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INTEROBSERVER AGREEMENT OF THE AMERICAN FOREGUT SOCIETY'S ENDOSCOPIC CLASSIFICATION SYSTEM OF ESOPHAGOGASTRIC JUNCTION INTEGRITY: A PROSPECTIVE COHORT STUDY
Zahraa Al Lami
*, Fares Ayoub, Patrick Boddie, Vinh V. Tran, Shifa Umar, Ned Snyder, Clark Hair, Scott Larson, David Y. Graham, Wasseem Skef
Gastroenterology and Hepatology, Baylor College of Medicine, Houston, TX
Introduction
The anti-reflux barrier (ARB) consists of 3 vital components – the crura, the gastroesophageal flap valve and the lower esophageal sphincter and sling fibers. Historically, endoscopic assessment of the ARB has been performed using the Hill classification. The Hill classification correlates with gastroesophageal reflux disease (GERD) severity but has been criticized due to incomplete assessment of the esophagogastric junction (EGJ) and subjectivity. Thus, the American Foregut Society (AFS) recently developed an improved grading system of the EGJ which defines anatomic disruption using an objective, quantitative and standardized grading system. In our study, we aimed to test the interobserver agreement of AFS EGJ classification system.
Methods
We conducted a prospective observational study at a single center. Study enrollment dates were from 10-2024 to 12-2024. Inclusion criteria were veterans ?18 referred for upper endoscopy for evaluation of GERD. Exclusion criteria included history of foregut surgery, upper aerodigestive cancer or known major disorder of esophageal peristalsis. Baseline sociodemographic and clinical variables were collected. GERD Questionnaires (GERDQ) were administered before endoscopy. One expert and four nonexpert endoscopists (raters) were involved and completed standardized instruction on EGJ assessment before study initiation. Two endoscopists independently scored the EGJ of each recruited patient following standard protocol. Endoscopists were blinded to one another and GERDQ score. A visual cue of the AFS endoscopic classification of EGJ was available for review by endoscopists before scoring. Interobserver agreement among endoscopists was determined by using the kappa statistic with corresponding 95% confidence intervals (CIs) and strength of agreement was categorized according to established definitions for kappa values.
Results
117 patients met inclusion criteria with 70 successfully recruited. Sociodemographic and clinical variables of study participants are summarized in table 1. No complications were reported. 43 (61.4%) patients had moderate to severe disruption of the EGJ with AFS hiatus grade 3-4. Interobserver agreement for AFS hiatus grade dichotomized to normal to mild EGJ disruption (AFS 1-2) versus moderate to severe EGJ disruption (AFS 3-4) was moderate (0.52, 95% CI [0.32-0.73]). However, strength of agreement was fair for individual AFS hiatus grade between two endoscopists (0.37, 95% CI [0.35-0.53]). Axial length of hernia, when present, demonstrated fair interobserver agreement (0.39, 95% CI [0.3-0.46]) whereas hiatus transverse diameter demonstrated slight agreement between two endoscopists (0.08, 95% CI [0.02-0.15]).
Conclusion:
The AFS EGJ classification demonstrates fair interobserver agreement between endoscopists for patients referred for endoscopy for evaluation of GERD.
Table 1: Sociodemographic and Clinical Variables of Study Participants
Table 2: Interobserver Agreement With Strength of Agreement Among Endoscopists Between AFS Hiatus Grade and Components
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