Impact of hypercontractile esophagus on clinical and physiologic outcomes after antireflux surgery: a matched-control study

BACKGROUND: Hypercontractile esophagus is a motility disorder defined by ≥20% of swallows with a distal contractile integral (DCI) > 8000 mmHg·cm·s on high-resolution manometry. Although hypercontractility has been associated with gastroesophageal reflux disease (GERD), its impact on outcomes after antireflux surgery (ARS) and on postoperative esophageal physiology remains unclear. METHODS: Patients undergoing primary ARS from 2014 to 2023 with hypercontractile esophagus were identified from a prospectively maintained database and matched 1:2 to controls without hypercontractility by age, sex, and procedure type. Symptom outcomes, objective reflux control, and postoperative manometric changes were compared between the cohorts. RESULTS: Of 2205 patients undergoing ARS, 38 (1.7%) met the criteria for hypercontractile esophagus and were matched to 76 controls. Preoperative symptom burden and reflux severity were similar between the groups. At 1 year, GERD-Health-Related Quality of Life scores, Eckardt scores, satisfaction (86.7% vs 80.4%; P =.561), freedom from proton pump inhibitor use (87.5% vs 83.6%; P =.765), and pH normalization rates (73.9% vs 76.3%; P =.788) were comparable between the cohorts. Patients with hypercontractile esophagus demonstrated a reduction in postoperative DCI, whereas controls demonstrated an increase (-1681.5 vs +235.6 mmHg·cm·s; P =.024). Among those who underwent postoperative manometry, 50% no longer met criteria for hypercontractile esophagus. CONCLUSION: Patients with preoperative manometric hypercontractility achieved symptomatic and objective reflux outcomes comparable to those of matched controls after ARS. Among patients who underwent postoperative manometry, half no longer met the criteria for hypercontractility, and contractile vigor decreased rather than demonstrating the compensatory increase observed in controls. These findings suggest that manometric hypercontractility may be modifiable after reflux correction in a subset of patients and, when identified during preoperative evaluation, should not be considered a contraindication to ARS in appropriately selected patients.