WISE E T AL.

excellent method; however, we have successfully used the intercostal pedicle to treat or prevent reflux and to close esophageal perforations.

Allison presented the idea of the sling action in the normal gastroesophageal area. The left seventh and the right third intercostal pedicles have been used as slings to control reflux and to prevent esophagitis around an esophagogastrostomy. We use a No. 15 blade to dissect the intercostal pedicle. Terrible hemorrhagic reflux esophagitis has been cured by the pedicle method.

The advantages of the pedicle method are (1) it is simple; (2) it can bq used on either side of the chest and at any level; (3) i t allows the patient to vomit, which is a very important function.

DR. READ: I would like to thank Drs. Paulson, Bartley, Malette, Taber, and Demos for their comments.

Dr. Paulson stressed the problem of reflux in all operations in this area. Reflux occurred in about 4 of Dr. Thal’s original 14 operations. We had a similar percentage. Dr. Woodward had about 100% reflux, as Dr. Bartley pointed out. Perhaps the difference is related to the amount of stomach that is incised when the incision is made into the stricture. We favor a very conservative approach when going down into the gastric portion of a gastroesophageal stricture.

Dr. Malette pointed out the importance of using the skin graft. We agree that perhaps we should have used it more than we did, because we did have a disturbing incidence of postoperative narrowing which we do believe was related to the healing of the surface.

Dr. Demos pointed out his pedicle, which, of course, will provide a valve. But unlike the Thal procedure, the pedicle does not act as a replacement for tissue in the esophagus, which is either lost in rupture or lost with stricture.

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222 THE ANNALS OF THORACIC SURGERY