Primary Motility  Disorders of the  Esophagus
 The Esophageal
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The Esophagogastric Junction OESO
Primary Motility Disorders of the Esophagus
450 questions
450 answers


It is a pleasure to express to Mr. Gilles Cahn, manager of Editions John Libbey Eurotext (Paris and London) as well as his entire team, particulary Ms Boulanger, Coche and Duval, the gratitude I feel for the production of this work.

I am aware that the sum total of our unending demands for this book, from the printing delay, the minutest details of the make-up of every page to its very construction and presentation, have been very heavy and continuously stressful from the time of our first meeting.

I can only say that I have met with nothing but an unreserved understanding in this publishing house, and an enlightened competence, offered freely and graciously, to help us in our work and thus to enable us today to present a production of rare technical quality.

Robert Giuli


It is a renewed pleasure for the Honorary President of OESO to have the duty, as after each of its Congresses, of presenting a new book from this international Organization for statistical studies of diseases of the esophagus.

The first two books were published in 1984 and 1987, inaugurating an unprecedented formula bringing together the experience of a number of specialized teams throughout the world.

Such a formula, conceived by Robert Giuli, diligent organizer of these studies and indefatigable coordinator of the various syntheses expounded by the participants, was arranged around questions previously posed by himself, each with a very specific objective.

Thus, there were answers to 135 questions in 1984, and to 210 in 1987.

I can state, as a pioneer of esophageal surgery in France 50 years ago and as a clinical pathologist of esophageal disorders, then almost unknown, that I find the information drawn from these two works quite considerable.

And now, in 1991, we have the production of a new text with 450 questions!

Obviously, this book is no longer a simple volume containing the proceedings of a Congress; rather, it consists of the elaboration, after a truly worldwide enquiry, multicentered, managed and controlled throughout by Robert Giuli, of a study extending far beyond the previous productions of OESO on cancer or benign lesions of the esophagus.

In fact, the study of the primary motor disorders of this « hypersensitive » organ confirms, while at the same time advancing, many previously acquired or developed concepts.

The extraordinary progress in biophysical investigation of the esophagus means that this work may be regarded as a major event in the history and knowledge of the biophysico-medico-surgical pathology of the esophagus.

It is a true encyclopedia of the pathology of the esophagus which has just been produced, based on varied, judicious and pertinent questions, studied collegially, and posed with the shrewd perspicacity to be expected from that reknown practitioner of esophageal surgery, Robert Giuli.

We thank him for this new step forward and the credit it bestows on OESO.

Jean-Louis Lortat-Jacob
President of Honour of OESO


In June 1990, an extraordinary event occurred in Paris.

For an entire week, international authorities from multiple specialties gathered together to present data and answer questions concerning esophageal motor disorders.

This Congress, sponsored by OESO under the leadership of Professor Robert Giuli, was the most intense examination ever given to these poorly understood and troublesome conditions.

The format for this Third International Polydisciplinary Congress sponsored by OESO was similar to that introduced in the two previous Congresses held in 1984 and 1987, and is a unique contribution introduced by Professor Giuli.

The series of specific questions is designed to address a subject in a comprehensive and logical sequence. Experts known to have specific data or strong opinions are invited to provide the answer to a question in a brief response, usually three to five minutes.

As related groups of questions are answered, there is an interval for discussion from all participants.

Such a meeting provides maximum information for the audience in the time allowed, and is particularly effective for a multi-disciplinary gathering.

This format also provides the basis for a comprehensive well-organized book on the subject. With typical Gallic persistence and intensity, Professor Giuli has pursued all of the respondents to 450 questions about motor disorders to submit their answers in writing, and has produced this remarkable book in near record time following the Congress.

Among the esophageal motility disorders, achalasia is perhaps the best defined, but controversy persists concerning the precise diagnosis, lack of specific correlation between microscopic pathology and the clinical presentation, and the indications and methods for treatment.

When so much is uncertain about the best known condition in this group of disorders, it is not surprising that even greater confusion and controversy surrounds the other related conditions covered in this Symposium.

These include oropharyngeal dysphagia or achalasia of the superior esophageal sphincter, diffuse esophageal spasm, the « nutcracker » esophagus with high peristaltic amplitude, the several types of esophageal diverticula which are now known to be part of the spectrum of motor disorders, causes of non-cardiac chest pain of esophageal origin, and the relationship of motility disorders to gastroesophageal reflux.

