Benign Lesions of the Esophagus and Cancer : Answers to 210 Questions

In an attempt to attain the best possible delimitation of all the problems posed today by benign diseases of the esophagus, 181 authors each agreed to answer one or more of 210 questions that had been drawn up on the subject. These questions, each one deliberately limited and difficult, mostly concerned reflux esophagitis: its natural history, the means of its diagnosis, all existing treatments, and its eventual degeneration. The authors approached are today's most reputed specialists in the fields of epidemiology, gastroenterology, endoscopy, pathology, and surgery of esophageal diseases. The authors were all assigned one or more questions in their own field, none of which was simple: all did their best to synthesize in their replies their own experience on the precise point under review and included all the most useful bibliographical references on the topic. The book is thus the result of an original, individual approach to try to pinpoint the heart of a problem. The 210 answers succeed one another in logical progression according to the different diagnostic and therapeutic stages, specifying, at each step, the degree of precision sought. Consequently, the reader has at his disposal an exceptional synthesis of facts and concepts. Opening the book at random he will find at once the detail he is looking for, the professional opinion he is lacking, or the development of a question he had perhaps not yet asked himself. Front Matter....Pages II-LIII Statistical estimation of the prevalence and incidence of the degeneration of benign lesions....Pages 1-2 Front Matter....Pages 3-3 Plummer Vinson Syndrome....Pages 7-8 Myomas....Pages 8-10 Diverticula....Pages 11-16 What is the prognostic significance of esophageal papillomas?....Pages 17-20 Can esophageal keratosis be considered as a precancerous lesion?....Pages 21-23 What is the association between granular cell tumors of the esophagus and cancer?....Pages 23-25 Isn’t treatment by repeated dilatations a factor of chronic mucosal irritation?....Pages 29-32 Should the ineffectiveness of dilatations lead to suspect a cancer?....Pages 32-32 What are the rules to follow in the surgical treatment of megaesophagus?....Pages 33-41 What is the incidence of reflux in achalasia?....Pages 41-47 Is it possible not to combine an antireflux procedure with the treatment of a megaesophagus?....Pages 47-54 What is the influence of the treatment of a megaesophagus on the development of a peptic esophagitis or a stenosis?....Pages 55-56 Are there pseudo-achalasias of neoplastic origin?....Pages 57-59 Caustic Stenosis: anatomo-radiological correlations....Pages 63-66 Can early calibration with an esophageal dilator prevent the anatomic development of granulation tissue?....Pages 66-68 What is the incidence of dysplasia associated with the regeneration of the esophageal mucosa?....Pages 68-69 What are the comparative late results of the different treatments?....Pages 69-75 Is it really possible to follow a patient for several decades?....Pages 75-76 Front Matter....Pages 79-79 How can esophageal dysplasia be demonstrated?....Pages 81-82 Front Matter....Pages 79-79 Is “Asiatic” dysplasia specific?....Pages 83-84 Do the endoscopic methods and the non-endoscopic methods have the same degree of reliability?....Pages 84-88 How should dyplasias be followed?....Pages 88-92 Do they require treatment?....Pages 92-95 Should severe dysplasia associated with esophagitis be resected?....Pages 95-95 Front Matter....Pages 97-97 When must we consider reflux esophagitis?....Pages 99-107 How can a normal esophago-gastric junction be defined?....Pages 107-111 Can clinical reflux exist together with normal esophagus?....Pages 111-113 Reflux can occur without hiatus hernia: misplacement of the cardia....Pages 113-118 There seems to be a total independence between the LES tonus and the existence of a hiatal hernia....Pages 118-127 Esophageal reflux can exist despite an elevated LES....Pages 127-129 Front Matter....Pages 131-131 Is stenosing esophagitis a different disease from esophagitis without stenosis?....Pages 133-135 What is the endoscopic incidence of stenosis related to reflux?....Pages 135-138 What is the endoscopic incidence of stenosis