Kenji Minatoya, Yukio Sato, Yasushi Toh, and Naoki Yoshimura contributed equally to this work.
Annual report by the Japanese Association for Thoracic Surgery: Committee for Scientific Affairs.
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Since 1986, the Japanese Association for Thoracic Surgery has conducted annual thoracic surgery surveys throughout Japan to determine statistics on the number of procedures performed by surgical categories. Herein, we summarize the results of the association’s annual thoracic surgery surveys in 2019. We regret that, for various reasons, this report has been delayed to 2023.
Adhering to the norm thus far, thoracic surgery had been classified into three categories, including cardiovascular, general thoracic, and esophageal surgeries, with patient data for each group being examined and analyzed. We honor and value all members’ continued professional support and contributions.
Anzeige
Incidence of hospital mortality was included in the survey to determine nationwide status, which has contributed to Japanese surgeons’ understanding of the present status of thoracic surgery in Japan while helping in surgical outcome improvements by enabling comparisons between their work and that of others. This approach has enabled the association to gain a better understanding of present problems and prospects, which is reflected in its activities and member education.
The 30-day mortality (also known as operative mortality) is defined as death within 30 days of surgery, regardless of the patient’s geographic location, including post-discharge from the hospital. Hospital mortality is defined as death within any time interval following surgery among patients yet to be discharged from the hospital.
Transfer to a nursing home or a rehabilitation unit is considered hospital discharge unless the patient subsequently dies of complications from surgery, while hospital-to-hospital transfer during esophageal surgery is not considered a form of discharge. In contrast, hospital-to-hospital transfer 30 days following cardiovascular and general thoracic surgeries are considered discharge given that National Clinical Database (NCD)-related data were used in these categories.
Survey abstract
All data on cardiovascular, general thoracic, and esophageal surgeries were obtained from the NCD. In 2018, the data collection method for general thoracic and esophageal surgeries had been modified from self-reports using questionnaire sheets following each institution belonging to the Japanese Association for Thoracic Surgery to an automatic package downloaded from the NCD in Japan.
Anzeige
The data collection related to cardiovascular surgery (initially self-reported using questionnaire sheets in each participating institution up to 2014) changed to downloading an automatic package from the Japanese Cardiovascular Surgery Database (JCVSD), which is a cardiovascular subsection of the NCD in 2015.
Final report: 2019
(A) Cardiovascular surgery
We are extremely pleased with the cooperation of our colleagues (members) in completing the cardiovascular surgery survey, which has undoubtedly improved the quality of this annual report. We are truly grateful for the significant efforts made by all participants within each participating institution in completing the JCVSD/NCD.
Figure 1 illustrates the development of cardiovascular surgery in Japan over the past 33 years. Aneurysm surgery includes only surgeries for thoracic and thoracoabdominal aortic aneurysms. Extra-anatomic bypass surgery for thoracic aneurysm and pacemaker implantation have been excluded from the survey since 2015. Assist device implantations were not included in the total number of surgical procedures but were included in the survey.
A total of 70,769 cardiovascular surgeries, including 84 heart transplants, had been performed in 2019, with a 0.32% increase compared to that in 2018 (n = 70,537).
Compared to data for 2018 [1] and 2009 [2], data for 2019 showed 2.7% (9006 vs 9253) and 4.0% fewer surgeries for congenital heart disease, 0.6% (23,340 vs 23,205) more and 36.5% more surgeries for valvular heart disease, 5.9% (12,693 vs 13,445) and 42.3% fewer surgeries for ischemic heart procedures, and 5.0% (22,708 vs. 21,624) and 89.9% more surgeries for thoracic aortic aneurysm, respectively. Data for individual categories are summarized in Tables 1, 2, 3, 4, 5, 6.
Table 1
Congenital (total; 9006)
(1) CPB (+) (total; 6890)
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
5
4
1 (25.0)
1 (25.0)
24
1 (4.2)
1 (4.2)
33
2 (6.1)
2 (6.1)
Coarctation (simple)
10
1 (10.0)
1 (10.0)
13
15
13
1 (7.7)
51
1 (2.0)
2 (3.9)
+ VSD
48
1 (2.1)
1 (2.1)
44
1 (2.3)
1 (2.3)
13
0
105
2 (1.9)
2 (1.9)
+ DORV
3
4
0
7
+ AVSD
1
1 (100.0)
2
1
0
4
1 (25.0)
+ TGA
0
2
0
2
+ SV
1
0
1
0
2
+ Others
7
4
3
0
14
Interrupt. of Ao (simple)
0
0
0
0
0
+ VSD
20
25
1 (4.0)
1 (4.0)
12
0
57
1 (1.8)
1 (1.8)
+ DORV
0
0
0
0
0
+ Truncus
4
1 (25.0)
1 (25.0)
7
1 (14.3)
2
0
13
1 (7.7)
2 (15.4)
+ TGA
0
0
0
0
0
+ Others
1
2
2
1
6
Vascular ring
0
1
0
0
1
PS
1
22
62
1 (1.6)
1 (1.6)
26
1 (3.8)
1 (3.8)
111
2 (1.8)
2 (1.8)
PA・IVS or Critical PS
10
1 (10.0)
1 (10.0)
52
1 (1.9)
2 (3.8)
65
9
136
1 (0.7)
1 (0.7)
3 (2.2)
TAPVR
106
7 (6.6)
11 (10.4)
49
1 (2.0)
1 (2.0)
20
0
175
8 (4.6)
12 (6.9)
PAPVR ± ASD
1
6
46
23
76
ASD
1
49
526
873
6 (0.7)
6 (0.7)
1,449
6 (0.4)
6 (0.4)
Cor triatriatum
1
10
8
1
20
AVSD (partial)
2
10
1 (10.0)
32
8
52
1 (1.9)
AVSD (complete)
6
102
1 (1.0)
1 (1.0)
110
2 (1.8)
4
222
1 (0.5)
3(1.4)
+ TOF or DORV
0
8
18
3
29
+ Others
0
0
0
0
0
VSD (subarterial)
1
85
156
7
249
VSD (perimemb./muscular)
14
663
2 (0.3)
372
2 (0.5)
23
1,072
4 (0.4)
VSD (Type Unknown)
0
1
1
132
2 (1.5)
2 (1.5)
134
2 (1.5)
2 (1.5)
VSD + PS
1
24
12
3
40
DCRV ± VSD
1
5
33
24
63
Aneurysm of sinus of Valsalva
0
1
2
3
TOF
11
172
1 (0.6)
1 (0.6)
184
2 (1.1)
35
402
1 (0.2)
3 (0.7)
PA + VSD
5
56
115
2 (1.7)
2 (1.7)
9
185
2 (1.1)
2 (1.1)
DORV
28
1 (3.6)
1 (3.6)
122
2 (1.6)
160
1 (0.6)
1 (0.6)
9
319
2 (0.6)
4 (1.3)
TGA (simple)
92
2 (2.2)
2 (2.2)
5
3
3
103
2 (1.9)
2 (1.9)
+ VSD
23
1 (4.3)
19
13
2
57
1 (1.8)
VSD + PS
0
2
0
2
Corrected TGA
3
9
1 (11.1)
1 (11.1)
37
4
53
1 (1.9)
1 (1.9)
Truncus arteriosus
5
1 (20.0)
16
1 (6.3)
24
3
48
2 (4.2)
SV
28
2 (7.1)
4 (14.3)
143
4 (2.8)
4 (2.8)
160
2 (1.3)
3 (1.9)
16
1 (6.3)
347
8 (2.3)
12 (3.5)
TA
5
1 (20.0)
34
38
9
86
1 (1.2)
HLHS
28
7 (25.0)
114
1 (0.9)
8 (7.0)
72
1 (1.4)
1 (1.4)
1
215
2 (0.9)
16 (7.4)
Aortic valve lesion
3
25
1 (4.0)
115
1 (0.9)
1 (0.9)
42
1 (2.4)
1 (2.4)
185
2 (1.1)
1 (0.5)
2 (1.1)
Mitral valve lesion
0
31
1 (3.2)
1 (3.2)
70
1 (1.4)
26
127
1 (0.8)
2 (1.6)
Ebstein
14
2 (14.3)
13
1 (7.7)
19
17
63
3 (4.8)
Coronary disease
2
9
1 (11.1)
2 (22.2)
18
4
33
1 (3.0)
2 (6.1)
Others
10
1 (10.0)
1 (10.0)
30
2 (6.7)
4 (13.3)
39
191
4 (2.1)
4 (2.1)
270
7 (2.6)
9 (3.3)
Conduit failure
0
0
16
5
21
Redo (excluding conduit failure)
3
56
2 (3.6)
6 (10.7)
100
2 (2.0)
5 (5.0)
89
1 (1.1)
2 (2.2)
248
5 (2.0)
13 (5.2)
Total
505
16 (3.2)
1 (0.2)
36 (7.1)
2,048
19 (0.9)
1 (0.05)
42 (2.1)
