Medical malpractices may give rise to both civil and criminal liabilities of doctors. While the civil liability is aimed at recovering damages for the victim, the criminal liability is the basis for punishing the doctor for his illegal conduct. The type of admissible evidence and the degree of proof regarding causal relationship and negligence may differ between civil and criminal proceedings.
With respect to criminal liability, there are two important legal questions. The one involves the question of whether measures of treatment are justified as a proper professional conduct under the current medical practices (Penal Code Art. 35). The other relates to the question of whether the death or injury of a patient has resulted from negligence on the part of a doctor who failed to exercise professionally required care in diagnosis, selection of treatment measures or application of such measures (Penal Code Art. 211).

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When the author started his study of surgery for esophageal cancer in 1934, the operative mortality rate was 95.7% throughout the world, which indicated that the disease was certainly fatal. The rate has gradually decreased to 5-10% due to continuous efforts of the author and his colleagues. The historical process was presented and discussed.

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Dynamics of swallowing in the pharyngo-esophageal junction was investigated in normal and pathological conditions. In this study, the electromyography of selected muscles and X-ray video images were simultaneously recorded.
In normal swallowing, the pharyngeal cavity at the level of the sixth cervical vertebra is opened after the cricopharyngeal muscle begins to relax, and it is closed nearly at the same time of the cricopharyngeal relaxation. The end of the bolus passes the entrance of the esophagus during the cricopharyngeal relaxation.
Following the transport of the bolus from the pharynx into the cervical esophagus, the cervical esophagus muscles contract inconsistently with respect to timing as well as the movement of the food channel.
In some pathological conditions such as amyotrophic lateral sclerosis, difficulty in swallowing is caused by weakness of the muscles participating in the pharyngeal stage. Incoordination of the passage of the bolus and the muscular kinesiology in the pharyngeal stage accelerated the problems. This can be attributed to the different location of the efferent neurons innervating the cricopharyngeal muscle and the cervical esophagus muscles in the brain stem.

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The detectinn of intraluminal pressure provided satisfactory recordings of a sequence of motor events in the esophagus and its sphincters. We designed a new pressure transducer with the tip cf diaphragmatic sensors. The manometric sequences mentioned below were obtained by this device.
A catheter with fcur openings of diaphragmatic transducers 1. 5cm apart was swallowed through the nose into the lower esophagus, and the swallowing pressures were recorded at the level of the nasopharynx, oropharynx, hypopharynx and cervical esophagus.
Dynamic propelling force of bolus in the hypopharynx and the upper esophagus was also measured by the use of a small plastic ball 9mm in diameter, which was connected to the strain gauge with the length of 45cm nylon string.
The results were as follows:
1) Resting positive pressure zone was present at the region of cricopharyngeal muscle 3cm in width. The pressure was 2 to 3mmHg.
2) A physiological low pressure zone was found around the vallecula on swallowing. This reflected that the remaining of barium at the vallecula is frequently observed in patients with mild dysphagia on X-ray esophagography.
3) Dynamic propelling force of bolus into the cervical esophagus was observed at the range of 18 to 27cm in male and 17 to 23cm in female. The difference of the power range between male and female might depend upon the height of subjects. The length of cervical esophagus is usually in proportion to the height. The maximum of the dynamic force was 21g in male and 23g in female, suggesting that no distinction of sex exists.

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Esophageal motility was observed using intraluminal electromyography in human subjects. Esophageal peristalsis was examined. Following water swallowing, two kinds of propagative spike-burst appeared. The first spike-burst of striated muscular origin appeared in the upper esophagus immediately after the swallowing and propagated to the mid-esophagus. Before the first spike-burst propagates to the mid-esophagus, the second spike-burst of smooth muscular origin appeared in the mid-esophagus and propagated to the lower esophagus. Esophageal peristalsis was not continuous in the mid-esophagus.
Electromyographic and intraluminal pressure correlation was investigated. A plateau-like pressure elevation was observed together with the spike-burst of smooth muscular origin. A hill-like pressure elevation was seen with the spike-burst of striated muscular origin in the upper and mid-esophagus. However, it was noted in the lower esophagus after the disappearance of the spike-burst of the smooth muscular origin.
In a patient with glossopharyngeal and vagus paresis by jugular foramen syndrome, the second phase of swallowing was not provoked smoothly. When the second phase was provoked, however, the propagative spike-burst appeared in the normal pattern. In a patient with Wallenberg's syndrome, the second phase was not provoked and the propagative spike-burst did not appear. These findings suggested that the difference of difficulty in swallowing between central and peripheral nervous origins may exist.

