An Exploratory Endoscopic Achalasia Phenotype With Visible Squamocolumnar Junction and Distal Esophagogastric Junction Relaxation Failure: Association With Gastroesophageal Reflux Disease After Peroral Endoscopic Myotomy (With Video)

BACKGROUNDS AND AIMS: Esophageal achalasia is typically defined by impaired lower esophageal sphincter (LES) relaxation. In rare cases, complete circumferential visibility of the squamocolumnar junction (SCJ) and upper gastric folds (GFs) is seen endoscopically, suggesting functional obstruction may extend to the distal esophagogastric junction rather than being confined to the LES. Such cases appear to be associated with a high risk of gastroesophageal reflux disease (GERD) after peroral endoscopic myotomy (POEM). We clarified the characteristics and significance of this rare endoscopic phenotype. METHODS: We retrospectively reviewed the data of 2553 patients who underwent POEM at our center between 2014 and 2023, and selected cases with full SCJ visibility and relaxation failure at the upper border of the GF before POEM. Patients with prior endoscopic or surgical treatments were excluded. Demographic, procedural, and GERD data were analyzed. GERD severity was assessed endoscopically. RESULTS: , respectively. None had a hiatal hernia. All had straight-type achalasia without advanced esophageal dilation. Median myotomy lengths were 7.0 (esophageal) and 4.0 (gastric) cm, respectively. Endoscopic esophagitis was observed in 92% and conclusive GERD in 75%, markedly exceeding previous rates. There was no significant difference in GERD incidence between the anterior and posterior myotomy approaches. CONCLUSIONS: These endoscopic findings may represent achalasia with distal relaxation failure and a high risk of conclusive GERD after POEM. Identifying this endoscopic feature is important for procedural planning.