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The Esophagogastric Junction OESO
Barrett's Esophagus
250 questions
250 Answers


With the edifying attention of the three co-editors whom I thank for their presence, here, then, is the 6th volume of OESO.
And, once again, over 1,000 pages, the in-depth exploration of a chosen theme of esophagology by the original process of its methodical dissection into a long series of questions relevant to very varied specialties, illustrating the specific, multi-disciplinary nature of OESO.
Each of these books makes up one more element in a kind of evolving encyclopaedia of esophagology which has, over the years, taken its place in the international community.

This 6th volume has the advantage to address a topic which is at the forefront of concern for all those involved with disease of the upper digestive tract:an entity inserted in the epidemiological sequence of GERD,a benign affection among the most widespread in the world, Barrett's esophagus, this lesion that Jean-Louis Lortat-Jacob described in his time under the enlightening name of "endo-brachy-esophagus" has, indeed, become today a problem of Public Health.
Its recognized propensity to degenerate has, in fact, made it one of the benign lesions of the upper digestive tract which legitimately arouses the convergent interest of clinicians, as well as those devoted to fundamental research.
Large scale epidemiological studies, the development of even sharper means for early detection of the precursory signs of its degeneration, the extreme diversity of the treatments available today, all lend new perspectives to the different centers of interest of this book.

They all enthusiastically joined in the uncommon game of making a difficult synthesis on a minute point of their experience those to whom I turned to request a contribution.
They are the bearers of the reputation of OESO, and a great number of them helped me, from the very first volume, to win the challenging wager of a true multi-disciplinary interaction, to create an innovative style for scientific work.
One finds, in the exhaustive Table of Contents, the details of a planned procedure which leads, step by step, to "complete" knowledge of a subject.
But also, opened at random, one finds, falling upon a page, under the pen of one of the most undisputed specialists in the world in his or her particular field, the detailed response to an extremely precise question, presented with tables, illustrations and selected bibliographical references to better guide the reflexion of the reader.
And this original approach for sharing of knowledge, based on a cascade of skills and abilities dosed out in all disciplines quickly takes the reader by surprise and invites him to venture outside his zone of interest to discover by chance another question, this becoming somewhat of a specialist himself in an area different from his own.

It is this particular methodology which has now been tried and tested for over twenty years, It is this assembling of experiences and talents, it is this mosaic of enthusiasm which has been, since its founding, the distinctive mark of OESO, which gives it today its entire originality among the various international scientific societies, and which has allowed it the exceptional privilege to be granted a Resolution of UNESCO, officially approved by the 187 member States.

It is in the same spirit, and on the grounds of the reputation acquired by OESO as a world reference in the domain of esophagology that the OESO Foundation was created whose acronym HOPES (Health Operating Polydisciplinary Expertise Services) is witness of its polydisciplinary originality.
The Foundation houses the books of OESO and, through the Inter-University network it has set up, contributes to making their contents be known, thus continuing the wide dissemination of knowledge in line with one of the missions of UNESCO.

This book represents an important stage in the work program of OESO.
And my warm recognition goes to each one of these who replied "present" when I proposed addressing one of the questions of a long series which succeed one another in the pages to follow, and which allowed the Scientific Director of OESO, this time again, to realize that relationships among persons, when founded on reciprocal respect are, from the outset, easy, efficient, and, especially, the source of fortifying shared satisfaction.

Robert Giuli, MD, FACS
Professor of Surgery
Scientific Director of OESO

For the realization of this new volume of OESO, I must again emphasize how much the cooperation, now long-standing, which has developed with John Libbey, that is, a professional team entirely devoted to expertness and quality, thus to the satisfaction of the authors has been, and remains invaluable to me.
My particular recognition goes to Mr Gilles Cahn, President and CEO, active, enthusiastic, efficient, and always ready to do more, capable of transforming any problem I posed into a solution.
It goes also to Mrs Catherine Cahn, for her attentive meticulousness to each page, so that the final outcome would be of the quality the OESO readers have come to expect from the previous volumes.
And very much aside, my exceptional gratitude to Michèle Liégeon, whose intelligence, enthusiasm, strength, and faith in all that we endeavor to do, leads, in great part, our projects to accomplishment.


This book contains a collection of the currently newest, and probably most important facts on the pathogenesis of Barrett's Esophagus and the clinical consequences implicit in its complications.
It was written with reference to the 6th OESO World Congress in Paris and is simultaneously the documentation of this meeting of esophagologeal experts from all over the world.

