Thoracic and cardiovascular surgery in Japan during 2015

The Japanese Association for Thoracic Surgery has conducted annual surveys of thoracic surgery throughout Japan since 1986 to determine the statistics regarding the number of procedures according to operative category. Here, we have summarized the results from our annual survey of thoracic surgery performed during 2015.

As has been done so far, thoracic surgery was classified into three categories—cardiovascular, general thoracic, and esophageal surgery—and the patient data were examined and analyzed for each group. Access to the computerized data is offered to all members of this Association. We honor and value all member’s continued professional support and contributions (Tables 1, 2).

Table 1 Table 1 Questionnaires sent out and received back by the end of December 2015

Table 2 Table 2 Categories subclassified according to the number of operations performed

The incidence of hospital mortality was added to the survey to determine the nationwide status, which has contributed to the Japanese surgeons to understand the present status of thoracic surgery in Japan and to make progress to improve operative results by comparing their work with those of others. The Association was able to gain a better understanding of present problems as well as future prospects, which has been reflected to its activity including education of its members.

Thirty-day mortality (so-called “operative mortality”) is defined as death within 30 days of operation regardless of the patient’s geographic location and even after the patient had been discharged from the hospital. Hospital mortality is defined as death within any time interval after an operation if the patient had not been discharged from the hospital.

Hospital-to-hospital transfer in the categories of esophageal surgery is not considered discharge: transfer to a nursing home or a rehabilitation unit is considered hospital discharge unless the patient subsequently dies of complications of the operation. On the contrary, hospital-to-hospital transfer after 30 days of operation in the categories of cardiovascular surgery and general thoracic surgery is considered discharge because data of national clinical database (NCD) 2015 were used in this category and hospital-to-hospital transfer after 30 days of operation is considered discharge in NCD.

Abstract of the survey

All data regarding cardiovascular surgery and thoracic surgery were obtained from NCD, whereas data regarding esophageal surgery were collected from survey questionnaire by The Japanese Association for Thoracic Surgery forms because NCD of esophageal surgery does not include non-surgical cases (i.e., patients with adjuvant chemotherapy or radiation alone). Based on the change in data aggregation, there are several differences between this 2015 annual report and previous annual reports: the number of institutions decreased in each category from 578 (2014) to 568 (2015) in cardiovascular, from 762 to 714 in general thoracic and from 626 to 571 in esophageal surgery. Because more than two departments in the same institute registered their data to NCD individually, we cannot calculate correct number of institutes in this survey. Then, the response rate is not indicated in the category of cardiovascular surgery (Table 1), and the number of institutions classified by the operation number is also not calculated in the category of cardiovascular surgery (Table 2).

2015 Final report

(A) Cardiovascular surgery

First, we are very pleased with our colleague’s (member’s) cooperation to our survey of cardiovascular surgery, which definitely enhances the quality of this annual report. We are truly grateful again for the enormous effort put into completing the NCD at each participating institution.

Figure 1 shows the development of cardiovascular surgery in Japan over the last 29 years. Aneurysm surgery includes only operations for thoracic and thoracoabdominal aortic aneurysm. Extra-anatomic bypass surgery for thoracic aneurysm and pacemaker implantation were totally excluded from the survey since 2015. The number of assist device implantation operations is not included in the total number of surgical operations, while it remained in the survey. A total of 69,512 cardiovascular operations were performed at 561 institutions during 2015 alone and included 44 heart transplantations, which were re-started in 1999.

Fig. 1

Cardiovascular surgery, IHD ischemic heart disease

The number of operations for congenital heart disease (9054 cases) decreased in 2.3% compared with that of 2014 (9269 cases) [1], and 2.5% decrease when compared with the data of 10 years ago (9287 cases in 2005) [2]. The number of operations for adult heart disease (19,820 cases in valvular heart disease, 15,103 ischemic heart disease, 17,444 cases in thoracic aortic aneurysm and 1897 cases for other procedures) decreased compared with those of 2014 (9.7, 3.4, 0.3 and 10.4%, respectively).

During the last 10 years, the numbers of operations for adult heart disease increased constantly except for that for ischemic heart disease (39.1% increase in valvular heart disease, 23.5% decrease in ischemic heart disease, 101.1% increase in thoracic aortic aneurysm, and 56.5% increase in other procedures compared those of 2005 [2]). The concomitant coronary artery bypass grafting procedure (CABG) is not included in ischemic heart disease but included in other categories such as valvular heart disease and thoracic aneurysm in our study, then, the number of CABG still remained over 20,000 cases per year (20,785 cases) in 2015. Data for individual categories are summarized in Tables 3, 4, 5, 6, 7, 8 and 9.

Table 3 Congenital (total 9269)

(2) CPB (−) (total 2344)

