Thoracic and cardiovascular surgery in Japan in 2016

The Japanese Association for Thoracic Surgery has conducted annual surveys of thoracic surgery throughout Japan since 1986 to establish the statistics for the number of procedures by operative category. The results from our annual survey of thoracic surgery performed in 2016 are summarized.

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 members’ continued professional support and contributions (Tables 1, 2).

Table 1 Number of institutions involved in the survey

Table 2 Categories subclassified according to the number of operations performed

The incidence of hospital mortality was added to the survey to clarify the situation nationwide, which has contributed to Japanese surgeons understanding the present status of thoracic surgery in Japan and to make progress to improve operative results by comparing their work with that of others. The Association was able to gain a better understanding of present problems, as well as future prospects, which has been reflected in its activities, 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 has been discharged from the hospital. Hospital mortality is defined as death within any time interval after an operation if the patient has 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 other hand, hospital-to-hospital transfer 30 days after operation in the categories of cardiovascular surgery and general thoracic surgery is considered discharge because data of the national clinical database (NCD) 2016 were used in this category, and hospital-to-hospital transfer 30 days after operation is considered discharge in the NCD.

Abstract of the survey

All data regarding cardiovascular surgery and thoracic surgery were obtained from the NCD, whereas data regarding esophageal surgery were collected from a 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).

In association with the change in data collection of cardiovascular surgery from self-reports using questionnaire sheets in each participating institution until the report in 2014 to automatic package download from the JCVSD (Japanese Cardiovascular Surgery Database, a cardiovascular part of the NCD), the response rate is not available and is not indicated in the category of cardiovascular surgery (Table 1). Further, the number of institutions classified by operation number is also not calculated in the category of cardiovascular surgery (Table 2).

2016 Final report

(A) Cardiovascular surgery

First, we are very pleased with our colleagues’ (members’) cooperation with 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 JCVSD/NCD at each participating institution.

Figure 1 shows the development of cardiovascular surgery in Japan over the last 30 years. Aneurysm surgery includes only operations for thoracic and thoracoabdominal aortic aneurysms. Extra-anatomic bypass surgery for thoracic aneurysms 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.

Fig. 1

Cardiovascular surgery. IHD ischemic heart disease

A total of 67,867 cardiovascular operations, including 51 heart transplantations, were performed at 580 institutions in 2016, which increased by 6.8% from the survey in 2015 (n = 63,520). Considering the trend in 2016, the data of which were collected and aggregated in the same method as in 2015, the actual number of cardiovascular operations is still continuously increasing, although the apparent number decreased in 2015 probably due to a major change in data collection and aggregation.

When compared with the data of 2015 [1] and of 2006 [2], the number of operations in 2016 for congenital heart disease decreased by 3.4% (8744 vs. 9054) and 7.6%, respectively; that for valvular heart disease increased by 16.1% (23,012 vs. 19,820) and 52.5%, respectively; that for thoracic aortic aneurysm increased by 9.4% (19,078 vs. 17,444) and 104.6%, respectively; that for ischemic heart decreased by 1.5% (14,874 vs. 15,103) and 21.1%, respectively; that for other cardiovascular procedures decreased slightly by 1.1% (1874 vs. 1895) and increased by 64.1%, respectively. Data for individual categories are summarized in Tables 3, 4, 5, 6, 7, 8.

Table 3 Congenital (total; 8744)

(2) CPB (–) (total; 2282)