2,696
10 (0.4)
0
21 (0.8)
1,641
16 (1.0)
0
19 (1.2)
6,890
61 (0.9)
2 (0.0)
118 (1.7)
( ), % mortality
CPB cardiopulmonary bypass; PDA patent 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 aortá; 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
(2) CPB (−) (total; 2116)
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
246
5 (2.0)
11 (4.5)
137
1 (0.7)
3 (2.2)
13
0
396
6 (1.5)
14 (3.5)
Coarctation (simple)
12
16
2
1
31
+ VSD
48
3 (6.3)
19
1 (5.3)
1 (5.3)
2 (10.5)
3
0
70
1 (1.4)
1 (1.4)
5 (7.1)
+ DORV
3
0
0
0
3
+ AVSD
2
0
0
0
2
+ TGA
2
1
0
0
3
+ SV
0
0
0
0
0
+ Others
5
5
0
1
11
Interrupt. of Ao (simple)
0
0
0
0
0
+ VSD
20
1 (5.0)
1 (5.0)
9
1
0
30
1 (3.3)
1 (3.3)
+ DORV
0
0
1
0
1
+ Truncus
8
1 (12.5)
1 (12.5)
0
0
0
8
1 (12.5)
1 (12.5)
+ TGA
0
0
0
0
0
+ Others
3
1 (33.3)
1 (33.3)
1
0
0
4
1 (25.0)
1 (25.0)
Vascular ring
5
17
10
1
33
PS
1
3
0
0
4
PA・IVS or Critical PS
14
19
1 (5.3)
2 (10.5)
10
0
43
1 (2.3)
2 (4.7)
TAPVR
16
5 (31.3)
6 (37.5)
17
2 (11.8)
2 (11.8)
1
0
34
7 (20.6)
8 (23.5)
PAPVR ± ASD
0
0
1
0
1
ASD
1
2
2
4
9
Cor triatriatum
0
0
0
0
0
AVSD (partial)
1
0
3
0
4
AVSD (complete)
34
81
1 (1.2)
9
1 (11.1)
2
126
1 (0.8)
1 (0.8)
+ TOF or DORV
1
3
2
0
6
+ Others
0
0
0
0
0
VSD (subarterial)
1
6
2
0
9
VSD (perimemb./muscular)
56
1 (1.8)
2 (3.6)
127
1 (0.8)
2 (1.6)
13
1 (7.7)
0
196
2 (1.0)
5 (2.6)
VSD (Type Unknown)
0
0
2
2
VSD + PS
0
0
0
0
DCRV ± VSD
0
0
0
0
Aneurysm of sinus of Valsalva
0
0
0
0
0
TOF
13
62
19
1 (5.3)
1 (5.3)
3
97
1 (1.0)
1 (1.0)
PA + VSD
12
40
12
2
66
DORV
41
2 (4.9)
2 (4.9)
61
1 (1.6)
14
1 (7.1)
2
118
2 (1.7)
4 (3.4)
TGA (simple)
4
4
1 (25.0)
1 (25.0)
1
2
11
1 (9.1)
1 (9.1)
+ VSD
7
2
0
1
10
VSD + PS
0
0
0
0
0
Corrected TGA
5
1 (20.0)
6
7
1
19
1 (5.3)
Truncus arteriosus
24
1 (4.2)
1
1
0
26
1 (3.8)
SV
60
1 (1.7)
3 (5.0)
40
1 (2.5)
3 (7.5)
18
2 (11.1)
2 (11.1)
6
124
4 (3.2)
8 (6.5)
TA
13
7
0
1
21
HLHS
85
2 (2.4)
10 (11.8)
31
3 (9.7)
5 (16.1)
23
2 (8.7)
2 (8.7)
0
139
7 (5.0)
17 (12.2)
Aortic valve lesion
4
1 (25.0)
3
1 (33.3)
0
0
7
1 (14.3)
1 (14.3)
Mitral valve lesion
3
2
1 (50.0)
1 (50.0)
1
1
7
1 (14.3)
1 (14.3)
Ebstein
10
1 (10.0)
2 (20.0)
3
5
0
18
1 (5.6)
2 (11.1)
Coronary disease
0
6
1 (16.7)
2 (33.3)
2
2
10
1 (10.0)
2 (20.0)
Others
6
11
17
3 (17.6)
4 (23.5)
2
36
3 (8.3)
4 (11.1)
Conduit failure
0
0
0
0
Redo (excluding conduit failure)
37
9 (24.3)
13 (35.1)
154
9 (5.8)
24 (15.6)
165
7 (4.2)
14 (8.5)
25
381
25 (6.6)
51 (13.4)
Total
803
29 (3.6)
0
58 (7.2)
896
22 (2.5)
3 (0.3)
48 (5.4)
358
15 (4.2)
0
26 (7.3)
59
0
0
0
2,116
66 (3.1)
3 (0.14)
132 (6.2)
( ), % mortality
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
96
2 (2.1)
4 (4.2)
330
4 (1.2)
9 (2.7)
51
1 (2.0)
2 (3.9)
4
481
7 (1.5)
15 (3.1)
2
PAB
293
8 (2.7)
19 (6.5)
306
3 (1.0)
1 (0.3)
8 (2.6)
15
2
616
11 (1.8)
1 (0.2)
27 (4.4)
3
Bidirectional Glenn or hemi-Fontan ±α
0
215
4 (1.9)
6 (2.8)
109
5
329
4 (1.2)
6 (1.8)
4
Damus-Kaye-Stansel operation
3
28
1 (3.6)
1 (3.6)
12
1
44
1 (2.3)
1 (2.3)
5
PA reconstruction/repair (including redo)
12
1 (8.3)
1 (8.3)
2 (16.7)
164
1 (0.6)
4 (2.4)
177
1 (0.6)
2 (1.1)
31
384
3 (0.8)
1 (0.3)
8 (2.1)
6
RVOT reconstruction/repair
6
206
1 (0.5)
2 (1.0)
281
1 (0.4)
2 (0.7)
42
535
2 (0.4)
4 (0.7)
7
Rastelli procedure
0
33
109
1 (0.9)
5
147
1 (0.7)
8
Arterial switch procedure
130
3 (2.3)
5 (3.8)
24
4
1
159
3 (1.9)
5 (3.1)
9
Atrial switch procedure
1
2
1 (50.0)
4
1
8
1 (12.5)
10
Double switch procedure
0
1
7
0
8
11
Repair of anomalous origin of CA
0
8
1 (12.5)
2 (25.0)
5
0
13
1 (7.7)
2 (15.4)
12
Closure of coronary AV fistula
3
2
2
4
11
13
Fontan / TCPC
0
1
360
2 (0.6)
4 (1.1)
34
1 (2.9)
1 (2.9)
2 (5.9)
395
3 (0.8)
1 (0.3)
6 (1.5)
14
Norwood procedure
25
3 (12.0)
88
1 (1.1)
6 (6.8)
3
0
116
1 (0.9)
9 (7.8)
15
Ventricular septation
0
0
0
0
0
16
Left side AV valve repair (including Redo)
1
38
73
22
134
17
Left side AV valve replace (including Redo)
0
12
45
1 (2.2)
22
2 (9.1)
79
3 (3.8)
18
Right side AV valve repair (including Redo)
24
3 (12.5)
77
2 (2.6)
6 (7.8)
91
1 (1.1)
1 (1.1)
81
1 (1.2)
273
3 (1.1)
11 (4.0)
19
Right side AV valve replace (including Redo)
1
1 (100.0)
1
13
1 (7.7)
22
37
2 (5.4)
20
Common AV valve repair (including Redo)
9
2 (22.2)
2 (22.2)
8
2 (25.0)
2 (25.0)
25
1 (4.0)
1 (4.0)
1
43
5 (11.6)
5 (11.6)
21
Common AV valve replace (including Redo)
0
5
11
1 (9.1)
1 (9.1)
1
1 (100.0)
17
2 (11.8)
1 (5.9)
22
Repair of supra-aortic stenosis
0
9
1 (11.1)
1 (11.1)
1 (11.1)
18
2
29
1 (3.4)
1 (3.4)
1 (3.4)
23
Repair of subaortic stenosis (including Redo)
0
1
35
6
42
24
Aortic valve plasty ± VSD Closure
5
16
48
1 (2.1)
1 (2.1)
1
70
1 (1.4)
1 (1.4)
25
Aortic valve replacement
0
0
32
1 (3.1)
1 (3.1)
43
1 (2.3)
2 (4.7)
1 (2.3)
75
2 (2.7)
2 (2.7)
2 (2.7)
26
AVR with annular enlargement
0
0
13
3
1 (33.3)
16
1 (6.3)
27
Aortic root Replace (except Ross)
0
0
6
1 (16.7)
18
1 (5.6)
1 (5.6)
24
1 (4.2)
1 (4.2)
1 (4.2)
28
Ross procedure
0
5
14
19
29
Bilateral pulmonary artery banding
160
2 (1.3)
15 (9.4)
12
1 (8.3)
2 (16.7)
1
0
173
3 (1.7)
17 (9.8)
Total
769
18 (2.3)
1 (0.1)
54 (7.0)
1,592
22 (1.4)
2 (0.1)
50 (3.1)
1,564
9 (0.6)
1 (0.1)
19 (1.2)
352
3 (0.9)
6 (1.7)
6 (1.7)
4,277
52 (1.2)
10 (0.23)
129 (3.0)
( ), % mortality
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
(c) Cases of conversion, during surgery, from off-pump CABG to on-pump CABG or on- pump beating-heart CABG (these cases are also included in category (b))
Primary, elective
Primary, emergent
Redo, elective
Redo, emergent
Cases
30 Day mortality
Hospital mortality
Cases
30 Day mortality
Hospital mortality
Cases
30 Day mortality
Hospital mortality
Cases
30 Day mortality
Hossspital mortality
Hospital
After discharge
Hospital
After discharge
Hospital
After discharge
Hospital
After discharge
Converted to arrest
21
2 (9.5)
3
0
Converted to beating
102
6 (5.9)
9 (8.8)
39
3 (7.7)
7 (17.9)
6
1 (16.7)
1 (16.7)
1
1 (100.0)
1 (100.0)
Total
123
6 (4.9)
11 (8.9)
42
3 (7.1)
7 (16.7)
6
1 (16.7)
1 (16.7)
1
1 (100.0)
1 (100.0)
On dialysis
21
2 (9.5)
5 (23.8)
7
1 (14.3)
3 (42.9)
5
1 (20.0)
1 (20.0)
0
( ), % mortality
CABG coronary artery bypass grafting
(B) Operation for complications of MI (total; 1296)
Except for 247 isolated cases, all remaining 6633 cases are doubly allocated, one for this subgroup and the other for the subgroup corresponding to the concomitant operations
(4) Operation for constrictive pericarditis (total; 191)
Among the 9006 procedures for congenital heart disease conducted in 2019, 6890 were open-heart surgeries, with an overall hospital mortality rate of 1.7%. The number of surgeries for neonates and infants in 2019 did not significantly differ compared to that in 2009; however, hospital mortality improved from 10.7% to 7.1% for neonates and from 3.7% to 2.1% for infants. In 2019, atrial septal defect was the most common disease (1449 cases) as previously reported, with patients aged ≥ 18 years accounting for 60.2% of atrial septal defect surgery. Ventricular septal defect (perimembranous/muscular), which had been the most common disease in 2015 and 2016, was the second most common disease (1072 cases).
