Preface

The esophagus is the long tube running from the back of the mouth to the stomach, and it transports ingested food to the location where real digestion begins. It is a rather simple or‐ gan both structurally and functionally, but can be life threatening once it becomes sick, espe‐ cially when it is malignant. As pointed out in the introductory chapter, "Esophagus and Esophageal Cancer," esophageal cancer kills more than 400,000 people annually and its 5 year survival rate is around 18%. What is even worse, while the incidence of other cancers is declining year after year, esophageal cancer has been moving up steadily for the past several decades, and it casts a really big shadow on the future of human life. Until now there have been no effective drugs to treat esophageal cancer. Most professionals agree that immuno‐ therapy might hold a brighter future in chemotherapy, as demonstrated by the outcomes that have been obtained in several types of cancers. Immunotherapy is a relatively new con‐ cept based on immunological principles to battle against cancers, such as activating and or‐ chestrating B-cells and T-cells to attack tumor cells, introducing specific antibodies to induce tumor cell apoptosis, blocking certain signaling pathways to let the tumor cells die of starva‐ tion, etc. Chapter 2, "Immunotherapy for Esophageal Cancer," gives a thorough review of this topic, including the history of immunotherapy, drugs that are in use as well as those in trials, and mechanisms of functionality of each drug. It is full of useful information not only for clinicians but also for researchers.

While chemotherapy has been making progress, surgical operation has been a common strategy for esophageal cancer patients. To be exact, during surgery the affected esophagus is cut off partially or entirely. Because of the critical location of the organ, however, the suc‐ cess of surgery often depends greatly on the skills of the operating surgeon. For this reason, robots have been brought into the surgical room in recent years. This has been proven to be at least comparable to a skillful surgeon at this point. Chapter 3, "Robotic Esophageal Sur‐ gery for Cancer," tells the story of the actual use of the technology in Germany. Based on experience, this is a promising new way to perform an operation because it can eliminate several human errors. However, a few limitations still exist, such as lack of tactile feedback, longer setup time, and higher overall cost. We believe that these shortcomings can be over‐ come in the near future, as we continue to improve the system. Even with the help from a robot, post-operative complications are still very common. To reduce such unfortunate chances, proper preparations and care are important not just before surgery, but also during and after surgery. Chapter 4, "Prevention and Management of Complications from Esopha‐ gectomy," gives a detailed discussion of this subject, from patient selection to surgeon selec‐ tion, from assessment of the hospital to a blueprint of the surgical procedure, and more. It also provides advice on how to prevent complications before surgery, as well as how to manage complications when they happen. It discusses six types of complications in particu‐ lar, including atrial fibrillation, respiratory illness, anastomotic leaks, fistula, delayed gastric emptying, and chyle leaks.

**Chapter 1**

Provisional chapter

**Introductory Chapter: Esophagus and Esophageal**

DOI: 10.5772/intechopen.77995

Our body obtains nutritional supplies from the environment through two primary pipes: bronchus and esophagus, the two simplest organs in the respiratory and digestive systems, respectively. While the bronchus passes oxygen to the lung and expels carbon dioxide out of our biological system, the esophagus transports water and food into the stomach from where a

Although skin cancer might be the most common malignancy in the world, accounting for at least 40% of all cancer cases [1], it is usually excluded from the annual cancer report due to its least perniciousness. The remainders are mostly found in the respiratory and digestive systems, particularly in the digestive system, which hides about twice as much cancer as found in the respiratory system. Five of the top 10 deadliest cancers take place in the digestive organs, including stomach, liver, colon, pancreas, and esophagus. Esophageal cancer is ranked as No. 6 on the list. While the incidence of most cancers is declining year by year, esophageal cancer continues climbing as the fast growing malignancy in the world. Based on a recent prediction, by the year of 2035, the global population of the esophageal cancer patients will be up by 77.4% [2]. In some regions of Asia, Africa, and the South America, the numbers could be doubled in less than 20 years. Logically, esophageal malignancy will very likely become one of the top

The human esophagus is just a short tube of ~25 cm, separating from the rest of the body by two muscular rings at the ends, the upper esophageal sphincter and the lower esophageal sphincter, which control the flow of ingested materials from the mouth to the stomach. Like a corridor that sends visitors from the gate to the main building, the esophagus sends food from the mouth to the stomach. It is a rather simple structure, but, because of its critical location, any

> © 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and eproduction in any medium, provided the original work is properly cited.

© 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use,

distribution, and reproduction in any medium, provided the original work is properly cited.

Introductory Chapter: Esophagus and Esophageal

Additional information is available at the end of the chapter

sophisticated process of digestion and nutrient extraction begins.

abnormalities associated with this organ can be devastating.

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/intechopen.77995

global concerns in the near future.

**Cancer**

Cancer

Jianyuan Chai

Jianyuan Chai

1. Introduction

There are two types of esophageal cancer commonly seen. Although esophageal squamous cell carcinoma (ESCC) is the most popular, esophageal adenocarcinoma (EAC) is the fastest growing cancer in the world. While tobacco smoking in conjunction with alcohol consump‐ tion might be blamed for causing ESCC, gastroesophageal reflux disease (GERD) has been recognized as the primary reason for the rise of EAC. GERD develops when the lower esophageal sphincter fails to keep the stomach contents from backing into the esophagus. Consequently, the esophageal epithelial lining is frequently exposed to highly acidic stom‐ ach fluid that often contains bile salts from the duodenum. When such episodes go on for a long time without proper management, EAC develops. According to recent studies, GERD increases the risk of EAC by 8.6-fold. Currently, GERD is the most common gastrointestinal diagnosis in the United States. Over 60% of Americans experience occasional episodes of acid reflux, and approximately 25% deal with the problem on a weekly basis. Chapter 5, "The Clinical Relevance of Gastroesophageal Reflux Disease and Laryngo-Pharyngeal Re‐ flux in Clinical Practice," is an updated review of GERD clinical practice. It also compares GERD with another abnormality that occurs in close vicinity, lanryngo-pharyngeal reflux (LPR), which is considered as an extra-esophageal manifestation of GERD. Unlike esopha‐ geal mucosa, both laryngeal and pharyngeal mucosa do not have sufficient self-protective mechanisms; therefore, the refluxant quickly leads to mucosal lesions. The chapter covers the physiology and pathology of GERD and LPR, as well as their diagnosis and treatment options. It is a good reference for clinical professionals.