The current state of knowledge and theory about each of these conditions is covered in the questions and answers including anatomy, pathology, histology, ultrastructure, physiology, diagnostic methods, classification, correlation of symptoms with objective findings, indications for treatment, and treatment methods including pharmacology, surgery, and dilatations, and finally the complications of the diseases and their treatment.

The result, when presented in this format, is an encyclopedic coverage of a complicated subject with answers concisely given by the world's foremost experts on the subjects from the fields of gastroenterology, endoscopy, thoracic and general surgery, otolaryngology, radiology, pathology and physiology.

This book thoroughly covers that which is known on this subject as of 1991 and will serve as a foundation from which future developments and knowledge will evolve during the next decade.

This volume should stand as the most comprehensive coverage of esophageal motor disorders yet available.

It will be a basic reference source for physicians of all disciplines who are students of this subject, or for practitioners called upon to diagnose and treat patients with these difficult conditions.

Professor Giuli is to be congratulated for the success of the format which he has developed for international Polydisciplinary Congresses and his effective transposition of this into an outstanding book.

It has been a privilege, along with Professor Rene Lambert, M. Ronald Belsey, and Professor J.-L. Lortat-Jacob, to serve with Professor Giuli in the organization of this Congress.

David B. Skinner M.D., Dsc (Hon) FACS
Professor of Surgery
President of the New York Hospital
Cornell Medical Center


The OESO Congress has become an institution, thanks to the generosity and exertions of Robert Giuli.

In June 1990, he brought together a constellation of specialists in the disorders of the esophagus, for the third time at intervals of 3 years. He succeeded in finding an original form of presentation by volleys of short questions accompanied by equally short answers, the whole providing a coherent view of a sector of physiopathology and pathology in a multidisciplinary context.

Nor did Robert Giuli stop at promoting a periodic international spoken discussion, for he then devotes himself to the publication of what amounts to a bible on the theme of the Congress.

This presentation supplies the international readership with an exhaustive analysis of the state of our knowledge.

After cancer of the esophagus and after benign lesions of the esophagus, here, OESO III provides a global view of the motor disorders of the esophagus.

While tumors and reflux constitute the high point of the majority of meetings devoted to the pathology of the esophagus, disorders of motility are usually accorded a much less prominent position. This caution is now out of place ; indeed, the physiopathology of gastroesophageal motor coordination has now become clearer, while the pharmacological actions of medication have at last become subject to measurement and objective assessment.

The reader will find in this book all the questions and answers to do with normal motor function of the esophagus, together with the corresponding anatomic and physiologic basis, as well as a critical study of procedures for measurement of peristalsis.

The different aspects of the pathology of motility are presented in similar analytic fashion. Besides such well-defined disorders as achalasia, diffuse esophageal spasm, diverticula and the motor disturbances associated with esophageal reflux, the reader will find all the modern concepts related to still ill-defined motor disorders, such as achalasia of the upper esophageal sphincter, painful peristalsis (the so-called nutcracker esophagus), the motor disorders associated with pseudoanginal pain and the motor disorders found in senescence.

The therapeutic spectrum is also extensively dealt with : methods of instrumental dilatation, surgical myotomy, prokinetic pharmacologic agents interfering with neural and humoral control (aminergic, serotoninergic and histaminergic neurotransmitters), digestive and opioid peptides, and agents interfering in the interplay of contraction and relaxation (modulators of ion flow, propotassium agents and calcium-blockers, modulators of cyclic endocellular messengers).

We have to thank Robert Giuli, the true inspirer of this coordinated international activity, steadily maintained over the last 12 years.

His actions have contributed to the advance in knowledge by bringing together specialists in this organ from all over the world.

Moreover, he provides his fellow gastroenterologists in France with the opportunity of attending these productive meetings every 3 years.

I hope that he will continue his activity, and that he will plan OESO IV and its accompanying book with the same success.

Rene Lambert
Professor of Medicine
Past President of the French Society of Gastroenterology and the French Society of Digestive Endoscopy


The genesis for this book dates to the gathering in Paris from June 19-23, 1990, for the Third International Congress of OESO, under the masterful organization and moderation of Professor Robert and Mrs Patricia Giuli.

The presidential leadership of Drs David Skinner and Rene Lambert, together with the President of Honor of the Congress, Mr Ronald, H. Belsey, guided us in integrating a polydisciplinary approach to a major topic in gastroenterology ; namely, the primary motility disorders of the esopghagus.