Hospital mortality for complex congenital heart disease within the past 10 years was as follows (2009 [2], 2014 [3], and 2019): complete atrioventricular septal defect (4.3%, 1.7%, and 1.4%); tetralogy of Fallot (1.8%, 1.1%, and 0.7%); transposition of the great arteries with the intact septum (4.2%, 6.6%, and 1.9%), ventricular septal defect (6.5%, 3.9%, and 1.8%), and single ventricle (4.3%, 4.3%, and 3.5%); and hypoplastic left heart syndrome (16.5%, 9.8%, and 7.4%). Currently, right heart bypass surgery has been commonly performed (329 bidirectional Glenn procedures, excluding 44 Damus–Kaye–Stansel procedures, and 395 Fontan type procedures, including total cavopulmonary connection) with acceptable hospital mortality rates (1.8% and 1.5%). The Norwood type I procedure was performed in 116 cases, with a relatively low hospital mortality rate (7.8%).
Valvular heart disease procedures, excluding transcatheter procedures, were slightly performed more than that in the previous year. Moreover, isolated aortic valve replacement/repair with/without coronary artery bypass grafting (CABG) (n = 10,268) was 3.0% lower than that in the previous year (n = 10,584) but 0.5% higher than that 5 years ago (n = 10,219), despite the rapid utilization of transcatheter aortic valve replacement (n = 8664 in 2019). Isolated mitral valve replacement/repairs with/without CABG (n = 5239) was 7.0% higher than that in the previous year (n = 4898) and 8.0% higher than that 5 years ago (n = 4851). Aortic and mitral valve replacement with bioprosthesis were performed in 11,207 and 2987 cases, respectively. The rate at which bioprosthesis was used had dramatically increased from 30% in the early 2000s [4, 5] to 83.0% and 73.0% in 2019 for aortic and mitral positions, respectively. Additionally, CABG was performed concurrently in 16.5% of all valvular procedures (17.2% in 2009 [2] and 17.3% in 2014 [3]). Valve repair was common in mitral and tricuspid valve positions (7632 and 6154 cases, respectively) but less common in aortic valve positions (257 patients, only 1.9% of all aortic valve procedures). Mitral valve repair accounted for 70.9% of all mitral valve procedures. Hospital mortality rates for single valve replacement for aortic and mitral positions were 2.9% and 6.4%, respectively, but only 1.2% for mitral valve repair. Moreover, hospital mortality rates for redo valve surgery for the aortic and mitral positions were 6.7% and 6.1%, respectively. Finally, overall hospital mortality rates did not significantly improve over the past 10 years (4.0% in 2009 [2], 3.1% in 2014 [3], and 3.3% in 2019).
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Isolated CABG had been performed in 11,307 cases, accounting for only 68.3% of the procedures performed 10 years ago (n = 16,536) [2]. Of the aforementioned cases, 6509 (57.6%) underwent off-pump CABG, with a success rate of 97.8%. The percentage of planned off-pump CABG in 2019 was similar to that in 2018 when it fell below 60% for the first time since 2004 [4]. Hospital mortality associated with primary elective CABG procedures among 9218 cases accounted for 1.6%, which is slightly higher than that in 2009 (1.2%) [2]. Hospital mortality for primary emergency CABG among 1667 cases remained high (8.0%). The percentage of conversion from off-pump to on-pump CABG or on-pump beating-heart CABG was 2.2% among the primary elective CABG cases, with a hospital mortality rate of 8.9%. Patients with end-stage renal failure on dialysis had higher hospital mortality rates than overall mortality, regardless of surgical procedure (on-pump arrest, on-pump beating, and off-pump). This study excluded concomitant CABGs alongside other major procedures under the ischemic heart disease category but rather under other categories, such as valvular heart disease and thoracic aortic aneurysm. Accordingly, the overall number of CABGs in 2019, including concomitant CABG with other major procedures, was 17,256.
Arrhythmia management was primarily performed as concomitant procedures in 6880 cases, with a hospital mortality rate of 3.2%. Pacemaker and implantable cardioverter-defibrillator implantation were not included in this category.
In 2019, 22,708 procedures for thoracic and thoracoabdominal aortae diseases were performed, among which aortic dissection and non-dissection accounted for 10,847 and 11,861, respectively. The number of surgeries for aortic dissection this year was 3.8% higher than that in the preceding year (n = 10,453). Hospital mortality rates for the 6347 Stanford type A acute aortic dissections remained high (10.4%). The number of procedures for non-dissected aneurysms decreased by 1.2%, with a hospital mortality rate of 5.7% for all aneurysms and 4.2% and 19.7% for unruptured and ruptured aneurysms, respectively. Thoracic endovascular aortic repair (TEVAR) has been performed for aortic diseases at an increasing rate. Stent graft placement was performed in 4356 patients with aortic dissection, including 2387 TEVARs and 1969 open stent graftings. Moreover, 1470 and 267 cases underwent TEVAR and open stent grafting for type B chronic aortic dissection, accounting for 61.6% and 13.6% of the total number of cases, respectively. Hospital mortality rates associated with simple TEVAR for type B aortic dissection were 8.0% and 2.1% for acute and chronic cases, respectively. Stent graft placement was performed in 5087 patients with non-dissected aortic aneurysms, among which 4072 were TEVARs (an 11.8% increase compared to that in 2018, n = 3641) and 1499 were open stent graftings (a 3.7% increase compared to that in 2018, n = 1446). Hospital mortality rates were 3.7% and 18.7% for TEVARs and 5.8% and 15.2% for open stenting in unruptured and ruptured aneurysms, respectively.
(B) General thoracic surgery
The 2019 survey of general thoracic surgeries comprised 679 surgical units, with bulk data submitted via a web-based collection system established by the NCD [1]. General thoracic surgery departments reported 91,626 procedures in 2019 (Table 7), which is 2.2 times more than that in 2000 and approximately 14,500 more procedures than that in 2014 (Fig. 2).
Table 7
Total cases of general thoracic surgery during 2019
Cases
%
Benign pulmonary tumor
2543
2.8
Primary lung cancer
48,052
52.4
Other primary malignant pulmonary tumor
432
0.5
Metastatic pulmonary tumor
9329
10.2
Tracheal tumor
117
0.1
Mesothelioma
682
0.7
Chest wall tumor
689
0.8
Mediastinal tumor
5861
6.4
Thymectomy for MG without thymoma
162
0.2
Inflammatory pulmonary disease
2,358
2.6
Empyema
3298
3.6
Bullous disease excluding pneumothorax
394
0.4
Pneumothorax
15,082
16.5
Chest wall deformity
208
0.2
Diaphragmatic hernia including traumatic
36
0.0
Chest trauma excluding diaphragmatic hernia
469
0.5
Lung transplantation
92
0.1
Others
1822
2.0
Total
91,626
100.0
Fig. 2
General thoracic surgery
×
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In 2019, 48,052 procedures for primary lung cancer had been performed which continued to increase annually. Accordingly, the number of procedures in 2019 was 2.6 times higher than that in 2000, with lung cancer procedures accounting for 52% of all general thoracic surgeries.
