Sir.—The article by Leape and Ramenofsky (Journal 1980;134:935-938) relating their experience with the surgical management of gastroesophageal reflux (GER) was most interesting. Several points demand further clarification and comment.
In the section entitled "Selection for Operation," a regimen for medical management is outlined that is patterned after the work of Carre.1 Much additional information has come to light concerning the physiology of GER, especially in the areas of lower esophageal sphincter function and gastric emptying, since Carre's article appeared. Since delayed gastric emptying may be part of the pathophysiologic process involved in infantile GER, it is probably unwise to thicken feedings (which delays gastric emptying) in infants younger than 4 months.2 In the same section, no mention is made as to duration of medical management or as to percentage of compliance by the care-givers.
Our experience with esophageal manometrics has been different from the authors. Since deglutition