American Foregut Society Recommends Improved Classification System to Help Clinicians Better Treat Gastroesophageal Reflux Disease (GERD)

By Ninh T. Nguyen, MD; Peter J. Kahrilas, MD; John Lipham, MD; Marcia Irene Canto, MD; Reginald Bell, MD; and Kenneth Chang, MD

A new white paper by the American Foregut Society (AFS) recommends expanding the classification of the esophagogastric junction (EGJ) to include an assessment of the hiatal hernia axial length and aperture diameter, and the presence or absence of the gastroesophageal flap valve making it more comprehensive. The manuscript was published in Foregut: The official journal of the AFS and the European Foregut Society. Foregut is the only subscription journal focused exclusively on foregut disease linking medical, endoscopic, and surgical disciplines.

Gastrointestinal reflux disease (GERD) is one of the most common esophageal conditions, affecting as many as one in five American adults. This condition can lead to debilitating symptoms and impairment in quality of life. Even in patients treated with proton pump inhibitors, up to 40% of individuals will have breakthrough symptoms of heartburn and regurgitation. The Hill grade is an endoscopic classification of the EGJ specifically based on the endoscopic appearance of the gastroesophageal flap valve on retroflexed view of the hiatus. This endoscopic classification gives healthcare providers insight into the extent of anatomic disruption of the flap valve that often correlates with GERD. However, the Hill classification is subjective with substantial inter-observer variability and its routine use in endoscopic practices has been limited due to skepticism as to its relevance and the perceived subjectivity in its application.  

With the advent of newer endoscopic treatment options for GERD, members of the AFS convened a working group to review the Hill classification and formulate a proposal to revise this system. The AFS working group comprised of 13 members tasked with developing an improved classification scheme for endoscopically gauging the endoscopic integrity of the EGJ. The group was composed of experts in foregut disease from gastroenterology (n = 7) and gastrointestinal surgery (n = 6). The expert consensus discussion was based on a modified Delphi method. A series of surveys that critiqued the Hill classification were circulated among the group and suggested improvements were solicited. Based on survey results and the working group’s discussion, a new classification was proposed and named -  the AFS Endoscopic Classification of EGJ Integrity.

With a broader understanding on the components of the anti-reflux barrier including the crura of the diaphragm, the lower esophageal sphincter including its gastric sling fibers, the flap valve, and the integral relationship among them, the new AFS classification seeks to improve the anatomic and physiologic relevance of the grading classification, to standardize the endoscopic methodology in applying it, and proposes nomenclature for endoscopic grading. The AFS classification expands on the grading classification by including measurements of the hiatal axial length and aperture along with presence or absence of the flap valve.

As detailed in the white paper, the new classification first stipulates appropriate endoscopic methodology prior to making the assessment. This is important to minimize inter-observer variability in grading. The key is to perform maximal insufflation and provocative maneuvers to elicit the hiatal hernia, if presence, prior to grading the hiatus. The new AFS grading system stratify EGJ integrity from intact (grade 1) to increasing degrees of EGJ disruption (grade 2 – 4). Grade 1 is considered as normal with an intact EGJ. Grade 2 demonstrate partial hiatus disruption with slight crura separation, loss of intraabdominal esophageal length, and loss of the gastroesophageal flap valve. Grade 3 depicts moderate disruption of the hiatus with up to 2 cm of axial hiatal length or 2-3 cm of hiatus aperture diameter. Finally, grade 4 represent complete hiatus disruption with >2 cm axial length herniation or >3 cm of hiatus aperture diameter.  It is important to note that this grading system reflects the grading of the gastroesophageal hiatus rather than just the flap valve as noted by the Hill grade. Hence, this new classification is also known as the “hiatus grade” (HG).