Information about the number of video-assisted thoracoscopic surgery (VATS), which is defined as surgical procedures using a skin incision less than 8 cm including a mini-thoracotomy (hybrid) approach, have been available since the 2015 annual report. Tables 8, 9, 11, 14, 15, 16, 18, 19, 20, 21, 22, and 24, 25, 26 present the number of VATS procedures for benign pulmonary tumors, primary lung cancer, metastatic pulmonary tumor, chest wall tumor, mediastinal tumor, thymectomy for myasthenia gravis, non-neoplastic disease, empyema, descending necrotizing mediastinitis, bullous diseases, diaphragmatic hernia, chest trauma and the total number of VATS procedures in 2019, respectively.
Table 8
Benign pulmonary tumor
Cases
30-Day mortality
Hospital mortality
By VATS
Hospital
After discharge
Benign pulmonary tumor
Hamartoma
565
549
Sclerosing hemangioma
108
102
Papilloma
27
27
Mucous gland adenoma bronchial
10
10
Fibroma
136
132
Lipoma
7
6
Neurogenic tumor
11
10
Clear cell tumor
2
2
Leiomyoma
24
23
Chondroma
3
1
Inflammatory myofibroblastic tumor
0
0
Pseudolymphoma
18
17
Histiocytosis
17
16
Teratoma
6
6
Others
1609
1 (0.1)
3 (0.2)
1536
Total
2543
1 (0.04)
3 (0.12)
2437
( ), Mortality %
Table 9
Primary malignant pulmonary tumor
Cases
30-Day mortality
Hospital mortality
VATS
Hospital
After discharge
2. Primary malignant pulmonary tumor
48,484
109 (0.2)
66 (0.1)
240 (0.5)
38,158
Lung cancer
48,052
107 (0.2)
66 (0.1)
238 (0.5)
38,158
Adenocarcinoma
34,290
49 (0.1)
39 (0.11)
99 (0.3)
Squamous cell carcinoma
8,642
47 (0.5)
23 (0.3)
107 (1.2)
Large cell carcinoma
311
LCNEC
611
1 (0.2)
1 (0.2)
5 (0.8)
Small cell carcinoma
776
1 (0.1)
3 (0.4)
5 (0.6)
Adenosquamous carcinoma
538
1 (0.2)
3 (0.6)
Carcinoma with pleomorphic, sarcomatoid or sarcomatous elements
540
4 (0.7)
6 (1.1)
Carcinoid
282
1 (0.4)
Carcinomas of salivary-gland type
45
Unclassified
42
1 (2.4)
2 (4.8)
Multiple lung cancer
1,623
3 (0.2)
7 (0.4)
Others
352
3 (0.9)
Unknown
1
1
2
Wedge resection
8,532
10 (0.1)
9 (0.1)
28 (0.3)
7,770
Segmental excision
5,467
5 (0.1)
6 (0.11)
19 (0.3)
4,674
(Sleeve segmental excision)
20
12
Lobectomy
33,445
85 (0.3)
49 (0.15)
177 (0.5)
25,487
(Sleeve lobectomy)
483
8 (1.7)
3 (0.6)
9 (1.9)
70
Pneumonectomy
278
4 (1.4)
10 (3.6)
31
(Sleeve pneumonectomy)
5
0
Other bronchoplasty
38
1 (2.6)
5
Pleuropneumonectomy
1
0
Others
291
4 (1.4)
3 (1.0)
5 (1.7)
191
Unknown
0
Sarcoma
47
2 (4.3)
2 (4.3)
AAH
120
Others
265
( ), Mortality %
A total of 2543 procedures for benign pulmonary tumors had been conducted in 2019 (Table 8). Hamartomas were the most frequent benign pulmonary tumors diagnosed, with 2437 patients (96%) undergoing VATS.
Tables 9 and 10 show additional information on primary malignant pulmonary tumors. Accordingly, the most frequently diagnosed lung cancer subtype was adenocarcinoma (71% of all lung cancers), followed by squamous cell carcinoma (18%). Sublobar resection was performed in 13,999 lung cancer cases (29% of all cases) and lobectomy in 33,455 cases (70% of all cases). Sleeve lobectomy was performed in 483 cases, while pneumonectomy was required in 278 cases (0.6% of all cases). VATS lobectomy was performed in 25,487 cases of lung cancer (76% of all lobectomy cases). Patients aged ≥ 80 years who underwent lung cancer surgery accounted for 6739 (14%). Among those who died within 30 days postoperatively, 107 and 66 died before and after hospital discharge, respectively. Overall, 173 patients died within 30 days postoperatively (30-day mortality rate, 0.4%), while 238 died before discharge (hospital mortality rate, 0.5%). Moreover, 30-day mortality rates according to the procedure were 0.1%, 0.3%, and 1.4% for segmentectomy, lobectomy, and pneumonectomy, respectively. Interstitial pneumonia had been the leading cause of death after lung cancer surgery, followed by pneumonia, respiratory failure, and cardiovascular events.
Table 10
Details of lung cancer operations
TNM
c-Stage
Cases
IA1
8727
IA2
13,908
IA3
8400
IB
5295
IIA
1687
IIB
4018
IIIA
2694
IIIB
457
IIIC
15
IVA
383
IVB
80
NA
2,388
Total
48,052
Sex
Cases
Male
29,065
Female
18,987
Total
48,052
Cause of death
Cases
Cardiovascular
30
Pneumonia
50
Pyothorax
2
Bronchopleural fistula
14
Respiratory failure
32
Pulmonary embolism
2
Interstitial pneumonia
87
Brain infarction or bleeding
10
Others
70
Unknown
10
Total
307
p-Stage
Cases
0 (pCR)
3532
IA1
9737
IA2
10,819
IA3
5323
IB
6496
IIA
1343
IIB
4712
IIIA
3949
IIIB
770
IIIC
10
IVA
942
IVB
92
NA
327
Total
48,052
Age (y)
Cases
<20
19
20–29
48
30–39
259
40–49
1299
50–59
3987
60–69
12,825
70–79
22,874
80–89
6,614
≥90
125
NA
2
Total
48,052
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Table 11 shows the procedures for metastatic pulmonary tumors, of which 9329 were performed in 2019. Among such procedures, the most frequent primary tumor was colorectal cancer (51% of all cases).
Table 11
Metastatic pulmonary tumor
Cases
30-Day mortality
Hospital mortality
VATS
Hospital
After discharge
3. Metastatic pulmonary tumor
9329
9 (0.1)
6 (0.06)
16 (0.2)
8709
Colorectal
4379
3 (0.07)
5 (0.1)
4083
Hepatobiliary/Pancreatic
525
1 (0.2)
1 (0.2)
497
Uterine
516
2 (0.4)
2 (0.4)
490
Mammary
568
547
Ovarian
75
72
Testicular
57
53
Renal
770
732
Skeletal
144
133
Soft tissue
246
3 (1.2)
229
Otorhinolaryngological
559
525
Pulmonary
449
1 (0.2)
1 (0.2)
2 (0.4)
386
Others
1041
2 (0.2)
2 (0.2)
6 (0.6)
962
( ), Mortality %
A total of 117 procedures for tracheal tumors, including 60, 30, and 27 cases of primary malignant, metastatic, and benign tracheal tumors, respectively, were performed in 2019. Further, 35 patients underwent sleeve resection and reconstruction (Table 12).
Table 12
Tracheal tumor
Cases
30-Day mortality
Hospital mortality
Hospital
After discharge
4. Tracheal tumor
117
2 (1.7)
3 (2.6)
5 (4.3)
A. Primary malignant tumor
Histological classification
Squamous cell carcinoma
14
2 (14.3)
Adenoid cystic carcinoma
31
1 (3.2)
Mucoepidermoid carcinoma
1
Others
14
Total
60
1 (1.7)
2 (3.3)
B. Metastatic/invasive malignant tumor, e.g. invasion of thyroid cancer
30
2 (6.7)
2 (6.7)
3 (10.0)
C. Benign tracheal tumor
Histological classification
Papilloma
3
Adenoma
2
Neurofibroma
1
Chondroma
1
Leiomyoma
2
Others
18
Histology unknown
0
Total
27
0
0
0
Operation
Sleeve resection with reconstruction
35
1 (2.9)
1 (2.9)
Wedge with simple closure
4
Wedge with patch closure
0
Total laryngectomy with tracheostomy
0
Others
1
Unknown
0
Total
40
0
1 (2.5)
1 (2.5)
( ), Mortality %
Overall, 682 pleural tumors had been diagnosed in 2019 (Table 13), with diffuse malignant pleural mesothelioma as the most frequent histologic diagnosis. Total pleurectomy was performed in 140 cases and extrapleural pneumonectomy in 43 cases. The 30-day mortality rate was 0% and 2.3% after total pleurectomy and extrapleural pneumonectomy, respectively, both of which had better outcomes than previously reported.
