Title : Clinical-endoscopic correlation of the surgical wrap after gastric fundoplication: Development and characterization of the Standardized Endoscopic Fundoplication (SEF) score
Abstract:
Background: Postoperative endoscopic assessment of the fundoplication wrap remains poorly standardized. Single-parameter classifications such as the Hill grade of the gastroesophageal flap valve, and Mittal-type descriptive systems, have been associated with substantial inter-observer variability and an inconsistent relationship with patients' symptomatic status.
Aim: To characterize the clinical-endoscopic correlation of the surgical wrap after gastric fundoplication using a novel composite endoscopic instrument, the Standardized Endoscopic Fundoplication (SEF) score (11 anatomical components, total range 0–16), and to test its convergent validity against two established endoscopic classifications — the postoperative Hill grade and the Los Angeles (LA) grade of reflux esophagitis — as well as against postoperative symptomatic status.
Methods: Retrospective cohort study based on a structured clinical registry of 178 consecutive patients undergoing laparoscopic or open fundoplication (Nissen, Toupet, or Dor) for gastroesophageal reflux disease and/or hiatal hernia. The SEF score, automatically computed from 11 endoscopic domains (wrap position, integrity, symmetry, length, tension, retroflexed appearance, and absence of hernia, migration, slippage, torsion, and severe esophagitis) recorded at postoperative endoscopy. Associations between the SEF total score and the ordinal Hill grade (4 categories) and LA grade (5 categories) were assessed with Spearman's correlation and the Kruskal-Wallis test; agreement between SEF category (1–4) and Hill grade was quantified with a linear-weighted kappa. Secondary, hypothesis-generating analyses examined SEF score by fundoplication type and its correlation with the Visick symptom grade.
Results: The mean SEF total score was 12.9 ± 3.8 (median 14; IQR 11–16), with 58.4% of patients (n = 104) classified as a functional wrap, 19.7% (n = 35) minor abnormalities, 10.1% (n = 18) partial disruption, and 11.8% (n = 21) as failed fundoplication. The SEF score correlated strongly and inversely with postoperative Hill grade (Spearman ρ = -0.75, p < 0.001) and with LA esophagitis grade (ρ = -0.72, p < 0.001), with significant between-group differences on Kruskal-Wallis testing (p < 0.001 for both). Agreement between SEF category and Hill grade was moderate (linear-weighted kappa = 0.585). The SEF score also correlated significantly with postoperative Visick symptom grade (ρ = -0.69, p < 0.001) and differed significantly by fundoplication type (p < 0.001), being highest after Nissen fundoplication.
Conclusion: The SEF score provides a granular, anchor-based description of postoperative wrap anatomy and shows strong convergent validity against two independent endoscopic classifications, together with a significant clinical-endoscopic correlation with symptomatic status. These findings support its potential as a standardized reporting instrument for postoperative fundoplication assessment, addressing the inter-observer variability documented for existing single-parameter classifications. Formal inter-observer reliability testing and prospective comparison against the surgical gold standard (intraoperative findings at redo surgery) remain necessary next steps before wider adoption.