Holding this congress in Paris, the birth place of Lortat-Jacob and his "cylinder-cell lined lower esophagus" (endo-brachy-esophagus), and naming it "Barrett Esophagus Congress" has to be regarded as a sign of the French host's extraordinary generosity and courtesy: in Paris in particular, there would have been any number of very good reasons for naming a congress on the subject "Cylinder-Cell-Lined Lower Esophagus" or "Lortat-Jacob Syndrome", for historical veracity demands that respect be paid to Lortat-Jacob who first described the phenomenon of cylinder cell metaplasia of the esophagus, and who was also the first to correctly interpret the metaplasia.
Unfortunately, Lortat-Jacob published his first observations in French, whereas Norman Barrett, on the other hand, was lucky enough to publish his findings ­ which he, furthermore, misinterpreted - in the renowned and widely read British Journal of Surgery in English. This fortunate turn of events made him world-famous, for which Lortat-Jacob, however, never bore him a grudge. Quite the contrary, their relationship was characterised by mutual respect and friendship.

Be this as it may, Paris is and remains the place of origin of cylinder-cell-lined lower esophagus, and no other city in the world has a better right to discuss the syndrome and compile the most recent research on the subject. It is thus only appropriate that the scientific monument dedicated to cylinder-cell-lined lower esophagus should be in Paris.
Robert Giuli created it and he has successfully looked after it through the years. He is the trustee of Lortat-Jacob's legacy.
Seen in this light, the Society he founded, OESO, would seem to have received special authorisation from history to continue its work, and this collection of scientific developments on the subject of cylinder-cell-lined lower esophagus gives evidence of how successfully Lortat-Jacob's legacy has been managed: whatever is new has been given a place in this book, and makes it an important and exciting report on progress in the field.

The historical background described above clearly justifies and legitimises holding OESO symposia in Paris and every good wish for their success should be expressed here.
It is a truly demanding and permanent obligation to look after the legacy received, and present new developments at regular 3-yearly intervals.

Jörg Rüdiger Siewert, MD, FACS
Professor of Surgery


The method on which the elaboration of this book rests, even if i twas conceived by the Scientific Director of OESO, Robert Giuli, some 20 years ago, remains highly original.
Drawing up over 250 questions o, a precise theme, motivating the most involved authors to reply to them, and bringing them together so that each one can express his or her own viewpoint in an open debate, is a wager. It is not because this exceptional event, the OESO Congress, takes place regularly every three years that we should be less amazed at this outstanding achievement that the medical and surgical world of Gastroenterology owes to Robert Giuli.
The conception of this scientific event and the book that is published fo;llowing it is, without a doubt, the result of a pursuit of exhaustiveness: ensuring the presentation of all the aspects of the subject, allowing the expressions of all the various standpoints, juxtaposing the ideas to better confront them, criticize them or, in the contrary, strengthen them, the findings contributed by the different specialists, be they clinicians, physicians, surgeons, biologists...
After those in attendance, the reader can now find readily available information he or she is confronted with uncertainties, contradictions but remains free to judge. This is not an attempt to attain an unreachable consensus resulting in indications. The reader finds himself in a ferment of ideas, hypotheses and innovative techniques: it's up to him to judge.

The choice of Barrett's esophagus was imperative as a subject of priority.
The approximations, not to say the flaws of conception that characterized the first descriptions of the disease, the controversies that resulted, the importance that this question has taken on, where it is a matter of medical responsibility, the persistence of numerous questions, make of Barrett's esophagus a privileged theme to submit to the OESO method.

With such an abundance of questions, the diversity of their nature must be noted.
There are general questions that aim to define exactly what we are talking about and to weigh the risks in its progression: agreement on a definition was first sought, today remaining a current topic, even if the first description by Barrett goes back to 1950.But, in order for the definition to be valid, the esophago-gastric junction had to be first specified and located.
If Barrett's esophagus is no longer considered a congenital abnormality but rather the result of an extension of the cardiac mucosa towards the esophagus, there is even more reason today to verify the arguments. And as the risk of neoplastic transformation is especially high, it is obviously essential to question the rate of occurrence of this eventuality as well as the stages preceding the development of carcinoma, because it is in this phase that the process can hopefully be reversed.

Questions remain that still challenge current knowledge: are adenocarcinomas of the cardia, and those which develop on the glandular mucosa of Barrett's esophagus one and the same? Do all the adenocarcinomas appearing on Barrett's esophagus develop from intestinal metaplasia? In the absence of intestinal metaplasia, can the risk of malignant degeneration be dismissed?
And this vital question: do the current treatments of gastroesophageal reflux protect against the risk of degeneration?