Table 13
Tumor of pleural origin
Histological classification
Cases
30-Day mortality
Hospital mortality
Hospital
After discharge
5. Tumor of pleural origin
Solitary fibrous tumor
133
Diffuse malignant pleural mesothelioma
292
2 (0.7)
10 (3.4)
Localized malignant pleural mesothelioma
37
1 (2.7)
Others
220
2 (0.9)
4 (1.8)
Total
682
4 (0.6)
15 (2.2)
Operative procedure
Cases
30-Day mortality
Hospital mortality
Hospital
After discharge
Extrapleural pneumonectomy
43
1 (2.3)
3 (7.0)
Total pleurectomy
140
3 (2.1)
Others
109
1 (0.9)
4 (3.7)
Total
292
2 (0.7)
10 (3.4)
( ), Mortality %
Overall, 689 chest wall tumor resections had been performed in 2019, including 116, 209, and 364 cases of primary malignant, metastatic, and benign tumors, respectively (Table 14).
Table 14
Chest wall tumor
Cases
30-Day mortality
Hospital mortality
VATS
Hospital
After discharge
6. Chest wall tumors
Primary malignant tumor
116
1 (0.9)
1 (0.9)
1 (0.9)
56
Metastatic malignant tumor
209
84
Benign tumor
364
283
Total
689
1 (0.1)
1 (0.1)
1 (0.1)
423
( ), Mortality %
In 2019, 5,881 mediastinal tumors were resected, which is 10% higher compared to that in the previous year (Table 15). Thymic epithelial tumors, including 2280 thymomas, 351 thymic carcinomas, and 44 thymic carcinoids, were the most frequently diagnosed mediastinal tumor subtype in 2019.
Table 15
Mediastinal tumor
Cases
30-Day mortality
Hospital mortality
By VATS
Hospital
After discharge
7. Mediastinal tumor
5881
2 (0.03)
10 (0.17)
10 (0.2)
4599
Thymoma*
2280
2 (0.1)
2 (0.1)
1612
Thymic cancer
351
1 (0.3)
1 (0.3)
222
Thymus carcinoid
44
25
Germ cell tumor
111
66
Benign
89
59
Malignant
22
7
Neurogenic tumor
526
1 (0.2)
490
Congenital cyst
1376
1 (0.1)
1 (0.1)
1293
Goiter
96
0
36
Lymphatic tumor
160
0
125
Excision of pleural recurrence of thymoma
30
0
23
Thymolipoma
15
1 (6.7)
0
9
Others
892
6 (0.7)
6 (0.7)
698
( ), Mortality %
A total of 499 patients underwent thymectomy for myasthenia gravis (Table 16), among which 337 procedures were associated with thymoma.
Table 16
Thymectomy for myasthenia gravis
Cases
30-Day mortality
Hospital mortality
By VATS
Hospital
After discharge
8. Thymectomy for myasthenia gravis
499
1 (0.2)
0
3 (0.6)
298
With thymoma
337
0
0
0
202
( ), Mortality %
Overall, 23,717 patients underwent procedures for non-neoplastic disease. Accordingly, 2358 patients underwent lung resection for inflammatory lung diseases (Tables 17, 18), among which 475 and 336 patients were associated with mycobacterial and fungal infections, respectively. Procedures for inflammatory nodules were performed in cases where lung cancer was suspected preoperatively (928 cases, 39%).
Table 17
Operations for non-neoplastic diseases:A+B+C+D+E+F+G+H+I
Cases
30-Day mortality
Hospital mortality
Hospital
After discharge
9. Operations for non-neoplastic diseases
23,717
221 (0.9)
33 (0.1)
491 (2.1)
Table 18
A. Inflammatory pulmonary disease
Cases
30-Day mortality
Hospital mortality
VATS
Hospital
After discharge
A. Inflammatory pulmonary disease
2358
7 (0.3)
1 (0.0)
15 (0.6)
2130
Tuberculous infection
41
35
Mycobacterial infection
475
1 (0.2)
2 (0.4)
425
Fungal infection
336
1 (0.3)
2 (0.6)
267
Bronchiectasis
52
42
Tuberculous nodule
70
1 (1.4)
69
Inflammatory pseudotumor
928
2 (0.2)
1 (0.1)
4 (0.4)
876
Interpulmonary lymph node
66
65
Others
390
3 (0.8)
6 (1.5)
351
( ), Mortality %
A total of 3298 procedures were performed for empyema (Table 19), among which 2597 (77%) were acute and 701 were chronic. Further, bronchopleural fistulas developed in 478 and 320 patients with acute and chronic empyema, respectively. The hospital mortality rate was 13% among patients with acute empyema with fistula.
Table 19
B. Empyema
Cases
30-Day mortality
Hospital mortality
By VATS
Hospital
After discharge
Acute empyema
2597
53 (2.0)
3 (0.1)
144 (5.5)
2,233
With fistula
478
10 (2.1)
62 (13.0)
287
Without fistula
2096
43 (2.1)
3 (0.1)
81 (3.9)
1,925
Unknown
23
1 (4.3)
21
Chronic empyema
701
20 (2.9)
2 (0.3)
55 (7.8)
404
With fistula
320
16 (5.0)
1 (0.3)
36 (11.3)
127
Without fistula
342
3 (0.9)
1 (0.3)
18 (5.3)
246
Unknown
39
1 (2.6)
1 (2.6)
31
Total
3298
73 (2.2)
5 (0.2)
199 (6.0)
2637
( ), Mortality %
Further, 93 operations were performed for descending necrotizing mediastinitis (Table 20), with a hospital mortality rate of 4.3%.
Table 20
C. Descending necrotizing mediastinitis
Cases
30-Day mortality
Hospital mortality
VATS
Hospital
After discharge
C. Descending necrotizing mediastinitis
93
2 (2.2)
4 (4.3)
78
( ), Mortality %
A total of 394 procedures were conducted for bullous diseases (Table 21), while only 13 patients underwent lung volume reduction surgery.
Table 21
D. Bullous diseases
Cases
30-Day mortality
Hospital mortality
VATS
Hospital
After discharge
D. Bullous diseases
394
1 (0.3)
1 (0.3)
359
Emphysematous bulla
296
1 (0.3)
1 (0.3)
270
Bronchogenic cyst
22
20
Emphysema with LVRS
13
13
Others
63
56
( ), Mortality %
LVRS lung volume reduction surgery
A total of 15,082 procedures were performed for pneumothorax (Table 22). Among the 11,200 procedures for spontaneous pneumothorax, 2762 (25%) were bullectomies alone, while 7714 (69%) required additional procedures, such as coverage with artificial material, as well as parietal pleurectomy. A total of 3,882 procedures for secondary pneumothorax were performed, with chronic obstructive pulmonary disease (COPD) being the most prevalent associated disease (2693 cases, 69%). The hospital mortality rate for secondary pneumothorax associated with COPD was 1.7%.
Table 22
E. Pneumothorax
Cases
30-Day mortality
Hospital mortality
VATS
Hospital
After discharge
15,082
78 (0.5)
22 (0.1)
163 (1.1)
14,711
Spontaneous pneumothorax
Operative procedure
Cases
30-Day mortality
Hospital mortality
VATS
Hospital
After discharge
Bullectomy
2762
5 (0.2)
1 (0.0)
6 (0.2)
2702
Bullectomy with additional procedure
7714
4 (0.1)
1 (0.01)
11 (0.1)
7596
Coverage with artificial material
7442
4 (0.1)
1 (0.01)
11 (0.1)
7327
Parietal pleurectomy
33
33
Coverage and parietal pleurectomy
71
71
Others
168
165
Others
721
2 (0.3)
10 (1.4)
688
Unknown
3
3
Total
11,200
11 (0.1)
2 (0.0)
27 (0.2)
10,989
Secondary pneumothorax
Associated disease
Cases
30-Day mortality
Hospital mortality
VATS
Hospital
After discharge
COPD
2693
25 (0.9)
9 (0.3)
57 (2.1)
2,611
Tumorous disease
168
11 (6.5)
4 (2.4)
19 (11.3)
158
Catamenial
164
162
LAM
49
0
48
Others (excluding pneumothorax by trauma)
808
31 (3.8)
7 (0.9)
60 (7.4)
745
Operative procedure
Cases
30 Day mortality
Hospital mortality
VATS
Hospital
After discharge
Bullectomy
627
7 (1.1)
3 (0.5)
13 (2.1)
615
Bullectomy with additional procedure
2285
21 (0.9)
8 (0.4)
42 (1.8)
2233
Coverage with artificial material
2190
19 (0.9)
8 (0.4)
39 (1.8)
2140
Parietal pleurectomy
6
6
Coverage and parietal pleurectomy
24
1 (4.2)
1 (4.2)
22
Others
65
1 (1.5)
2 (3.1)
65
Others
966
39 (4.0)
9 (0.9)
81 (8.4)
872
Unknown
4
0
4
Total
3882
67 (1.7)
20 (0.5)
136 (3.5)
3724
( ), Mortality %
The 2019 survey reported 208 procedures for chest wall deformity (Table 23). However, this may have been underestimated because the Nuss procedure for pectus excavatum was more likely performed in pediatric surgery centers not associated with the Japanese Association for Thoracic Surgery.