	Neonate				Infant				1–17 years				≧ 18 years				Total
	Cases	30-day mortality		Hospital mortality	Cases	30-day mortality		Hospital mortality	Cases	30-day mortality		Hospital mortality	Cases	30-day mortality		Hospital mortality	Cases	30-day mortality		Hospital mortality
		Hospital	After discharge			Hospital	After discharge			Hospital	After discharge			Hospital	After discharge			Hospital	After discharge
PDA	347	5 (1.4)	0	17 (4.9)	182	1 (0.5)	0	4 (2.2)	45	0	0	0	6	0	0	0	580	6 (1.0)	0	21 (3.6)
Coarctation (simple)	21	0	0	0	21	0	0	0	2	0	0	0	2	0	0	0	46	0	0	0
+ VSD	41	1 (2.4)	0	2 (4.9)	20	0	0	0	1	0	0	0	0	0	0	0	62	1 (1.6)	0	2 (3.2)
+ DORV	2	0	0	0	0	0	0	0	1	0	0	0	0	0	0	0	3	0	0	0
+ AVSD	6	0	0	1 (16.7)	0	0	0	0	1	0	0	0	0	0	0	0	7	0	0	1 (14.3)
+ TGA	2	0	0	0	1	0	0	0	0	0	0	0	0	0	0	0	3	0	0	0
+ SV	5	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	5	0	0	0
+ Others	12	1 (8.3)	0	1 (8.3)	5	0	0	0	1	0	0	0	0	0	0	0	18	1 (5.6)	0	1 (5.6)
Interrupt. of Ao (simple)	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0
+ VSD	26	0	0	0	6	0	0	0	0	0	0	0	0	0	0	0	32	0	0	0
+ DORV	1	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	1	0	0	0
+ Truncus	6	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	6	0	0	0
+ TGA	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0
+ Others	2	0	0	0	1	0	0	0	1	0	0	0	0	0	0	0	4	0	0	0
Vascular ring	4	0	0	0	14	0	0	0	4	0	0	0	0	0	0	0	22	0	0	0
PS	8	0	0	0	9	0	0	0	0	0	0	0	0	0	0	0	17	0	0	0
PA ∙ IVS or critical PS	33	1 (3.0)	0	2 (6.1)	35	0	0	0	8	0	0	0	0	0	0	0	76	1 (1.3)	0	2 (2.6)
TAPVR	5	0	0	0	5	0	0	1 (20.0)	2	0	0	0	1	0	0	0	13	0	0	1 (7.7)
PAPVR ± ASD	0	0	0	0	0	0	0	0	1	0	0	0	0	0	0	0	1	0	0	0
ASD	1	0	0	0	0	0	0	0	0	0	0	0	1	0	0	0	2	0	0	0
Cor triatriatum	0	0	0		0	0	0	0	1	0	0	0	0	0	0	0	1	0	0	0
AVSD (partial)	2	0	0	1 0	3	0	0	0	0	0	0	0	0	0	0	0	5	0	0	1 (20.0)
AVSD (complete)	39	0	0	2 (5.1)	66	2 (3.0)	0	2 (3.0)	6	0	0	0	2	0	0	0	113	2 (1.8)	0	4 (3.5)
+ TOF or DORV	1	0	0	0	4	0	0	0	1	0	0	0	0	0	0	0	6	0	0	0
+ Others	0	0	0	0	1	0	0	0	0	0	0	0	0	0	0	0	1	0	0	0
VSD (subarterial)	3	0	0	0	3	0	0	0	0	0	0	0	0	0	0	0	6	0	0	0
VSD (perimemb./muscular)	66	0	0	0	156	0	0	1 (0.6)	4	0	0	0	0	0	0	0	226	0	0	1 (0.4)
VSD + PS	0	0	0	0	1	0	0	0	0	0	0	0	0	0	0	0	1	0	0	0
DCRV ± VSD	0	0	0	0	0	0	0	0	2	0	0	0	0	0	0	0	2	0	0	0
Aneurysm of sinus valsalva	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0
TOF	17	0	0	0	71	0	0	0	8	0	0	0	1	0	0	0	97	0	0	0
PA + VSD	16	0	0	1 (6.3)	61	2 (3.3)	0	3 (4.9)	35	0	0	0	0	0	0	0	112	2 (1.8)	0	4 (3.6)
DORV	50	2 (4.0)	0	2 (4.0)	76	0	0	1 (1.3)	8	0	0	0	2	0	0	0	136	2 (1.5)	0	3 (2.2)
TGA (simple)	6	0	0	0	3	0	0	0	0	0	0	0	3	0	0	0	12	0	0	0
+ VSD	10	0	0	0	9	0	0	0	2	0	0	0	0	0	0	0	21	0	0	0
VSD + PS	0	0	0	0	3	0	0	0	0	0	0	0	0	0	0	0	3	0	0	0
Corrected TGA	2	0	0	0	9	0	0	0	20	0	0	0	6	0	0	0	37	0	0	0
Truncus arteriosus	20	0	0	0	6	0	0	0	2	0	0	1 (50.0)	0	0	0	0	28	0	0	1 (3.6)
SV	76	2 (2.6)	0	6 (7.9)	66	1 (1.5)	0	3 (4.5)	17	0	0	0	4	0	0	0	163	3 (1.8)	0	9 (5.5)
TA	10	0	0	0	16	0	0	0	5	0	0	0	3	0	0	0	34	0	0	0
HLHS	109	2 (1.8)	0	9 (8.3)	34	0	0	0	14	0	0	0	0	0	0	0	157	2 (1.3)	0	9 (5.7)
Aortic valve lesion	8	1 (12.5)	0	2 (25.0)	3	0	0	0	2	0	0	0	1	0	0	0	14	1 (7.1)	0	2 (14.3)
Mitral valve lesion	0	0	0	0	2	0	0	0	0	0	0	0	0	0	0	0	2	0	0	0
Ebstein	2	0	0	0	8	0	0	0	1	0	0	0	1	0	0	0	12	0	0	0
Coronary disease	0	0	0	0	0	0	0	0	4	1 (25.0)	0	1 (25.0)	0	0	0	0	4	1 (25.0)	0	1 (25.0)
Others	10	2 (20.0)	0	4 (40.0)	14	2 (14.3)	0	2 (14.3)	16	0	0	0	1	0	0	0	41	4 (9.8)	0	6 (14.6)
Conduit failure	1	0	0	0	1	0	0	0	0	0	0	0	0	0	0	0	2	0	0	0
Redo (excluding conduit failure)	21	1 (4.8)	0	1 (4.8)	71	0	0	1 (1.4)	104	1 (1.0)	0	2 (1.9)	14	0	0	0	210	2 (1.0)	0	4 (1.9)
Total	991	18 (1.8)	0	51 (5.1)	986	8 (0.8)	0	18 (1.8)	319	2 (0.6)	0	4 (1.3)	48	0	0	0	2344	28 (1.2)	0	73 (3.1)

1. (), % mortality
2. CPB cardiopulmonary bypass, PDA patient ductus arteriosus, VSD ventricular septal defect, DORV double-outlet right ventricle, AVSD atrioventricular septal defect, TGA transposition of great arteries, SV single ventricle, Interrupt. of Ao interruption of aorta, PS pulmonary stenosis, PA-IVS pulmonary atresia with intact ventricular septum, TAPVR total anomalous pulmonary venous return, PAPVR partial anomalous pulmonary venous return, ASD atrial septal defect, TOF tetralogy of Fallot, DCRV double-chambered right ventricle, TA tricuspid atresia, HLHS hypoplastic left heart syndrome, RV-PA right ventricle-pulmonary artery

