In function-preserving operations of the esophagus and lung, it is crucial to have a precise knowledge of the mediastinal and deep cervical lymphatics and their relationships to surrounding structures. The lymphatics of the mediastinum and neck, which are associated with the esophagus and run along the trachea, were dissected in detail in several anatomical specimens. The actual photographs taken during the dissection are included for a more complete understanding of the intricate topographical relationships. Although there are numerous transverse connections, the mediastinal lymphatics can be roughly divided into two major ascending pathways: the right and the left. Each pathway can then be subdivided into a superficial pathway along the major blood vessels and a deep pathway along the trachea and esophagus. Various deep right ascending pathways are shown to illustrate the problem of the differing levels at which lymph vesseles leave the paratracheal nodes to reach the right venous angle. Further, the brachiocephalic node group is discussed as the critical intermediary nodes between the superficial and deep pathways. Numerous deep left pathways are also dissected from the left tracheobronchial nodes. Some lymphatics ascend along the left recurrent nerve to finally reach the left venous angle, while some pathways traverse to the right side. Still other pathways directly connect to the thoracic duct.

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Tracheoesophageal (TE) fistulization following pharyngolaryngectomy and tracheojejunal (TJ) fistulization following pharyngolaryngo-esophagectomy with free jejunum reconstruction for advanced hypopharyngeal and cervical esophageal cancer have been performed over the past 20 years at Kobe University Hospital.
Out of 42 patients who underwent TE fistulization and 19 patients who received TJ fistulization, 32 patients (76%) and 16 patients (84%) regained voice capability with TE and TJ speech, respectively. The main causes of restoration failure were stenosis, the destruction of the TE or TJ fistula and a lack of motivation on the part of the patients. Most patients who underwent the TE or TJ procedure started speaking at 1 month postoperatively. The average values of the sustained vowel duration in the group of TE speakers and TJ speakers were 18 seconds and 11 seconds, respectively, at month. As far as the swallowing function is concerned, no regurgitation or aspiration was seen in 24 of the TE speakers (75%), with the use of bilateral esophageal muscle flaps, and in 15 of the TJ speakers (94%).

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A modified technique was devised for simultaneous esophageal reconstruction and voice restoration after laryngopharyngoesophagectomy. This technique minimizes the length of intestinal tract which is sacrificed and uses a free jejunal graft to create an elephant-type shunt aimed at improving the chances for successful voice restoration. The results of voice restoration with this free jejunal graft technique compared favorably with results in cases reexamined after application of Ehrenberger & Kawahara's reconstructive technique. This free jejunal graft technique is briefly described, together with endoscopic findings and barium contrast findings at the time of phonation. The endoscopic findings revealed that the grafted intestinal mucosa on the oral-cavity side constricted simultaneously with phonation. The shape of this constriction differed among patients, showing three basic patterns: uniform constriction, anteroposterior constriction and side-to-side constriction. At the time of phonation, barium fluoroscopy revealed, a dilation of the reconstructed esophagus in the vicinity of the junction with the shunt and constriction of the grafted intestinal tract. However, phonation was not always accompanied by images of constriction. Based on these findings, two possible sites for the neoglottis permitting phonation after this reconstruction technique were hypothesized: the mucosa of the shunt aperture opening mucosa and the constricting portion of the reconstructed esophagus. However, the actual site remains to be elucidated.
Possible causes and solutions are also discussed for the potential problems involved with this modified reconstruction, including reflux, stenosis of the shunt opening, permanent stenosis of the tracheal opening etc.

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We reported, in 1989, a one-stage surgical technique for creating a phonatory shunt after pharyngo-laryngo-esophagectomy using a free ileocolic graft (tracheoileocecal shunt: TIC shunt). Recently, we have made a further modification which is accomplished in a two-stage operative procedure. The shunt is opened during the second-stage operation for the purpose of eliminating the need for intensive care after surgery. A total of fifteen patients underwent the TIC shunt operation.The first six consecutive patients received the original one-stage procedure and the remaining nine underwent the modified technique.There was no pulmonary complication in the latter patients. It was concluded that the TIC shunt is a successful method of surgical voice restoration, and that the two-stage technique makes postoperative care more simple and easy, so that complications seem to be reduced.