	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	After discharge			Hospital	After discharge			Hospital	After discharge			Hospital	After discharge			Hospital	After discharge	Hospital mortality
PDA	344	5 (1.5)	0	12 (3.5)	197	1 (0.5)	0	4 (2.0)	25	0	0	0	3	0	0	0	569	6 (1.1)	0	16 (2.8)
Coarctation (simple)	18	0	0	0	7	0	0	0	3	0	0	0	0	0	0	0	28	0	0	0
+ VSD	38	0	0	0	11	1 (9.1)	0	1 (9.1)	2	0	0	0	0	0	0	0	51	1 (2.0)	0	1 (2.0)
+ DORV	3	0	0	0	0	0	0	0	1	0	0	0	0	0	0	0	4	0	0	0
+ AVSD	2	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	2	0	0	0
+ TGA	1	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	1	0	0	0
+ SV	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0
+ Others	12	0	0	0	5	0	0	0	1	0	0	0	0	0	0	0	18	0	0	0
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	1 (3.8)	0	1 (3.8)	3	0	0	0	0	0	0	0	0	0	0	0	29	1 (3.4)	0	1 (3.4)
+ DORV	1	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	1	0	0	0
+ Truncus	7	2 (28.6)	0	2 (28.6)	3	0	0	0	0	0	0	0	0	0	0	0	10	2 (20.0)	0	2 (20.0)
+ TGA	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0
+ Others	1	0	0	0	2	0	0	0	0	0	0	0	0	0	0	0	3	0	0	0
Vascular ring	3	0	0	0	12	0	0	0	8	0	0	0	0	0	0	0	23	0	0	0
PS	5	0	0	0	9	0	0	0	1	0	0	0	1	0	0	0	16	0	0	0
PA·IVS or critical PS	27	1 (3.7)	0	1 (3.7)	34	1 (2.9)	0	1 (2.9)	6	0	0	0	1	0	0	0	68	2 (2.9)	0	2 (2.9)
TAPVR	13	1 (7.7)	0	1 (7.7)	2	0	0	0	0	0	0	0	0	0	0	0	15	1 (6.7)	0	1 (6.7)
PAPVR ± ASD	0	0	0	0	2	0	0	0	1	0	0	0	0	0	0	0	3	0	0	0
ASD	0	0	0	0	2	0	0	0	4	0	0	0	2	0	0	0	8	0	0	0
Cor triatriatum	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0
AVSD (partial)	1	0	0	0	0	0	0	0	2	0	0	0	0	0	0	0	3	0	0	0
AVSD (complete)	50	0	0	1 (2.0)	82	0	1 (1.2)	1 (1.2)	7	0	0	0	0	0	0	0	139	0	1 (0.7)	2 (1.4)
+ TOF or DORV	0	0	0	0	5	0	0	0	2	0	0	0	0	0	0	0	7	0	0	0
+ Others	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0
VSD (subarterial)	4	0	0	0	6	0	0	0	0	0	0	0	0	0	0	0	10	0	0	0
VSD (perimemb./muscular)	47	0	0	1 (2.1)	111	1 (0.9)	0	1 (0.9)	5	0	0	0	1	0	0	0	164	1 (0.6)	0	2 (1.2)
VSD + PS	0	0	0	0	2	0	0	0	0	0	0	0	0	0	0	0	2	0	0	0
DCRV ± VSD	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0
Aneurysm of sinus of Valsalva	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0
TOF	16	1 (6.3)	0	1 (6.3)	84	1 (1.2)	0	1 (1.2)	12	0	0	0	3	0	0	0	115	2 (1.7)	0	2 (1.7)
PA + VSD	20	0	0	0	54	0	0	1 (1.9)	25	1 (4.0)	0	3 (12.0)	1	0	0	0	100	1 (1.0)	0	4 (4.0)
DORV	50	0	0	0	83	0	0	0	16	0	0	0	0	0	0	0	149	0	0	0
TGA (simple)	5	0	0	0	3	0	0	0	0	0	0	0	2	0	0	0	10	0	0	0
+ VSD	9	0	0	0	4	0	0	0	1	0	0	0	1	0	0	0	15	0	0	0
VSD + PS	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0	0
Corrected TGA	4	0	0	0	8	0	0	0	14	0	0	0	4	0	0	0	30	0	0	0
Truncus arteriosus	24	0	0	1 (4.2)	7	0	0	0	2	0	0	0	0	0	0	0	33	0	0	1 (3.0)
SV	68	3 (4.4)	1 (1.5)	6 (8.8)	51	1 (2.0)	0	3 (5.9)	19	0	0	0	2	0	0	0	140	4 (2.9)	1 (0.7)	9 (6.4)
TA	20	0	0	1 (5.0)	21	1 (4.8)	0	1 (4.8)	3	0	0	0	3	0	0	0	47	1 (2.1)	0	2 (4.3)
HLHS	77	2 (2.6)	0	4 (5.2)	25	0	0	0	15	0	0	0	0	0	0	0	117	2 (1.7)	0	4 (3.4)
Aortic valve lesion	6	0	1 (16.7)	2 (33.3)	2	0	0	0	1	0	0	0	0	0	0	0	9	0	1 (11.1)	2 (22.2)
Mitral valve lesion	1	1 (100.0)	0	1 (100.0)	2	0	0	0	4	0	0	0	1	0	0	0	8	1 (12.5)	0	1 (12.5)
Ebstein	6	1 (16.7)	0	1 (16.7)	3	0	0	0	1	0	0	0	0	0	0	0	10	1 (10.0)	0	1 (10.0)
Coronary disease	5	0	0	0	3	0	0	0	1	0	0	0	2	0	0	0	11	0	0	0
Others	10	0	0	0	16	0	0	2 (12.5)	13	3 (23.1)	0	3 (23.1)	5	0	0	0	44	3 (6.8)	0	5 (11.4)
Conduit failure	0	0	0	0	0	0	0	0	0	0	0	0	1	0	0	0	1	0	0	0
Redo (excluding conduit failure)	7	0	0	0	106	0	0	1 (0.9)	126	1 (0.8)	0	1 (0.8)	30	0	0	0	269	1 (0.4)	0	2 (0.7)
Total	931	18 (1.9)	2 (0.2)	36 (3.9)	967	7 (0.7)	1 (0.1)	17 (1.8)	321	5 (1.6)	0	7 (2.2)	63	0	0	0	2282	30 (1.3)	3 (0.13)	60 (2.6)

