Exploring esophagogastric junction morphology and contractile integral: implications for refractory gastroesophageal reflux disease pathophysiology

Background: Evaluate the clinical significance of esophagogastric junction (EGJ) morphology and esophagogastric junction contractile integral (EGJ-CI) in refractory gastroesophageal reflux disease (RGERD) patients. Methods: From June 2021 to June 2023, 144 RGERD patients underwent comprehensive evaluation, recording symptom scores, demographic data. GERD classification (NERD or RE, A-D) was based on endoscopic findings. Reflux was assessed through 24-hour pH-impedance monitoring, and high-resolution esophageal manometry(HREM) measured parameters including EGJ-CI. Results: HREM revealed EGJ morphologies (type I, II, III) in 80.6%, 13.9%, and 5.6% of subjects, respectively. As the separation between the lower esophageal sphincter(LES) and crural diaphragm(CD) increased, EGJ-CI decreased (p < 0.005). Subjects with EGJ morphology types II and III had significantly higher acid exposure times(AET), DeMeester scores, and impedance reflux times than type I (p < 0.05). There was no statistical difference between types II and III. Impedance reflux times in subjects with type III morphology were significantly higher than those with types I and II (p < 0.05). The optimal EGJ-CI cutoff for distinguishing pathological reflux was 24.8 mmHg<middle dot>cm, with 68% sensitivity, 72.3% specificity, and an AUC of 0.693 (95% CI 0.609-0.768). Logistic regression analysis identified EGJ-CI <24.8 mmHg<middle dot>cm (OR = 2.5, 95% CI 1.1-5.5, p = 0.022) and ineffective esophageal motility(IEM) (OR = 2.4, 95% CI 1.2-5.2, p = 0.027) as independent risk factors. Conclusion: EGJ-CI is crucial for clinically assessing EGJ barrier function, predicting pathological reflux and selecting patients with persistent reflux symptoms for surgery.