Endoscopic Classification of Fundoplication Integrity Predicts Pathologic Reflux: Development and Prospective Validation

We aimed to validate individual endoscopic parameters against clinical and functional testing and to build a simple classification of fundoplication integrity.

Endoscopy is the main tool to assess the gastroesophageal valve after antireflux surgery (ARS), but existing classifications are complex and have never been validated against objective pathophysiologic data.

This was a single-center, two-phase cohort study of adults undergoing endoscopy, high-resolution manometry (HRM), and reflux monitoring after ARS. Retroflexed videoclips were reviewed blinded to functional results. In the development cohort (2018-2024), endoscopic parameters were tested against pathologic GERD (Lyon 2.0 criteria); those correlating with reflux were included in the classification and the population was stratified according to the number of impaired mechanisms (0-3). In the second phase, the classification was validated prospectively (2024-2026).

Of 122 patients, 73 formed the development and 49 the validation cohort. Three parameters were associated with pathologic GERD: intrathoracic valve, disrupted valve, and visible hiatus. Clinical, manometric, and reflux metrics worsened stepwise with the number of impaired mechanisms, and pathologic GERD rose from 11.8% to 37.5% to 85.7%. The new classification discriminated pathologic GERD with an area under the curve of 0.860 in the development and 0.870 in the validation cohort (0.869 overall).

A simple endoscopic classification based on valve location, disruption, and hiatal opening reliably identifies fundoplication failure and correlates with symptoms, manometric features, and reflux burden.