Reply to the Esophagogastric Junction Integrity

N. Nguyen, K. Chang, M. Canto, J. Lipham, R. Bell, P. Kahrilas
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Abstract

We thank the reader for their letter and interest in the American Foregut Society (AFS) endoscopic classification of esophagogastric junction (EGJ) integrity.1,2 The reader raised 2 issues regarding potential limitations of our approach. First, it does not consider the effect of anesthesia and the reader commented on the observation that the hiatal aperture tends to enlarge under general anesthesia with the use of paralytics as compared to conscious sedation endoscopy. While this observation is interesting, we are not advocating doing routine upper endoscopy under general anesthesia. It is also worth noting that we were more driven by endoscopic undergrading of hiatal integrity due to insufficient gastric insufflation rather than overgrading, even going so far as to advocate eliciting a hernia with a provocative endoscopic maneuver. The second observation from the reader is that obese patients commonly have a large fat pad at the level of the hiatus that may preclude an accurate depiction of the hiatal defect. We agree that this can lead to “undergrading” the EGJ and should be kept in mind with obese patients. It also emphasizes the need to utilize maximal insufflation of the stomach and provocative maneuvers to elicit a sliding hiatal hernia. However even if the fat pad leads to an underestimation of the hiatus grade, it would not obscure an AFS grade II which is a key difference between AFS grading and the Hill classification. An AFS grade II is considered pathologic, representing partial hiatus disruption with loss of the intraabdominal esophageal length along with the gastroesophageal flap valve and the angle of His. In contrast, a Hill grade II is considered to be a normal finding. We thank the reader for their interest and astute comments. Declaration of Conflicting Interests
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对食管胃交界完整性的回答
我们感谢读者来信并对美国前肠学会(AFS)食管胃结(EGJ)完整性的内镜分类感兴趣。读者就我们的方法的潜在局限性提出了两个问题。首先,它没有考虑麻醉的影响,读者评论了与有意识镇静内窥镜相比,在全身麻醉下使用麻痹剂时,裂孔孔径倾向于扩大。虽然这个观察结果很有趣,但我们并不提倡在全身麻醉下进行常规的上消化道内窥镜检查。同样值得注意的是,我们更多的是由于胃充气性不足而导致的内镜对裂孔完整性的低估,而不是高估,甚至提倡通过挑衅性的内镜操作引发疝气。来自读者的第二个观察是,肥胖患者通常在裂孔水平有一个大的脂肪垫,这可能会妨碍对裂孔缺陷的准确描述。我们认为这可能导致EGJ“降级”,肥胖患者应牢记这一点。它还强调需要利用最大的胃和刺激的操作,以引起滑动裂孔疝。然而,即使脂肪垫导致对中断等级的低估,它也不会模糊AFS等级II,这是AFS等级与Hill等级之间的关键区别。AFS II级被认为是病理性的,表现为部分食管裂孔破裂,伴有腹内食管长度、胃食管瓣瓣和His角度的丧失。相比之下,Hill II级被认为是正常的发现。我们感谢读者的兴趣和敏锐的评论。利益冲突声明
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