1. (), % mortality
2. CPB cardiopulmonary bypass, PDA patent ductus arteriosus, VSD ventricular septal defect, DORV double outlet right ventricle, AVSD atrioventricular septal defect, TGA transposition of the 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	162	4 (2.5)	1 (0.6)	7 (4.3)	431	5 (1.2)	0	8 (1.9)	49	0	0	1 (2.0)	0	0	0	0	642	9 (1.4)	1 (0.2)	16 (2.5)
2	PAB	270	5 (1.9)	1 (0.4)	11 (4.1)	284	2 (0.7)	1 (0.4)	5 (1.8)	16	0	0	0	0	0	0	0	570	7 (1.2)	2 (0.4)	16 (2.8)
3	Bidirectional Glenn or hemi-Fontan ± α	0	0	0	0	285	2 (0.7)	0	5 (1.8)	114	0	0	1 (0.9)	6	0	0	0	405	2 (0.5)	0	6 (1.5)
4	Damus–Kaye–Stansel operation	3	0	0	0	31	3 (9.7)	0	5 (16.1)	13	0	0	1 (7.7)	1	0	0	0	48	3 (6.3)	0	6 (12.5)
5	PA reconstruction/repair (including redo)	16	0	0	0	138	3 (2.2)	0	4 (2.9)	200	1 (0.5)	0	2 (1.0)	14	0	0	0	368	4 (1.1)	0	6 (1.6)
6	RVOT reconstruction/repair	6	0	0	0	186	0	0	2 (1.1)	303	2 (0.7)	0	3 (1.0)	44	0	0	2 (4.5)	539	2 (0.4)	0	7 (1.3)
7	Rastelli procedure	1	0	0	0	27	0	0	1 (3.7)	106	0	0	0	9	0	0	0	143	0	0	1 (0.7)
8	Arterial switch procedure	138	3 (2.2)	0	7`(5.1)	26	2 (7.7)	0	2 (7.7)	6	1 (16.7)	0	1 (16.7)	1	0	0	0	171	6 (3.5)	0	10 (5.8)
9	Atrial switch procedure	1	0	0	0	2	0	0	1 (50.0)	7	0	0	1 (14.3)	1	0	0	0	11	0	0	2 (18.2)
10	Double switch procedure	0	0	0	0	0	0	0	0	7	0	0	0	0	0	0	0	7	0	0	0
11	Repair of anomalous origin of CA	3	1 (33.3)	0	1 (33.3)	4	0	0	1 (25.0)	2	0	0	0	1	0	0	0	10	1 (10.0)	0	2 (20.0)
12	Closure of coronary AV fistula	1	0	0	0	4	0	0	0	5	0	0	0	0	0	0	0	10	0	0	0
13	Fontan/TCPC	1	0	0	0	3	0	0	0	364	2 (0.5)	0	7 (1.9)	42	2 (4.8)	0	2 (4.8)	410	4 (1.0)	0	9 (2.2)
14	Norwood procedure	0	0	0	0	18	1 (5.6)	0	3 (16.7)	2	0	0	0	0	0	0	0	20	1 (5.0)	0	3 (15.0)
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)	2	0	0	0	43	0	0	0	67	0	0	1 (1.5)	13	0	0	0	125	0	0	1 (0.8)
17	Left side AV valve replace (including Redo)	0	0	0	0	15	0	0	0	37	0	0	1 (2.7)	11	1 (9.1)	0	1 (9.1)	63	1 (1.6)	0	2 (3.2)
18	Right side AV valve repair (including Redo)	15	2 (13.3)	0	2 (13.3)	71	0	0	0	85	1 (1.2)	0	3 (3.5)	57	0	0	0	228	3 (1.3)	0	5 (2.2)
19	Right side AV valve replace (including Redo)	0	0	0	0	1	0	0	0	9	0	0	0	25	1 (4.0)	0	1 (4.0)	35	1 (2.9)	0	1 (2.9)
20	Common AV valve repair (including Redo)	8	3 (37.5)	0	6 (75.0)	19	1 (5.3)	0	3 (15.8)	10	1 (10.0)	0	1 (10.0)	1	0	0	0	38	5 (13.2)	0	10 (26.3)
21	Common AV valve replace (including Redo)	1	0	0	1 (100.0)	4	0	0	0	6	0	0	0	3	0	0	1 (33.3)	14	0	0	2 (14.3)
22	Repair of supra-aortic stenosis	2	1 (50.0)	0	1 (50.0)	2	0	0	0	8	0	0	0	1	0	0	0	13	1 (7.7)	0	1 (7.7)
23	Repair of subaortic stenosis (including Redo)	1	0	0	0	11	0	0	0	33	0	0	0	7	0	0	0	52	0	0	0
24	Aortic valve plasty ± VSD Closure	8	1 (12.5)	0	1 (12.5)	10	0	0	2 (20.0)	28	0	0	0	5	0	0	0	51	1 (2.0)	0	3 (5.9)
25	Aortic valve replacement	0	0	0	0	2	0	0	0	35	0	0	0	29	2 (6.9)	0	4 (13.8)	66	2 (3.0)	0	4 (6.1)
26	AVR with annular enlargement	0	0	0	0	0	0	0	0	10	0	0	0	0	0	0	0	10	0	0	0
27	Aortic root replace (except Ross)	0	0	0	0	0	0	0	0	7	0	0	0	10	0	0	0	17	0	0	0
28	Ross procedure	1	0	0	0	4	0	0	0	13	0	0	0					18	0	0	0
29	Bilateral pulmonary artery banding	156	4 (2.6)	1 (0.6)	8 (5.1)	19	1 (5.3)	0	2 (10.5)	0	0	0	0	0	0	0	0	175	5 (2.9)	1 (0.6)	10 (5.7)
Total		796	24 (3.0)	3 (0.4)	45 (5.7)	1640	20 (1.2)	1 (0.1)	44 (2.7)	1542	8 (0.5)	0	23 (1.5)	281	6 (2.1)	0	11 (3.9)	4259	58 (1.4)	4 (0.09)	123 (2.9)

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 operations for arrhythmia in (3); 40,152

TAVR	Cases	30-Day mortality		Hospital mortality
		Hospital	After discharge
	2250	15 (0.7)	1 (0.0)	30 (1.3)

(2) Ischemic heart disease (total, (A) + (B); 14,874)(A) Isolated CABG (total; (a) + (b); 13,654)(a-1) On-pump arrest CABG (total; 3023)

	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	53	2 (3.8)	0	2 (3.8)	17	1 (5.9)	0	2 (11.8)	2	0	0	0	0	0	0	0	23	25	24	0	0
2VD	343	5 (1.5)	0	8 (2.3)	54	4 (7.4)	0	4 (7.4)	4	0	0	0	0	0	0	0	68	299	30	1	3
3VD	1140	9 (0.8)	1 (0.1)	16 (1.4)	164	10 (6.1)	0	12 (7.3)	9	0	0	0	1	0	0	0	87	1193	27	5	2
LMT	969	17 (1.8)	0	25 (2.6)	256	13 (5.1)	0	20 (7.8)	8	0	0	1 (12.5)	3	0	0	0	113	1064	40	10	9
Total	2505	33 (1.3)	1 (0.0)	51 (2.0)	491	28 (5.7)	0	38 (7.7)	23	0	0	1 (4.3)	4	0	0	0	291	2581	121	16	14
Kawasaki	9	0	0	0	2	0	0	0	0	0	0	0	0	0	0	0	5	4	2	0	0
Hemodialysis	244	14 (5.7)	0	18 (7.4)	48	6 (12.5)	0	6 (12.5)	6	0	0	0	1	0	0	0	18	257	19	3	2

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, LMT includes LMT alone or LMT with other branch diseases

(a-2) On-pump beating CABG (total; 2077)