(3) Main procedure

		Neonate				Infant				1–17 years				≧ 18 years				Total
		Cases	30-day mortality		Hospital mortality	Cases	30-day mortality		Hospital mortality	Cases	30-day mortality		Hospital mortality	Cases	30-day mortality		Hospital mortality	Cases	30-day mortality		Hospital mortality
			Hospital	After discharge			Hospital	After discharge			Hospital	After discharge			Hospital	After discharge			Hospital	After discharge
1	SP Shunt	135	3 (2.2)	0	7 (5.2)	364	5 (1.4)	0	8 (2.2)	63	1 (1.6)	0	1 (1.6)	4	0	0	0	566	9 (1.6)	0	16 (2.8)
2	PAB	415	7 (1.7)	0	22 (5.3)	324	1 (0.3)	0	3 (0.9)	17	0	0	0	2	0	0	0	758	8 (1.1)	0	25 (3.3)
3	Bidirectional Glenn or hemi-Fontan ± α	0	0	0	0	263	2 (0.8)	0	5 (1.9)	99	0	0	1 (1.0)	2	0	0	0	364	2 (0.5)	0	6 (1.6)
4	Damus–Kaye–Stansel operation	4	1 (25.0)	0	1 (25.0)	31	1 (3.2)	0	2 (6.5)	11	1 (9.1)	0	1 (9.1)	2	1 (50.0)	0	1 (50.0)	48	4 (8.3)	0	5 (10.4)
5	PA reconstruction/repair(including redo)	15	1 (6.7)	0	3 (20.0)	92	3 (3.3)	0	6 (6.5)	104	0	0	1 (1.0)	5	0	0	0	216	4 (1.9)	0	10 (4.6)
6	RVOT reconstruction/repair	5	1 (20.0)	0	1 (20.0)	161	2 (1.2)	0	3 (1.9)	308	5 (1.6)	0	6 (1.9)	33	0	0	0	507	8 (1.6)	0	10 (2.0)
7	Rastelli procedure	1	0	0	0	30	2 (6.7)	0	2 (6.7)	100	4 (4.0)	0	5 (5.0)	5	0	0	0	136	6 (4.4)	0	7 (5.1)
8	Arterial switch procedure	155	5 (3.2)	0	11 (7.1)	28	2 (7.1)	0	2 (7.1)	6	1 (16.7)	0	1 (16.7)	0	0	0	0	189	8 (4.2)	0	14 (7.4)
9	Atrial switch procedure	0	0	0	0	2	0	0	0	1	0	0	0	0	0	0	0	3	0	0	0
10	Double switch procedure	0	0	0	0	2	1 (50.0)	0	1 (50.0)	8	0	0	1 (12.5)	0	0	0	0	10	1 (10.0)	0	2 (20.0)
11	Repair of anomalous origin of CA	0	0	0	0	5	0	0	0	10	0	0	0	0	0	0	0	15	0	0	0
12	Closure of coronary AV fistula	0	0	0	0	2	0	0	0	7	1 (14.3)	0	1 (14.3)	8	0	0	0	17	1 (5.9)	0	1 (5.9)
13	Fontan/TCPC	0	0	0	0	0	0	0	0	347	3 (0.9)	0	9 (2.6)	23	0	0	0	370	3 (0.8)	0	9 (2.4)
14	Norwood procedure	29	2 (6.9)	0	4 (13.8)	110	7 (6.4)	0	16 (14.5)	6	1 (16.7)	0	1 (16.7)	0	0	0	0	145	10 (6.9)	0	21 (14.5)
15	Ventricular septation	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0
16	Left side AV valve repair (including Redo)	3	0	0	0	48	1 (2.1)	0	1 (2.1)	53	0	0	0	14	0	0	0	118	1 (0.8)	0	1 (0.8)
17	Left side AV valve replace (including Redo)	0	0	0	0	8	1 (12.5)	0	2 (25.0)	33	0	0	1 (3.0)	14	0	0	1 (7.1)	55	1 (1.8)	0	4 (7.3)
18	Right side AV valve repair (including Redo)	7	2 (28.6)	0	3 (42.9)	22	0	0	0	41	0	0	2 (4.9)	29	0	0	0	99	2 (2.0)	0	5 (5.1)
19	Right side AV valve replace (including Redo)	0	0	0	0	1	0	0	0	7	0	0	0	16	0	0	0	24	0	0	0
20	Common AV valve repair(including Redo)	3	0	0	0	14	0	0	2 (14.3)	19	2 (10.5)	0	2 (10.5)	2	0	0	0	38	2 (5.3)	0	4 (10.5)
21	Common AV valve replace(including Redo)	0	0	0	0	7	1 (14.3)	0	1 (14.3)	8	0	0	1 (12.5)	1	0	0	0	16	1 (6.3)	0	2 (12.5)
22	Repair of supra-aortic stenosis	1	0	0	0	10	1 (10.0)	0	1 (10.0)	17	0	0	0	1	0	0	0	29	1 (3.4)	0	1 (3.4)
23	Repair of subaortic stenosis (including Redo)	0	0	0	0	4	0	0	0	34	0	0	0	5	0	0	0	43	0	0	0
24	Aortic valve plasty ± VSD closure	2	0	0	0	12	0	0	0	24	0	0	1 (4.2)	2	0	0	0	40	0	0	1 (2.5)
25	Aortic valve replacement	0	0	0	0	1	0	0	0	26	0	0	0	23	0	0	0	50	0	0	0
26	AVR with annular enlargement	0	0	0	0	0	0	0	0	13	1 (7.7)	0	1 (7.7)	1	0	0	0	14	1 (7.1)	0	1 (7.1)
27	Aortic root replacement (except Ross)	0	0	0	0	0	0	0	0	12	0	0	1 (8.3)	6	0	0	0	18	0	0	1 (5.6)
28	Ross procedure	0	0	0	0	2	1 (50.0)	0	1 (50.0)	12	0	0	0	0	0	0	0	14	1 (7.1)	0	1 (7.1)
Total		775	22 (2.8)	0	52 (6.7)	1543	31 (2.0)	0	56 (3.6)	1386	20 (1.4)	0	37 (2.7)	198	1 (0.5)	0	2 (1.0)	3902	74 (1.9)	0	147 (3.8)

1. (), % mortality
2. SP systemic pulmonary, PAB pulmonary artery banding, PA pulmonary artery, RVOT right ventricular outflow tract, CA coronary artery, AV fistula arteriovenous fistula, TCPC total cavopulmonary connection, AV valve atrioventricular valve, VSD ventricular septal defect, AVR aortic valve replacement

Table 4 Acquired [total, (1) + (2) + (4) + (5) + (6) + (7) + isolated ope. for arrhythmia in (3)] 39,485

(2) Ischemic heart disease (total, (A) + (B) + (C), 15,103)(A) Isolated CABG (total, (a) + (b), 13,830)(a−1) On-pump arrest CABG (total 3121)

	Primary, elective				Primary, emergency				Redo, elective				Redo, emergency				Arterial graft only	Artery graft + SVG	SVG only	Others	Unclear
	Cases	30-day mortality		Hospital mortality	Cases	30-day mortality		Hospital mortality	Cases	30-day mortality		Hospital mortality	Cases	30-day mortality		Hospital mortality
		Hospital	After discharge			Hospital	After discharge			Hospital	After discharge			Hospital	After discharge
1VD	78	4 (5.1)	0	4 (5.1)	11	3 (27.3)	0	5 (45.5)	2	0	0	0	3	0	0	0	45	24	25	0	0
2VD	345	3 (0.9)	0	5 (1.4)	47	5 (10.6)	0	6 (12.8)	6	0	0	0	0	0	0	0	68	302	25	3	0
3VD	1186	14 (1.2)	0	28 (2.4)	174	9 (5.2)	0	11 (6.3)	10	2 (20.0)	0	2 (20.0)	2	0	0	0	92	1234	31	6	9
LMT	945	10 (1.1)	0	14 (1.5)	297	20 (6.7)	1 (0.3)	25 (8.4)	10	1 (10.0)	0	1 (10.0)	5	1 (20.0)	0	1 (20.0)	130	1078	43	5	1
Total	2554	31 (1.2)	0	51 (2.0)	529	37 (7.0)	1 (0.2)	47 (8.9)	28	3 (10.7)	0	3 (10.7)	10	1 (10.0)	0	1 (10.0)	335	2638	124	14	10
Kawasaki	15	0	0	0	1	0	0	0	0	0	0	0	0	0	0	0	7	7	1	0	1
Hemodialysis	220	7 (3.2)	0	11 (5.0)	57	9 (15.8)	0	13 (22.8)	4	1 (25.0)	0	1 (25.0)	0	0	0	0	19	245	16	1	3

