Letter to the Editor
Dear Editor: There appears in this issue an article describing forceful dilatation of esophageal strictures accompanied by anti-reflux surgery; promising early results are reported. Our experience with this difficult problem dates back to 1953. Thirty-nine such patients were operated upon by this method during the ensuing- ten years. It became apparent that the recurrence rate for both hiatal hernia and stricture was very high, over one-half the patients requiring either prolonged bougienage or further surgical procedures. Most strictures secondary to reflux peptic esophagitis are superficial, readily dilated, and tend not to recur after successful anti-reflux surgery. Clearly, pliable esophageal mucosa develops when further acid-peptic insult is prevented. This is not true, however, in the tough, fibrous, transmural strictures. The dense, fibrous scar contracts both concentrically and longitudinally, re-
sulting in shortening of the distal esophagus. Pliability in the proximal esophagus permits reduction below the diaphragm, but the repair is done under tension with, inevitably, a high incidence of recurrent hiatal hernia and recurrent reflux. Forceful fracture of these strictures produces multiple tears in the fibrotic wall. These heal by granulations followed by ingrowth of fibroblasts and maturing, contracting fibrous tissue. In some patients prevention of reflux will lessen the reaction, but the incidence of recurrent stricture is unacceptably high. The patch graft method, described by Thal, et al.,' follows the sound surgical principle of advancing normal, pliable wellvascularized tissue to replace the fibrous scar. This procedure, when accompanied by an anti-reflux maneuver, is much more likely to produce an enduring, satisfactory result. E. R. Woodward, M.D. Reference
784
1. Thal, A. P., Hatafuku, T. and Kurtzman, R.: New Operation for Distal Esophageal Stricture. Arch. Surg., 90:464, 1965.
Dear Editor: There appears in this issue an article describing forceful dilatation of esophageal strictures accompanied by anti-reflux surgery; promising early results are reported. Our experience with this difficult problem dates back to 1953. Thirty-nine such patients were operated upon by this method during the ensuing- ten years. It became apparent that the recurrence rate for both hiatal hernia and stricture was very high, over one-half the patients requiring either prolonged bougienage or further surgical procedures. Most strictures secondary to reflux peptic esophagitis are superficial, readily dilated, and tend not to recur after successful anti-reflux surgery. Clearly, pliable esophageal mucosa develops when further acid-peptic insult is prevented. This is not true, however, in the tough, fibrous, transmural strictures. The dense, fibrous scar contracts both concentrically and longitudinally, re-
sulting in shortening of the distal esophagus. Pliability in the proximal esophagus permits reduction below the diaphragm, but the repair is done under tension with, inevitably, a high incidence of recurrent hiatal hernia and recurrent reflux. Forceful fracture of these strictures produces multiple tears in the fibrotic wall. These heal by granulations followed by ingrowth of fibroblasts and maturing, contracting fibrous tissue. In some patients prevention of reflux will lessen the reaction, but the incidence of recurrent stricture is unacceptably high. The patch graft method, described by Thal, et al.,' follows the sound surgical principle of advancing normal, pliable wellvascularized tissue to replace the fibrous scar. This procedure, when accompanied by an anti-reflux maneuver, is much more likely to produce an enduring, satisfactory result. E. R. Woodward, M.D. Reference
784
1. Thal, A. P., Hatafuku, T. and Kurtzman, R.: New Operation for Distal Esophageal Stricture. Arch. Surg., 90:464, 1965.