	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	30	0	0	0	10	1 (10.0)	0	1 (10.0)	2	0	0	0	0	0	0	0	9	24	9	0	0
2VD	164	2 (1.2)	0	3 (1.8)	44	2 (4.5)	0	3 (6.8)	2	0	0	0	1	0	0	0	46	146	18	0	1
3VD	672	10 (1.5)	1 (0.1)	18 (2.7)	180	13 (7.2)	0	27 (15.0)	15	0	0	0	1	0	0	0	109	711	39	4	5
LMT	597	10 (1.7)	0	18 (3.0)	332	22 (6.6)	0	29 (8.7)	23	2 (8.7)	0	2 (8.7)	4	2 (50.0)	0	2 (50.0)	139	756	54	1	6
Total	1463	22 (1.5)	1 (0.1)	39 (2.7)	566	38 (6.7)	0	60 (10.6)	42	2 (4.8)	0	2 (4.8)	6	2 (33.3)	0	2 (33.3)	303	1637	120	5	12
Kawasaki	1	0	0	0	1	0	0	0	0	0	0	0	0	0	0	0	0	2	0	0	0
Hemodialysis	211	8 (3.8)	0	17 (8.1)	77	8 (10.4)	0	12 (15.6)	8	0	0	0	1	0	0	0	30	243	21	1	2

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, LMT LMT alone or LMT with other branch diseases

(b) Off-pump CABG (total; 8554)(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	439	2 (0.5)	0	2 (0.5)	50	0	0	0	9	1 (11.1)	0	1 (11.1)	6	3 (50.0)	0	4 (66.7)	360	103	36	3	2
2VD	1222	9 (0.7)	0	16 (1.3)	136	4 (2.9)	0	6 (4.4)	17	0	0	0	3	1 (33.3)	0	1 (33.3)	510	808	40	5	15
3VD	2721	15 (0.6)	0	34 (1.2)	360	10 (2.8)	0	15 (4.2)	28	0	0	0	5	1 (20.0)	0	1 (20.0)	662	2359	56	15	22
LMT	2804	17 (0.6)	0	35 (1.2)	715	25 (3.5)	0	42 (5.9)	31	2 (6.5)	0	2 (6.5)	8	0	0	0	977	2438	95	15	33
Total	7186	43 (0.6)	0	87 (1.2)	1261	39 (3.1)	0	63 (5.0)	85	3 (3.5)	0	3 (3.5)	22	5 (22.7)	0	6 (27.3)	2509	5708	227	38	72
Kawasaki	14	0	0	0	3	1 (33.3)	0	1 (33.3)	0	0	0	0	0	0	0	0	12	4	0	1	0
Hemodialysis	818	20 (2.4)	0	38 (4.6)	139	4 (2.9)	0	10 (7.2)	11	0	0	0	3	1 (33.3)	0	1 (33.3)	229	688	46	2	6

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, LMT includes LMT alone or LMT with other branch diseases

(c) Conversion from off-pump CABG to on-pump CABG or on- pump beating-heart CABG during surgery (total; 233)

	Primary, elective				Primary, emergency				Redo, elective				Redo, emergency
	Cases	30-Day mortality		Hospital mortality	Cases	30-Day mortality		Hospital mortality	Cases	30-Day mortality		Hospital mortality	Cases	30-Day mortality
		Hospital	After discharge			Hospital	After discharge			Hospital	After discharge			Hospital	After discharge	Hospital mortality
Conversion to on-pump CABG arrest heart	28	1 (3.6)	0	1 (3.6)	9	0	0	0	1	1 (100.0)	0	1 (100.0)	2	1 (50.0)	0	1 (50.0)
Conversion to on-pump beating-heart CABG	148	6 (4.1)	0	12 (8.1)	41	4 (9.8)	0	6 (14.6)	3	1 (33.3)	0	1 (33.3)	1	1 (100.0)	0	1 (100.0)
Total	176	7 (4.0)	0	13 (7.4)	50	4 (8.0)	0	6 (12.0)	4	2 (50.0)	0	2 (50.0)	3	2 (66.7)	0	2 (66.7)
Hemodialysis	35	3 (8.6)	0	6 (17.1)	6	0	0	0	0	0	0	0	1	1 (100.0)	0	1 (100.0)

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

(B) Operation for complications of MI (total; 1220)

	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	145	4 (2.8)	0	11 (7.6)	16	5 (31.3)	0	5 (31.3)	90	43	17
VSP closure	45	5 (11.1)	0	5 (11.1)	222	71 (32.0)	1 (0.5)	89 (40.1)	81	0	2
Cardiac rupture	35	6 (17.1)	1 (2.9)	8 (22.9)	212	79 (37.3)	0	88 (41.5)	43	0	4
Mitral regurgitation
(1) Papillary muscle rupture	16	2 (12.5)	0	3 (18.8)	33	7 (21.2)	0	9 (27.3)	19	6	43
(2) Ischemic	309	19 (6.1)	0	32 (10.4)	37	7 (18.9)	0	11 (29.7)	254	229	117
Others	73	5 (6.8)	0	6 (8.2)	77	26 (33.8)	0	34 (44.2)	59	9	7
Total	623	41 (6.6)	1 (0.2)	65 (10.4)	597	195 (32.7)	1 (0.2)	236 (39.5)	546	287	190

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

(3) Operation for arrhythmia (total; 7168)

	Cases	30-Day mortality		Hospital mortality	Concomitant operation
					Isolated	Congenital	Valve	IHD	Others	Multiple combination
		Hospital	After discharge							2 categories	3 categories
Maze	3974	82 (2.1)	0	138 (3.5)	136	168	3459	665	288	712	42
For WPW	1	0	0	0	0	0	0	1	0	0	0
For ventricular tachyarrhythmia	34	1 (2.9)	0	1 (2.9)	4	1	17	18	4	10	1
Others	3159	59 (1.9)	1 (0.03)	104 (3.3)	199	116	2478	671	306	572	48
Total	7168	142 (2.0)	1 (0.01)	243 (3.4)	339	285	5954	1355	598	1294	91

1. (),  % mortality
2. Except for 339 isolated cases, all remaining 6829 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; 172)