Table 23
F. Chest wall deformity
Cases
30-Day mortality
Hospital mortality
Hospital
After discharge
F. Chest wall deformity
208
Funnel chest
196
Others
12
( ), Mortality %
Surgical treatment for diaphragmatic hernia was performed in 36 patients (Table 24). This figure may have been underestimated because procedures may have been classified as gastrointestinal surgery.
Table 24
G. Diaphragmatic hernia
Cases
30-Day mortality
Hospital mortality
VATS
Hospital
After discharge
G. Diaphragmatic hernia
36
21
Congenital
6
5
Traumatic
10
4
Others
20
12
( ), Mortality %
The survey reported 469 procedures for chest trauma, excluding iatrogenic injuries (Table 25), with a hospital mortality rate of 5.5%.
Table 25
H. Chest trauma
Cases
30-Day mortality
Hospital mortality
VATS
Hospital
After discharge
H. Chest trauma
469
26 (5.5)
1 (0.2)
29 (6.2)
302
( ), Mortality %
Table 26 summarizes the procedures for other diseases, including 110 and 118 cases of arteriovenous malformation and pulmonary sequestration, respectively.
Table 26
I. Other respiratory surgery
Cases
30-Day mortality
Hospital mortality
VATS
Hospital
After discharge
I. Other respiratory surgery
1783
34 (1.9)
4 (0.2)
80 (4.5)
1400
Arteriovenous malformation*
110
1 (0.9)
1 (0.9)
104
Pulmonary sequestration
118
105
Postoperative bleeding ・air leakage
555
9 (1.6)
34 (6.1)
404
Chylothorax
85
2 (2.4)
2 (2.4)
77
Others
915
23 (2.5)
3 (0.3)
43 (4.7)
710
( ), Mortality %
A total of 92 lung transplantations were performed in 2019 (Table 27), among which 80 and 12 were from brain-dead and living-related donors, respectively.
Table 27
Lung transplantation
10. Lung transplantation
Cases
30-Day mortality
Hospital mortality
Hospital
After discharge
Lung transplantation from brain-dead donor
44
2 (4.5)
Bilateral lung transplantation from brain-dead donor
36
1 (2.8)
1 (2.8)
Lung transplantation from living donor
12
1 (8.3)
Total lung transplantation
92
1 (1.1)
4 (4.3)
Donor of living donor lung transplantation
23
( ), Mortality %
The number of VATS procedures has continued to increase annually, ultimately reaching 77,059 (84% of all general thoracic surgeries) in 2019 (Table 28).
Tables 29, 30, 31, 32 present the details regarding tracheobronchoplasty, pediatric surgery, and combined resection of neighboring organs.
Table 29
Tracheobronchoplasty
Cases
30-Day mortality
Hospital mortality
Hospital
After discharge
12. Tracheobronchoplasty
787
13 (1.7)
6 (0.8)
21 (2.7)
Trachea
52
1 (1.9)
1 (1.9)
2 (3.8)
Sleeve resection with reconstruction
37
0
1 (2.7)
1 (2.7)
Wedge with simple closure
6
0
0
0
Wedge with patch closure
0
0
0
0
Total laryngectomy with tracheostomy
0
0
0
0
Others
9
1 (11.1)
0
1 (11.1)
Carinal reconstruction
23
2 (8.7)
0
2 (8.7)
Sleeve pneumonectomy
5
0
0
0
Sleeve lobectomy
486
6 (1.2)
3 (0.6)
7 (1.4)
Sleeve segmental excision
25
0
0
0
Bronchoplasty without lung resection
22
0
0
1 (4.5)
Others
174
4 (2.3)
2 (1.1)
9 (5.2)
( ), Mortality %
Table 30
Pediatric surgery
Cases
30-Day mortality
Hospital mortality
Hospital
After discharge
13. Pediatric surgery
341
7 (2.1)
9 (2.6)
( ), Mortality %
Table 31
Combined resection of neighboring organ(s)
Cases
30-Day mortality
Hospital mortality
Hospital
After discharge
14. Combined resection of neighboring organ(s)
1355
3 (0.2)
15 (1.1)
Organ resected
Cases
30-Day mortality
Hospital mortality
Hospital
After discharge
A. Primary lung cancer
Aorta
10
Superior vena cava
22
1 (4.5)
2 (9.1)
Brachiocephalic vein
4
Pericardium
82
1 (1.2)
2 (2.4)
Pulmonary artery
124
3 (2.4)
4 (3.2)
Left atrium
19
Diaphragm
65
1 (1.5)
Chest wall (including ribs)
327
5 (1.5)
Vertebra
12
Esophagus
3
Total
668
5 (0.7)
0
14 (2.1)
B. Mediastinal tumor
Aorta
2
0
0
2 (100.0)
Superior vena cava
56
0
0
1 (1.8)
Brachiocephalic vein
121
0
0
1 (0.8)
Pericardium
345
0
0
2 (0.6)
Pulmonary artery
6
0
0
1 (16.7)
Left atrium
1
0
0
0
Diaphragm
39
0
0
0
Chest wall (including ribs)
10
0
0
0
Vertebra
11
0
0
0
Esophagus
4
0
0
0
Lung
510
0
0
2 (0.4)
Total
1105
0
0
9 (0.8)
( ), Mortality %
Table 32
Operation of lung cancer invading the chest wall of the apex
Cases
30-Day mortality
Hospital mortality
Hospital
After discharge
15. Operation of lung cancer invading the chest wall of the apex
782
3 (0.4)
1 (0.1)
11 (1.4)
( ), Mortality %
Includes tumors invading the anterior apical chest wall and posterior apical chest wall (superior sulcus tumor, so called Pancoast type)
(C) Esophageal surgery
In 2018, the data collection method for esophageal surgery had been modified from self-reports using questionnaire sheets following each institution belonging to the Japanese Association for Thoracic Surgery to an automatic package downloaded from the NCD in Japan. Consequently, the registry excluded data for non-surgical cases with esophageal diseases. Furthermore, data regarding the histological classification of malignant tumors, multiple primary cancers, and mortality rates for cases with combined resection of other organs could not be registered because they were not included in the NCD. Instead, detailed data regarding postoperative surgical and non-surgical complications were collected from the NCD. Moreover, data regarding surgeries for corrosive esophageal strictures and salvage surgeries for esophageal cancer had been exceptionally registered by participating institutions.
Throughout 2019, 7235 patients underwent surgery for esophageal diseases (1074 and 6161 for benign and malignant esophageal diseases, respectively) from 499 institutions across Japan. Among them, 296 (59.3%) and 379 (76.0%) institutions performed surgeries for benign and malignant esophageal diseases, respectively. Among 379 institutions performing surgeries for malignant esophageal diseases, 53 (14.0%) had ≥ 30 patients, while 299 (78.9%) had < 20 patients (i.e., 1–19 patients) who underwent esophageal surgeries within 2019 (Table 33). This distribution was different from that in 2018 (10.4% and 87.3%, respectively), suggesting that hospital centralization for esophagectomy might be gradually proceeding in Japan. Annual trends among registered in-patients with benign or malignant esophageal diseases have remained unchanged for the past 6 years (Fig. 3).
Table 33
Distribution of number of esophageal operations in 2019 in each institution
Esophageal surgery
Number of operations in 2019
Benign esophageal diseases
Malignant Esophageal disease
Benign+Malignant
0
203
120
85
1–4
240
139
145
5–9
42
77
82
10–19
9
83
84
20–29
1
27
44
30–39
0
18
14
40–49
2
9
13
≧ 50
2
26
32
Total
499
499
499
Fig. 3
Annual trend of in-patients with esophageal diseases
×
Concerning benign esophageal diseases (Table 34), thoracoscopic and/or laparoscopic surgeries were performed in 91.1% (72/79), 84.8% (451/532), 46.8% (22/47), and 44.6% (90/202) of patients with esophagitis (including esophageal ulcer), hiatal hernia, benign tumors, and achalasia, respectively. Conversely, 95.7% (134/140) of patients with spontaneous rupture of the esophagus underwent open surgery. Hospital mortality rates within 30 postoperative days were 0.8% (4/532), 5.7% (8/140), 16.7% (1/6), 1.3% (1/79), and 3.3% (1/30) for hiatal hernia, esophagus, esophagi-tracheal fistula, esophagitis, including esophageal ulcer, and corrosive stricture of the esophagus, respectively.
