Miwa H, Yokoyama T, Hori K, Sakagami T, Oshima T, Tomita T, Fujiwara Y, Saita H, Itou T, Ogawa H, Nakamura Y, Kishi K, Murayama Y, Hayashi E, Kobayashi K, Tano N, Matsushita K, Kawamoto H, Sawada Y, Ohkawa A, Arai E, Nagao K, Hamamoto N, Sugiyasu Y, Sugimoto K, Hara H, Tanimura M, Honda Y, Isozaki K, Noda S, Kubota S, Himeno S
Department of Internal Medicine, Hyogo College of Medicine, Nishinomiya, Japan.
Dis Esophagus. 2008;21(4):355-63. doi: 10.1111/j.1442-2050.2007.00788.x.
The Los Angeles classification system is the most widely employed criteria associated with the greatest interobserver agreement among endoscopists. In Japan, the Los Angeles classification system has been modified (modified LA system) to include minimal changes as a distinct grade of reflux esophagitis, rather than as auxiliary findings. This adds a further grading M defined as minimal changes to the mucosa, such as erythema and/or whitish turbidity. The modified LA system has come to be used widely in Japan. However, there have been few reports to date that have evaluated the interobserver agreement in diagnosis when using the modified LA classification system incorporating these minimal changes as an additional grade. A total of 100 endoscopists from university hospitals and community hospitals, as well as private practices in the Osaka-Kobe area participated in the study. A total of 30 video clips of 30-40 seconds duration, mostly showing the esophagocardiac junction, were created and shown to 100 endoscopists using a video projector. The participating endoscopists completed a questionnaire regarding their clinical experience and rated the reflux esophagitis as shown in the video clips using the modified LA classification system. Agreement was assessed employing kappa (kappa) statistics for multiple raters. The kappa-value for all 91 endoscopists was 0.094, with a standard error of 0.002, indicating poor interobserver agreement. The endoscopists showed the best agreement on diagnosing grade A esophagitis (0.167), and the poorest agreement when diagnosing grade M esophagitis (0.033). The kappa-values for the diagnoses of grades N, M, and A esophagitis on identical video pairs were 0.275-0.315, with a standard error of 0.083-0.091, indicating fair intraobserver reproducibility among the endoscopists. The study results consistently indicate poor agreement regarding diagnoses as well as fair reproducibility of these diagnoses by endoscopists using the modified LA classification system, regardless of age, type of practice, past endoscopic experience, or current workload. However, grade M reflux esophagitis may not necessarily be irrelevant, as it may suggest an early form of reflux disease or an entirely new form of reflux esophagitis. Further research is required to elucidate the pathophysiological basis of minimal change esophagitis.
洛杉矶分类系统是内镜医师中应用最广泛且观察者间一致性最高的标准。在日本，洛杉矶分类系统已被修改（改良洛杉矶系统），将微小变化作为反流性食管炎的一个独立等级，而非辅助发现。这增加了一个进一步的分级M，定义为黏膜的微小变化，如红斑和/或白色浑浊。改良洛杉矶系统已在日本广泛使用。然而，迄今为止，很少有报告评估在使用纳入这些微小变化作为额外等级的改良洛杉矶分类系统时观察者间在诊断方面的一致性。来自大阪 - 神户地区大学医院、社区医院以及私人诊所的100名内镜医师参与了该研究。总共制作了30个时长30 - 40秒的视频片段，大多展示食管胃贲门交界处，并使用视频投影仪播放给100名内镜医师观看。参与的内镜医师完成了一份关于他们临床经验的问卷，并使用改良洛杉矶分类系统对视频片段中显示的反流性食管炎进行评分。采用kappa统计量评估多位评分者之间的一致性。所有91名内镜医师的kappa值为0.094，标准误为0.002，表明观察者间一致性较差。内镜医师在诊断A级食管炎时一致性最好（0.167），在诊断M级食管炎时一致性最差（0.033）。对于相同视频对中N级、M级和A级食管炎诊断的kappa值为0.275 - 0.315，标准误为0.083 - 0.091，表明内镜医师之间观察者内再现性一般。研究结果始终表明，无论年龄、执业类型、既往内镜经验或当前工作量如何，使用改良洛杉矶分类系统时内镜医师在诊断方面的一致性较差，且这些诊断的再现性一般。然而，M级反流性食管炎不一定无关紧要，因为它可能提示反流疾病的早期形式或一种全新的反流性食管炎形式。需要进一步研究以阐明微小变化性食管炎的病理生理基础。
