Esophageal achalasia is a chronic and progressive motility disorder that leads to massive esophageal dilation when left untreated. Treatment for achalasia is palliative and aimed to relieve the outflow obstruction at the level of the lower esophageal sphincter, yet protecting the esophageal mucosa from refluxing gastric acids. The best way to accomplish this goal is through an esophageal myotomy and partial fundoplication, with a success rate >90%. Progression of disease, treatment failure, and complications from gastroesophageal reflux disease cause progressive deterioration of the esophageal function to an end stage in about 5% of patients. The only chance to improve symptoms in this small group of patients is through an esophageal resection. This article will review the indications for esophagectomy in end-stage achalasia, present the different types of surgical approach and possibilities for reconstruction of the alimentary tract, and summarize the short-term and long-term postoperative results.