To the Editor.—In reply to the letter by Stephen Tolins, MD, we certainly concur that in the great majority of cases surgical correction of gastroesophageal reflux can be satisfactorily performed by the transabdominal approach and we use this method preferentially. There are exceptional cases, however, where the transthoracic route is preferable. In our experience, the most common indication is fibrotic transmural stricture of the esophagus with acquired short esophagus. Under such circumstances, the completed repair cannot be reduced below the diaphragm and exposure for the combined Thal patch and Nissen fundoplication is considerably better through the left transpleural approach. We also prefer the transthoracic approach in the short, squat, muscular obese patient and in the patient who has had prior extensive surgery in the upper part of the abdomen.
The purpose of the article was to point out that the thoracic approach has the added hazard of the diaphragmatic