To the Editor.—We wish to thank Dr Ellis for his comments on our article, "Esophagogastric Fistula" (Arch Surg 110:826-828, 1975).
The reason for adding the ancillary procedure of fundoplication or fundoplasty to the esophagocardiomyotomy for achalasia stemmed from our experience and belief than an adequate myotomy could not be done via thoracotomy without some disruption of the hiatal support structures in order to deliver the cardia into the surgical field. Among the early patients treated by us were two who had had esophagocardiomyotomies without ancillary procedures; in both, severe reflux esophagitis occurred. One other patient in our series had a concomitant sliding hiatus hernia. We therefore began adding fundoplication to myotomy to prevent reflux esophagitis, a complication of esophagocardiomyotomy not infrequently reported.
Since it has been shown the fundoplication raises esophageal pressure to normal range in most patients with hiatus hernia, and since esophagocardiomyotomy results in a return to