Correspondence
management policy as described totally excludes endoscopic surveillance after the initial diagnosis is made and excludes anti-reflux surgery from the management programme in 84 per cent of cases, in whom less than half were over 70 years of age, and it is on these two points that I would take issue with the authors.
The observation that true fibrous strictures may resolve following anti-reflux surgery alone'.' suggests the superior efficacy of surgical reflux control in these circumstances. This hypothesis was tested in a study ofdilatation requirements in a personal series of 120 patients with benign oesophageal stricture, the results of which were presented to the 1983 meeting of the Association of Surgeons and published recently3. In 42 patients treated by intermittent fibreoptic endoscopic dilatation and anti-reflux surgery, 71 percent needed no further dilatation after initial treatment, compared with 41 percent of those treated by intermittent dilatation and pharmacological anti-reflux measures. The mean number ofdilatations required in a mean follow-up period of 3.3 years was 1.6 in the surgically treated group, being approximately half that of those treated medically. There was no mortality or significant morbidity in the surgically treated group to offset this advantage in reducing dilatation requirements and the need for long term medical treatment.
Another important observation in our series was a 2.5 percent incidence of the subsequent development of adenocarcinoma occurring 1.5 to 2.5 years after initial confirmation of benignity by punch biopsy and brush cytology, this incidence occurring entirely in the medically treated group. The observation has been made by others, with reported incidences of 2 . 8 4 per ~e n t ~. ~ which represents an increased incidence approximately 300 times that expected in the overall British population. The absence of this complication in the Liverpool/Sheffeld series is surprising, although this cannot beclaimed with certainty in theabsence of regular endoscopic and histological surveillance unless life-long follow-up including autopsy data was absolute.
Whilst agreeing that the method proposed by Messrs Stoddard and Simms is suitable for the frail, elderly patient who is unsuitable for surgery and therefore for active treatment of an adenocarcinoma even if one developed. I would submit that in the significant group of younger, fitter patients, regular endoscopic and histological surveillance as part of a programme of intermittent fibreoptic endoscopic dilatation is desirable.
Whilst no form of dilatation is entirely without risk, the very small risk of guide-wire perforation (less than 0.05 per cent in our hands) would appear justified to achieve this superior control, not only on subsequent developments but indeed on the conduct of individual dilatations, as the screening of patients who have apparently successfully swallowed self-administered bougiescan be revealing! Furthermore, this group of younger, fitter patients, accounting for up to 40 per cent of those with benign peptic stricture, should be considered for anti-reflux surgery in order to reduce the need for regular dilatation and obviate the need to take long-term anti-reflux therapy.