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Loss of voice often results from combined removal of the larynx, hypopharynx and cervical esophagus in patients with cancer. The author devised a new voice reconstruction method (T. E. G. double shunt) for these patients, using an esophago-cardiac loop as a new glottis with a physiological, non-regurgitation mechanism.
A lower esophago-cardiac loop (6-7cm long) with a gastric tube was mobilized to the neck with good blood supply from the right gastric and gastro-epiploic artery. A stenosis (2cm long) was formed in the esophagus near the cardia. A double tracheo-esophago-gastric shunt was created by anastomosis between the trachea and the distal end of the esophagus. Patients were evaluated with certain criteria for capability of conversation determined by the Japan Society for Head and Neck Cancer and examined for regurgitation of milk and Barium swallowing.
This method resulted in a new voice without milk regurgitation for all patients to some degree. 60% of the patients had moderately to very successful conversation with high-quality and high-efficiency phonation. A physiological study of these voices revealed a normal intensity in spite of a low air-flow rate. Sound spectrography characteristically indicated intermittent sounds with little noise.
Some patients did not achieve any speech after the surgery due to a rapid cancer recurrence and/or the loss of a desire for conversation. The recovery of phonation using a esophago-cardiac loop as a new glottis, however, seems to hold promising prospects for the laryngo-pharyngo-esophagectomized patients with cancer.

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Recently, the incidence of subglottic stenosis has increased following prolonged endotracheal intubation for respiratory support, or secondary to blunt injury and malignant neoplasm. We described our surgical procedures for treating subglottic stenosis. In cases without injury or deformity of the cricoid cartilage, a laryngofissure is performed with the removal of scar tissue in the stenosis and the oral mucosa graft sutured to the defect. About 2 to 3 weeks after such an operation, the anterior wall is covered by a hinge flap.
In cases with recurrent laryngeal nerve paralysis, partial cricoid resection including the crico-thyroid joint, has been possible. After the recurrent laryngeal nerve was identified on the opposite side, a primary anastomosis was performed between the distal trachea and the residual cricoid cartilage.
In cases without recurrent laryngeal nerve paralysis, half of all cricoid resections were performed with the preserved recurrent laryngeal nerve, and then the lateral wall of the cricoid was made of an advancement flap. Secondary reconstruction of the anterior wall was performed with a hinge flap and an advancement flap.
Surgical procedures for subglottic stenosis are considered based on the type of the stenosis, its degree, and its association with recurrent laryngeal nerve paralysis.

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Treatment of diseases of the upper trachea by surgical resection and reconstruction may impair quality of life (QOL) because of the anatomically close relation between the trachea and larynx. We studied factors which determine QOL after tracheal reconstruction by analyzing cases who underwent upper tracheal and/or laryngeal resection and reconstruction.
We studied 99 tracheal-lesion cases who had had tracheobronchial reconstruction. There were 61 thyroid carcinomas invading the trachea and/or larynx, 10 primary tracheal tumors, one esophageal tumor invading the trachea, four metastatic tracheal tumor, 22 benign tracheal stenoses, and one congenital tracheal stenoses.
Among these 99 cases, 30 cases showed tumor invasion of the cricoid cartilage which required a partial resection. After this operation, 7 cases developed complications (4 had partial dehiscence of the anastomosis; and 3 a stenotic change in the anastomosis). Because of the involvement of the recurrent nerve in the tumors, 19 cases developed bilateral recurrent nerve palsy. Since bilateral recurrent nerve palsy causes serious impairment of QOL, we treated those patients with fenestration and/or tracheostomy in initial cases, and with insertion of a T-tube in later cases. When the oral end of the T-tube was placed just above the vocal cords, breathing, phonation and swallowing were maintained, although hoarseness persisted. The T-tube was successfully removed in thirteen cases when the vocal cords had been fixed to a juxta-lateral position 6 to 18 months after insertion.
Regarding survival in case of thyroid carcinoma invading the trachea, complete resection is superior to incomplete resection, however, total laryngectomy impairs QOL so much that a maximum effort should be made to avoid total laryngectomy.

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From April 1994 to March 1998, we managed twenty-eight patients with tracheobronchial obstructive disease (27 cases of malignant disease and 1 benign stricture). Cylindrical resection of the trachea and end-to-end anastomosis were performed in 6 patients; resection of the membranous portion of the trachea and patch repair using the latissimus dorsi muscle in 1, and carinal resection and primary reconstruction in 9 (right pneumonectomy in 3, left pneumonectomy in 1, upper right lobectomy in 4). Twelve patients with unresectable disease underwent airway stenting. Four patients who underwent carinal resection and upper right lobectomy or pneumonectomy with a combined resection of the superior vena cava for lung cancer, died of myocardial infarction, respiratory failure, airway bleeding or brain edema within 30 days after the surgery. There was no anastomotic leakage or anastomotic stricture in any of the patients.
After stenting, the dyspnea remarkably improved in 11 of the 12 patients with unresectable disease.

