For recent thirty years I have carried out 1, 174 resections of the esophageal cancer in the upper and middle thoracic segments. By early diagnosis and combined therapy of the pre-operative irradiation and the ante-thoracic subcutaneous esophagoplasty, divided into three stages if necessary, the operative mortality was decreased (6.0%), whereas the survival rate was increased.
For the protection of the leakage at the anastomotic site in the ante-thoracic esophagogastrostomy, some modified techniques have been devised. The greater omentum was covered to the anastomotic site and the circular cuttings of the sero-muscular layers of the stomach were performed to elongate the gastric tube.
The anastomosis was carried out in layer-to-layer suturing.
The five year survival rate was 12.3%. In 149 patients to whom the pre-operative irradiation was administered, the five year survival rate rose to 15.8%, whereas in the remaining 390 patients five year survival rate was 10.8%. At the end of the last year, 110 of my cases had survived over five years, 40 of these had lived for more than ten years, 13 for more than fifteen years and 4 for more than twenty years.
The statistical analysis of the long-term living patients revealed the following results. When the defect on the X-ray film was less than 6cm, the long-term prognosis was more favorable.
The shape of the defet on the X-ray film also affected the prognosis. The prognosis was best in cases with a saw-like shape, but it was worst in those with funnel shape. Whether the operation was radical or conservative was of greatest importance for the prognosis. When the radical resections were performed in grade III, the five year survival rate was 26.7%. Otherwise when the radical operation was performed in grade I, the five year survival rate was 2.7%.

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Forms of stenosis of the cervical trachea, subglottic region and the larynx are analyzed. In the early stages ulceration and granulation occur as the tissue respond to injury. Any superimposed infection can destroy the cartilageneous framework whereas the luminal diameter will skrink. The cricoid cartilage however, shows a long time progressive thickening through involvement of its inner perichondrium.
A technique for surgical repair is described, in which a vertical midline “gutter” is created by incising the trachea, the cricoid cartilage and the larynx. In subglottic stenosis the anterior third of the cricoid is resected. Additional to this external triangles of cartilage are removed but leaving the inner perichondrium intact, to allow release of tension to the skin margins which are approximated to the tracheal rings. In a second stage, six to nine weeks postoperatively or later (after stabilization of the tracheal wall by scar formation to surrounding tissues), closure of the gutter is accomplished by the use of the composite cartilage-skin graft from the auricle. The form of this graft permits further enlargement of the tracheal lumen.
21 patients since 1971 have been treated successfully with the ear composite graft for correcting tracheal and subglottic stenosis. In addition, histologic studies of the graft in pigs confirmed its effectiveness in tracheal reconstruction.

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For the purpose of elucidating relationship between the upper and lower respiratory tracts, the present work was performed from immunogical point of view.
1) The immunological function of the tonsil was investigated on separated tonsillar cells by using in-vitro culture system. As a result, it was revealed that the tonsil was composed of three cellular components (T cell, B cell and macrophage) necessary for the immune response and cellular co-operation among them was required for the effective immune response to a hapten-carrier antigen.
2) To elucidate experimentally some characteristics of the immune response against inhaled antigens, guinea pigs were exposed to an aerosolized hapten-protein antigen. Specific anti-hapten antibody forming cells were determined by PFC (plaque-forming cell) assay.
When the antigen was given via respiratory tract by inhalation, the antibody production was much more predominant in the paratracheal and peribronchial lymphnodes than in the spleen -a distant lymphoid organ. On the contrary, when the antigen was given by subcutaneous injection, a reverse result was obtained.
This suggests a possibility that the immune response to air-borne antigens may be carried-out selectively and locally in the lymphoid tissues in the vicinity of the respiratory tract.
3) Our clinical studies on 700 patients with pollinosis revealed that 67.7 percent of the patients had nasal symptoms without any bronchial symptom, while only 11.6 percent had bronchial symptom without any nasal symptom.
This result suggests that alllergic reactions in the respiratory tract initially takes place in the nose, i. e, the upper respiratory tract in general, which may protect the lower repiratory tract from external antigen.

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The correlation between the upper and lower airways was investigated from biochemical aspects. The materials used in this study were the nasal septal mucosa of the rabbit as a representative structure of the upper airway (UA) and the tracheal epithelium for the lower airway (LA). The biochemical change and defence mechanism against ozone (O₃) exposure in the two different structures were compared. The results obtained were as follows:
1. The TBA value as an indication of lipid peroxidation decreased in LA, while it stayed unchanged in UA after O₃ exposure of 5-10ppm.
2. Na-K, ATPase and glucose-6-phosphatase activities in microsomal fraction decreased after O₃ exposure both in UA and LA. These findings indicated the damage in the cell membrane caused by lipid peroxidation.
3. The activities of glutathione peroxidase and glucose-6-phosphatase, both of which metabolize lipid peroxide, remained unchanged in LA, while reduced in UA. Superoxide dismutase activity increased in both UA and. LA. These findings would suggest that lipid peroxides were removed enzymatically in LA.
In conclusion, the biochemical defence mechanism against lipid peroxidation was considered to be more prominent in LA.