related to reflux and what is the incidence of recurrences of reflux stenosis?....Pages 138-140 Is it possible to quantify reflux?....Pages 141-142 What are the relations between gastroesophageal reflux and pharyngoesophageal dysphagia?....Pages 143-144 What is an appropriate biopsy?....Pages 144-147 What are the limitations of the histological interpretation of a biopsy taken from the area of esophagitis?....Pages 148-153 In what proportion of cases are there poor quality biopsies?....Pages 153-153 What is the role of a decrease in the peristalsis secondary to esophagitis linked disorders?....Pages 154-155 Front Matter....Pages 131-131 Can the role of esophageal clearance disorders be defined?....Pages 156-164 What are the troubles of gastric emptying of solid food which most often causes an esophagitis? Disorders of the proximal tonus, Disorders of antrum motility....Pages 165-166 What is the incidence of alkaline reflux in patients suffering from esophageal reflux?....Pages 166-167 What is the underlying mechanism of the toxicity of biliary acids?....Pages 167-168 There is no demonstrated correlation between the severity of esophagitis and the concentration of biliary salts in the reflux fluid....Pages 168-169 Front Matter....Pages 171-171 The physiology of the LES is now well-known....Pages 173-174 The essential anatomical features of peptic stenosis are quite accurate....Pages 174-177 The concordance between endoscopy and histology seems good in certain types of esophagitis....Pages 177-179 A methodology and a precise histological technique actually often enable a good concordance between clinical symptoms, endoscopy and histological alterations....Pages 179-179 Transit with Technetium-99 enables to detect motility disorders unnoticed by usual means....Pages 180-191 Radioisotopes techniques do not seem to be able to replace pH measurement....Pages 191-199 The increase of intra-parietal esophageal collagen could provide elements in the evaluation of motor disorders associated with esophagitis....Pages 200-202 Does the determination of an acid reflux score enable a better classification of the disease in question?....Pages 202-204 When are motility tests indicated for the choice of treatment?....Pages 204-211 Front Matter....Pages 213-213 Is the dilatation of tight esophageal stenosis a therapeutic procedure?....Pages 215-219 What is the risk of declining results when a peptic stenosis is treated by dilatation?....Pages 220-221 Front Matter....Pages 223-223 Introduction....Pages 225-226 Is esophageal reflux always symptomatic?....Pages 226-228 Is the underlying mechanism of LES insufficiency known? Can there be some independence between the value of LES and the existence of a hiatal hernia?....Pages 229-233 Can the natural history of reflux esophagitis be defined?....Pages 233-236 Front Matter....Pages 223-223 What is the rate of gastric acid secretion in patients with esophagitis?....Pages 237-238 What factors intervene in the genesis of esophageal mucosal lesions caused by reflux?....Pages 239-241 Can the brief duration of action of antacids enable them to practically decrease nocturnal acidity?....Pages 241-244 Is the use of antacids justified in biliary reflux?....Pages 244-247 Is the antalgic effect of antacids on reflux pain linked with a neutralizing action? (Comparison with placebo)....Pages 247-247 What is the effectiveness of antacids on the healing of esophageal lesions?....Pages 247-249 What is the effect of alginates on acid neutralization and on LES pressure?....Pages 249-257 What is the action of sucralfate in the treatment of peptic esophagitis?....Pages 257-261 Metoclopramide has an effect on LES pressure, esophageal contractions and gastric acid secretion....Pages 261-263 Doesn’t metoclopramide allow a significant decrease in antacid consumption?....Pages 263-263 Is the effect of metoclopramide on the healing of the lesions of esophagitis different from that of cimetidine?....Pages 264-264 What effective dosage to propose for metoclopramide?....Pages 265-265 Domperidone: is its effect different from that of metoclopramide?....Pages 266-274 Domperidone: is its effect different from that of metoclopramide and does it have central side effects?....Pages 274-276 Bethanechol: is its association to antacid therapy