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Fourteen patients with tracheal lesions underwent primary reconstruction of the airway at the Hyogo Medical Center.
The tracheal resection ranging from 3 to 9 rings and end-to-end anastomoses were performed in 11 of the 14 patients, including in 3 cases of primary tumors of the trachea, 5 cases of secondary tumors and 3 postintubation strictures cases. Before operation, paralysis of the vocal cord was observed on one side in 4 patients and on both sides in 1. In three patients (2 of the former and 1 of the latter), the recurrent laryngeal nerve was found to be invaded bilaterally by the tumor during the operation and was resected on both sides. Of these 3 patients, one with an adenoid cystic carcinoma, in whom 9 rings were resected, underwent laryngectomy after eight-months of difficulty swallowing: one patient with esophageal cancer was managed well by use of a T-tube and another with thyroid cancer by tracheostomy.
Of the 14 patients, the remaining 3 with lesions of the tracheal membraneous portion underwent tracheoplasty successfully.
There was no operative death and no postoperative stenosis of the reconstructed trachea in any of the 14 patients. Surgeons should take care to preserve the recurrent laryngeal nerve and discuss the most appropriate method of anesthetization and reconstruction with the anesthetist before surgery.

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Anastomotic complications of tracheo-bronchoplasty often lead to critical postoperative conditions and deteriorated QOL. Operative approaches, tension-reducing techniques and wrapping procedures for improvement of anastomotic circulation depend on the localization and range of the involved lesions. In this study, intrathoracic tracheal reconstructions were evaluated from the viewpoint of complications in 36 cases: 11 middle and lower tracheal resections, 12 right pneumonectomies (RP), 6 left pneumonectomies (LP), and 7 right upper lobectomies (RUL) with carinal resection.
The results were as follows: (1) Postero-lateral thoracotomy is a standard approach for RP and RUL, except for the cases requiring a combined resection of the SVC. For RUL cases with carinal reconstruction, release techniques and wrappings are essential because of frequent anastomotic complications. (2) An operative approach for LP hasn't been established so far. However, clamshell incision and reconstructions under ECMO have provided better visibilities in certain anastomoses. (3) Median sternotomy with a collar incision is convenient for middle and lower tracheal reconstructions because of its availability for immediate release techniques and wrappings.

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Recent advances in esophageal cancer clinics in Japan include the early detection and treatment of esophageal mucosal cancer. Endoscopic staining techniques have made possible the early detection of mucosal cancers and their eradication using endoscopic mucosal resection techniques (EMR) with minimal invasion, thus preserving the esophagus. The iodine staining technique is the most sensitive in detection of mucosal cancer, for it can differentiate abnormal mucosa as a yellowish white “unstained area” against a dark brown normal mucosa. The number, size and distribution of mucosal cancers can also be identified with ease. EMR can be employed as a radical treatment for mucosal cancers confined to the lamina propria mucosae, which seldom have lymph node metastasis. Ten-year-survival curves of our patients with mucosal cancer of the esophagus treated by esophagectomy and that by EMR showed no significant difference. Clinical estimation of the depth of a cancer invasion into the esophageal wall was essential for the precise indication of EMR. Endoscopy aided by toluidin blue-iodine double staining was most useful for this estimation, and its accuracy rate was 96%. In the case of type IIc lesions (slightly depressed type), which is most frequent among mucosal cancers of the esophagus, the area unstained by toluidine blue can be observed when the lesion is confined to the epithelium layer. Blue stained dots, or reticulum, in a unstained area strongly suggests cancer infiltration into the lamina propria mucosae.