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In order to elucidate the relationship of respiratory neurons in the lateral part of the bulbar reticular formation to reflexogenic afferent inputs, responses of respiratory neurons to afferent stimulation of the vagus and internal branches of the superior laryngeal nerves were investigated under controlling evoked potentials of both nerves. Besides the respiratory neurons (type 1, 101 neurons in cats, 130 in rabbits), the unitary discharge pattern of which was changed by afferent stimulation, the other neurons (type 2=input respiratory neuron, 55 neurons in cats, 32 in rabbits) responded to afferent nerve stimulation with single orthodromic spike with latency ranging from 1.9 to 19 msec in cats, and 1.4 to 7.0 msec in rabbits. Three subtypes of input respiratory neurons could be differentiated with respect to their relation to the afferent pathways: neuron driven by vagal stimulation: one activated by stimulation given to another nerve; and cell which receives synaptic inputs mediated mainly by the Aα-γ fiber groups of both nerves. A striking difference in the proportion of the 3 subtypes between the two species was noted. The input respiratory neurons responded also to the adequate stimulus respectively, e. g., to lung inflation and/or to mechanical stimulation to the laryngeal mucosa. The specific neuronal organization found in the input respiratory neuron population may play an important role in the central integrative process in the brain stem for the reflexogenic afferent inputs of various modalities originating in the upper and lower airways.

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The surface ultrastructure of the respiratory normal mucosal cells and cancer cells in the larynges extirpated from the patients who have been treated with or without radiotherapy were studied by SEM cinematography.
A similar distribution pattern of epithelial cells composed of ciliated or non-ciliated cells was observed in either entrance portion of the nasal cavity or subglottic areas.
By radioactive particle (resin beads labeled with 99Tc) technique, mucociliary transport rate (MTR) on nasal septal mucoua was measured in normal subjects, laryngectomees and patients with chronic sinusitis or Sjögren's syndrome.
An average of MTR was 6.8 and 6.7mm/min in normal subjects and laryngectomees, respectively. However, smalles rate was noted in patients with chronic sinusitis and Sjögren's syndrome.
The immunoglobulin pattern was studied in nasal and maxillary sinus secretions with chronic sinusitis. It was shown that a larger amount of IgA, IgG and IgM existed in both nasal and maxillary sinus secretion as compared with normal nasal secretion, and IgA and scretory component levels were significantly higher in sinus secretions than in nasal ones.
Immunohistological study revealed that a large number of IgA forming cells were mainly localized around mucous glands and IgG forming cells in subepithelial layer.
It was interesting that the level of both immunoglobulins in the inferior nasal turbinate and false vocal cord increased significantly.
Using laryngofiberscopy, pneumatography and photoeletric glottography, closure reflex activity of the larynx evoked by transnasal application of various concentrations of isovaleric acid and ammonia solutions during the inspiration were determined in normal subjects and patients with chronic sinusitis, anosmia, nasal allergy and COPD.
This reflex activity had a remarkable tendency to decrease among normal older subjects and most of patients with upper and lower respiratory diseases except for nasal allergy.
It was assumed that closure reflex activity of the larynx might be of great importance to protect the inhalation of hazardous materials into lung, therefore a depression or absence of reflex sensitivity in the upper respiratory tract might head to a higher incidence of various pulmonary diseases.

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These studies were performed especially from the viewpoints of chest physician.
I. Clinical study: The rhinoscopic examination was done by otolaryngologists in 58 patients with respiratory diseases diagnosed by various methods including selective alveolo-bronchography. Sixty-seven percent of these patients had nasal and/or paranasal diseases. Among them, in the patients with bronchial asthma, 58% had sinusitis and 67% had allergic rhinitis, but in the patients with chronic bronchitis and chronic pulmonary emphysema, sinusitis ocurred more frequently than rhinitis.
II. Experimental study: A. Respiratory defense mechanism and choanal flow. 1) Three hundred μl of tantalum-suspended human sputum and paranasal fluid were injected via a catheter into an anesthetized canine trachea and ciliary transport rate were roentogenographically measured. In normal dogs, the transport rate of paranasal fluid was 9.7±3.0mm/min as compared to 13.3±2.6mm/min in sputum.
These values were extremely higher than those of other mucus or solutions. In a previous experiment, it was determined that the effect of gravity on ciliary transport was negligible when cilia were covered with appropriate mucus. So, it was proved that choanal fluid can be easily expelled out when it flows down into the normal lower respiratory tract. 2) The experimental study on infection promoting effect revealed that this effect of paranasal fluid was less than that of sputum from the lower respiratory tract.
B. Cyclic nucleotides in the respiratory tracts of guinea pigs. Cyclic AMP and cyclic GMP in the respiratory tracts were measured by radioimmunoassay method. The levels of cyclic AMP and cyclic GMP were highest in lungs, and decreased in bronchi, trachea and nose in order. The lower value of cyclic AMP in nasal mucosa compared to the lower respiratory tract was supposed to be one of the factors predisposing the nasal mucosa to hypersensitivity.
These results suggest that more attention should be paid to common genetic factors causing various disorders in both the upper and lower respiratory tracts.

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