Endoscopic Classification of Fundoplication Integrity Predicts Pathologic Reflux

OBJECTIVE: We aimed to validate individual endoscopic parameters against clinical and functional testing and to build a simple classification of fundoplication integrity. SUMMARY BACKGROUND DATA: 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. METHODS: 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). RESULTS: 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). CONCLUSIONS: 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.