advantageous for the healing of esophagitis lesions?....Pages 276-278 Does the eso-gastric prokinetic action of cisapride play a role in the treatment of esophagitis?....Pages 278-279 What are the indications of pirenzepine?....Pages 280-281 What are the effects of H 2 -receptor- antagonists on esophageal burns, on esophagitis lesions and on the evolution of peptic stenosis?....Pages 281-286 Is healing of esophagitis lesions possible with this treatment? What is the optimal daily dosage? Is maintenance treatment necessary?....Pages 287-289 Can Omeprazole allow healing of certain ulcerated esophagitis?....Pages 289-292 Front Matter....Pages 223-223 Can Omeprazole be efficient in cases that do not heal under H 2 -receptor blockers?....Pages 293-295 Do we know the effect of inhibitors in the synthesis of prostaglandins (indomethacin) in the treatment of esophagitis?....Pages 295-298 Can peptic esophagitis be healed by prostaglandins?....Pages 298-311 What are the comparative effects of the different treatments on LES pressure?....Pages 312-315 Comparative effects of the treatments on esophageal motricity and esophageal clearance....Pages 315-317 Comparative effects of the treatments on duodeno-gastric reflux....Pages 317-321 Comparative effects of the treatments on the volume and the number of bouts of reflux....Pages 321-323 Effects of the different treatments on the acidity of reflux....Pages 323-328 What are the treatments that undoubtedly increase the pressure of LES?....Pages 328-329 Can continuous administration of antacids be considered?....Pages 329-330 After interruption of the treatment, is the risk of recurrence elevated, and what other factors could be implicated in the determinism of reflux to avoid an indefinite intake of antacids?....Pages 330-333 What are the factors that play a role in the genesis of esophagitis and on which ones do antacids react?....Pages 333-334 At what time must medical treatment give way to surgical indication in erythematous esophagitis....Pages 335-335 Surgical indication in erosive esophagitis....Pages 336-337 Surgical indication in Barrett’s esophagus....Pages 338-340 Surgical indication in peptic esophagitis in children....Pages 340-342 Surgical indication in stenosis....Pages 342-347 When a peptic esophageal lesion is healed, is maintenance therapy nevertheless indicated?....Pages 347-349 Is it necessary to consider standardizing the methods of evaluation in order to compare the different treatments?....Pages 349-352 Conclusion....Pages 352-352 Front Matter....Pages 353-353 What are the factors contributing to the continence of the cardia? Increase of the LES....Pages 355-356 How does the length of the abdominal esophagus contribute to the continence of the cardia?....Pages 356-360 How does intra-abdominal pressure contribute to the continence of the cardia?....Pages 360-364 Anatomical procedures....Pages 365-369 The Lortat-Jacob procedure....Pages 369-374 The Belsey Mark IV procedure....Pages 374-375 Cardiopexy with umbilical ligament....Pages 375-383 What is the real function of a gastro-esophageal valve?....Pages 383-386 What is a Nissen fundoplication?....Pages 386-396 Effects of fundoplication on gastric emptying....Pages 396-397 Results of the Nissen procedure....Pages 397-403 Partial fundoplication....Pages 407-409 What is the value of an intrathoracic fundoplication?....Pages 409-417 The fixed retroesophageal valve....Pages 417-421 The degradation of posterior fundoplication....Pages 421-426 The Hill procedure....Pages 427-430 The Toupet procedure....Pages 430-442 What is the effect of an antireflux procedure on esophageal dyskinesis?....Pages 442-444 When is it appropriate to add vagotomy to an antireflux procedure?....Pages 445-453 Migration of the cardia and the posterior aspect of the stomach in large irreducible hiatal hernias....Pages 457-459 Front Matter....Pages 353-353 How can a conservative procedure be considered in view of a stenosis on an irreducible cardia?....Pages 459-463 The Collis-Nissen procedure....Pages 463-466 The advantage of Collis-Nissen procedure via an abdominal or thoracic approach....Pages 466-474 Results of Collis-Nissen operation....Pages 474-479 The Collis-Belsey procedure....Pages 479-482 Comparison of Collis-Nissen and Collis-Belsey