
Low Gastric suture (including gastric suture for gastric rupture, Suture closure for gastroduodenal perforation, omental implantation and omental transposition） 5801 1975/34.0 925/15.9 250/4.3 361/6.2
Low Local gastrectomy (including wedge resection)） 4338 2925/67.4 135/3.1 18/0.4 28/0.6
Med Gastrectomy (including distal gastrectomy, pylorus preserving gastrectomy and segmental [transverse] gastrectomy) 33 988 16 355/48.1 2327/6.8 227/0.7 393/1.2
Med Selective vagotomy 7 2/28.6 0/0 0/0 0/0
High Total gastrectomy (including fundusectomy)） 13 223 3344/25.3 1529/11.6 148/1.1 265/2.0
High Left upper abdominal exenteration 0 0/0 0/0 0/0 0/0
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TABLE 6.

Number of surgeries, endoscopic surgery, and mortality rates according to the selected 115 gastrointestinal operative procedures in 2018 (small intestine and colon)

Organ Degree of difficulty Procedure No. surgeries No. Endoscopic surgeries/ rate (%) No. postoperative complications*/rate (%) No. postoperative 30‐d mortalities/rate (%) No. postoperative 90‐d mortalities/rate (%)
Small intestine and colon Low Enterotomy and enterorrhaphy 4501 684/15.2 791/17.6 183/4.1 392/8.7
Low Disinvagination (invasive) 225 62/27.6 20/8.9 12/5.3 13/5.8
Low Partial enterectomy (benign) 9381 1601/17.1 1845/19.7 572/6.1 830/8.8
Low Ileocecal resection (benign) 4784 1765/36.9 452/9.4 83/1.7 118/2.5
Low Partial colectomy and sigmoid colectomy (benign) 8073 2319/28.7 1243/15.4 301/3.7 430/5.3
Low Appendectomy 54 877 35 558/64.8 1001/1.8 58/0.1 89/0.2
Low Enterostomy and closure (without enterectomy) 26 086 8163/31.3 4482/17.2 1013/3.9 1796/6.9
Med Enterectomy (malignant) 3717 927/24.9 446/12.0 85/2.3 157/4.2
Med Ileocecal resection (malignant) 13 858 7995/57.7 756/5.5 87/0.6 162/1.2
Med Partial colectomy and sigmoid colectomy (malignant) 32 212 18 626/57.8 2176/6.8 199/0.6 336/1.0
Med Right hemicolectomy 22 610 11 165/49.4 1679/7.4 276/1.2 424/1.9
Med Left hemicolectomy 6072 2964/48.8 667/11.0 124/2.0 177/2.9
Med Total colectomy 1760 489/27.8 404/23.0 144/8.2 179/10.2
Med Intestinal obstruction surgery (with bowel resection) 24 572 5248/21.4 2532/10.3 577/2.3 835/3.4
Med Enterostomy and closure (with enterectomy) 23 313 3722/16.0 3325/14.3 734/3.1 1173/5.0
High Proctocolectomy and ileoanal (canal) anastomosis 455 195/42.9 62/13.6 4/0.9 5/1.1
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TABLE 7.

Number of surgeries, endoscopic surgery, and mortality rates according to the selected 115 gastrointestinal operative procedures in 2018 (rectum and anus)

Organ Degree of difficulty Procedure No. surgeries No. Endoscopic surgeries/ rate (%) No. postoperative complications*/rate (%) No. postoperative 30‐d mortalities/rate (%) No. postoperative 90‐d mortalities/rate (%)
Rectum Low Transanal rectal tumor removal 3751 103/2.7 22/0.6 2/0.1 3/0.1
Low Proctocele surgery (transanal) 2870 29/1.0 49/1.7 9/0.3 14/0.5
Med Rectectomy (benign) 1371 118/8.6 265/19.3 23/1.7 43/3.1
Med High anterior resection 10 741 7081/65.9 744/6.9 50/0.5 78/0.7
Med Hartmann's procedure 6075 1040/17.1 1238/20.4 309/5.1 448/7.4
Med Proctocele surgery (abdominoperineal) 1993 1058/53.1 31/1.6 9/0.5 10/0.5
Med Malignant anorectal tumor excision (transanal) 663 80/12.1 15/2.3 1/0.2 1/0.2
Med Anal sphincteroplasty (by tissue replacement) 2641 15/0.6 16/0.6 4/0.2 6/0.2
High Rectectomy (malignant) 4935 3144/63.7 660/13.4 23/0.5 49/1.0
High Low anterior resection 20 636 13 825/67.0 2454/11.9 90/0.4 142/0.7
High Pelvic evisceration 441 85/19.3 121/27.4 2/0.5 9/2.0
High Anorectal malignant tumor excision (posterior approach) 45 5/11.1 7/15.6 0/0 0/0
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TABLE 8.