Future directions for additional research include: 1) validation studies to determine the accuracy of this new classification in its ability to accurately predict the presence and severity of gastroesophageal reflux, and 2) extending the work to encompass grading of the hiatal appearance in patients who have undergone anti-reflux interventions. Going forward, it is our hope that all endoscopists grade and document the EGJ using this new classification as this assessment is critical in the management of patients with pathologic reflux. 

The AFS Endoscopic Classification of the Esophagogastric Junction Integrity as depicted by the LDF components (Length/Diameter/Flap valve). The arrow represents the relative level of the diaphragmatic hiatus starting with normal anatomy with a good segment of intraabdominal esophagus and an intact hiatus and progressing to increasing degree of hiatal disruption (hiatal axial length and widening of the crural defect) and loss of the flap valve. Note. LDF components: hiatal axial length; hiatal aperture measured in centimeters; and the present or absent of a functioning flap valve.

Article Details
The American Foregut Society White Paper on the Endoscopic Classification of Esophagogastric Junction Integrity
Ninh T. Nguyen, Nirav C. Thosani, Marcia Irene Canto, Kenneth Chang, John Lipham, Barham Abu Dayyeh, Erik B. Wilson, V. Raman Muthusamy, John Clarke, Reginald Bell, Peter Janu, Lee Swanstrom, Ava Runge, and Peter J. Kahrilas
First published online September 28, 2022
DOI: 10.1177/26345161221126961
Foregut: The Journal of the American Foregut Society

About the Authors
Ninh Nguyen, MD is a gastrointestinal surgeon in Orange, California. He graduated from University of Texas Medical School at San Antonio and currently is the Chair of Surgery at UCI Medical Center. His clinical specialties include bariatric surgery and management of benign and malignant foregut diseases.

Peter Kahrilas has been on faculty at the Feinberg School of Medicine at Northwestern University in Chicago for 38 years, since completing a fellowship in gastroenterology at Northwestern McGaw/Northwestern Memorial Hospital in 1984. His career as a physician-scientist spans more than 450 publications in the areas of esophageal disorders, gastroesophageal reflux disease and swallowing disorders.

John C. Lipham is a professor of surgery at Keck Medicine of the University of Southern California in Los Angeles focusing on benign and malignant diseases of the foregut. His clinical interests include the diagnosis and treatment of GERD, esophageal motility disorders, malignant diseases of the esophagus and stomach as well as complex general surgery issues. Dr. Lipham earned his medical degree from the Medical College of Wisconsin before joining the faculty of USC in 2001.

Marcia (Mimi) Canto is an Associate Professor of Medicine and Oncology at The Johns Hopkins University School of Medicine. Dr. Canto received her medical degree from the University of the Philippines. She then completed a fellowship in Gastroenterology-Hepatology and a Master of Health Science in Clinical Epidemiology from The Johns Hopkins University. Her primary clinical interests include endoscopy, particularly the use of endoscopic ultrasound in detecting early pancreatic cancer and its precursors.

Reginald C.W. Bell is the founder of the Institute of Esophageal and Reflux Surgery in Lone Tree, Colorado, a part of SOFI Research, LLC. Dr. Bell has practiced for more 30 years and has extensive experience performing minimally invasive procedures on the esophagus and stomach. Dr. Bell received his medical degree in 1985 from Virginia Commonwealth University in Richmond, Virginia. He is currently the president of the American Foregut Society, a specialty society guiding and fostering collaboration between gastroenterologists and foregut surgeons in the treatment of foregut disease.

Dr. Kenneth Chang is the executive director of the University of California Irvine Health Digestive Health Institute with clinical research interests in the development of endoscopic modalities for cancer diagnosis, staging and therapy. Dr. Chang completed his medical degree at Brown University in Providence, R.I. He then finished a fellowship in gastroenterology at UCI Medical Center and the UCI School of Medicine, where he has been a faculty member for more than 25 years. He holds the Vincent Kong Chair of Gastrointestinal Oncology and serves as chief of the medical school's Division of Gastroenterology and Hepatology.