1. (), % mortality
2. CABG coronary artery bypass grafting, 1VD one-vessel disease, 2VD two-vessel disease, 3VD three-vessel disease, LMT left main trunk, SVG saphenous vein graft
3. LMT includes LMT alone or LMT with other branch diseases

(a−2) On-pump beating CABG (total 2024)

	Primary, elective				Primary, emergency				Redo, elective				Redo, emergency				Arterial graft only	Artery graft + SVG	SVG only	Others	Unclear
	Cases	30-day mortality		Hospital mortality	Cases	30-day mortality		Hospital mortality	Cases	30-day mortality		Hospital mortality	Cases	30-day mortality		Hospital mortality
		Hospital	After discharge			Hospital	After discharge			Hospital	After discharge			Hospital	After discharge
1VD	25	0	0	1 (4.0)	10	1 (10.0)	0	1 (10.0)	7	0	0	0	2	2 (100.0)	0	2 (100.0)	16	16	12	0	0
2VD	184	1 (0.5)	0	2 (1.1)	48	5 (10.4)	0	7 (14.6)	6	0	0	0	2	0	0	0	47	173	13	1	6
3VD	643	13 (2.0)	1 (0.2)	24 (3.7)	174	19 (10.9)	0	24 (13.8)	10	1 (10.0)	0	1 (10.0)	2	1 (50.0)	0	1 (50.0)	95	691	30	2	11
LMT	591	8 (1.4)	0	10 (1.7)	305	32 (10.5)	0	41 (13.4)	9	0	0	0	6	2 (33.3)	0	2 (33.3)	143	706	44	5	13
Total	1443	22 (1.5)	1 (0.1)	37 (2.6)	537	57 (10.6)	0	73 (13.6)	32	1 (3.1)	0	1 (3.1)	12	5 (41.7)	0	5 (41.7)	301	1586	99	8	30
Kawasaki	1	0	0	0	0	0	0	0	1	0	0	0	0	0	0	0	1	1	0	0	0
Hemodialysis	182	7 (3.8)	0	13 (7.1)	76	18 (23.7)	0	23 (30.3)	2	0	0	0	3	1 (33.3)	0	1 (33.3)	25	214	19	2	3

1. () % mortality
2. CABG coronary artery bypass grafting, 1VD one-vessel disease, 2VD two-vessel disease, 3VD three-vessel disease, LMT left main trunk, SVG saphenous vein graft
3. LMT includes LMT alone or LMT with other branch diseases

(b) Off-pump CABG (total 8685)(The present section also includes cases of planned off-pump CABG in which, during surgery, the change is made to an on-pump CABG or on-pump beating-heart procedure)

	Primary, elective				Primary, emergency				Redo, elective				Redo, emergency					Arterial graft only	Artery graft + SVG	SVG only	Others	Unclear
	Cases	30-day mortality		Hospital mortality	Cases	30-day mortality		Hospital mortality	Cases	30-day mortality		Hospital mortality	Cases	30-day mortality		Hospital mortality
		Hospital	After discharge			Hospital	After discharge			Hospital	After discharge			Hospital	After discharge
1VD	464	0	0	1 (0.2)	58	2 (3.4)	0	3 (5.2)	10	0	0	0	5	1 (20.0)	0	1	(20.0)	386	111	32	1	7
2VD	1172	6 (0.5)	0	10 (0.9)	143	4 (2.8)	0	7 (4.9)	17	0	0	0	5	2 (40.0)	0	2	(40.0)	477	785	44	9	22
3VD	2939	20 (0.7)	1 (0.0)	44 (1.5)	417	13 (3.1)	0	21 (5.0)	22	0	0	0	7	0	0	1	(14.3)	706	2595	49	11	24
LMT	2694	12 (0.4)	0	31 (1.2)	683	18 (2.6)	0	24 (3.5)	36	4 (11.1)	0	5 (13.9)	13	2 (15.4)	0	2	(15.4)	956	2367	94	13	0
Total	7269	38 (0.5)	1 (0.0)	86 (1.2)	1301	37 (2.8)	0	55 (4.2)	85	4 (4.7)	0	5 (5.9)	30	5 (16.7)	0	6	(20.0)	2525	5858	219	34	53
Kawasaki	12	0	0	0	1	0	0	0	0	0	0	0	0	0	0	0		11	2	0	0	1
Hemodialysis	706	18 (2.5)	0	32 (4.5)	135	7 (5.2)	0	11 (8.1)	14	4 (28.6)	0	4 (28.6)	8	1 (12.5)	0	1	(12.5)	212	610	33	4	4

1. () % mortality
2. CABG coronary artery bypass grafting, 1VD one-vessel disease, 2VD two-vessel disease, 3VD three-vessel disease, LMT left main trunk, SVG saphenous vein graft
3. LMT includes LMT alone or LMT with other branch diseases

(c) Includes cases of conversion, during surgery, from off-pump CABG to on-pump CABG or on-pump beating-heart CABG (total 240)

	Primary, elective				Primary, emergency				Redo, elective				Redo, emergency
	Cases	30-day mortality			Cases	30-day mortality			Cases	30-day mortality			Cases	30-day mortality
		Hospital	After discharge	Hospital mortality		Hospital	After discharge	Hospital mortality		Hospital	After discharge	Hospital mortality		Hospital	After discharge	Hospital mortality
A conversion to on-pump CABG arrest heart	36	3 (8.3)	0	3 (8.3)	9	2 (22.2)	0	2 (22.2)	4	2 (50.0)	0	2 (50.0)	0	0	0	0
A conversion to on-pump beating-heart CABG	132	4 (3.0)	0	9 (6.8)	56	8 (14.3)	0	11 (19.6)	2	0	0	0	1	0	0	0
Total	168	7 (4.2)	0	12 (7.1)	65	10 (15.4)	0	13 (20.0)	6	2 (33.3)	0	2 (33.3)	1	0	0	0
Hemodialysis	30	4 (13.3)	0	5 (16.7)	11	3 (27.3)	0	4 (36.4)	3	2 (66.7)	0	2 (66.7)	0	0	0	0

1. (), % mortality
2. CABG coronary artery bypass grafting

(B) Operation for complications of MI (total 1273)