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The prognosis of esophageal cancer depends on the depth of its invasion into the esophageal wall and the presence or absence of lymph node metastases. Selecting an appropriate treatment strategy is therefore dependent on accurate tumor staging. Recent advances have greatly broadened the available therapeutic options. For example, patients with advanced esophageal cancer first undergo neoadjuvant therapy in order to downstage the tumor. Esophagectomies are accompanied by aggressive two- or three-field lymph node dissections. Thoracoscopy has been developed to provide a less invasive surgical approach. Finally, patients with superficial esophageal cancer are treated with endoscopic mucosal resection. Recent advances in endoscopic ultrasonography (EUS) have expanded its diagnostic capabilities for assessing tumor staging. For example, imaging of tracheal invasion with an ultrasonic transducer situated in the esophagus had been hindered by the artifact produced by tracheal air. Situating the ultrasonic transducer in the trachea using a miniprobe contained within a water-filled balloon can obviate this difficulty. The decision for endoscopic mucosal resection versus esophagectomy is influenced by the presence of lymph node metastases, and an EUS-guided puncture biopsy can now be used to obtain tissue for this pathological examination.

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Accurate diagnosis of tumor extension in cases of esophageal cancer is very important to establish an adequate therapeutic strategy. The main purpose of examination (s) using CT and/or MRI is to determine the staging of the esophageal cancer. These examinations are also necessary in the evaluation of some therapeutic effects and in follow-up studies.
Tumor invasion into adjacent organs can be diagnosed by certain anatomical abnormalities. Recently, neoadjuvant therapy or non-surgical treatment has often been selected for patients with locally far-advanced cancer. Therefore, the accuracy rate of diagnoses using CT and/or MRI is unclear. The accuracy rate of direct observation of tumor invasion of adjacent organs in our department is 70-90%.
Although the size, figure, and location of the lymph nodes are referred for diagnosing nodal involvement, the diagnostic accuracy for nodal metastasis is only about 65%, which is unsatisfactory. From the practical point of view, we should suspect all lymph nodes detected by CT and/or MRI as having metastasis.
The hardware for CTs and MRIs is rapidly developing. Three-demensional reconstruction and virtual endoscopy have become common in clinical use. We should make more clinical applications of advanced technology in CTs and MRIs to establish more reliable pre-treatment diagnosis in the staging of esophageal cancer.

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Surgical resection for esophageal cancer is highly invasive, especially in elderly patients. Unfortunately, some cases also result in a poor quality of life after operation.
We have performed endoscopic mucosal resections (EMR) since 1989 as a first choice of treatment in cases of early esophageal cancer limited to the lamina propria mucosa (1pm, m2). m3 or sml cases. We have estimated the eligibility and rate of one from the long term results. At our institution, as of 1997, 289 EMRs were performed in 200 patients with early stage esophageal cancers to remove 289 lesions. Depths of invasion on final pathological diagnosis were as follows: ml, 2: 137 cases, m3: 38 cases, sml: 17 cases and sm2, 3: 8 cases. Until now, local recurrence has been observed in only 6 cases. The depth of invasion of the recurrent lesion was ml in one case, m3 in 3 cases, and sm in 2 cases. Local recurrence after EMR was 3.0% of all cases and 2.1% of the total number of lesions. As for treatment, re-EMR or ethanol injection was performed in 4 cases and surgical resection in two cases. No lymph node metastasis was evaluated before the EMRs, however upper mediastinal lymph node recurrence was recognized in two sm (sml, sm2) cases. The five-year-survival rate was 100% after EMR, excluding both sm2 cases and deaths due to other diseases.
In order to detect the early stage of esophageal cancer, endoscopic examination combined with iodine staining is necessary especially for high risk groups such as males over than 50 years of age, heavy drinkers, heavy smokers and H & N cancer patients.

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Conventional esophagectomy gives the postoperative patients a restrictive respiratory condition. We recognized that the postoperative vital capacity in patients who had undergone a conventional esophagectomy by thoracotomy fell to 75% of their preoperative level and was fixed at that level for more than 4 years. On the other hand, postoperative vital capacity in patients with thoracoscopic esophagectomy returned to their preoperative level within two months after surgery. The thoracoscopic-esophagectomy group reported less pain than the conventional operation group did, even though both groups were under continuous epidural anesthesia during the first postoperative week.
The patients' survival curve in the group undergoing thoracoscopic esophagectomy turned out to be identical to that in the group undergoing conventional surgery. Although this study was not conducted under controlled condition, there was no apparent discrepancy between these two groups.
Thoracoscopic esophagectomy alone has not achieved the goal of being a “minimally invasive surgery, ” because a patient's vital capacity and FEV1 still decline in the early postoperative phase. Encouraged by the results of laparoscopic cholecystectomy, we have introduced a laparoscopic procedure to our routine thoracoscopic procedure to further improve patients' postoperative pulmonary function.

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