Table 34
Benign esophageal diseases
Operation (+)
T/L*3
Cases
Hospital mortality
Cases
Hospital mortality
~30 days
31–90 days
Total (including after 91 days mortality)
~30 days
31–90 days
Total (including after 91 days mortality)
1. Achalasia
202
90
2. Benign tumor
47
22
3. Diverticulum
38
6
4. Hiatal hernia
532
4 (0.8)
1 (0.2)
5 (0.9)
451
2 (0.4)
2 (0.4)
5. Spontaneous rupture of the esophagus
140
8 (5.7)
3 (2.1)
11 (7.9)
6
6. Esophago-tracheal fistula
6
1 (16.7)
1 (16.7)
1
1 (100.0)
1 (100.0)
7. Esophagitis, Esophageal ulcer
79
1 (1.3)
1 (1.3)
2 (2.5)
72
1 (1.4)
1 (1.4)
2 (2.8)
8. Corrosive stricture of the esophagus
30
1 (3.3)
1 (3.3)
2 (6.7)
18
Total
1074
15 (1.4)
6 (0.6)
21 (2.0)
666
4 (0.6)
1 (0.2)
5 (0.8)
( ), Mortality %
T/L Thoracoscopic and/or laparoscopic
The most common tumor location for malignant esophageal diseases was the thoracic esophagus (Table 35). Among 6161 cases with esophageal malignancies, esophagectomy for superficial and advanced cancers was performed in 2400 (39.0%) and 3761 (61.0%), respectively. Hospital mortality rates within 30 days after esophagectomy were 0.3% and 1.1% for patients with superficial and advanced cancer, respectively.
Table 35
Malignant esophageal disease
Operation (+)
Thoracoscopic and/or laparscopic procedure
Cases
Hospital mortality
Cases
Conversion to thoracotomy
Hospital mortality
~30 days
31–90 days
Total (including after 91 days mortality)
~30 days
31–90 days
Total (including after 91 days mortality)
Location
(1) Cervical esophagus
155
3 (1.9)
3 (1.9)
57
(2) Thoracic esophagus
5142
38 (0.7)
36 (0.7)
74 (1.4)
4145
39 (0.9)
28 (0.7)
26 (0.6)
54 (1.3)
(3) Abdominal esophagus
508
6 (1.2)
4 (0.8)
10 (2.0)
350
5 (1.4)
1 (0.3)
6 (1.7)
Total
5805
44 (0.8)
43 (0.7)
87 (1.5)
4552
39 (0.9)
33 (0.7)
27 (0.6)
60 (1.3)
Tumor depth
(A) Superficial cancer (T1)
(1) Transhiatal esophagectomy
13
0
(2) Mediastinoscopic esophagectomy and reconstruction
126
126
(3) Transthoracic (rt.) esophagectomy and reconstruction
1659
5 (0.3)
5 (0.3)
10 (0.6)
1409
6 (0.4)
4 (0.3)
5 (0.4)
9(0.6)
(4) Transthoracic (lt.) esophagectomy and reconstruction
29
14
(5) Cervical esophageal resection and reconstruction
26
0
(6) Robot-assisted esophagectomy and reconstruction
295
2 (0.7)
2 (0.7)
294
1 (0.3)
2 (0.7)
2 (0.7)
(7) Others
19
0
(8) Esophagectomy without reconstruction
233
0
Subtotal
2400
7 (0.3)
5 (0.2)
12 (0.5)
1843
7 (0.4)
6 (0.3)
5 (0.3)
11 (0.6)
(B) Advanced cancer (T2-T4)
(1) Transhiatal esophagectomy
21
1 (4.8)
2 (9.5)
3 (14.3)
0
(2) Mediastinoscopic esophagectomy and reconstructio
112
1 (0.9)
2 (1.8)
3 (2.7)
112
1 (0.9)
2 (1.8)
3 (2.7)
(3) Transthoracic (rt.) esophagectomy and reconstruction
2910
30 (1.0)
26 (0.9)
56 (1.9)
2178
27 (1.2)
22 (1.0)
15 (0.7)
37 (1.7)
(4) Transthoracic (lt.) esophagectomy and reconstruction
74
1 (1.4)
1 (1.4)
2 (2.7)
23
1 (4.3)
1 (4.3)
(5) Cervical esophageal resection and reconstruction
68
0
(6) Robot-assisted esophagectomy and reconstruction
374
2 (0.5)
4 (1.1)
6 (1.6)
374
4 (1.1)
2 (0.5)
4 (1.1)
6 (1.6)
(7) Others
59
1 (1.7)
1 (1.7)
2 (3.4)
0
(8) Esophagectomy without reconstruction
143
4 (2.8)
6 (4.2)
10 (7.0)
0
Subtotal
3761
40 (1.1)
42 (1.1)
82 (2.2)
2687
31 (1.2)
26 (1.0)
21 (0.8)
47 (1.7)
Total
6161
47 (0.8)
47 (0.8)
94 (1.5)
4530
38 (0.8)
32 (0.7)
26(0.6)
58 (1.3)
Cases
Overall morbidity
Morbidity ≥CD III
Surgical complications
Surgical site infection
Anastomotic leakage
Recurrent nerve palsy
Wound dehiscence
Superficial incision
Deep incision
Organ space
Location
(1) Cervical esophagus
155
104 (67.1)
56 (36.1)
15 (9.7)
8 (5.2)
10 (6.5)
24 (15.5)
20 (12.9)
2 (1.3)
(2) Thoracic esophagus
5142
2950 (57.4)
1148 (22.3)
391 (7.6)
205 (4.0)
459 (8.9)
707 (13.7)
774 (15.1)
85 (1.7)
(3) Abdominal esophagus
508
253 (49.8)
97(19.1)
27 (5.3)
10 (2.0)
46 (9.1)
75 (14.8)
40 (7.9)
5 (1.0)
Total
5805
3307 (57.0)
1301 (22.4)
433 (7.5)
223 (3.8)
515 (8.9)
806 (13.9)
834 (14.4)
92 (1.6)
Tumor depth
(A) Superficial cancer (T1)
(1) Transhiatal esophagectomy
13
9 (69.2)
7 (53.8)
3 (23.1)
2 (15.4)
2 (15.4)
2 (15.4)
1 (7.7)
0
(2) Mediastinoscopic esophagectomy and reconstructio
126
77 (61.1)
28 (22.2)
9 (7.1)
3 (2.4)
7 (5.6)
19 (15.1)
35 (27.8)
2 (1.6)
(3) Transthoracic (rt.) esophagectomy and reconstruction
1659
891 (53.7)
325 (19.6)
116 (7.0)
58 (3.5)
146 (8.8)
236 (14.2)
222 (13.4)
25 (1.5)
(4) Transthoracic (lt.) esophagectomy and reconstruction
29
15 (51.7)
6 (20.7)
2 (6.9)
2 (6.9)
5 (17.2)
4 (13.8)
4 (13.8)
2 (6.9)
(5) Cervical esophageal resection and reconstruction
26
19 (73.1)
10 (38.5)
1 (3.8)
2 (7.7)
1 (3.8)
2 (7.7)
6 (23.1)
1 (3.8)
(6) Robot-assisted esophagectomy and reconstruction
295
172 (58.3)
75 (25.4)
21 (7.1)
15 (5.1)
32 (10.8)
47 (15.9)
46 (15.6)
3 (1.0)
(7) Others
19
10 (52.6)
5 (26.3)
1 (5.3)
4 (21.1)
6 (31.6)
1(5.3)
0
(8) Esophagectomy without reconstruction
233
34 (14.6)
9 (3.9)
Subtotal
2400
1227 (51.1)
465 (19.4)
153 (6.4)
82 (3.4)
197 (8.2)
316 (13.2)
315 (13.1)
33 (1.4)
(B) Advanced cancer (T2-T4)
(1) Transhiatal esophagectomy
21
12 (57.1)
9 (42.9)
7 (33.3)
5 (23.8)
2 (9.5)
3 (14.3)
1 (4.8)
2 (9.5)
(2) Mediastinoscopic esophagectomy and reconstructio
112
74 (66.1)
27 (24.1)
11 (9.8)
4 (3.6)
8 (7.1)
27 (24.1)
24 (21.4)
2 (1.8)
(3) Transthoracic (rt.) esophagectomy and reconstruction
2910
1693 (58.2)
675 (23.2)
222 (7.6)
120 (4.1)
275 (9.5)
404 (13.9)
427 (14.7)
45 (1.5)
(4) Transthoracic (lt.) esophagectomy and reconstruction
74
40 (54.1)
18 (24.3)
6 (8.1)
3 (4.1)
3 (4.1)
7 (9.5)
4 (5.4)
3 (4.1)
(5) Cervical esophageal resection and reconstruction
68
43 (63.2)
21 (30.9)
9 (13.2)
3 (4.4)
3 (4.4)
8 (11.8)
8 (11.8)
1 (1.5)
(6) Robot-assisted esophagectomy and reconstruction
374
218 (58.3)
82 (21.9)
22 (5.9)
5 (1.3)
21 (5.6)
35 (9.4)
52 (13.9)
5 (1.3)
(7) Others
59
20 (33.9)
7 (11.9)
1 (1.7)
4 (6.8)
5 (8.5)
(8) Esophagectomy without reconstruction
143
84 (58.7)
42 (29.4)
Subtotal
3761
2184 (58.1)
881 (23.4)
278 (7.4)
140 (3.7)
316 (8.4)
489 (13.0)
516 (13.7)
58 (1.5)
Total
6161
3411 (55.4)
1346 (21.8)
431 (7.0)
222 (3.6)
513 (8.3)
805 (13.1)
831 (13.5)
91 (1.5)
Cases
Nonsurgical complications
Pneumonia
Unplanned intubation
Prolonged ventilation>48h
Pulmonary embolism
Atelectasis
Renal failure
CNS events
Cardiac events
Septic shock
Readmission within 30d
Reoperation within 30d
Location
(1) Cervical esophagus
155
22 (14.2)
10 (6.5)
17 (11.0)
1 (0.6)
6 (3.9)
2 (1.3)
1 (0.6)
1 (0.6)
2 (1.3)
1 (0.6)
23 (14.8)
(2) Thoracic esophagus
5142
815 (15.8)
246 (4.8)
333 (6.5)
42 (0.8)
