Traditional treatment of achalasia, pneumatic dilatation or surgical myotomy, results in satisfactory relief of dysphagia in 85% to 90% of patients. Unfortunately, a small percentage of patients do not respond to these therapies or remain refractory, often because of a severely dilated or sigmoid esophagus. Esophagectomy, with gastric pull up or color interposition, is the procedure of choice in these patients, which can result in satisfactory relief of dysphagia with minimal mortality. This article reviews the strategies for management of achalasia patients with refractory dysphagia.