Number of surgeries, endoscopic surgery, and mortality rates according to the selected 115 gastrointestinal operative procedures in 2018 (liver)

Organ Degree of difficulty Procedure No. surgeries No. Endoscopic surgeries/ rate (%) No. postoperative complications*/rate (%) No. postoperative 30‐day mortalities/rate (%) No. postoperative 90‐day mortalities/rate (%)
Liver Low Hepatorrhaphy 54 3/5.6 21/38.9 8/14.8 9/16.7
Low Liver abscess drainage (excluding percutaneous procedures) 47 4/8.5 9/19.1 0/0.0 1/2.1
Low Hepatic cyst resection. Suture. Drainage 794 618/77.8 42/5.3 3/0.4 5/0.6
Low Partial hepatectomy 12 543 4072/32.5 940/7.5 52/0.4 96/0.8
Low Liver biopsy (excluding percutaneous procedures) 235 41/17.4 10/4.3 4/1.7 7/3.0
Low Liver coagulonecrotic therapy (excluding percutaneous procedures) 705 143/20.3 57/8.1 6/0.9 15/2.1
Med Lateral segmentectomy of the liver 1626 564/34.7 90/5.5 5/0.3 14/0.9
Med Esophageal and gastric varix surgery 42 29/69.0 5/11.9 1/2.4 2/4.8
High Hepatectomy (segmented or more; excluding lateral segments) 7192 791/11.0 1137/15.8 83/1.2 163/2.3
High Systematic subsegmentectomy 2474 455/18.4 210/8.5 7/0.3 23/0.9
High Liver transplant 705 1/0.1 165/23.4 17/2.4 33/4.7
High Hepatopancreatoduodenectomy 114 2/1.8 51/44.7 3/2.6 4/3.5
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TABLE 9.

Number of surgeries, endoscopic surgery, and mortality rates according to the selected 115 gastrointestinal operative procedures in 2018 (gall bladder)

Organ Degree of difficulty Procedure No. surgeries No. Endoscopic surgeries/ rate (%) No. postoperative complications*/rate (%) No. postoperative 30‐d mortalities/rate (%) No. postoperative 90‐d mortalities/rate (%)
Gall bladder Low Cholangiotomy 100 10/10.0 16/16.0 1/1.0 1/1.0
Low Cysticolithectomy 60 8/13.3 12/20.0 1/1.7 1/1.7
Low Cholecystectomy 132 548 90 831/68.5 4782/3.6 469/0.4 735/0.6
Low External cholecystostomy 121 16/13.2 27/22.3 10/8.3 15/12.4
Low Cystoenteric anastomosis 53 8/15.1 12/22.6 2/3.8 5/9.4
Med Cysticolithectomy 2664 693/26.0 248/9.3 25/0.9 55/2.1
Med Biliary tract reconstruction 336 13/3.9 75/22.3 2/0.6 3/0.9
Med Biliary bypass 1210 67/5.5 187/15.5 31/2.6 62/5.1
Med Cholangioplasty 113 16/14.2 22/19.5 3/2.7 6/5.3
Med Duodenal papilloplasty 32 1/3.1 6/18.8 0/0 0/0
Med Choledocal dilatation 289 45/15.6 29/10.0 0/0.0 1/0.3
Med Biliary fistula closure 38 7/18.4 8/21.1 1/2.6 1/2.6
High Malignant gallbladder tumor surgery (excluding simple cholecystectomy)） 1007 39/3.9 117/11.6 6/0.6 8/0.8
High Malignant bile duct tumor surgery 1263 12/1.0 423/33.5 33/2.6 61/4.8
High Biliary atresia surgery 10 0/0 0/0 0/0 0/0
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TABLE 10.