procedures....Pages 482-488 Are there still indications for cardioplasty?....Pages 488-493 Total duodenal diversion....Pages 493-496 Must duodenal diversion be reserved for alkaline reflux?....Pages 497-497 From the clinical point of view, do peptidic hormones have an effect on LES?....Pages 497-500 Front Matter....Pages 501-501 Introduction....Pages 503-503 Gastric replacement....Pages 504-509 Colon interposition....Pages 509-512 Can a jejunal loop offer more resistance to acidity?....Pages 513-515 The Thal procedure, combined with that of Nissen....Pages 515-520 Why have so many antireflux procedures been devised? Can specific factors be defined in order to properly choose the procedure to offer?....Pages 523-525 Is intra-operative manometry useful?....Pages 525-535 What are the criteria for evaluation of the results of an operation for peptic esophagitis?....Pages 535-537 The effects of the different procedures on the opening pressures of the LES....Pages 537-538 A comparison of manometric and pH measurements in different continence procedures....Pages 538-550 Front Matter....Pages 501-501 Is the measurement of LES always parallel to the functional results of an antireflux procedure?....Pages 550-554 The role of incomplete LES relaxation in postoperative dysphagia....Pages 555-557 Is it possible to quantify dysphagia to enable comparison between patients?....Pages 557-561 Can the pharmacological improvement of gastric emptying improve the results of certain procedures?....Pages 561-567 Can we specify the differences existing between endoscopic healing and histologic healing?....Pages 571-574 Healing of esophagitis and intraparietal esophageal collagen....Pages 574-576 Recurrences and technical pseudo-recurrences....Pages 577-578 What follow-up period is required to assess the results of surgical treatment?....Pages 578-580 Should the reported failure of a method be linked to its popularity?....Pages 581-581 Recurrences with different techniques....Pages 582-587 Mortality of reoperations....Pages 587-591 Does the persistence of histologic signs suggest that other factors than acidity could occur?....Pages 591-592 What is the incidence of gastric epithelium lying below a treated peptic stenosis?....Pages 592-594 What value should be attributed to the persistence of radiological signs of reflux or persistent acid pH without clinical signs following anti-reflux surgery?....Pages 594-597 Do radioactive methods enable a better approach to reflux by evaluating the esophageal clearance?....Pages 597-601 Are the disorders of esophageal motility corrected by anti-reflux surgery?....Pages 601-606 How does one interpret peptic stenosis occurring after antireflux surgery?....Pages 607-608 Is the progression of the stenosis controlled permanently after treatment?....Pages 609-610 Do the classifications of peptic stenosis allow a definition of the risk of degeneration?....Pages 610-613 What is the respective incidence of peptic stenosis and columnar epithelium lined lower esophagus (Barrett’s esophagus)?....Pages 613-615 Front Matter....Pages 617-617 What is the definition of Barrett’s esophagus?....Pages 619-621 The various degrees of differentiation toward gastric or intestinal epithelium seem to predispose to dysplasia and cancer....Pages 621-622 Is the initial anomaly definitely congenital in certain cases?....Pages 622-625 Experimental Barrett’s esophagus leads to conclude that this lesion is almost constantly acquired....Pages 625-631 “Diffuse” Barrett’s esophagus....Pages 632-633 Are there specific radiologic signs in Barrett’s esophagus?....Pages 633-639 Is post-prandial pH measurement an adequate method of diagnosis?....Pages 639-643 What is the importance of the difference of esophageal potentials after manometry in the diagnosis of Barrett’s esophagus?....Pages 643-644 Are the histochemical and immuno-cyto-chemical criteria useful?....Pages 644-650 How long does it take for Barrett’s esophagus to develop?....Pages 650-654 Can the pathogenesis of this lesion be defined?....Pages 655-656 Front Matter....Pages 657-657 Classifications of Barrett’s esophagus....Pages 659-662 Can motility studies be of use in the classification of these lesions?....Pages 663-664 How should one interpret the histologic changes observed during the endoscopic