Because we are talking about the larynx and pharynx, their malignancies are also commonly treated by surgical operation to remove the troubled organ. Consequently, the patient ends up with loss of vocal ability. To help the patient to maintain minimal voice communication skills, the individual has to be trained to use his/her esophagus as the secondary vocal appa‐ ratus, using airflow to cause esophageal mucosa vibration and thereby producing sound. As discussed in Chapter 6, "The Role of Esophagus in Voice Rehabilitation of Laryngectomees," there are two ways to do this: the esophageal speech method and trachea-esophageal speech method. In the esophageal speech method, the respiratory and digestive systems are com‐ pletely separated. Therefore, the esophagus has to work alone to generate a voice. In the trachea-esophageal speech method, on the other hand, a silicon prosthesis is inserted into the location where the larynx used to be, and connects the respiratory system to the esopha‐ gus, so that the patient uses airflow from the lung to vibrate the esophageal mucosa to make a sound. It is a tough job, but there is no other way to deal with the problem at this point.

We have come to a realization that this book might be light by weight, but the subject is quite heavy. Esophageal cancer is the sixth deadliest cancer in the world and could get worse because of the increasing patient population. Through this book, we hope to raise the awareness of health professionals as well as non-professionals, such as politicians and ad‐ ministrators in funding agencies. We need to inject more resources and effort into the battle against this disease.

> **Jianyuan Chai, Ph.D.** Inner Mongolia Institute of Digestive Diseases Baotou, China

#### **Introductory Chapter: Esophagus and Esophageal Cancer** Introductory Chapter: Esophagus and Esophageal Cancer

DOI: 10.5772/intechopen.77995

#### Jianyuan Chai Jianyuan Chai

lar, including atrial fibrillation, respiratory illness, anastomotic leaks, fistula, delayed gastric

There are two types of esophageal cancer commonly seen. Although esophageal squamous cell carcinoma (ESCC) is the most popular, esophageal adenocarcinoma (EAC) is the fastest growing cancer in the world. While tobacco smoking in conjunction with alcohol consump‐ tion might be blamed for causing ESCC, gastroesophageal reflux disease (GERD) has been recognized as the primary reason for the rise of EAC. GERD develops when the lower esophageal sphincter fails to keep the stomach contents from backing into the esophagus. Consequently, the esophageal epithelial lining is frequently exposed to highly acidic stom‐ ach fluid that often contains bile salts from the duodenum. When such episodes go on for a long time without proper management, EAC develops. According to recent studies, GERD increases the risk of EAC by 8.6-fold. Currently, GERD is the most common gastrointestinal diagnosis in the United States. Over 60% of Americans experience occasional episodes of acid reflux, and approximately 25% deal with the problem on a weekly basis. Chapter 5, "The Clinical Relevance of Gastroesophageal Reflux Disease and Laryngo-Pharyngeal Re‐ flux in Clinical Practice," is an updated review of GERD clinical practice. It also compares GERD with another abnormality that occurs in close vicinity, lanryngo-pharyngeal reflux (LPR), which is considered as an extra-esophageal manifestation of GERD. Unlike esopha‐ geal mucosa, both laryngeal and pharyngeal mucosa do not have sufficient self-protective mechanisms; therefore, the refluxant quickly leads to mucosal lesions. The chapter covers the physiology and pathology of GERD and LPR, as well as their diagnosis and treatment

Because we are talking about the larynx and pharynx, their malignancies are also commonly treated by surgical operation to remove the troubled organ. Consequently, the patient ends up with loss of vocal ability. To help the patient to maintain minimal voice communication skills, the individual has to be trained to use his/her esophagus as the secondary vocal appa‐ ratus, using airflow to cause esophageal mucosa vibration and thereby producing sound. As discussed in Chapter 6, "The Role of Esophagus in Voice Rehabilitation of Laryngectomees," there are two ways to do this: the esophageal speech method and trachea-esophageal speech method. In the esophageal speech method, the respiratory and digestive systems are com‐ pletely separated. Therefore, the esophagus has to work alone to generate a voice. In the trachea-esophageal speech method, on the other hand, a silicon prosthesis is inserted into the location where the larynx used to be, and connects the respiratory system to the esopha‐ gus, so that the patient uses airflow from the lung to vibrate the esophageal mucosa to make a sound. It is a tough job, but there is no other way to deal with the problem at this point. We have come to a realization that this book might be light by weight, but the subject is quite heavy. Esophageal cancer is the sixth deadliest cancer in the world and could get worse because of the increasing patient population. Through this book, we hope to raise the awareness of health professionals as well as non-professionals, such as politicians and ad‐ ministrators in funding agencies. We need to inject more resources and effort into the battle

**Jianyuan Chai, Ph.D.**

Baotou, China

Inner Mongolia Institute of Digestive Diseases

emptying, and chyle leaks.

VIII Preface

against this disease.

options. It is a good reference for clinical professionals.

Additional information is available at the end of the chapter Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/intechopen.77995