Number of surgeries, endoscopic surgery, and mortality rates according to the selected 115 gastrointestinal operative procedures in 2018 (pancreas)

Organ Degree of difficulty Procedure No. of surgeries No. Endoscopic surgeries/ rate (%) No. postoperative complications*/rate (%) No. postoperative 30‐d mortalities/rate (%) No. postoperative 90‐d mortalities/rate (%)
Pancreas Low External pancreatic cyst drainage 21 4/19.0 11/52.4 1/4.8 2/9.5
Low External pancreatic duct drainage 6 0/0.0 2/33.3 0/0.0 1/16.7
Med Pancreatorrhaphy 13 0/0.0 8/61.5 3/23.1 4/30.8
Med Partial pancreatic resection 162 36/22.2 36/22.2 0/0.0 1/0.6
Med Distal pancreatectomy (benign) 1493 599/40.1 293/19.6 5/0.3 9/0.6
Med Pancreatoenteric anastomosis 28 1/3.6 3/10.7 1/3.6 2/7.1
Med Pancreatic (duct) anastomosis 286 4/1.4 48/16.8 7/2.4 9/3.1
Med Acute pancreatitis surgery 88 8/9.1 41/46.6 5/5.7 12/13.6
Med Pancreatolithiasis surgery 8 0/0 1/12.5 0/0 0/0
Med Plexus pancreaticus capitalis resection 0 0/ 0/ 0/ 0/
High Pancreaticoduodenectomy 11 626 194/1.7 2716/23.4 111/1.0 204/1.8
High Distal pancreatectomy (malignant)） 4611 795/17.2 971/21.1 19/0.4 42/0.9
High Total pancreatectomy 599 9/1.5 105/17.5 25/4.2 38/6.3
High Duodenum preserving pancreas head resection 49 0/0.0 14/28.6 0/0.0 0/0
High Segmental pancreatic resection 136 5/3.7 52/38.2 1/0.7 1/0.7
High Distal pancreatectomy 26 0/0 8/30.8 0/0 0/0
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TABLE 11.

Number of surgeries, endoscopic surgery, and mortality rates according to the selected 115 gastrointestinal operative procedures in 2018 (spleen)

Organ Degree of difficulty Procedure No. surgeries No. Endoscopic surgeries/ rate (%) No. postoperative complications*/rate (%) No. postoperative 30‐d mortalities/rate (%) No. postoperative 90‐d mortalities/rate (%)
Spleen Low Splenorrhaphy 23 4/17.4 6/26.1 1/4.3 1/4.3
Med Splenectomy 2490 694/27.9 409/16.4 68/2.7 103/4.1
Med Partial splenic resection 31 16/51.6 3/9.7 0/0 0/0
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TABLE 12.

Number of surgeries, endoscopic surgery, and mortality rates according to the selected 115 gastrointestinal operative procedures in 2018 (other)

Organ Degree of difficulty Procedure No. surgeries No. Endoscopic surgeries/ rate (%) No. postoperative complications*/rate (%) No. postoperative 30‐d mortalities/rate (%) No. postoperative 90‐d mortalities/rate (%)
Other Low Localized intra‐abdominal abscess surgery 2617 645/24.6 400/15.3 56/2.1 114/4.4
Low Exploratory laparotomy 10 825 5335/49.3 1329/12.3 515/4.8 718/6.6
Med Acute diffuse peritonitis surgery 14 835 2820/19.0 3943/26.6 1117/7.5 1617/10.9
Med Ventral hernia surgery 13 768 3931/28.6 497/3.6 84/0.6 117/0.8
Med Diaphragm suture 243 76/31.3 30/12.3 4/1.6 6/2.5
Med Esophageal hiatus hernia surgery 1033 668/64.7 81/7.8 19/1.8 25/2.4
Med Retroperitoneal tumor surgery 866 129/14.9 60/6.9 5/0.6 10/1.2
Med Abdominal wall/mesenteric/omental tumor resection 1832 422/23.0 151/8.2 25/1.4 41/2.2
Med Gastrointestinal perforation closure 511 60/11.7 149/29.2 39/7.6 59/11.5
High Diaphragmatic hiatus hernia surgery 57 17/29.8 5/8.8 1/1.8 3/5.3
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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 2018 are shown in Table 13. The percentages of elderly patients have been increasing, especially for gastrectomy (distal and total), right hemicolectomy, and acute diffuse peritonitis surgery. Regarding the Institutional groups in which surgeries were performed, more than 70% of the surgeries were performed at certified institutions, and more than 90% were for esophagectomy, hepatectomy (non‐lateral segments), and pancreaticoduodenectomy in 2018 (Table 14). Board‐certified surgeon participation rates have been increasing year by year for all procedures. Table 15 shows the morbidity and mortality rates of the eight main operative procedures. Other than acute diffuse peritonitis surgery, the postoperative 30‐day mortality rate was 0.4%‐1.2% and the operative mortality rate was 0.7%‐2.3%; a very low level relatively. The postoperative 30‐day mortality rate and operative mortality rate for acute diffuse peritonitis surgery was 7.5% and 10.9% in 2018, respectively. Figure 2 shows the annual changes in the number of surgeries, postoperative complication rate, and mortalities. Although the complication rates were increasing for esophagectomy (22.9% in 2018) and pancreaticoduodenectomy (23.4%), the mortality rates for these procedures (0.9% and 1.9%, 1.0% and 1.8%, in 2018, respectively) were decreasing. The case numbers for acute diffuse peritonitis surgery were increasing; however, the morbidity and mortality rates were decreasing.