	CPB (+)				CPB (−)
	Cases	30-Day mortality		Hospital mortality	Cases	30-Day mortality		Hospital mortality
		Hospital	After discharge			Hospital	After discharge
Total	81	11 (13.6)	0	15 (18.5)	91	7 (7.7)	0	10 (11.0)

1. (), % mortality
2. CPB cardiopulmonary bypass

(5) Cardiac tumor (total; 535)

	Cases	30-Day mortality		Hospital mortality	Concomitant operation
		Hospital	After discharge		AVR	MVR	CABG	Others
Benign tumor	462	2 (0.4)	0	3 (0.6)	15	12	38	111
(Cardiac myxoma)	353	2 (0.6)	0	3 (0.8)	4	7	23	84
Malignant tumor	73	4 (5.5)	0	8 (11.0)	2	1	3	12
(Primary)	12	0	0	1 (8.3)	0	0	1	2

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

(6) HOCM and DCM (total; 310)

	Cases	30-Day mortality		Hospital mortality	Concomitant operation
		Hospital	After discharge		AVR	MVR	MVP	CABG
Myectomy	120	1 (0.8)	0	2 (1.7)	65	16	17	14
Myotomy	10	0	0	1 (10.0)	4	0	1	1
No-resection	168	8 (4.8)	0	15 (8.9)	33	88	80	21
Volume reduction surgery of the left ventricle	12	1 (8.3)	0	1 (8.3)	0	2	6	4
Total	310	10 (3.2)	0	19 (6.1)	102	106	104	40

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; 668)

	Cases	30-Day mortality		Hospital mortality
		Hospital	After discharge
Open-heart operation	383	40 (10.4)	1 (0.3)	54 (14.1)
Non-open-heart operation	285	43 (15.1)	0	53 (18.6)
Total	668	83 (12.4)	1 (0.1)	107 (16.0)

1. (), % mortality

Table 5 Thoracic aortic aneurysm (total; 19,078)

(2) Non-dissection (total; 9637)

Replaced site	Unruptured				Ruptured				Concomitant operation						Redo
	Cases	30-Day mortality		Hospital mortality	Cases	30-Day mortality		Hospital mortality	AVP	AVR	MVP	MVR	CABG	Others	Cases	30-Day mortality		Hospital mortality
		Hospital	After discharge			Hospital	After discharge									Hospital	After discharge
1. Ascending Ao.	1528	30 (2.0)	0	45 (2.9)	53	5 (9.4)	0	9 (17.0)	85	1048	89	50	201	240	196	12 (6.1)	0	23 (11.7)
2. Aortic Root	864	25 (2.9)	0	31 (3.6)	52	8 (15.4)	0	10 (19.2)	193	593	62	20	126	133	152	17 (11.2)	0	20 (13.2)
3. Arch	1729	46 (2.7)	1 (0.06)	83 (4.8)	130	13 (10.0)	0	22 (16.9)	42	276	16	9	295	112	185	10 (5.4)	0	20 (10.8)
4. Aortic Root + Asc.Ao. + Arch	254	11 (4.3)	0	14 (5.5)	8	3 (37.5)	0	4 (50.0)	55	161	17	7	40	38	43	8 (18.6)	0	10 (23.3)
5. Descending Ao.	307	7 (2.3)	0	15 (4.9)	64	15 (23.4)	0	19 (29.7)	2	13	0	0	29	5	75	5 (6.7)	0	10 (13.3)
6. Thoracoabdominal Ao.	349	16 (4.6)	0	24 (6.9)	42	7 (16.7)	0	12 (28.6)	0	1	0	0	7	1	88	9 (10.2)	0	13 (14.8)
7. Stent graft*a	3837	97 (2.5)	1 (0.03)	170 (4.4)	420	66 (15.7)	3 (0.71)	87 (20.7)	22	108	22	3	212	74	830	42 (5.1)	1 (0.1)	65 (7.8)
1) TEVARl*b	2727	59 (2.2)	1 (0.04)	102 (3.7)	336	55 (16.4)	3 (0.89)	72 (21.4)	0	4	0	0	16	24	713	31 (4.3)	1 (0.1)	49 (6.9)
2) Open stent	1110	38 (3.4)	0	68 (6.1)	84	11 (13.1)	0	15 (17.9)	22	104	22	3	196	50	117	11 (9.4)	0	16 (13.7)
a) with total arch*c	983	34 (3.5)	0	62 (6.3)	65	9 (13.8)	0	12 (18.5)	21	99	22	3	186	47	93	9 (9.7)	0	13 (14.0)
b) without total arch*d	127	4 (3.1)	0	6 (4.7)	19	2 (10.5)	0	3 (15.8)	1	5	0	0	10	3	24	2 (8.3)	0	3 (12.5)
Total	8868	232 (2.6)	2 (0.02)	382 (4.3)	769	117 (15.2)	3 (0.39)	163 (21.2)	399	2200	206	89	910	603	1569	103 (6.6)	1 (0.1)	161 (10.3)

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

Table 6 Pulmonary thromboembolism (total; 138)

Table 7 Implantation of VAD (total; 164)

Table 8 Heart transplantation (total; 51)

In 2016, of 8744 operations for congenital heart disease, 6462 open-heart surgeries were performed with overall hospital mortality of 2.2%. The number of operations decreased gradually throughout these 10 years (maximum 7386 cases in 2006), and overall hospital mortality showed a plateau at around 3.0%. In detail, the most common disease was ventricular septal defect (VSD) (perimembranous/muscular) (1232 cases), as in 2015 when VSD became the most common disease for the first time since the inauguration of this survey. Atrial septal defect (ASD) was the “second” most common one (1032 cases) in 2016. It was mainly due to the development and increasing use of commercially available catheter devices for ASD closure. In the last 10 years, hospital mortality for complex congenital heart disease was as follows (2006 [2], 2011 [3], and 2016), complete atrio-septal defect (4.5%, 4.7%, and 3.5%), tetralogy of Fallot (1.9%, 0.7%, and 1.6%), transposition of the great arteries with intact septum (4.4%, 2.5%, and 4.4%) and with ventricular septal defect (9.1%, 3.6%, and 8.3%), single ventricle (6.7%, 4.4%, and 5.1%), and hypoplastic left heart syndrome (16.6%, 14.3%, and 7.5%). Right heart bypass surgery is now commonly performed (405 bidirectional Glenn procedures excluding 48 Damus–Kaye–Stansel procedures and 410 Fontan-type procedures including total cavo-pulmonary connection) with acceptable hospital mortality (1.5% and 2.2%, respectively). The Norwood type I procedure was performed in 20 cases, with a relatively low hospital mortality rate of 15%.