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Physiological dynamic state of the esophagus, especially at the esophago-cardiac junction, is studied by examining intraluminal pressure and electromyography.
As a result, the late positive phase of intraluminal peristaltic wave may be attributed to the mass action potential at the late half of the negative phase of the wave appeared at the esophago-cardiac junction.
Because of the precedence of the negative wave, the late positive wave was overlapped and partially cancelled. Therefore, the mass action potential seemed to occur with a time lag. The negative wave at the esophago-cardiac junction usually disappeared in patients with achalasia of the esophagus by tracing the esophageal intraluminal pressure. The appearance of the positive wave and mass electromyogram was variable in each part of the esophagus according to its severity of pathological change.
It is concluded that the mechanism of the disturbance of food passage in patients with achalasia of the esophagus is highly related to the negative wave seen at the esophago-cardiac junction.

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Functional tests in addition to morphological tests including serial X-ray examination, X-ray cinematography and endoscopic cinematography have come into wide use in examining the cardiac function.
The pH determination in the internal pressure change of the esophagus is one of them.
With the development of a micreglass electrode, it has become possible to make simultaneous measurement of pH and internal pressure in the esophagus. Furthermore, the pH determination combined with an esophageal endoscope has enabled one to make macroscopic observations on the esophageal mucosa and conduct a functional test simultaneously.
Appling clinically these methods, we have studied gastroescphageal reflux on the basis of pH values and changes in the swallowing pressure of the esophagus, and the resting pressure of the esophagus, particularly at the gastroesophageal junction.
In the present study we have made observations on changes of the pH curve and the internal pressure of the esophagus in cases of abnormalities of the cardiac function such as hiatal hernia and cases of postoperative reflux escphagitis in cardioplasty. We have also reported a method for measuring the internal pressure with a recently developed transducer or the so-called microtip transducer using a semiconductor.

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The esophagoscopic examination has been mainly utilized for the detection of the morphologic findings of the esophagus, especially the diagnosis of the tiny lesions of the esophagus. Moreover the esophagoscopy reveals some characteristic findings in the functional diseases of the esophagocardiac region. In achalasia, the endoscopy discloses the spasm of the distal part of the esophagus. And the tube-like appearance of the gastric mucosa surrounding the axis of the instrument-so-called “wrapping” phenomenon-is observed by the angle manipulation till 210° in the stomach. Such an endoscopic finding is specific for achalasia, because this is improved after the radical operation for achalasia. The esophagitis and the cancer have been sometimes observed in achalasia, so the endoscopic examination is considered to be more effective for the diagnosis of these two lesions accompanying with achalasia. The esophagoscopy reveals the hypotonic state of cardia, the prolapse of the gastric mucosa into the esophagus and pinch-cock action (Jackson) in the low grade of hiatus hernia. The esophagitis is accompanied in 93% of the middle and high grades of hiatus hernia. But the esophagitis is seen in 12% of low grade of hiatus hernia. In the diagnosis of low grade of hiatus hernia without esophagitis, the manometric examination and the pH measurement are required additionally to the endoscopic examination. Barrett syndrome is diagnosed clinically only with the esophagoscopic examination. Barrett syndrome is defined as the esophagus lined with columnar epithelium. But it is important that the esophagus is proved to be proper esophagus by the X-ray examination and the manometric study. In some cases, slight degree of hiatus hernia is observed. The ulcer and the adenocarcinoma have been observed in a few cases of Barrett syndrome. The endoscopy is advisable for the connection between the morphologic and functional findings in the functional diseases of the esophagus.