TABLE 13.

Annual changes of surgeries by sex, age group, and organ for eight main operative procedures

Procedure Year No. surgeries Percentage by sex 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
2018 6207 80.5 19.5 17.2 14.2 22.6 22.8 16.8 6.5
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
2018 33 988 66.6 33.4 12.9 9.1 16.9 19.0 18.1 24.0
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
2018 13 223 74.4 25.6 10.8 9.1 18.0 20.6 20.6 20.9
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
2018 22 610 51.4 48.6 10.7 6.9 13.9 17.7 19.6 31.2
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
2018 20 636 64.9 35.1 22.9 12.5 19.3 18.0 14.4 12.9
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
2018 7192 69.5 30.5 17.2 9.6 19.1 21.4 19.4 13.3
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
2018 11 626 60.3 39.7 13.3 9.1 18.9 22.2 22.0 14.6
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
2018 14 835 59.2 40.8 26.1 7.7 12.7 13.1 13.5 26.9
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TABLE 14.

Institution and anesthesiologist and specialist participation rates by organ for eight main operative procedures

Procedure Year No. surgeries Percentage by institution group 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
2018 6207 95.9 2.7 1.4 99.1 96.6 78.8 21.2
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
2018 33 988 80.7 14.4 4.8 95.6 84.2 46.6 53.4
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
2018 13 223 79.6 15.5 4.9 95.4 82.6 46.2 53.8
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
2018 22 610 74.8 19.0 6.2 94.7 77.8 38.2 61.8
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
2018 20 636 80.9 14.3 4.8 95.2 84.5 54.4 45.6
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
2018 7192 92.8 5.2 2.0 97.7 95.8 72.8 27.2
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
2018 11 626 91.4 6.4 2.2 97.4 94.0 67.6 32.4
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
2018 14 835 83.4 12.4 4.2 93.6 70.4 28.7 71.3
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TABLE 15.

Number of surgeries and mortality rates according to organ treated using the eight main operative procedures

Procedure Year No. surgeries No. postoperative complications*/rate (%) No. re‐operation/rate (%) No. postoperative 30‐d mortalities/rate (%) No. postoperative 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
2018 6207 1420/22.9 367/5.9 53/0.9 115/1.9
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
2018 33 988 2327/6.8 737/2.2 227/0.7 393/1.2
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
2018 13 223 1529/11.6 487/3.7 148/1.1 265/2.0
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
2018 22 610 1679/7.4 740/3.3 276/1.2 424/1.9
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
2018 20 636 2454/11.9 1424/6.9 90/0.4 142/0.7
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
2018 7192 1137/15.8 211/2.9 83/1.2 163/2.3
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
2018 11 626 2716/23.4 402/3.5 111/1.0 204/1.8
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
2018 14 835 3943/26.6 1183/8.0 1117/7.5 1617/10.9
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*

Complications were defined by Clavien‐Dindo gradeⅢa‐Ⅴ.

FIGURE 2.