The total number of operations for valvular heart disease is increasing, although the apparent number dropped in the survey in 2015, probably because of a major change in the process of data collection. The number of isolated aortic valve replacements/repairs with/without CABG (n = 9472) increased by 9.5% from the previous year (8651) and by 10.3% from 5 years ago (n = 8589), although trans-catheter aortic valve replacement (TAVR or TAVI) was introduced in 2013 and is rapidly spreading.

The hospital mortality of single valve placement was 3.1% and 6.3% for the aortic and mitral positions, while that for mitral valve repair was only 1.5%. The hospital mortality for redo valve surgery was 7.1% in the aortic and 8.2% in the mitral positions, respectively. Finally, overall hospital mortality did not show a dramatic improvement over the last 10 years (4.0% in 2006 [2], 3.4% in 2011 [3], and 3.5% in 2016), which might be partially due to the recent increasing age of the patients. Repair of the valve became a common procedure (367 cases of aortic, 6711 cases of mitral, and 5400 cases tricuspid), and mitral valve repair constituted 29.2% of all valvular operations and 64.4% of all mitral valve procedures, which are similar to those of the last 5 years. Aortic and mitral valve replacements with bioprostheses were performed in 9693 cases and 2499 cases, respectively. The ratio of bioprostheses was 81.9% in the aortic and 65.2% in the mitral positions. This ratio of using bioprostheses increased dramatically from 30 to 40% in the early 2000s [4, 5]. CABG was performed as a concomitant procedure in 18.5% of all valvular operations (15.1% in 2006 [2] and 17.5% in 2011 [3]).

Isolated CABG was performed in 13,654 cases, only 76.1% of that 10 years ago (n = 17,941) [2]. Among these, off-pump CABG was intended in 8554 cases (62.6%), with a success rate of 97.3%, so that the final success rate of off-pump CABG was 60.9%. The percentage of intended off-pump CABG reached 60.3% in 2004 [4], and it was then kept at over 60% until now. In 13,654 isolated CABG patients, 13,029 patients (95.4%) received at least one arterial graft, while all-arterial-graft CABG was performed in only 3103 patients or 22.7% of them. The operative and hospital mortality rates associated with primary elective CABG procedures in 11,154 cases were 0.9% and 1.6%, respectively. A 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 that the operative results of primary CABG have been stable. Hospital mortality of primary emergency CABG in 2318 cases was still high, at 6.9%. The conversion from off-pump CABG rate was 2.7%, with hospital mortality of 9.9%. A total of 1220 patients underwent surgery for complications of myocardial infarction, including 675 operations for left ventricular aneurysm, ventricular septal perforation, or cardiac rupture and 395 operations for ischemic mitral regurgitation. In this report, the number of concomitant coronary artery bypass grafting (CABG) procedures with other major procedures is not included in the category of ischemic heart disease but in other categories such as valvular heart disease and thoracic aneurysm; then, the overall number of CABG procedure including concomitant CABG with other major procedures still remained at over 20,000 cases per year (20,589 cases) in 2016.

Operations for arrhythmia were performed mainly as a concomitant procedure in 7168 cases, with a 24.3% increase compared with that of 2015. Implantations of pacemakers and ICDs are not included in this category. The hospital mortality of arrhythmia surgery including 3974 MAZE procedures was 3.4%. The MAZE procedure has become a quite common procedure (2944 cases in 2006 [2], and 3771 cases in 2011 [3]).

In 2016, 19,078 operations were performed for diseases of the thoracic and thoracoabdominal aortae: 9441 for aortic dissection and 9637 for non-dissection. The number of operations for aortic dissection increased by 10.5% this year compared with the previous year (n = 8547). The hospital mortality of operations for 5461 Stanford type A acute aortic dissections remained as high as 11.3%. The number of operations for non-dissected aneurysm increased by 8.3%, with overall hospital mortality of 5.7% (4.3% and 21.2% for unruptured and ruptured aneurysms, respectively).

The number of stent graft procedures has recently increased remarkably. Most importantly, the number of open stent grafts with total arch replacement strikingly increased 5 times (228–1155) and 3.4 times (308–1048) in dissecting and non-dissecting aortic aneurysms, respectively. This must be associated with the commercial availability of special designed device for open stent grafting since 2014.

A total of 3287 patients with aortic dissection underwent stent graft placement: 2052 thoracic endovascular aortic repair (TEVAR) and 1235 open stent grafting. The number of TEVAR procedures for type B chronic aortic dissections increased by 41.4% from 1065 cases in 2015 to 1506 cases in 2016. The hospital mortality rates associated with TEVAR for type B aortic dissection were 9.6% and 2.1% in acute and chronic cases, respectively.

A total of 4257 patients with non-dissected aortic aneurysms underwent stent graft placement, consisting of 3063 TEVAR [5.2% increase compared with 2015 (n = 2912)] and 1194 open stent grafts [27.4% increase compared with 2015 (n = 937)]. The hospital mortality rates for TEVAR and open stenting were as follows: TEVAR, 3.7% for unruptured and 21.4% for ruptured aneurysms; open stent grafting, 6.1% for unruptured and 17.9% for ruptured aneurysms.

