We reported on our operation techniques for esophageal achalasia and hiatal hernia. At the same time, we outlined the practice of intraesophageal pressure, pH determination and endoscopic ultrasonography (EUS), and further, the relation between the results of these determinations and postoperative follow-up in this diseases. The results of EUS for esophageal achalasia showed a thick hypoechoic fourth layer. We classified the degree of muscular hypertrophy in achalasia into three levels.
Hiatal hernia was represented as a hypoechoic mass in the third and fourth layers of the esophageal wall, and it was classified into three types.
Therefore, we concluded that EUS is a useful examination method in patients with esophageal achalasia and hiatal hernia.

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A right sleeve pneumonectomy was performed on a 65-year-old patient who had a squamous cell carcinoma invading the trachea and right intermediate bronchus. A posterolateral incision was made under general anesthesia. The right main pulmonary artery, superior and inferior pulmonary veins were cut. The mediastinal lymph nodes were dissected and a right pneumonectomy was performed, with a cutting the carinal portion. An end-to-end anastomosis between the trachea and the left main bronchus was performed with a 4-0 absorbable suture. Two kinds of experimental tracheal reconstruction were performed using allografts from the trachea and carina. For the tracheal transplant, a graft with 6 rings was removed from a donor dog. This was interposed into the defective region of a recipient dog in which 14 rings of the trachea had been removed. Omentum was wrapped around the graft. For the carinal transplant, carina with 2 rings of the trachea, 1 ring of the right main bronchus and 2 rings of the left main bronchus were removed from a donor dog for a graft. This was also interposed into the defective region of a recipient dog in which a long Y-shaped carina with 9 rings of the trachea, 4 rings of the left main bronchus and 2 rings of the right main bronchus had been removed.
In these experiments, good healing of the grafts were observed under the bronchofiberscope, and these dogs have shown long-term survival.

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The patient was 51-year-old male with squamous cell carcinoma located around the orifice of the right upper-lobe bronchus invading the trachea and the bronchus intermedius. Pneumonectomy and concomitant resection of the carina were performed, followed by end-to-end anastomosis of the trachea and the left main bronchus.
Anastomosis was completed with interrupted sutures using 3-0 nylon. Ventilation was maintained through a flexible endotracheal tube inserted into the left main bronchus via the operating field. The site of the anastomosis was covered with an anterior mediastinal fat pad pedunculated with the internal thoracic artery and vein. The post-operative course was uneventful, and no abnormal granulation or stenosis was found endoscopically.

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Recently, the number of tracheal resection has increased. We have performed 3 tracheal resections for primary tracheal cancer: 1 for mucoepidermoid carcinoma, and 2 for adenoid cystic carcinoma. A 72-year-old male with adenoid cystic carcinoma had a resection of a cervical tracheal segment and reconstruction with a heavy Marlex-mesh roll. Two years and six months later, the patient died of pulmonary metastasis.
A 42-year-old male with mucoepidermoid carcinoma had a lower tracheal segmental resection; 12 years after the operation the patient is alive and well.
A 65-year-old female complained of dry cough for 3 months; a history of dyspnea was also elicited. Tomograph and CT showed a tumor in her middle thoracic trachea. A diagnosis of adenoid cystic carcinoma was made by bronchoscopic biopsy.
Median sternotomy was carried out and 2.5cm of the trachea was resected under high frequent jet ventilation with end-to-end anastomosis by monofilament suture material (4-0 PDS, 17 interrupted sutures). The patient is alive and well 5 years after the operation.

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Loss of voice often results from removal of the laryngo-trachea and pharyngo-esophagus in patients with cervical esophageal or hypopharyngeal cancer. A new voice reconstruction method (the double T. E. G. shunt) for laryngectomized, pharyngo-esophagectomized patients was devised by the author.
A gastric tube with a lower esophago-cardiac loop (6-7cm long) is mobilized up to the neck with good blood supply from the right gastric and gastro-epiploic artery. A stenosis (2.5cm long) is formed in the esophagus near the cardia. A double tracheo-esophago-gastric shunt is created by anastomosis between the trachea and the distal end of the esophagus.
This new method makes high-quality and high-efficiency phonation possible. Physiological studies on these voices have revealed a normal intensity in spite of a low air-flow rate. Sound spectrography has characteristically indicated intermittent sounds with a little noise. The patients could speak well. Recovery of phonation using the esophago-cardiac loop thus seems to be a promising prospect for laryngectomized patients with cervical esophageal or hypopharyngeal cancer using the double T. E. G. shunt method.

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The procedure of esophagectomy without thoracotomy is now widely used in the surgical treatment of various esophageal disorders. This procedure is usually carried out together with truncal vagotomy, particularly when the blunt finger dissection technique is used, and is often followed by the postvagotomy syndrome. Despite the fact that correct management of the vagus nerve is a key aspect of esophagectomy without thoracotomy, a precise description of vagal management and particularly of the feasibility of vagal preservation has not yet been reported. Techniques for esophageal reconstruction while preserving the vagus nerve so as to avoid the post-vagotomy syndrome are described. With these techniques 4 cases showed an improved quality of life.

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In patients with cervical esophageal cancer, when the tumor is located in the neck, reconstructive surgery can be performed in the neck using a jejunal free graft. But in cases where the tumor extends down to the thoracic esophagus, total pharyngolaryngoesophagectomy is often made and reconstruction is most commonly performed with the stomach. However, sometimes the stomach is too short to be anastomosed to the pharynx. In this condition, we use a reconstructive method using a stomach and jejunum composite. The stomach pedicled only on the right gastroepiploic vessels can be easily stretched to the pharynx using a division just distal to the pyloric ring. Thus, for the purpose of the gastrojejunostomy, the pyloric part is partially resected. The duodenal stump is closed and end-to-side gastrojejunostomy is performed with a Roux-en-Y loop which is placed about 40cm distal to the gastrojejunostomy.
Postoperative examination has revealed good passage and no reflux of bile.

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We presented our surgical procedure for treating inferopharyngocervical esophageal carcinoma: after total esophagectomy without thoracotomy, pharyngogastrostomy was performed with insertion of a stapler. This operation has been performed by our otolaryngological and surgical teams: the former performed the neck dissection, total laryngectomy and separation of the inferior pharynx and the cervical esophagus. The latter used GIA autosuture to prepare a gastric tube and remove the esophagus upward. The gastric tube was elevated along the posteromediastinal route, and a Premiam curved EEA (PCEEA) 31mm in diameter was orally inserted for the pharyngogastrostomy. Adjuvant suturing was completed via several interrupted sutures made in the parapharyngeal tissue, gastric tube and serous membrane.

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