Background: There are currently two different treatment modalities available for treatment of achalsia; pneumatic dilation (PD) and Heller myotomy (HM). Both of them are focused on decreasing the LES resting pressure thereby allowing the distal esophagus to empty with the aid of gravity. Ideally, the choice between the 2 treatment options should be based upon prospective, randomized and comparative studies. Studies comparing pneumatic dilatation with rigiflex balloon and laparoscopic Heller myotomy have recently been reported. This study aims to compare the results of pneumatic dilatation versus laparoscopic Heller's myotomy combined with Dor fundoplication in cases of achalasia of the cardia to consider which group of patients should be subjected to either methods for better management. Methods: This study is a prospective randomized clinical trial conducted in Ain Shams University Hospitals during the period from June 2012 till October 2014. Thirty patients who were diagnosed as having achalsia were randomized into 2 groups: group A included 15 patients who underwent pneumatic dilatation and group B included 15 patients who underwent laparoscopic Heller's myotomy. Results: The mean operative time was significantly longer in Heller's myotomy group [99 (80-120min)] than pneumatic dilatation group [46.6(40-60min)] (P < 0.001). The mean hospital stay was significantly longer in the HM group 2.1 days than the PD group 1.1 day (P< 0.001). There was no need for conversion to open Heller's in the HM. There was no significant difference in the incidence of intraoperative complications between both groups. There was a statistically significant lower symptom scoring in the HM group than PD group (P<0.001). Postoperative complications in the form of reflux symptoms and recurrence of achalasia symptoms were significantly lower in the HM group than the PD group (P<0.001). Conclusion: Laparoscopic cardiomyotomy was found to be superior to an endoscopic balloon dilatation strategy in the treatment of achalasia when studied during the first 12 month after treatment with special care must be taken in the future studies to laparoscopic myotomy alone as it is thought to be the best way for the management of achalasia in the future.