(B) General thoracic surgery

The 2016 survey of general thoracic surgery comprised 693 surgical units, and most data were submitted through the web-based collection system of the national clinical database (NCD) [6]. In total, 82,193 operations were reported by general thoracic surgery departments in 2016, 1.9 times the number of operations in 2001 and 2418 more operations than in 2015, while the number of surgical units submitting reports to this survey decreased by 43 due to conversion of the data collection system since 2014 (Fig. 2).

Fig. 2

General thoracic surgery

In 2016, 42,107 operations for primary lung cancer were performed (Table 9), and the number has increased every year. The 2016 value is 2.2 times that of 2001. Operations for lung cancer accounted for 51.2% of all procedures in general thoracic surgery.

Table 9 Total cases of general thoracic surgery during 2016

The number of video-assisted thoracic surgery (VATS) operations, defined as a surgical procedure using a skin incision longer than 8 cm and/or a minithoracotomy (hybrid) approach, has been described since the Annual Report 2015. The number of VATS operations for benign pulmonary tumor, primary lung cancer, and the total number of VATS operations in 2016 are shown in Tables 10, 11, 13, 16, 17, 18, 19, 20, 21, 22, 23, 25, 26, 27, and 29, respectively.

Table 10 Benign pulmonary tumor

Table 11 Primary malignant pulmonary tumor

There were 2124 operations for benign pulmonary tumors in 2016, similar to the number in 2015 (Table 10). Hamartoma was the most frequent diagnosis in operations for benign pulmonary tumors. VATS was performed in 2015 patients (94.7%).

Additional information on primary malignant pulmonary tumors is shown in Tables 11 and 12. With regard to lung cancer subtype, adenocarcinoma was by far the most frequent diagnosis (70.3% of all lung cancer operations), followed by squamous cell carcinoma (18.7%). Sublobar resection was performed in 10,666 lung cancer cases (25.1% of all cases), and lobectomy was performed in 30,597 cases (72.0% of all cases). Sleeve lobectomy was performed in 481 cases, and pneumonectomy was required in 477 cases (1.1% of all cases). VATS lobectomy for lung cancer was performed in 19,697 cases (64.3% of all lobectomy cases). The number of VATS procedures for primary lung cancer was slightly higher than in 2015. The number of patients aged 80 years or older who underwent lung cancer surgery was 5279 (12.5%). In total, 115 patients died before hospital discharge within 30 days after surgery, and 52 patients died after discharge within 30 days after surgery. Therefore, 167 patients died within 30 days after surgery (30-day mortality rate, 0.4%). In total, 237 patients died before discharge (hospital mortality rate, 0.6%), and the 30-day mortality rate, by procedure, was 0.3% for segmentectomy, 0.6% for lobectomy, and 4.6% for pneumonectomy. Interstitial pneumonia was the leading cause of death after lung cancer surgery, followed by pneumonia, cardiovascular events, and respiratory failure. The risk calculators for mortality and morbidity, such as broncho-pleural fistula and respiratory failure, after lung cancer surgery based on the NCD are now available [7, 8].

Table 12 Details of lung cancer operations

Operations for metastatic pulmonary tumors are shown in Table 13; 8497 operations were performed in 2016. Colorectal cancer was the most frequent diagnosis (47.7% of all cases).

Table 13 Metastatic pulmonary tumor

There were 122 operations for malignant tracheal tumor in 2016, but only 29 patients were treated with curative intent (Table 14).

Table 14 Tracheal tumor

There were 634 pleural tumors in 2016 (Table 15). Diffuse malignant pleural mesothelioma was the most frequent histologic diagnosis. Total pleurectomy was performed in 73 cases, and extrapleural pneumonectomy was performed in 64 cases. The hospital mortality rate was 0% after total pleurectomy and 1.6% after extrapleural pneumonectomy, which were better than the previous outcomes.

Table 15 Tumor of pleural origin

In total, 664 chest wall tumors were resected in 2016 (Table 16), of which 346 (52.1%) were benign. Among the 318 malignant chest wall tumors, 207 (65.1%) were metastatic tumors.

Table 16 Chest wall tumor

Mediastinal tumors were resected in 5026 patients, a slight increase from the previous year (Table 17). Thymic epithelial tumor, including 1986 thymomas, 314 thymic carcinomas, and 40 thymic carcinoids, was the most frequent mediastinal tumor type in 2016.

Table 17 Mediastinal tumor

Thymectomy for myasthenia gravis was performed in 478 patients (Table 18); 333 operations were associated with thymoma, and the remaining were not associated with thymoma.

Table 18 Thymectomy for myasthenia gravis

Operations for non-neoplastic disease were performed in 22,424 patients. There were 2142 cases of lung resection for inflammatory lung diseases (Table 19); 21.7% of the cases were associated with atypical mycobacterium infections, and 15.2% were fungal infections. An operation for inflammatory nodules was performed because lung cancer was suspected before surgery in 913 cases (42.6%)

Table 19 Operations for non-neoplastic diseases

The 2833 operations for empyema (Table 20) included 2085 cases (73.6%) of acute empyema and 748 cases of chronic empyema. A bronchopleural fistula was reported in 470 patients with acute empyema and 359 patients with chronic empyema. The hospital mortality rate was 18.3% in patients with acute empyema with fistula.

Table 20 B. Empyema

There were 100 operations for descending necrotizing mediastinitis (Table 21). The hospital mortality rate was 14.0%.

Table 21 C. Descending necrotizing mediastinitis

There were 436 operations for bullous diseases (Table 22). Lung volume reduction surgery was performed in only 18 patients.

Table 22 D. Bullous diseases

A total of 14,867 operations were performed for spontaneous pneumothorax (Table 23). The 11,835 operations for primary pneumothorax included 3028 patients (25.6%) who underwent bullectomy only and 7966 patients (67.3%) who underwent an additional procedure. There were 3032 operations for secondary pneumothorax. COPD was by far the most prevalent associated disease (70.7%). The hospital mortality rate for secondary pneumothorax associated with COPD was 2.8%.