272 (5.3)
20 (0.4)
29 (0.6)
18 (0.4)
33 (0.6)
125 (2.4)
334 (6.5)
(3) Abdominal esophagus
508
63 (12.4)
19 (3.7)
23 (4.5)
11 (2.2)
25 (4.9)
6 (1.2)
1 (0.2)
3 (0.6)
8 (1.6)
11 (2.2)
32 (6.3)
Total
5805
900 (15.5)
275 (4.7)
373 (6.4)
54 (0.9)
303 (5.2)
28 (0.5)
31 (0.5)
22 (0.4)
43 (0.7)
137 (2.4)
389 (6.7)
Tumor depth
(A) Superficial cancer (T1)
(1) Transhiatal esophagectomy
13
2 (15.4)
3 (23.1)
3 (23.1)
1 (7.7)
2 (15.4)
(2) Mediastinoscopic esophagectomy and reconstructio
126
19 (15.1)
5 (4.0)
7 (5.6)
7 (5.6)
4 (3.2)
(3) Transthoracic (rt.) esophagectomy and reconstruction
1659
214 (12.9)
61 (3.7)
84 (5.1)
16 (1.0)
89 (5.4)
7 (0.4)
6 (0.4)
7 (0.4)
7 (0.4)
44 (2.7)
97 (5.8)
(4) Transthoracic (lt.) esophagectomy and reconstruction
29
3 (10.3)
2 (6.9)
2 (6.9)
3 (10.3)
1 (3.4)
1 (3.4)
3 (10.3)
(5) Cervical esophageal resection and reconstruction
26
4 (15.4)
2 (7.7)
3 (11.5)
1 (3.8)
1 (3.8)
1 (3.8)
5 (19.2)
(6) Robot-assisted esophagectomy and reconstruction
295
41 (13.9)
16 (5.4)
17 (5.8)
5 (1.7)
10 (3.4)
1 (0.3)
2 (0.7)
2 (0.7)
4 (1.4)
16 (5.4)
(7) Others
19
1 (5.3)
2 (10.5)
2 (10.5)
1 (5.3)
3 (15.8)
(8) Esophagectomy without reconstruction
233
3 (1.3)
Subtotal
2400
284 (11.8)
89 (3.7)
118 (4.9)
21 (0.9)
113 (4.7)
9 (0.4)
9 (0.4)
7 (0.3)
11 (0.5)
52 (2.2)
130 (5.4)
(B) Advanced cancer(T2-T4)
(1) Transhiatal esophagectomy
21
7 (33.3)
3 (14.3)
4 (19.0)
1 (4.8)
1 (4.8)
1 (4.8)
2 (9.5)
(2) Mediastinoscopic esophagectomy and reconstructio
112
21 (18.8)
8 (7.1)
7 (6.3)
5 (4.5)
2 (1.8)
1 (0.9)
1 (0.9)
7 (6.3)
(3) Transthoracic (rt.) esophagectomy and reconstruction
2910
487 (16.7)
146 (5.0)
210 (7.2)
25 (0.9)
155 (5.3)
17 (0.6)
15 (0.5)
11 (0.4)
22 (0.8)
71 (2.4)
200 (6.9)
(4) Transthoracic (lt.) esophagectomy and reconstruction
74
11 (14.9)
3 (4.1)
6 (8.1)
6 (8.1)
1 (1.4)
2 (2.7)
8 (10.8)
(5) Cervical esophageal resection and reconstruction
68
9 (13.2)
2 (2.9)
6 (8.8)
2 (2.9)
1 (1.5)
1 (1.5)
1 (1.5)
1 (1.5)
10 (14.7)
(6) Robot-assisted esophagectomy and reconstruction
374
72 (19.3)
18 (4.8)
18 (4.8)
8 (2.1)
19 (5.1)
2 (0.5)
2 (0.5)
2 (0.5)
6 (1.6)
11 (2.9)
27 (7.2)
(7) Others
59
2 (3.4)
3 (5.1)
2 (3.4)
1 (1.7)
1 (1.7)
1 (1.7)
4 (6.8)
(8) Esophagectomy without reconstruction
143
6 (4.2)
Subtotal
3761
609 (16.2)
183 (4.9)
253 (6.7)
33 (0.9)
189 (5.0)
19 (0.5)
22 (0.6)
15 (0.4)
30 (0.8)
94 (2.5)
258 (6.9)
Total
6161
893 (14.5)
272 (4.4)
371 (6.0)
54 (0.9)
302 (4.9)
28 (0.5)
31 (0.5)
22 (0.4)
41 (0.7)
146 (2.4)
388 (6.3)
Among esophagectomy procedures, transthoracic esophagectomy via right thoracotomy or right thoracoscopy was most commonly adopted for patients with superficial (1659/2400, 69.1%) and advanced cancer (2910/3761, 77.4%) (Table 35). Transhiatal esophagectomy, which is commonly performed in Western countries, was adopted in only 13 (0.5%) and 21 (0.6%) patients with superficial and advanced cancer who underwent esophagectomy in Japan, respectively. Thoracoscopic and/or laparoscopic esophagectomy was utilized in 1843 (76.8%) and 2687 (71.4%) patients with superficial and advanced cancer, respectively. Patients who underwent thoracoscopic and/or laparoscopic surgery (minimally invasive esophagectomy: MIE) for superficial or advanced cancer have been increasing, whereas that of open surgery, especially for advanced cancer, has been decreasing annually (Fig. 4). Mediastinoscopic esophagectomy was performed for 126 (5.3%) and 112 (3.0%) patients with superficial and advanced esophageal cancer, respectively. Robot-assisted esophagectomy was performed for 295 (12.3%) and 374 (9.9%) patients with superficial and advanced esophageal cancer, respectively. Patients who underwent robot-assisted surgery are increasing for both superficial and advancer esophageal cancers compared to that in 2018 (6.8% and 4.2% in 2018, respectively). Hospital mortality rates within 30 days after thoracoscopic and/or laparoscopic esophagectomy were 0.3% and 1.0% for patients with superficial and advanced cancer, respectively (Table 35).
Fig. 4
Annual trend of esophagectomy
×
Detailed data collection regarding postoperative surgical and non-surgical complications was initiated in 2018. Overall, 1346 (21.8%) of 6161 patients developed grade III or higher complications based on the Clavien–Dindo classification in 2019. Among surgical complications, anastomotic leakage and recurrent nerve palsy occurred in 14.0% and 14.3% of the patients who underwent right transthoracic esophagectomy, in 12.3% and 14.6% of those who underwent robot-assisted esophagectomy, and in 19.7% and 24.8% of those who underwent mediastinoscopic esophagectomy, respectively. Among non-surgical postoperative complications, pneumonia occurred in 14.5% of the patients, 4.4% of whom underwent unplanned intubation. The possible advantage in postoperative pneumonia in patients with mediastinoscopic esophagectomy in 2018 was not observed this year. Postoperative pulmonary embolism occurred in 0.9% of the patients. These complication rates, including the others, were similar to those in 2018.
Salvage surgery following definitive (chemo)radiotherapy was performed in 500 patients, with hospital mortality rates of 0.8% within 30 days postoperatively. Thoracoscopic and/or laparoscopic esophagectomy were performed in 329 (65.8%) patients (47.7% in 2018) (Table 36).
Table 36
Salvage surgery
Operation (+)
Thoracoscopic and/or laparscopic procedure
EMR or ESD
Cases
Hospital mortality
Cases
Conversion to thoracotomy
Hospital mortality
~30 days
31–90 days
Total (including after 91 days mortality)
~30 days
31–90 days
Total (including after 91 days mortality)
Salvage surgery
500
4 (0.8)
6 (1.2)
10 (2.0)
329
14 (4.3)
2 (0.6)
4 (1.2)
6 (1.8)
148
We aim to continue our efforts in collecting comprehensive survey data through more active collaboration with the Japan Esophageal Society and other related institutions.
Acknowledgements
On behalf of the Japanese Association for Thoracic Surgery, the authors thank the Heads of the Affiliate and Satellite Institutes of Thoracic Surgery for their cooperation and the Councilors of the Japan Esophageal Society. We also appreciate Mr. Hiroaki Miyata for his contribution as one of the founders of the JCVSD.
Declarations
Conflict of interest
Hiroyuki Yamamoto and Hiraku Kumamaru 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 K.K., Nipro Corporation and Intuitive Surgical Sàrl.
Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.
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