	Chronic				Acute				Concomitant operation
	Cases	30-day mortality		Hospital mortality	Cases	30-day mortality		Hospital mortality
		Hospital	After discharge			Hospital	After discharge		CABG	MVP	MVR
Infarctectomy or aneurysmectomy	202	13 (6.4)	0	19 (9.4)	19	2 (10.5)	0	2 (10.5)	143	68	10
VSP closure	56	4 (7.1)	0	10 (17.9)	219	64 (29.2)	1 (0.5)	87 (39.7)	89	4	6
Cardiac rupture	14	4 (28.6)	0	4 (28.6)	199	71 (35.7)	1 (0.5)	80 (40.2)	33	1	3
Mitral regurgitation
1)Papillary muscle rupture	14	1 (7.1)	0	3 (21.4)	50	15 (30.0)	0	17 (34.0)	30	10	52
2) Ischemic	326	22 (6.7)	0	33 (10.1)	44	10 (22.7)	0	13 (29.5)	279	260	108
Others	54	5 (9.3)	0	7 (13.0)	76	14 (18.4)	0	23 (30.3)	55	10	2
Total	666	49 (7.4)	0	76 (11.4)	607	176 (29.0)	2 (0.3)	222 (36.6)	629	353	181

1. (), % mortality
2. MI myocardial infarction, CABG coronary artery bypass grafting, MVP mitral valve repair, MVR mitral valve replacement, VSP ventricular septal perforation
3. Acute, within 2 weeks from the onset of myocardial infarction

(C) TMLR (total 0)

	Cases	30-day mortality		Hospital mortality
		Hospital	After discharge
Isolated	0	0	0	0
with CABG	0	0	0	0
Total	0	0	0	0

1. TMLR transmyocardial laser revascularization

(3) Operation for arrhythmia (total 5765)

	Cases	30-day mortality		Hospital mortality	Concomitant operation
					Isolated	Congenital	Valve	IHD	Others	Multiple combination
		Hospital	After discharge							2 categories	3 categories
Maze	3795	73 (1.9)	1 (0.03)	108 (2.8)	80	180	3338	607	290	636	49
For WPW	2	0	0	0	0	0	2	0	0	0	0
For ventricular tachyarrhythmia	40	1 (2.5)	0	2 (5.0)	2	0	15	24	8	8	1
Others	1928	35 (1.8)	0	68 (3.5)	122	82	1531	400	214	384	30
Total	5765	109 (1.9)	1 (0.02)	178 (3.1)	204	262	4886	1031	512	1028	80

1. () % mortality
2. Except for 106 isolated cases, all remaining 3749 cases are doubly allocated, one for this subgroup and the other for the subgroup corresponding to the concomitant operations
3. WPW Wolff–Parkinson–White syndrome, IHD ischemic heart disease

(4) Operation for constrictive pericarditis (total 184)

	CPB (+)				CPB (−)
	Cases	30-day mortality		Hospital mortality	Cases	30-day mortality		Hospital mortality
		Hospital	After discharge			Hospital	After discharge
Total	96	10 (10.4)	0	17 (17.7)	88	5 (5.7)	0	7 (8.0)

1. () % mortality
2. CPB cardiopulmonary bypass

(5) Cardiac tumor (total 560)

	Cases	30-day mortality		Hospital mortality	Concomitant operation
		Hospital	After discharge		AVR	MVR	CABG	others
Benign tumor (cardiac myxoma)	465	2 (0.4)	0	6 (1.3)	10	7	32	82
	347	1 (0.3)	0	4 (1.2)	8	4	22	53
Malignant tumor (primary)	95	9 (9.5)	1 (1.1)	12 (12.6)	0	3	3	15
	29	3 (10.3)	1 (3.4)	3 (10.3)	0	1	2	7

1. (), % mortality
2. AVR aortic valve replacement, MVR mitral valve replacement, CABG coronary artery bypass grafting

(6) HOCM and DCM (total 304)

	Cases	30-day mortality		Hospital mortality	Concomitant operation
		Hospital	After discharge		AVR	MVR	MVP	CABG
Myectomy	139	6 (4.3)	0	10 (7.2)	73	33	16	20
Myotomy	4	0	0	0	1	0	1	1
No resection	144	7 (4.9)	0	15 (10.4)	27	63	81	16
Volume reduction surgery of the left ventricle	17	0	0	2 (11.8)	0	1	13	4
Total	304	13 (4.3)	0	27 (8.9)	101	97	111	41

1. (), % mortality
2. HOCM hypertrophic obstructive cardiomyopathy, DCM dilated cardiomyopathy, AVR aortic valve replacement, MVR mitral valve replacement, MVP mitral valve repair, CABG coronary artery bypass grafting

(7) Other open-heart operation (total 669)

	Cases	30-day mortality		Hospital mortality
		Hospital	After discharge
Open-heart operation	390	32 (8.2)	0	41 (10.5)
Non-open-heart operation	279	33 (11.8)	1 (0.4)	38 (13.6)
Total	669	65 (9.7)	1 (0.1)	79 (11.8)

1. (), % mortality

Table 5 Thoracic aortic aneurysm (total 17,444)

(2) Non-dissection (total 8897)

Replaced site	Unruptured				Ruptured				Concomitant operation						Redo
	Cases	30-day mortality		Hospital mortality	Cases	30-day mortality		Hospital	AVp	AVR	MVP	MVR	CABG	Others	Case	30-day mortality		Hospital mortality
		Hospital	After discharge			Hospital	After discharge	Mortality								Hospital	After discharge
1. Ascending Ao.	1375	25 (1.8)	0	41 (3.0)	46	6 (13.0)	0	10 (21.7)	65	991	85	36	184	215	148	10 (6.8)	0	15 (10.1)
2. Aortic root	735	24 (3.3)	0	30 (4.1)	29	7 (24.1)	0	8 (27.6)	168	485	50	10	100	91	160	14 (8.8)		16 (10.0)
3. Arch	1714	57 (3.3)	0	107 (6.2)	123	19 (15.4)	0	30 (24.4)	25	278	22	15	301	106	183	9 (4.9)	0	21 (11.5)
4. Aortic root + Asc.Ao. + Arch	257	8 (3.1)	0	11 (4.3)	16	2 (12.5)	0	2 (12.5)	49	167	21	1	34	46	41	4 (9.8)	0	5 (12.2)
5. Descending Ao.	365	13 (3.6)	0	20 (5.5)	52	12 (23.1)	0	17 (32.7)	2	10	2	0	28	3	86	7 (8.1)	0	11 (12.8)
6. Thoracoabdominal Ao.	356	18 (5.1)	0	34 (9.6)	35	10 (28.6)	0	11 (31.4)	0	2	0	0	2	0	116	12 (10.3)	0	20 (17.2)
7. Stent graft *a	3489	96 (2.8)	3 (0.1)	161 (4.6)	389	65 (16.7)	1 (0.3)	83 (21.3)	19	65	10	2	184	52	770	38 (4.9)	1 (0.1)	55 (7.1)
1) TEVARl*b	2334	51 (2.2)	1 (0.0)	80 (3.4)	298	51 (17.1)	1 (0.3)	63 (21.1)	1	3	1	0	14	10	626	28 (4.5)	1 (0.2)	39 (6.2)
2) Open stent	1075	45 (4.2)	2 (0.2)	81 (7.5)	91	14 (15.4)	0	20 (22.0)	18	62	9	2	170	42	144	10 (6.9)	0	16 (11.1)
a) With total arch *c	296	14 (4.7)	1 (0.3)	17 (5.7)	38	6 (15.8)	0	7 (18.4)	2	3	1	1	22	4	52	3 (5.8)	0	3 (5.8)
b) Without total arch *d	779	31 (4.0)	1 (0.1)	64 (8.2)	53	8 (15.1)	0	13 (24.5)	16	59	8	1	148	38	92	7 (7.6)	0	13 (14.1)
Total	8209	249 (3.0)	3 (0.04)	404 (4.9)	688	121 (17.6)	1 (0.1)	161 (23.4)	328	1998	190	64	833	513	1504	94 (6.3)	1 (0.1)	143 (9.5)

