Reply to the Esophagogastric Junction Integrity

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