Esophageal achalasia is the most common primary motility disorder of the esophageal body and lower esophageal sphincter. The optimal management strategy for elderly patients with achalasia remains inconclusive, however elderly patients are still more likely to be recommended for endoscopic treatments rather than LHM, due to a perception of increased surgical risk in these patients. Advantages of surgical myotomy in the elderly over pneumatic dilation are: 1. the risk of mucosal perforation during surgery is better controlled than after endoscopic balloon dilatation and 2. the greater efficacy for the surgical approach where only one procedure is routinely required whereas pneumatic dilation often requires repeat treatment to achieve long-term relief of symptoms.