1. (), % mortality
2. Ao aorta, AVP aortic valve repair, AVR aortic valve replacement, MVP mitral valve repair, MVR mitral valve replacement, CABG coronary artery bypass grafting, TEVAR thoracic endovascular aortic(aneurysm) repair
3. *a = *b + *c + *d + unspecified

Table 6 Pulmonary thromboembolism (total 134)

Table 7 Assisted circulation (total 1637)

Table 8  Heart transplantation (total 44)

Table 9  Pacemaker + ICD (total 4078)

In 2015, 6894 open-heart operations for congenital heart disease were performed with overall hospital mortality of 2.7%. The number of operations for congenital heart disease decreased gradually throughout these 10 years (maximum 7386 cases in 2006), and overall hospital mortality showed plateau around 3.0%. In detail, the most common disease was ventricular septal defect (1253 cases), for the first time since the inauguration of this survey. Atrial septal defect (ASD), which had been the most common disease, was the “second” common one (1031 cases) in 2015. It was mainly due to the development of catheter device for ASD closure commercially available in Japan since 2005. In the last 10 years, hospital mortality for complex congenital heart disease was as follows (2005 [2], 2010 [3], and 2015): complete atrio-septal defect (4.7, 4.2 and 1.7%), tetralogy of Fallot (1.6, 0.8 and 1.3%), transposition of the great arteries with intact septum (6.2, 4.1 and 6.6%) and with ventricular septal defect (15.9, 7.3 and 3.9%), single ventricle (5.3, 7.5 and 4.3%), and hypoplastic left heart syndrome (24.4, 13.1 and 9.8%). Right heart bypass surgery is now commonly performed (364 bidirectional Glenn procedures excluding 48 Damus–Kaye–Stansel procedures and 370 Fontan type procedures including total cavopulmonary connection) with acceptable hospital mortality (1.6 and 2.4%). Norwood type I procedure was performed in 145 cases with relatively low hospital mortality rate of 14.5%.

The number of operations for valvular heart disease has constantly increased until 2014 (21,939 cases) [1], and that was 19,820 cases in 2015. The hospital mortality of primary single valve placement was 2.8 and 8.7% for the aortic and the mitral position, while that for primary mitral valve repair was 1.7%. Hospital mortality rate for redo valve surgery was 5.7% in aortic and 7.1% in mitral positions, respectively. Finally, overall hospital mortality did not show dramatic improvement during the last 10 years (3.6% in 2005 [2], 3.1% in 2010 [3], and 4.0% in 2015), which might be partially due to the recent progression of age of the patients. Repair of the valve became a popular procedure (377 cases in the aortic, 6417 cases in the mitral, and 4942 cases in the tricuspid), and mitral valve repair constituted 32.4% of all valvular operations and 65.0% of all mitral valve procedures, which are similar to those of the last 5 years. Aortic and mitral valve replacements with bioprosthesis were performed in 6704 cases and 789 cases, respectively. The ratio of bioprosthesis was 76.4% at the aortic and 23.8% at the mitral position. This ratio of the aortic bioprosthesis increased dramatically from 30 to 40% in the early 2000s [4, 5] to more than 70% recent 5 years. CABG as a concomitant procedure was performed in 20.8% of operations for all valvular heart disease (14.4% in 2005 [2] and 17.3% in 2010 [3]).

Isolated CABG was performed in 13,830 cases which were only 75.4% of that of 10 years ago (2005 [2]). Among these, off-pump CABG was intended in 8685 cases (63.0%) with a success rate of 97.2%, so final success rate of off-pump CABG was 61.1%. The percentage of intended off-pump CABG reached 60.3% in 2004 [4] and then was kept over 60% until now. In 13,830 isolated CABG patients, 96.8% of them received at least one arterial graft, while all arterial graft CABGs were performed only in 22.9% of them. The operative and hospital mortality rates associated with primary elective CABG procedures in 11,266 cases were 0.8 and 1.5%, respectively. Similar data analysis of CABG including primary/redo and elective/emergency data was begun in 2003 [5], and the operative and hospital mortality rates associated with primary elective CABG procedures in 2003 were 1.0 and 1.5%, respectively, so operative results of primary CABG have been stable. Hospital mortality of primary emergency CABG in 2367 cases was still high and was 7.4%. The result of conversion from off-pump CABG rate was 2.8% and hospital mortality in that was 11.3%. A total of 1273 patients underwent surgery for complications of myocardial infarction, including 272 operations for left ventricular aneurysm, ventricular septal perforation or cardiac rupture and 340 operations for ischemic mitral regurgitation.

Operations for arrhythmia were performed mainly as a concomitant procedure in 5765 cases associated with 49.5% increase comparing with that of 2014. The hospital mortality of arrhythmia surgery including 3795 MAZE procedures was 3.1%. MAZE procedure has become quite popular procedure (2497 cases in 2005 [2] and 3591 cases in 2010 [3]).

Operations for thoracic aortic dissection were performed in 8691 cases and this increased by 12.4% this year compared with those of last year. For 6575 Stanford type A acute aortic dissections, hospital mortality remained high and was 9.9%. Operations for a non-dissected thoracic aneurysm were carried out in 9226 cases (decreased by 5.6%), with overall hospital mortality of 6.0%. The hospital mortality associated with unruptured aneurysm was 4.5%, and that of ruptured aneurysm was 24.2%, which remains markedly high.

The number of stent graft procedures remarkably increased recently. A total of 2521 patients with aortic dissection underwent stent graft placement: thoracic endovascular aortic repair (TEVAR) in 1650 cases and open stent grafting in 871 cases. The number of TEVAR for type B chronic aortic dissections increased from 835 cases in 2014 to 1065 cases in 2015. The hospital mortality rates associated with TEVAR for type B aortic dissection were 8.9% in acute cases and 2.6% for chronic cases, respectively.