surveillance of these patients ?....Pages 664-671 What is the role of alkaline reflux in the development of complications?....Pages 671-673 Are clinical symptoms of reflux a necessary indication for antireflux surgery in Barrett’s esophagus?....Pages 673-674 Can the ectopic epithelium regress after antireflux surgery?....Pages 675-681 Can esophageal mucosa return to a malpighian configuration?....Pages 682-683 What is the outcome of esophageal fibrosis after correction of reflux?....Pages 683-685 Front Matter....Pages 687-687 Experimental cancers of the esophagus....Pages 689-701 Front Matter....Pages 687-687 What are the histologic criteria of developing carcinoma in biopsies of benign lesions?....Pages 701-701 What is the value of retrograde biopsies?....Pages 701-702 Front Matter....Pages 703-703 Degeneration of megaesophagus. Is there a particular symptomatology?....Pages 705-706 Malignant change in megaesophagus: has it a specific clinical picture?....Pages 707-709 Is the incidence of this degeneration known?....Pages 709-712 Verrucous cancers of the esophagus....Pages 712-714 Degeneration of caustic stenosis....Pages 715-723 What are the indications of conservative surgery in caustic stenosis?....Pages 723-725 Degeneration in peptic esophagitis....Pages 725-731 Must the risks of degeneration be taken into consideration in the choice of treatment for a caustic or peptic stenosis in an infant or a child?....Pages 732-738 Degeneration of Barrett’s esophagus....Pages 738-741 Can the delay in this degeneration be defined?....Pages 741-743 What are the means of early detection of malignant degeneration?....Pages 744-750 Does the symptomatology of cancer differ when occurring in Barrett’s esophagus?....Pages 751-752 How to differentiate cancers of the cardia from those occurring in Barrett’s esophagus?....Pages 752-755 May squamous cell carcinoma occur in Barrett’s mucosa?....Pages 755-755 Front Matter....Pages 757-757 The incidence of cancer in Barrett’s esophagus vary according to series....Pages 759-765 Is their prevalence in patients with Barrett’s esophagus overestimated?....Pages 765-768 How can the risk of degeneration be distinguished from the associated epidemiologic risk?....Pages 768-769 Must scleroderma, a factor of Barrett’s esophagus, be considered as a precancerous lesion?....Pages 769-771 Front Matter....Pages 757-757 Does aperistalsis, in certain cases, lead to abandon a Nissen type procedure on behalf of a direct resection?....Pages 771-772 Does the presence of an associated stenosis modify the principle of the operation proposed?....Pages 773-774 Is it logical to treat a Barrett’s type lesion by a simple antireflux operation?....Pages 775-776 What should be the approach to surveillance of these patients?....Pages 776-779 Front Matter....Pages 781-781 Introduction to the classification of esophageal neoplasms....Pages 783-783 What are the morphologic features of usual squamous cell carcinoma?....Pages 783-788 Superficial squamous cell carcinoma....Pages 788-790 What is known about precursor and squamous cell carcinoma? Are there different nomenclatures in different parts of the world for these lesions?....Pages 790-798 Are there animal models in non-human primates of precursor lesions and squamous cell carcinoma of the esophagus?....Pages 798-808 What are the morphologic predictors of behavior of squamous cell carcinoma of the esophagus? The OESO malignancy index and histologic staging....Pages 809-814 The role of the pathology panel in the OESO study....Pages 814-816 What are the general morphologic features of Barrett’s esophagus and the carcinomas arising in it? Can Barrett’s carcinoma be differentiated from carcinoma of the gastric cardia?....Pages 819-826 What is the status of our understanding of the morphologic predictors of cancer risk in patients with Barrett’s mucosa? How do histochemistry and immunohistochemistry help in the prediction of this risk?....Pages 826-829 Unusual and rare epithelial tumors of the esophagus....Pages 829-833 Stromal and lymphoid tumors of the esophagus....Pages 833-835 Current state of the various surveys and therapeutic trials conducted by the group OESO....Pages 837-840 General conclusions and future outlook....Pages 841-846 Conclusions of the Congress....Pages 847-847