Background: Clinical guidelines for the treatment of achalasia encourage surgical myotomy for patients under age 45, based on poor outcome of balloon dilatation of patients in this age group and a perceived higher operative risk in older patients, who are generally switched to endoscopic treatments. The purpose of this study was to evaluate the impact of age on the outcome of laparoscopic myotomy as primary treatment for esophageal achalasia. Methods: From 1992 to December 2007, 407 laparoscopic Heller-Dor (LapHD) procedures were performed by 4 staff surgeons at the same institution. Eighty-nine patients who underwent surgery after failed endoscopic treatment were excluded from the analysis. The study population was divided in 3 groups according of age (Group A: patients > 45 years; Group B patients older than 45 and younger than 65; Group C: patients > older than 65). All patients were evaluated preoperatively by a detailed symptom questionnaire, esophageal manometry, endoscopy and barium swallow. Results: There were 179 patients in the group A, 103 in the group B and 36 in the group C. The median duration of symptoms was similar in the three groups. Regarding the functional and radiological findings, the three groups differed for the symptoms score (Group A: median 25 [IQR 18-34], Group B median 27 [IQR 23-37], Group C: median 27 [IQR 22-39]; p<0.05), the esophageal diameter (Group A: median 35 mm [IQR 30-45], Group B median 40 mm [IQR 30-47], Group C: median 40 mm [IQR 35-50]; p<0.05) and the total length of the LES pressure (Group A: median 40 mmHg [IQR 34-47], Group B median 41.5 mmHg [IQR 34-50], Group C: median 49.5 mmHg [IQR 38.5-57.5]; p<0.05). Mortality was nil. The frequency of intraoperative complication (i.e. mucosal lesions) was higher in the group C (5/179, 2.8% vs 5/103, 4.9% vs 5/36, 13.8%; p<0.05). Findings on manometry (sphincter length, resting pressure, sphincter relaxation) were similar in the three groups. The symptoms score similarly decreased in the three groups (p<0.05). At a median follow up of 32 months, the percentage of patients classified as failure and requiring further treatment was similar in the three groups (19/179, 10.6% vs 9/103, 8.7% vs 3/36, 8.3%; p=n.s.). The same applied for patients showing post-operative GERD.Conclusion: Despite a higher frequency of intraoperative perforations ageing does not affect the feasibility and final outcome of LapHD. Surgical myotomy is an effective procedure that significantly improves symptoms in all patients, irrespective of age.