There is a long series of questions which, in the area of diagnosis, as well as in that of treatment, leads us to assess the efficacy of new techniques: the interest of markers predictive of degeneration: ploidy, p53, bcl2; the value of the new techniques of treatment: mucosectomy, phototherapy.
Other topics, rather practical, put the strategies of endoscopic surveillance into question, be they traditional or with the help of magnifying optics; on the action of agents of redifferentiation, the Cox2 selective inhibitors for example, to prevent dysplasia or make it regress; and, the, a very simple, but essential one: how to optimize our standard endoscopic techniques to detect dysplastic transformation in Barrett's esophagus?

But there no point in rephrasing in my words the table of contents that the reader will find several pages on, and which will enable him to use this book as the complete and indisputable reference on "Barrett's esophagus".

Daniel Couturier, MD
Professor of Gastroenterology


In the age of information technology proliferation, do we need another textbook on esophageal disease? The Editors of this book and the Publisher clearly think so.

Knowledge concerning esophageal pathophysiology has until recently lagged far behind that of the pathophysiology of other portions of the gastrointestinal tract for reasons that still remain unclear. Yet, it is the fact that, at least until the last few decades, interest in the esophagus was primarily based on pathologic anatomy. The recent development of methods of studying both morphology and function of the esophagus has resulted in a better understanding of normal and abnormal esophageal patterns with a corresponding improvement in treatment that is now physiologically, rather than anatomically based.
As customary, the World O.E.S.O Congresses are planned to provide each time a thorough analysis of a single topic on esophageal disease. The sixth International Congress of O.E.S.O. was entirely devoted to the columnar-lined esophagus. The so-called Barrett's esophagus is a complication that develops in a minority of patients with gastroesophageal reflux disease. It would be of little interest were it not for its well-established association with adenocarcinoma of the esophagus, a cancer whose incidence has increased rapidly since the 1970s, and remains on the rise. Despite the enormous advances in science and medical technology in recent times, our knowledge of the pathophysiology and treatment of neoplasia is far from complete and, for the patients at least, the myths that surround cancer remain intact. Cancer remains the "bogyman" of medicine as we enter the new millennium, and the very mention of the word strikes mortal fear in patients and their families in a way not generally seen with any other disease.
Although our understanding of Barrett's esophagus has improved considerably in recent years, much remains unknown especially in the field of cancer development and prevention. The choice of the topic was therefore an appropriate and timely one.

Unlike some of the other publications, this volume does not merely represent the proceedings of an International Congress. It collects the answers to 250 key questions, offered by 160 basic scientists and clinicians from the World over, all of whom have personally contributed to the topic, in order to provide a glimpse of what may lie ahead. It is indeed important for the practicing physician to keep up with advances in diagnosis and therapy in this rapidly evolving field.

Gastroenterologists and digestive surgeons are fortunate to have many excellent textbooks that provide a large body of information regarding digestive diseases. Such "traditional" textbooks concentrate on pathophysiology, on diagnosis or on therapy and are comprehensive in their scope. This book is not intended to replace these texts, since its focus is on specific questions and answers. Excellent electronic databases are available, and many traditional publications contain relevant research evidence and important summaries to support evidence based clinical practice: however, it has been found that physicians often find the acquisition of data from these sources difficult and time consuming. With its original format, this book will save valuable time for busy practitioners and scientists alike. By opening the book at random, the reader will easily locate the question she or he is asking and find the appropriate answer.

Like the organization of the Congress from which the book arises, the challenge to draw up a whole series of questions on the topic, to identify those who could answer, and to assembly the various manuscripts, rested ­ as always ­ upon Robert Giuli: his scientific competence and never failing enthusiasm are a guarantee of excellent and thorough editorial work. I am very proud to have been asked to join him and his talented coeditors in this endeavor. We strongly hope this book will become "the" standard reference book for the years to come, because it contains a wealth of information in an appropriately designed format. It is also hoped that this volume will play a useful role in further stimulating the interest of clinical and basic researchers alike in this important area of medicine which is gastroesophageal reflux disease and Barrett's esophagus.

Carmelo Scarpignato, MD, DSc (Hons), PharmD (h.c.), GCP, FACG
Professor of Pharmacology and Therapeutics
Associate Professor of Gastroenterology


Publication date: August 2003 OESO©2015