A total of 3935 patients with non-dissected aortic aneurysm underwent stent graft placement: TEVAR in 2912 cases (17.3% decrease compared with that in 2014) and open stent grafting in 937 cases (155% increase compared with that in 2014). The reason of striking increase of open stent grafting might be due to commercial availability since 2014. The hospital mortality rates for TEVAR and open stenting were as follows: TEVAR (3.2% for unruptured, 21.7% for ruptured aneurysm,) and open stenting (7.2% for unruptured and 25.6% for ruptured.)

In summary, the total cardiovascular operations decreased during 2015 by 2933 cases with steadily constant results in almost all categories. The main reason why the number of operations decreased in 2015 was the number of extra-anatomical bypass operations in thoracic aortic aneurysm and the number of trans-venous pacemaker implantations was excluded from the total number of cardiovascular operations in association with the change of data aggregation as was referred to earlier.

(B) General thoracic surgery

The 2015 survey of general thoracic surgery comprised 736 surgical units, and most data were submitted using the web-based collection system of the national clinical database (NCD) [1]. In total, 79,775 operations were reported by general thoracic surgery departments in 2015—1.8 times the number of operations in 2001 and 2705 more operations than in 2014 (Fig. 2).

Fig. 2

General thoracic surgery

In 2015, 40,302 operations for primary lung cancer were performed (Table 10), and the number has increased every year. The 2015 value is 2.1 times that of 2001. Operations for lung cancer were 50.5% of all procedures in general thoracic surgery.

Table 24 Table 10 Total entry cases of General Thoracic Surgery during 2015

The number of video-assisted thoracic surgery (VATS) procedures in the NCD unexpectedly increased in 2014; however, the exact number of such procedures was not published. The increase was attributed to the use of a non-standard definition of VATS for the NCD registry until 2013. The NCD registry previously included VATS procedures utilizing a skin incision longer than 8 cm and/or a minithoracotomy (hybrid) approach, which are traditionally not regarded as VATS procedures. In this report, the traditional VATS definition is used to describe the number of VATS procedures in the NCD. The number of VATS operations for benign pulmonary tumor, primary lung cancer, and the total number of VATS operation in 2014 and 2015 are shown in Tables 11, 12, 14, 17, 18, 19, 20, 21, 22, 23, 24, 26, 27, 28, and 30, respectively.

Table 25 Table 11 1. Benign pulmonary tumor

Table 26 Table 12 2. Primary malignant pulmonary tumor

Table 27 Table 13 Details of lung cancer operation

Table 28 Table 14 3. Metastatic pulmonary tumor

Table 29 Table 15 4. Tracheal tumor

Table 30 Table 16 5. Tumor of pleural origin

Table 31 Table 17 6. Chest wall tumor

Table 32 Table 18 7. Mediastinal tumor

Table 33 Table 19 8. Thymectomy for myasthenia gravis

Table 34 Table 20 9. Operations for non-neoplastic disease

Table 35 Table 21 9. Operations for non-neoplastic disease

Table 36 Table 22 9. Operations for non-neoplastic disease

Table 37 Table 23 9. Operations for non-neoplastic disease

Table 38 Table 24 9. Operations for non-neoplastic disease

Table 39 Table 25 9. Operations for non-neoplastic disease

Table 40 Table 26 9. Operations for non-neoplastic disease

Table 41 Table 27 9. Operations for non-neoplastic disease

Table 42 Table 28 9. Operations for non-neoplastic disease

Table 29 10. Lung transplantation

Table 44 Table 30 11. Video-assisted thoracic surgery

There were 2161 operations for benign pulmonary tumors in 2015, which was similar to the number in 2014 (Table 11). Hamartoma was the most frequent diagnosis in operations for benign pulmonary tumors. VATS was performed in 2063 patients (95.5%). Additional information on primary malignant pulmonary tumors is shown in Tables 12 and 13. With regard to lung cancer subtype, adenocarcinoma was by far the most frequent diagnosis (70.0% of all lung cancer operations), followed by squamous cell carcinoma (19.0%). Sublobar resection was performed in 10,040 lung cancer cases (24.9% of all cases) and lobectomy was performed in 29,323 cases (72.8% of all cases). Sleeve lobectomy was performed in 541 cases, and pneumonectomy was required in 533 cases (1.3% of all cases). VATS lobectomy for lung cancer was performed in 18,078 cases (61.7%). The number of VATS procedures for primary lung cancer was slightly higher than in 2014.

In total, 129 patients died before hospital discharge within 30 days after lung cancer surgery, and 45 patients died after discharge within 30 days after lung cancer surgery. Therefore, 174 patients died within 30 days after lung cancer surgery (30-day mortality rate, 0.43%). In total, 277 patients died before discharge (hospital mortality rate, 0.69%), and the 30-day mortality rate, by procedure, was 0.26% for segmentectomy, 0.44% for lobectomy, and 2.44% for pneumonectomy. Interstitial pneumonia was the leading cause of death after lung cancer surgery, followed by pneumonia, respiratory failure, and cardiovascular events, as was the case in 2014.

Operations for metastatic pulmonary tumors are shown in Table 14; 8226 such operations were performed in 2015, an increase from the previous year. Colorectal cancer was the most frequent diagnosis (47.2% of all cases).

There were 127 operations for malignant tracheal tumor in 2015, but only 16 patients were treated with curative intent (Table 15).

There were 635 pleural tumors in 2015 (Table 16). Diffuse malignant pleural mesothelioma was the most frequent histologic diagnosis. Total pleurectomy was performed in 89 cases and extrapleural pneumonectomy in 80 cases. The hospital mortality rate was 4.5% after total pleurectomy and 5.0% after extrapleural pneumonectomy.

In total, 677 chest wall tumors were resected in 2015 (Table 17); 352 (52.0%) were benign. Among the 325 malignant chest wall tumors, 195 (60.0%) were metastatic tumors.

Mediastinal tumors were resected in 4813 patients, a slight increase from the previous year (Table 18). Thymic epithelial tumor—including 1912 thymomas, 336 thymic carcinomas, and 30 thymic neuroendocrine carcinomas—was the most frequent mediastinal tumor type in 2015.

Thymectomy for myasthenia gravis was performed in 474 cases (Table 19); 310 cases were associated with thymoma and the remaining cases were not associated with thymoma.

There were 2265 cases of lung resection for inflammatory lung diseases (Table 20); 34.2% of the cases were inflammatory tumors of unknown origin, 22.2% were atypical mycobacterium infections, and 13.6% were fungal infections.

The 2739 operations for empyema (Table 21) comprised 1999 cases (73.0%) of acute empyema and 740 cases of chronic empyema. Bronchopleural fistula was reported in 466 patients (23.3%) with acute empyema and 325 patients (43.9%) with chronic empyema. The hospital mortality rate was 16.5% in patients with acute empyema with fistula.

There were 98 operations for descending necrotizing mediastinitis (Table 22). The hospital mortality rate was 8.2%.

There were 416 operations for bullous diseases (Table 23). Lung volume reduction surgery was performed in only 21 patients.

