{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,3,22]],"date-time":"2026-03-22T08:34:07Z","timestamp":1774168447080,"version":"3.50.1"},"reference-count":40,"publisher":"Oxford University Press (OUP)","issue":"1","license":[{"start":{"date-parts":[[2026,1,28]],"date-time":"2026-01-28T00:00:00Z","timestamp":1769558400000},"content-version":"vor","delay-in-days":19,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2026,1,9]]},"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:p>Gastroesophageal reflux disease (GERD) is driven by anti-reflux barrier (ARB) disruption, requiring precise endoscopic tools to guide diagnosis and management. The Hill classification, based solely on flap valve (FV), lacks precision. The American Foregut Society (AFS) classification, integrating hiatal hernia length (L), hiatal opening diameter (D), and FV (F), offers a comprehensive approach to phenotype esophago-gastric junction (EGJ) dysfunction. This study aims to assess the superiority of the AFS classification over the Hill and to weight the single AFS components contribution.<\/jats:p>\n                  <jats:p>A retrospective analysis of adult patients evaluated with upper-GI endoscopy (EGD), high-resolution manometry, and reflux monitoring study for GERD symptoms at our Institution (2022\u20132025) was performed. GERD was defined by Lyon 2.0 criteria. EGJ was graded using AFS and Hill classifications. GERD prevalence was compared across AFS and Hill grades and by the number of disrupted AFS components. Logistic regression assessed individual AFS component contributions.<\/jats:p>\n                  <jats:p>Of 249 patients (median age 52\u00a0years, 47% male, BMI 23.9\u00a0kg\/m2), 127 had GERD. At least one AFS component was disrupted in 71.9% of the patients. GERD prevalence differed significantly across AFS grades 1\u20132 vs. 3 and 3 vs. 4, unlike Hill grades, where 2 and 3 overlapped. Patients with 1 and 2 impaired components were significantly different from those with 3 and 4. Pathologic D (OR\u2009=\u20092.537) and F (OR\u2009=\u20093.336) were independent GERD predictors. ROC analysis confirmed AFS superiority over Hill (AUC 0.750 vs. 0.653, P\u2009&amp;lt;\u20090.001).<\/jats:p>\n                  <jats:p>The AFS classification enhances EGD diagnostic yield, outperforming Hill in EGJ phenotyping. The AFS improves patient stratification for pathophysiological testing and tailored therapies, offering a practical tool for GERD management.<\/jats:p>","DOI":"10.1093\/dote\/doag004","type":"journal-article","created":{"date-parts":[[2026,1,14]],"date-time":"2026-01-14T12:39:59Z","timestamp":1768394399000},"source":"Crossref","is-referenced-by-count":1,"title":["The American Foregut Society endoscopic classification outperforms Hill in phenotyping the esophago-gastric junction to guide gastroesophageal reflux disease management"],"prefix":"10.1093","volume":"39","author":[{"given":"Carlo Galdino","family":"Riva","sequence":"first","affiliation":[{"name":"Division of General and Emergency Surgery, IRCCS Policlinico San Donato, San Donato Milanese (Milan), University of Milan ,","place":["Italy"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0532-3135","authenticated-orcid":false,"given":"Stefano","family":"Siboni","sequence":"additional","affiliation":[{"name":"Division of General and Emergency Surgery, IRCCS Policlinico San Donato, San Donato Milanese (Milan), University of Milan ,","place":["Italy"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Roberta","family":"De Maron","sequence":"additional","affiliation":[{"name":"Division of General and Emergency Surgery, IRCCS Policlinico San Donato, San Donato Milanese (Milan), University of Milan ,","place":["Italy"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Jiurgen","family":"Mema","sequence":"additional","affiliation":[{"name":"Division of General and Emergency Surgery, IRCCS Policlinico San Donato, San Donato Milanese (Milan), University of Milan ,","place":["Italy"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Pamela","family":"Milito","sequence":"additional","affiliation":[{"name":"Division of General and Emergency Surgery, IRCCS Policlinico San Donato, San Donato Milanese (Milan), University of Milan ,","place":["Italy"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Andrea","family":"Lovece","sequence":"additional","affiliation":[{"name":"Division of General and Emergency Surgery, IRCCS Policlinico San Donato, San Donato Milanese (Milan), University of Milan ,","place":["Italy"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Daniele","family":"Bernardi","sequence":"additional","affiliation":[{"name":"Division of General and Emergency Surgery, IRCCS Policlinico San Donato, San Donato Milanese (Milan), University of Milan ,","place":["Italy"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1153-123X","authenticated-orcid":false,"given":"Marco","family":"Sozzi","sequence":"additional","affiliation":[{"name":"Division of General and Emergency Surgery, IRCCS Policlinico San Donato, San Donato Milanese (Milan), University of Milan ,","place":["Italy"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Emanuele","family":"Asti","sequence":"additional","affiliation":[{"name":"Division of General and Emergency Surgery, IRCCS Policlinico San Donato, San Donato Milanese (Milan), University of Milan ,","place":["Italy"]}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"286","published-online":{"date-parts":[[2026,1,28]]},"reference":[{"issue":"6","key":"2026012808272250500_ref1","doi-asserted-by":"crossref","first-page":"582","DOI":"10.1016\/S2468-1253(20)30007-8","article-title":"Global burden of oesophageal cancer, 1990\u20132017: a systematic analysis for the global burden of disease study 2017","volume":"5","author":"GBD 2017 Oesophageal Cancer Collaborators","year":"2020","journal-title":"Lancet Gastroenterol Hepatol"},{"issue":"4","key":"2026012808272250500_ref2","doi-asserted-by":"crossref","first-page":"339","DOI":"10.1177\/26345161221126961","article-title":"The American foregut society white paper on the endoscopic classification of esophagogastric junction integrity","volume":"2","author":"Nguyen","year":"2022","journal-title":"Foregut"},{"issue":"3","key":"2026012808272250500_ref3","doi-asserted-by":"publisher","first-page":"541","DOI":"10.1016\/j.giec.2025.01.003","article-title":"The esophagogastric junction reconsidered","volume":"35","author":"Kahrilas","year":"2025","journal-title":"Gastrointest Endosc Clin N Am"},{"issue":"2","key":"2026012808272250500_ref4","doi-asserted-by":"publisher","first-page":"361","DOI":"10.1136\/gutjnl-2023-330616","article-title":"Updates to the modern diagnosis of GERD: Lyon consensus 2.0","volume":"73","author":"Gyawali","year":"2024","journal-title":"Gut"},{"issue":"5","key":"2026012808272250500_ref5","doi-asserted-by":"publisher","first-page":"541","DOI":"10.1016\/S0016-5107(96)70006-8","article-title":"The gastroesophageal flap valve: in vitro and in vivo observations","volume":"44","author":"Hill","year":"1996","journal-title":"Gastrointest Endosc"},{"issue":"2","key":"2026012808272250500_ref6","doi-asserted-by":"publisher","first-page":"240","DOI":"10.1002\/ueg2.12721","article-title":"Prospective evaluation of real-time artificial intelligence for the Hill classification of the gastroesophageal junction","volume":"13","author":"Kafetzis","year":"2025","journal-title":"United European Gastroenterol J"},{"key":"2026012808272250500_ref7","doi-asserted-by":"publisher","first-page":"doae051","DOI":"10.1093\/dote\/doae051","article-title":"Systematic review of the perioperative classification, diagnosis, description and repair of hiatus hernias in randomized controlled trials","volume":"37","author":"Abouelella","year":"2024","journal-title":"Dis Esophagus"},{"issue":"7\u20138","key":"2026012808272250500_ref8","doi-asserted-by":"publisher","first-page":"789","DOI":"10.3109\/00365521.2011.579154","article-title":"Endoscopic grading of gastroesophageal flap valve helps predict proton pump inhibitor response in patients with