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We devised an operation designed to produce a one stage cure for cases that showed stenosis of the larynx and trachea.
1. The scar tissue of the stenosis area is resected.
2. To reconstruct the inner lining of the lumen, the island pedicle neck flap is inserted.
3. To insure the stable structural framework, the cartilage of the rib is usually used.
4. The stent is inserted into the lumen by using a finger cot, filled with silicon sponge to maintain an adequate airway for about four weeks.
5. The external covering is done by direct closure.
6. The tracheostoma should remain open for four to six months.
When this operation is done with special attention given to treatment of the flaps and making the lumen a little wider, it is possible to complete the reconstruction in a short period.
In eight cases, all obtained satisfactory results for airway by this method.
Recently, “end to end anastomosis”technique is getting to be noteworthy because of a one stage cure. However, if the stenosis exists at glottic level, cur method is better than “end to end anastomosis” from a standpoint of vocal function.

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We performed tracheoplasty for a total of 9 cases including 6 neoplasms, 2 post-traumatic stenosis and 1 post-tracheostomy stenosis and reported the operative approach, the method for end to end anastomosis and clinical results.
In the canine experiment on air tightness of tracheal end to end anastomosis, each suture should be placed at more than 70 percent of tracheal cartilageneous width and 3∼4mm interval was appropriate.
Tracheal stenosis could be diagnosed by typical pattern of flow volume curve demonstrating cut off of peak flow and plateau formation, and the disturbance of flow volume curve can be reversible within one month postoperatively. However, symptoms of peripheral airway stenosis were observed in the patients with long-term dyspnea at the preoperative period.
We, also, discussed the method for respiratory management under anesthesia in a patient with high tracheal stenosis of 5mm in diameter due to tracheostomy.

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The tracheal mobilization technique has enabled to increase the resectable length of the trachea. This paper reported on the results of measurement of the extensibility of the canine trachea and the effect of the mobilization technique on the tension at the site of tracheal anastomosis. The maximum extensibility of the canine trachea was found to be only 36% of the original length. Conventional techniques of tracheal elongation (Som and Narodick) were not effective enough to reduce the tension developing at the anastomotic site. On the other hand, the tracheal mobilization technique has proved to be effective for increasing the extent of tracheal resection. The clinical value of the tracheal mobilization technique was discussed based on the author's experience on 94 cases of tracheobronchial plasty.

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Laryngeal release is of great importance in order to appose the cut ends without significant tension. There are two kinds of release technique for larynx, i. e., suprahyoid and infrahyoid techniques.
As a result of comparison between them, in 6 patients, suprahyoid release technique was much more simpler and took shorter time to perform than the other because neither the important vessels nor nerves exist in the suprahyoid region, and any trouble with deglutition was not recognized, On the basis of operative procedures, some clinico-anatomical points were discussed on the end-to-end anastomosis of the cervical trachea.

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We successfully reconstructed the airway after wide resection of the cervical trachea using a new technique as follows. The cricoid cartilage and a few tracheal rings were removed partially. The next several rings were excised wholly and a few rings below them partially. Partially remained trachea was sutured by the technique of an end-to-end anastomosis with a half defect due to the insufficient tracheal wall. A small local skin flap was inserted into the defect and tracheostoma was built in this area. Later, the tracheostoma was closed with two sequential skin flaps.

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In the last few years various techniques have been developed with the aim of reconstructive procedure after total laryngectomy. Among these techniques, subtotal or total laryngectomy with tracheohyoidopexia was discussed. This paper reported especially on the suprahyoidal laryngeal release and the tracheal mobilization to reduce the tension developing at the anastomotic site.

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Major airway obstruction from various causes should be assessed properly based on the altered respiratory mechanics. In diagnosing such problems, previous measures such as physical findings, X-ray and other endoscopic examinations, of course, are valuable, but the flow volume curve used in combination with other pulmonary function tests has been found to be very useful in identifying and often localizing the obstructive lesions in the larynx and trachea, as pointed out by many others.
The increasing incidence of such problems involving long term endotracheal intubation, tracheostomy, and trauma, such as car accidents, suggests the increasing value of certain pulmonary function tests in diagnosis and decisions regarding reconstructive surgery, as well as in evaluating results of surgery and assessing prognosis.
Furthermore, these tests are relatively noninvasive and uncomplicated to carry out. Therefore, recognition of their usefulness should be increased.
Also, through our own experience of a case of preoperatively unrecognized lesion, the value of these measures was fully demonstrated.

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