The NCD showed 14,728 operations for spontaneous pneumothorax (Table 24). The 11,816 operations for primary pneumothorax comprised 3118 patients (26.4%) who underwent bullectomy only and 7805 patients (66.1%) who underwent an additional procedure. There were 2851 operations for secondary pneumothorax. COPD was by far the most prevalent associated disease (69.5%). The hospital mortality rate for secondary pneumothorax associated with COPD was 3.1%.

The 2015 survey reported 174 operations for chest wall deformity (Table 25). However, this might be an underestimate, because the Nuss procedure was more likely to have been performed in centers not associated with JATS.

Diaphragmatic hernia was treated surgically in 36 patients (Table 26). This figure might be an underestimate, as some procedures might have been classified as gastrointestinal surgery.

The survey reported 388 procedures for chest trauma excluding iatrogenic injuries (Table 27). The hospital mortality rate was 6.7%.

Table 28 shows operations for other diseases, including 82 cases of arteriovenous malformation and 90 cases of pulmonary sequestration.

A total of 63 lung transplantations were performed in 2015 (Table 29): 47 patients received lung transplants from brain-dead donors and 16 received transplants from living-related donors. The number of lung transplantation procedures has remained constant for several years.

The number of VATS procedures has increased annually, reaching 60,735 in 2015 (Table 30).

The details of tracheobronchoplasty, pediatric surgery, and combined resection of neighboring organs are shown in Tables 31, 32, 33 and 34.

Table 45 Table 31 12. Tracheobronchoplasty

Table 46 Table 32 13. Pediatric surgery

Table 47 Table 33 14. Combined resection of neighboring organ(s)

Table 48 Table 34 15. Operation of lung cancer invading the chest wall of the apex

(C) Esophageal surgery

During 2015 alone, a total of 12,732 patients with esophageal diseases were registered from 571 institutions (response rate: 93.6%) affiliated to the Japanese Association for Thoracic Surgery and/or to the Japan Esophageal Society. Among these institutions, those where 20 or more patients underwent esophageal surgeries within the year of 2015 were 136 institutions (23.8%), which shows no definite shift of esophageal operations to high-volume institutions when compared to the data of 2014 (22.1%) (Table 35). Of 2991 patients with a benign esophageal disease, 1619 (54.1%) patients underwent surgery, and 77 (2.6%) patients underwent endoscopic resection, while 1295 (43.3%) patients did not undergo any surgical treatment (Table 36). Of 10,288 patients with a malignant esophageal tumor, 8106 (78.8%) patients underwent resection, esophagectomy for 6151 (59.8%) and endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) for 1955 (19.0%), while 2182 (21.2%) patients did not undergo any resection (Tables 37, 38). The patients registered, particularly those undergoing non-surgical therapy for a malignant esophageal disease, have been increasing since 1990 (Fig. 3).

Table 49 Table 35 Distribution of number of esophageal operations in 2015 in each institution

Table 50 Table 36 Benign esophageal diseases

Table 51 Table 37 Malignant esophageal diseases (histologic classification)

Table 52 Table 38 Malignant esophageal disease (clinical characteristics)

Fig. 3

Annual trend of in-patients with esophageal diseases. EMR endoscopic mucosal resection (including endoscopic submucosal)

Among benign esophageal diseases (Table 36), hiatal hernia, esophageal varices, esophagitis (including reflux esophagitis) and achalasia were the most common conditions in Japan. On the other hand, spontaneous rupture of the esophagus, benign esophageal tumors and congenital esophageal atresia were common diseases which were surgically treated as well as the above-mentioned diseases. The thoracoscopic and/or laparoscopic procedures have been widely adopted for benign esophageal diseases, in particular achalasia, hiatal hernia and benign tumors. Open surgery was performed in 1072 (66.2%) patients with a benign esophageal disease, with 30-day mortality in 7 (0.7%), while thoracoscopic and/or laparoscopic surgery was performed for 547 (33.8%) patients, with none of the 30-day mortality. The difference in these death rates between open and scopic surgery seems to be related to the conditions requiring open surgery.

The majority of malignant diseases were carcinomas (Table 37). Among esophageal carcinomas, the incidence of squamous cell carcinoma was 90.1%, while that of adenocarcinomas including Barrett cancer was 7.2%. The resection rate for patients with a squamous cell carcinoma was 77.9%, while that for patients with an adenocarcinoma was 88.9%.

According to location, cancer in the thoracic esophagus was the most common (Table 38). Of the 4137 patients (40.2% of total esophageal malignancies) having superficial esophageal cancers within mucosal and submucosal layers, 6151 (59.8%) patients underwent esophagectomy, while 1955 (19.0%) patients underwent EMR or ESD. The 30-day mortality rate and hospital mortality rate after esophagectomy for patients with a superficial cancer were 0.5 and 1.7% (141/6151), respectively.

Multiple primary cancers were observed in 1816 (17.7%) of all the 10,288 patients with esophageal cancer. Synchronous cancer was found in 960 (9.3%) patients, while metachronous cancer was observed in 856 (8.3%) patients. The stomach is the commonest site for both synchronous and metachronous malignancy followed by head and neck cancer (Table 38).

Among esophagectomy procedures, transthoracic esophagectomy through right thoracotomy was the most commonly adopted for patients with a superficial cancer as well as for those with an advanced cancer (Table 39). Transhiatal esophagectomy commonly performed in Western countries was adopted in only 2.8% of patients having a superficial cancer who underwent esophagectomy and in 1.4% of those having an advanced cancer in Japan. The thoracoscopic and/or laparoscopic esophagectomy were adopted for 1036 patients (51.3%) with a superficial cancer, and for 1734 patients (42.0%) with an advanced cancer. The number of cases of thoracoscopic and/or laparoscopic surgery for superficial or advanced cancer has been increasing for these several years (Fig. 4).

Table 53 Table 39 Malignant esophageal disease (surgical procedures)

Fig. 4

Annual trend of video-assisted esophagectomy for esophageal malignancy

Combined resection of the neighboring organs during resection of an esophageal cancer was performed in 351 patients (Tables 39, 40). Resection of the aorta together with esophagectomy was performed in three cases. Tracheal and/or bronchial resection combined with esophagectomy was performed in 15 patients, with the both of 30-day mortality rate and the hospital mortality rate at 0%. Lung resection combined with esophagectomy was performed in 67 patients, with the 30-day mortality rate at 4.5% and the hospital mortality rate at 6.0%.

Table 54 Table 40 Mortality after combined resection of the neighboring organs

Salvage surgery after definitive (chemo-)radiotherapy was performed in 264 patients, with the 30-day mortality rate at 1.5% and with the hospital mortality rate at 8.0% (Table 39).

Lastly, in spite of the efforts of the Committee to cover wider patient populations to this annual survey, the majority of the institutions which responded to the questionnaire were the departments of thoracic or esophageal surgery. It should be noted that larger number of patients with esophageal diseases should have been treated medically and endoscopically. We should continue our effort for complete survey through more active collaboration with the Japan Esophageal Society and other related societies.