gastroesophageal reflux disease","volume":"46","author":"Cheong","year":"2011","journal-title":"Scand J Gastroenterol"},{"issue":"3","key":"2026012808272250500_ref9","doi-asserted-by":"publisher","first-page":"E311","DOI":"10.1055\/s-0042-101021","article-title":"Hill classification is superior to the axial length of a hiatal hernia for assessment of the mechanical anti-reflux barrier at the gastroesophageal junction","volume":"4","author":"Hansdotter","year":"2016","journal-title":"Endosc Int Open"},{"issue":"4","key":"2026012808272250500_ref10","doi-asserted-by":"crossref","first-page":"404","DOI":"10.1177\/26345161241293522","article-title":"American foregut classification is superior to Hill classification in evaluation of the gastroesophageal junction","volume":"4","author":"Swei","year":"2024","journal-title":"Foregut"},{"issue":"2","key":"2026012808272250500_ref11","doi-asserted-by":"crossref","first-page":"107","DOI":"10.1177\/26345161241230940","article-title":"Does the American foregut society endoscopic classification of Esophago-gastric junction integrity predict acid reflux and Esophago-gastric junction disruption?","volume":"5","author":"Siboni","year":"2024","journal-title":"Foregut"},{"issue":"10","key":"2026012808272250500_ref12","doi-asserted-by":"publisher","first-page":"1030","DOI":"10.1111\/j.1365-2036.2009.04142.x","article-title":"Development of the GerdQ, a tool for the diagnosis and management of gastro-oesophageal reflux disease in primary care","volume":"30","author":"Jones","year":"2009","journal-title":"Aliment Pharmacol Ther"},{"issue":"2","key":"2026012808272250500_ref13","doi-asserted-by":"crossref","first-page":"130","DOI":"10.1111\/j.1442-2050.2007.00658.x","article-title":"The development of the GERD-HRQL symptom severity instrument","volume":"20","author":"Velanovich","year":"2007","journal-title":"Dis Esophagus"},{"issue":"2","key":"2026012808272250500_ref14","doi-asserted-by":"crossref","first-page":"274","DOI":"10.1016\/S0892-1997(02)00097-8","article-title":"Validity and reliability of the reflux symptom index (RSI)","volume":"16","author":"Belafsky","year":"2002","journal-title":"J Voice"},{"issue":"8","key":"2026012808272250500_ref15","doi-asserted-by":"publisher","first-page":"1760","DOI":"10.14309\/ajg.0000000000003499","article-title":"Validation of esophageal global symptom severity as a patient-reported outcome for evaluation of reflux symptoms","volume":"120","author":"Chan","year":"2025","journal-title":"Am J Gastroenterol"},{"issue":"2","key":"2026012808272250500_ref16","doi-asserted-by":"publisher","first-page":"131","DOI":"10.1055\/a-2205-2613","article-title":"Training in basic gastrointestinal endoscopic procedures: a European Society of Gastrointestinal Endoscopy (ESGE) and European Society of Gastroenterology and Endoscopy Nurses and associates (ESGENA) position statement","volume":"56","author":"Antonelli","year":"2024","journal-title":"Endoscopy"},{"issue":"1","key":"2026012808272250500_ref17","doi-asserted-by":"publisher","first-page":"e14058","DOI":"10.1111\/nmo.14053","article-title":"Esophageal motility disorders on high-resolution manometry: Chicago classification version 4.0\u00a9","volume":"33","author":"Yadlapati","year":"2021","journal-title":"Neurogastroenterol Motil"},{"issue":"3","key":"2026012808272250500_ref18","doi-asserted-by":"publisher","first-page":"353","DOI":"10.1111\/nmo.12267","article-title":"Quantifying esophagogastric junction contractility with a novel HRM topographic metric, the EGJ-contractile integral: normative values and preliminary evaluation in PPI non-responders","volume":"26","author":"Nicod\u00e8me","year":"2014","journal-title":"Neurogastroenterol Motil"},{"issue":"7","key":"2026012808272250500_ref19","doi-asserted-by":"publisher","first-page":"1761","DOI":"10.1016\/j.cgh.2022.10.008","article-title":"Improving the diagnostic yield of high-resolution esophageal manometry for GERD: the \"straight leg-raise\" international study","volume":"21","author":"Siboni","year":"2023","journal-title":"Clin