title: Endoscopic grading of the gastroesophageal flap valve is correlated with reflux activity and can predict the size of the esophageal hiatus in patients with gastroesophageal reflux disease.
abstract: BACKGROUND
  Endoscopic grading of the gastroesophageal flap valve (GEFV) is simple, reproducible, and suggested to be a good predictor of reflux activity. This study aimed to investigate the potential correlation between grading of the GEFV and quality of life (QoL), gastroesophageal reflux disease (GERD) symptoms, esophageal manometry, multichannel intraluminal impedance monitoring (MII) data, and size of the hiatal defect.
  
  
  METHODS
  The study included 43 patients with documented chronic GERD who underwent upper gastrointestinal endoscopy, esophageal manometry, and ambulatory MII monitoring before laparoscopic fundoplication. The GEFV was graded 1-4 using Hill's classification. QoL was evaluated using the Gastrointestinal Quality-of-Life Index (GIQLI), and gastrointestinal symptoms were documented using a standardized questionnaire. The size of the esophageal hiatus was measured during surgery by calculating the hiatal surface area (HSA). Analysis of the correlation between QoL, GERD symptoms, esophageal manometry, MII data, HSA size, and GEFV grading was performed. Statistical significance was set at a p value of 0.05.
  
  
  RESULTS
  A significant positive correlation was found between increased GEFV grade and DeMeester score, total number of acid reflux events, number of reflux events in the supine position, and number of reflux events in the upright position. Additionally, a significant positive correlation was found between HSA size and GEFV grading. No significant influence from intensity of GERD symptoms, QoL, and the GEFV grading was found. The mean LES pressures were reduced with increased GEFV grade, but not significantly.
  
  
  CONCLUSIONS
  The GEFV plays a major role in the pathophysiology of GERD. The results underscore the importance of reconstructing a valve in patients with GERD and an altered geometry of the gastroesophageal junction when they receive a laparoscopic or endoscopic intervention.
authors.affiliation: Department of General and Visceral Surgery, Sisters of Charity Hospital, 4010, Linz, Austria, oliver.owen.koch@gmail.com.
authors.forename: Oliver Owen
authors.initials: OO
authors.lastname: Koch
authors.forename: Georg
authors.initials: G
authors.lastname: Spaun
authors.forename: Stavros A
authors.initials: SA
authors.lastname: Antoniou
authors.forename: Charlotte
authors.initials: C
authors.lastname: Rabl
authors.forename: Gernot
authors.initials: G
authors.lastname: Köhler
authors.forename: Klaus
authors.initials: K
authors.lastname: Emmanuel
authors.forename: Dietmar
authors.initials: D
authors.lastname: Öfner
authors.forename: Rudolph
authors.initials: R
authors.lastname: Pointner
mesh_terms: D016099:Endoscopy, Gastrointestinal / Q000379:methods*; D050782:Esophageal pH Monitoring; D004943:Esophagogastric Junction / Q000378:metabolism / Q000503:physiopathology / Q000601:surgery*; D004947:Esophagus / Q000378:metabolism / Q000503:physiopathology*; D005260:Female; D005500:Follow-Up Studies; D018662:Fundoplication / Q000379:methods*; D005764:Gastroesophageal Reflux / Q000175:diagnosis / Q000503:physiopathology / Q000601:surgery*; D006801:Humans; D010535:Laparoscopy; D008297:Male; D008365:Manometry; D008875:Middle Aged; D011237:Predictive Value of Tests; D012189:Retrospective Studies; D012720:Severity of Illness Index