Despite several advances in the understanding of the pathophysiology of achalasia, treatment remains palliative as the neuronal defect of the disease seems to be irreversible. Currently, the most effective treatment options are graded endoscopic pneumatic dilation and laparoscopic Heller myotomy with partial fundoplication. Although both treatments seem to have similar efficacy in the short-term, the durability of surgical myotomy makes it the favored approach in young patients and in those who want to avoid frequent repeated interventions. Predictors of treatment response have been well defined and should be considered when one therapeutic option is chosen over another. In addition, patient preferences and local are the major are major factors that determine treatment choice. A complete preoperative work up, evaluating patient and disease characteristics, is a key element of a successful treatment.