Gastroenterol Hepatol"},{"key":"2026012808272250500_ref20","doi-asserted-by":"publisher","first-page":"e70102","DOI":"10.1111\/nmo.70102","article-title":"Optimizing the straight leg raise maneuver to improve prediction of conclusive gastro-esophageal reflux disease","volume":"37","author":"Siboni","year":"2025","journal-title":"Neurogastroenterol Motil"},{"issue":"5","key":"2026012808272250500_ref21","doi-asserted-by":"publisher","first-page":"552","DOI":"10.1002\/ueg2.12565","article-title":"The Milan score: a novel manometric tool for a more efficient diagnosis of gastro-esophageal reflux disease","volume":"12","author":"Siboni","year":"2024","journal-title":"United European Gastroenterol J"},{"issue":"10","key":"2026012808272250500_ref22","doi-asserted-by":"publisher","first-page":"1","DOI":"10.1111\/nmo.13067","article-title":"Ambulatory reflux monitoring for diagnosis of gastro-esophageal reflux disease: update of the Porto consensus and recommendations from an international consensus group","volume":"29","author":"Roman","year":"2017","journal-title":"Neurogastroenterol Motil"},{"issue":"9","key":"2026012808272250500_ref23","doi-asserted-by":"publisher","first-page":"966","DOI":"10.1016\/j.dld.2020.04.031","article-title":"A SIGE-SINGEM-AIGO technical review on the clinical use of esophageal reflux monitoring","volume":"52","author":"Savarino","year":"2020","journal-title":"Dig Liver Dis"},{"issue":"32","key":"2026012808272250500_ref24","doi-asserted-by":"publisher","first-page":"4371","DOI":"10.3748\/wjg.v18.i32.4371","article-title":"Alginate controls heartburn in patients with erosive and nonerosive reflux disease","volume":"18","author":"Savarino","year":"2012","journal-title":"World J Gastroenterol"},{"issue":"9","key":"2026012808272250500_ref25","doi-asserted-by":"publisher","first-page":"1976","DOI":"10.1016\/j.cgh.2020.09.002","article-title":"Inter-reviewer variability in interpretation of pH-impedance studies: the Wingate consensus","volume":"19","author":"Gyawali","year":"2021","journal-title":"Clin Gastroenterol Hepatol"},{"issue":"1","key":"2026012808272250500_ref26","doi-asserted-by":"publisher","first-page":"40","DOI":"10.1016\/j.cgh.2015.06.026","article-title":"Analyses of the post-reflux swallow-induced peristaltic wave index and nocturnal baseline impedance parameters increase the diagnostic yield of impedance-pH monitoring of patients with reflux disease","volume":"14","author":"Frazzoni","year":"2016","journal-title":"Clin Gastroenterol Hepatol"},{"issue":"8","key":"2026012808272250500_ref27","doi-asserted-by":"publisher","first-page":"1881","DOI":"10.1007\/s10620-017-4625-8","article-title":"Impedance-pH monitoring for diagnosis of reflux disease: new perspectives","volume":"62","author":"Frazzoni","year":"2017","journal-title":"Dig Dis Sci"},{"issue":"4","key":"2026012808272250500_ref28","doi-asserted-by":"crossref","first-page":"740","DOI":"10.1111\/j.1572-0241.2003.07398.x","article-title":"Ambulatory esophageal pH monitoring using a wireless system","volume":"98","author":"Pandolfino","year":"2003","journal-title":"Am J Gastroenterol"},{"issue":"4","key":"2026012808272250500_ref29","doi-asserted-by":"publisher","first-page":"453","DOI":"10.5056\/jnm21077","article-title":"2020 Seoul consensus on the diagnosis and Management of Gastroesophageal Reflux Disease","volume":"27","author":"Jung","year":"2021","journal-title":"J Neurogastroenterol Motil"},{"issue":"1","key":"2026012808272250500_ref30","doi-asserted-by":"publisher","first-page":"27","DOI":"10.14309\/ajg.0000000000001538","article-title":"ACG clinical guideline for the diagnosis and Management of Gastroesophageal Reflux Disease","volume":"117","author":"Katz","year":"2022","journal-title":"Am J Gastroenterol"},{"issue":"5","key":"2026012808272250500_ref31","doi-asserted-by":"publisher","first-page":"984","DOI":"10.1016\/j.cgh.2022.01.025","article-title":"AGA clinical practice update on the personalized approach to the evaluation and management of GERD: expert