A 62-year-old male attorney presents with a 2-year history of severe intermittent retrosternal chest pain, dysphagia to solids and liquids, and 8 kg weight loss. Cardiac workup is completely normal. Upper endoscopy shows no obstruction. High-resolution esophageal manometry demonstrates elevated integrated relaxation pressure (IRP 28 mmHg), and the structure marked **B** in the diagram is documented in 70% of swallows. Which of the following best explains why this patient has the WORST prognosis with conventional therapies like pneumatic dilation and botulinum toxin injection compared to other achalasia subtypes?
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