FIGURE 2

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Annual changes of number of surgeries, 30‐Day mortality, operative mortality, and complications: Analysis of 8 major surgical procedures. Postoperative complication rate: the rate of C–D classification grade III or higher complications

An increase in the incidence of endoscopic surgery over time is shown in Figure 3. Endoscopic surgeries have been prevalent, especially in gastrointestinal procedures, with 67.0% for low anterior resection and 61.0% for esophagectomy in 2018. Even for acute diffuse peritonitis, laparoscopic surgery had been done in 19.0% of cases in 2018.

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

4. DISCUSSION

The National Clinical Database, a robust nationwide registry on surgical outcomes, shows the real status of Japanese surgical treatment. The purpose of NCD was to systematically gather clinical information, analyze these data for quality improvement, follow the best medical practices, and maintain a high standard of care for all people in Japan.

More than half of all patients who underwent surgical treatment in the gastroenterological field were senior patients aged 65 years or over. With the increase in the aging population, the rates of preoperative comorbidities such as diabetes mellitus or hypertension also increased. Age category was reported as a risk factor both for operative morbidity and mortality in all eight main procedures. 5 , 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 Although the annual rate of postoperative complications with C‐D classification of grade III or higher gradually increased over time, the postoperative mortality was kept at a low level. These results may be explained by the high participation rate of board‐certified surgeons in gastroenterological surgeries. 23 The annual percentage of surgeries with participation of board‐certified surgeons in gastroenterological surgeries in the eight procedures gradually increased and the operative mortality was kept at a low level. Also, centralization of the surgical center may be important for improving surgical outcomes. The operative mortality rate after distal gastrectomy definitively decreased as both surgeon volume and hospital volume increased. 25 After risk adjustment for surgeon and hospital volume and patient characteristics, hospital volume was significantly associated with low operative mortality. As for esophagectomy, high‐volume hospitals had a lower risk‐adjusted mortality rate compared with low‐volume hospitals. 26 The factors causing these phenomena should be investigated for each procedure.

The rates of endoscopic surgery have been increasing year by year. This is the first report of the annual number of endoscopic surgeries in the selected 115 gastrointestinal operative procedures in the training curriculum for board‐certified surgeons in gastroenterology. Studies using the NCD data showed that the length of hospital stay was significantly shorter in patients who underwent endoscopic surgery for gastrectomy 27 , 28 , 29 , 30 and hepatectomy. 31 , 32 Laparoscopic liver resection has been safely developed with a low mortality and complication rates relative to open liver resection. 32 Laparoscopic gastrectomy is also safe and feasible even for elderly patients 33 or those with poor physical status, such as the American Society of Anesthesiologists physical status (ASA‐PS) class ≥3. 34

A risk‐adjusted analysis based on nationwide data allows personnel to establish and provide feedback on the risks that patients face before undergoing a procedure. 21 The risk calculator for all eight procedures is available on the websites of the hospitals that are part of the NCD. Standardized information on patient risk and predicted mortality can be reformulated as case reports and shared at conferences. In liver transplant recipients, real‐time risk models of postoperative morbidities and mortality at various perioperative time points were established. 35 These real‐time risk models provide the expected risk of morbidities and mortality at any time point from pre‐, intra‐, and postoperative periods within 30 days after the surgery. With the availability of real‐time risk models of postoperative morbidity and mortality at each time point post‐surgery, the treatment team and caregivers might be encouraged to pay attention and possibly prevent or enhance recovery from specific morbidities and avoid mortality. These real‐time risk models may be applicable to other surgical procedures. The NCD also provides data on each facility's severity‐adjusted clinical performance (benchmark), which can be compared with national data. 21 , 36 , 37 We can trace, periodically, where we are in the national standard, which will improve surgical care on an international basis.

Many valuable studies that use “big data” from the NCD have been published in succession. The NCD has contributed to evidence‐based medicine, to the accountability of medical professionals, and to quality assessment/improvement of surgery in Japan.

DISCLOSURE

Conflict of interests: Arata Takahashi, Hiroyuki Yamamoto, and Hiroaki Miyata are affiliated with the Department of Healthcare Quality Assessment at the University of Tokyo. The department is a social collaboration department supported by grants from the National Clinical Database, Johnson & Johnson KK, and Nipro Co.

ACKNOWLEDGEMENTS

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

Kakeji Y, Takahashi A, Hasegawa H, et al. Surgical outcomes in gastroenterological surgery in Japan: Report of the National Clinical Database 2011‐2018. Ann Gastroenterol Surg. 2020;4:250–274. 10.1002/ags3.12324

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