review","volume":"20","author":"Yadlapati","year":"2022","journal-title":"Clin Gastroenterol Hepatol"},{"issue":"2","key":"2026012808272250500_ref32","doi-asserted-by":"publisher","first-page":"93","DOI":"10.3322\/caac.21388","article-title":"The eighth edition AJCC cancer staging manual: continuing to build a bridge from a population-based to a more \"personalized\" approach to cancer staging","volume":"67","author":"Amin","year":"2017","journal-title":"CA Cancer J Clin"},{"issue":"11","key":"2026012808272250500_ref33","doi-asserted-by":"publisher","first-page":"E1468","DOI":"10.1055\/a-0990-9737","article-title":"A novel endoscopic assessment of the gastroesophageal junction for the prediction of gastroesophageal reflux disease: a pilot study","volume":"07","author":"Inoue","year":"2019","journal-title":"Endosc Int Open"},{"key":"2026012808272250500_ref34","doi-asserted-by":"publisher","first-page":"doad004","DOI":"10.1093\/dote\/doad004","article-title":"What is the significance of the Hill classification?","volume":"36","author":"Br\u00e4nnstr\u00f6m","year":"2023","journal-title":"Dis Esophagus"},{"issue":"6","key":"2026012808272250500_ref35","doi-asserted-by":"publisher","first-page":"1148","DOI":"10.1097\/XCS.0000000000001088","article-title":"Correlation of the endoscopic gastroesophageal flap valve with pathologic reflux","volume":"238","author":"Manasa","year":"2024","journal-title":"J Am Coll Surg"},{"issue":"1","key":"2026012808272250500_ref36","doi-asserted-by":"crossref","first-page":"22","DOI":"10.1016\/j.gie.2005.07.030","article-title":"Endoscopic measurement of cardia circumference as an indicator of GERD","volume":"63","author":"Seltman","year":"2006","journal-title":"Gastrointest Endosc"},{"issue":"1 Pt 1","key":"2026012808272250500_ref37","doi-asserted-by":"publisher","first-page":"G139","DOI":"10.1152\/ajpgi.1989.256.1.G139","article-title":"Sphincteric action of the diaphragm during a relaxed lower esophageal sphincter in humans","volume":"256","author":"Mittal","year":"1989","journal-title":"Am J Physiol"},{"issue":"16","key":"2026012808272250500_ref38","doi-asserted-by":"publisher","first-page":"1513","DOI":"10.1056\/NEJMoa1811424","article-title":"Randomized trial of medical versus surgical treatment for refractory heartburn","volume":"381","author":"Spechler","year":"2019","journal-title":"N Engl J Med"},{"key":"2026012808272250500_ref39","doi-asserted-by":"publisher","DOI":"10.1097\/SLA.0000000000006747","article-title":"Abnormal Milan score and compromised esophageal mucosal integrity stratify gastroesophageal reflux disease severity","author":"Sozzi","year":"2025","journal-title":"Ann Surg"},{"key":"2026012808272250500_ref40","doi-asserted-by":"publisher","first-page":"1048","DOI":"10.1111\/apt.70413","article-title":"Combined Lyon and Milan scores predict Gerd Management outcome better than either score alone or their individual components","volume":"62","author":"Siboni","year":"2025","journal-title":"Aliment Pharmacol Ther"}],"container-title":["Diseases of the Esophagus"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/academic.oup.com\/dote\/article-pdf\/39\/1\/doag004\/66610785\/doag004.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"syndication"},{"URL":"https:\/\/academic.oup.com\/dote\/article-pdf\/39\/1\/doag004\/66610785\/doag004.pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,1,28]],"date-time":"2026-01-28T13:27:29Z","timestamp":1769606849000},"score":1,"resource":{"primary":{"URL":"https:\/\/academic.oup.com\/dote\/article\/doi\/10.1093\/dote\/doag004\/8443124"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,1,9]]},"references-count":40,"journal-issue":{"issue":"1","published-print":{"date-parts":[[2026,1,9]]}},"URL":"https:\/\/doi.org\/10.1093\/dote\/doag004","relation":{},"ISSN":["1120-8694","1442-2050"],"issn-type":[{"value":"1120-8694","type":"print"},{"value":"1442-2050","type":"electronic"}],"subject":[],"published-other":{"date-parts":[[2026,2]]},"published":{"date-parts":[[2026,1,9]]},"article-number":"doag004"}}