This book reflects the state-of-the art in this area relating to the fields of anatomy, physiology, gastroenterology, endoscopy, pathology, psychological aspects, and surgery.

The world's most recognized investigators, authors, and clinical experts, representing over 20 countries, have contributed to a landmark publication which, as the 1990's begin, is clearly the foremost international reference book for esophageal motility problems.

I am Australian, Dr Giuli, French, and Dr Skinner, American, so truly international editorship sets the tone for achieving this goal.

The foresight, perseverance, commitment and genius of our host and principal editor of this book, Robert Giuli, is exhibited throughout the organization of this text. This hithertofore unappreciated approach to a medical book is based on assembling a succession of replies to questions specifically focused in logical order.

This has resulted in a dynamic approach to textbook reading, providing the reader with a sense of the atmosphere of active debate and scientific exchange which the question and answer format provides.

Dr Giuli's concept of a textbook sets a new standard of appreciation for crisp, concise responses to the major questions that investigators, clinicians and patient care providers are asking about the esophagus today.

In the jargon of the United States popular publishing press, this book would equate to « everything you wanted to know about esophageal motility disorders but have been afraid to ask ».

Every basic and small detail is addressed as the intensity of the questions mount and the complexity of the answers build, providing one with a feeling that having completed this enjoyable reading, one is fully satisfied that one has successfully « swallowed » the knowledge of the world's experts and is fully equipped to venture into the 1990s.

Perhaps another way of looking at it would be to say that readers, having finished this textbook, will be able to « swallow » more easily, in the knowledge that for this 20 cm organ they now have more information on the esophagus per cm than for any other organ in the GI tract.

If that goal has been attained, then I am very happy as one of the co-editors to recommend this truly international textbook on esophageal motility disorders to medical students, house officers, internists, surgeons, gastroenterologists, radiologists, pathologists, pharmacologists, as well as our colleagues in basic and physiologic research.

Please bring this information to the patient's bedside as you pursue our common goal of improving patient care by ameliorating esophageal disease.

Richard W., McCallum, M.D., FACP,
FRACP (Australia), FACG
Professor of Medicine
Chief of the Division of Gastroenterology
University of Virginia
Charlottesville, USA


When I had established the 450 questions that form this text, I endeavored to ensure that, in each specialty, the motor disorders of the esophagus were separated, cut up, broken down into a multitude of facets which would allow the greatest possible practical understanding of this vast field of pathology.

After having drafted the last of the questions comprised in the contents of this book, a great deal of thought was required in composing the list of the 200 specialists, most of them giants in their specific areas, to reply to one or more of these questions, in the aim of producing a critical synthesis on a very precise instance of their experience.

Coming from 20 countries, all these selected figures accepted this difficult task, and it is this collective enthusiasm that now gives me the great satisfaction of presenting this third volume of OESO, which continues in the exact path in which it set out: international and multidisciplinary cooperation.

The exceptional character of David Skinner, his international stature, and all he contributes to our profession, the noted scientific reputation of Richard McCallum, add to the lustre of this book.

The faithful friendship of each one is precious to me.

It is to my greatest satisfaction today to be able to express mine in return, and to let them know how much value I attach, as do all the readers, to their names this volume bears as co-editors.

Whatever his specialty, the reader interested in the motor disorders of the esophagus has an exceptional synthesis at his disposal here.

On opening this book at random, or consulting the detailed index, he should be able to find straightaway the detail he is seeking, the relevant opinion his is acking, or even the development of a question which he may not yet have asked himself.

Robert Giuli, M.D., FACS, FCCP
Professor of surgery

A volume of this breadth and scope could certainly not have been achieved without running into some slight difficulties, without demanding a certain perseverance, even unremitting effort, and without having to deal with an infinite variety of daily problems.

From the very conception of this book, to its preparation, and finally to its realization, I was fortunate to benefit from the irreplaceable structure of the Association Internationale pour la Recherche Medicale et les Echanges Culturels.

The core and soul of this Organization Michele Liegeon gave me invaluable work through her enthusiasm, her rigour, and her far reaching intelligence. Only an exceptional personality of dedication like her could have assumed such a task.

She participated fervently in each aspect of every line.

May I express my gratitude to her for all she gives and contributes each day, and has given, since the beginning, to the forward drive of OESO.

R. G.


Publication date: May 1991 OESO©2015