ENDOSCOPIC EVALUATION OF THE ANTIREFLUX VALVE AFTER FUNDOPLICATION: SYNTHESIS OF THE EVIDENCE AND PROPOSAL OF A FUNCTIONAL ENDOSCOPIC SCORE

Abstract

Background. Antireflux fundoplication failure — recurrent reflux, dysphagia, gas-bloat syndrome, secondary to a herniated, slipped, too-tight, disrupted, or twisted valve — remains common, and its endoscopic diagnosis lacks a common, standardized reporting language.

Aim. To narratively review existing endoscopic instruments for postoperative antireflux valve assessment, the evidence on their interobserver reliability, and to position an original instrument — the Endoscopic Fundoplication Score (SEF) — within this landscape.

Methods. Narrative review, with a targeted search in PubMed/MEDLINE and Google Scholar (last search: 24 September 2026) using the terms “fundoplication,” “endoscopic grading,” “gastroesophageal valve,” “Hill classification,” “antireflux surgery outcome,” “interobserver reliability,” “wrap integrity,” and “hiatal hernia recurrence,” covering literature published between 1996 and 2026 in English or with an English abstract, supplemented by reference-list screening of identified articles.

Results. Three major endoscopic instruments were identified — the Hill classification (1996), the Jobe system (2004), and the American Foregut Society (AFS) nomenclature (2025) — alongside a descriptive, non-scored taxonomy of failure types (herniated, slipped, tight, disrupted, twisted). The interobserver reliability studies [1,2] identified in this review for the postoperative setting report low agreement, and a retrospective comparison of endoscopy reports [3] documented major discrepancies between external endoscopists and operating surgeons. The AFS classification of esophagogastric junction integrity achieved substantial agreement on static images (κ=0.65) but only fair agreement under dynamic conditions (κ=0.371), and the postoperative AFS nomenclature has not yet been tested for interobserver reliability. The SEF score, an 11-item composite instrument (0–16 points) applied to a cohort of 178 patients, correlated in preliminary single-centre data with the Hill classification, Los Angeles (LA) esophagitis grade, and the Visick patient-satisfaction score (own data, manuscript submitted for publication), offering a numeric, quantifiable alternative to existing categorical systems. The SEF threshold of ≤10 points, defined in the same cohort, is exploratory.

Conclusions. The field of postoperative endoscopic antireflux valve assessment remains fragmented, without an interobserver-reliable consensus standard. The SEF score partially addresses this gap through a numeric structure, with experience-based weights and an exploratory threshold, but requires formal interobserver reliability testing and multicenter validation against the surgical gold standard.