Currently there are three acceptable long-term treatments of achalasia: pneumatic dilatation, laparoscopic Heller myotomy, and botulinum toxin injection. Primarily retrospective studies suggest equal efficacy of pneumatic dilatation and surgical myotomy, especially in centers with expertise in both treatments. Randomized prospective studies find pneumatic dilatation superior to botulinum toxin because of the need for serial frequent treatments with the latter therapy. All cost analysis studies support the superiority of pneumatic dilatation over the two other treatments.