Background Esophagectomy for esophageal achalasia is usually performed after failed surgical myotomy or in case of sigmoid megaesophagus. We retrospectively reviewed the hospital records of patients undergoing esophageal resection and gastric pull-up for achalasia during the last decade and assessed the results using a prospectively collected database. Methods Between January 1997 and October 2006 11 patients [6M:5F; median age 52 years, Interquartile Range (IQR) 25-58], underwent esophagectomy for achalasia. They all had a megaesophagus secondary to achalasia: seven patients had undergone previous Heller myotomy followed by endoscopic dilation; one patient had had two and another patient three myotomies. Results All patients had an Ivor-Lewis esophagectomy; in two a laparoscopic mobilization of the stomach was performed. Esophagectomy was performed a median of 19.6 (IQR: 12-26.5) years after myotomy. Intraoperative complications included spleen damage in one patient, which required splenectomy; there were no deaths. Postoperative morbidity was 27.3%. One patient had anastomotic bleeding on post-op day 10, which required Argon laser treatment. One patient had early reoperation for chylothorax (post-op day 6). The median hospital stay was 13 days (IQR: 11-19). Four (36%) patients developed postoperative dysphagia: one underwent reoperation for remodeling of the gastric pull-up and three had endoscopic dilations (n. dil=2). All patients were free of dysphagia at a median follow-up of 54 (IQR: 32-59) months. They all had endoscopic follow-up, at a median of 30 months (IQR 10-47) after esophagectomy: one patient presented supra-anastomotic esophagitis at the last control. Four (36%) patients were on PPI therapy at last follow-up.Conclusions Esophageal resection and gastric pull-up achieves significant improvement of symptoms in patients with megaesophagus, even when previous endoscopic treatments or non-resective procedures are unsuccessful. However, esophagectomy, even for benign diseases, remains a major surgical procedure, burdened by a significant morbidity rate.