Table 23 E. Pneumothorax

The 2016 survey reported 181 operations for chest wall deformity (Table 24). However, this might be an underestimate, because the Nuss procedure for pectus excavatum was more likely to have been performed in pediatric surgery centers not associated with JATS.

Table 24 F. Chest wall deformity

Diaphragmatic hernia was treated surgically in 37 patients (Table 25). This figure might be an underestimate, since some procedures might have been classified as gastrointestinal surgery.

Table 25 G. Diaphragmatic hernia

The survey reported 426 procedures for chest trauma excluding iatrogenic injuries (Table 26). The hospital mortality rate was 7.3%.

Table 26 H. Chest trauma

Table 27 shows operations for other diseases, including 81 cases of arteriovenous malformation and 113 cases of pulmonary sequestration.

Table 27 I. Other respiratory surgery

A total of 75 lung transplantations were performed in 2016 (Table 28): 58 patients received lung transplants from brain-dead donors and 17 received transplants from living-related donors. The number of lung transplantation procedures has increased slightly.

Table 28 Lung transplantation

The number of VATS procedures has increased annually, reaching 64,036 (77.9% of all general thoracic surgeries) in 2016 (Table 29).

Table 29 Video-assisted thoracic surgery

The details of tracheobronchoplasty, pediatric surgery, and combined resection of neighboring organs are shown in Tables 30, 31, and 32, 33.

Table 30 Tracheobronchoplasty

Table 31 Pediatric surgery

Table 32 Combined resection of neighboring organ(s)

Table 33 Operation of lung cancer invading the chest wall of the apex

(C) Esophageal surgery

During 2016 alone, a total of 12,753 patients with esophageal diseases were registered from 543 institutions (response rate: 93.0%) 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 2016 were 133 institutions (24.5%), which shows no definite shift of esophageal operations to high-volume institutions when compared to the data of 2015 (23.8%) (Table 34). Of 2418 patients with a benign esophageal disease, 1525 (63.1%) patients underwent surgery, and 73 (3.0%) patients underwent endoscopic resection, while 820 (33.9%) patients did not undergo any surgical treatment (Table 35). Of 10,830 patients with a malignant esophageal tumor, 8296 (76.6%) patients underwent resection, with esophagectomy for 6158 (56.9%) and endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) for 2138 (19.7%), while 2534 (23.4%) patients did not undergo any resection (Tables 36, 37). The annual trend of registered in-patients with esophageal diseases has not changed in the last decades (Fig. 3).

Table 34 Distribution of number of esophageal operations in 2016 in each institution

Table 35 Benign esophageal diseases

Table 36 Malignant esophageal diseases (histologic classification)

Table 37 Malignant esophageal diseases (clinical characteristics)

Fig. 3

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

Among benign esophageal diseases (Table 35), hiatal hernia, achalasia, esophageal varices, and esophagitis (including reflux esophagitis) were the most common conditions in Japan. On the other hand, benign esophageal tumors, spontaneous rupture of the esophagus, and congenital esophageal atresia were common diseases that were surgically treated, as well as the above-mentioned diseases. Open surgery was performed in 1030 (67.5%) patients with a benign esophageal disease, with 30-day mortality in 6 (0.6%), while thoracoscopic and/or laparoscopic surgery was performed for 495 (32.5%) patients, with no 30-day mortality. The difference in these death rates between open and endoscopic surgery seems to be related the conditions requiring open surgery.

The majority of malignant diseases were carcinomas (Table 36). Among esophageal carcinomas, the incidence of squamous cell carcinoma was 89.6%, while that of adenocarcinomas including Barrett’s cancer was 7.8%. The resection rate for patients with a squamous cell carcinoma was 75.3%, while that for patients with an adenocarcinoma was 89.7%.

According to location, cancer in the thoracic esophagus was the most common (Table 37). Of the 4305 patients (40.0% of all esophageal malignancies) having superficial esophageal cancers within mucosal and submucosal layers, 6158 (56.9%) patients underwent esophagectomy, while 2138 (19.7%) patients underwent EMR or ESD. The 30-day mortality rate and hospital mortality rate after esophagectomy for patients with a superficial cancer were 0.4% and 0.8%, respectively.

Multiple primary cancers were observed in 2068 (19.1%) of the 10,830 patients with esophageal cancer. Synchronous cancer was found in 1008 (9.3%) patients, while metachronous cancer was observed in 1060 (9.8%) patients. The stomach, and head and neck region are the common sites for both synchronous and metachronous malignancies (Table 37).

Among esophagectomy procedures, transthoracic esophagectomy through right thoracotomy was the most commonly performed for patients with a superficial cancer, as well as for those with an advanced cancer (Table 38). Transhiatal esophagectomy, commonly performed in western countries, was performed in only 5.8% of patients having a superficial cancer and advanced cancer who underwent esophagectomy in Japan. Thoracoscopic and/or laparoscopic esophagectomy was performed for 1296 patients (67.7%) with a superficial cancer and for 2060 patients (48.6%) with an advanced cancer. The number of cases of thoracoscopic and/or laparoscopic surgery for superficial or advanced cancer has been increasing for several years (Fig. 4).

Table 38 Malignant Esophageal diseases (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 226 patients (Tables 38, 39). Resection of the aorta together with esophagectomy was performed in 3 cases. Tracheal and/or bronchial resection combined with esophagectomy was performed in 12 patients, with both 30-day mortality and hospital mortality of 0%. Lung resection combined with esophagectomy was performed in 56 patients, with 30-day mortality of 0% and hospital mortality of 3.6%.

Table 39 Mortality after combined resection of the neighbouring organs

Salvage surgery after definitive (chemo-) radiotherapy was performed in 250 patients, with 30-day mortality of 1.6% and hospital mortality of 6.0% (Table 38).

Lastly, we should continue our efforts for complete surveys through more active collaboration with the Japan Esophageal Society and other related societies.