Achalasia is a neurodegenerative motility disorder of the esophagus; dysphagia, weight loss, chest pain, and regurgitation are its main symptoms. Surgical myotomy (HM) is considered the gold standard treatment. However, peroral endoscopic myotomy (POEM) seems to be a safe and effective alternative option. The aim of this study is to compare the safety and efficacy of these techniques. From March 2012 to June 2015, 74 patients with symptomatic primary achalasia underwent myotomy. The two groups were compared in terms of intraoperative and postoperative outcomes and Eckardt score at last follow-up. A morphofunctional comparison was also performed. Thirty-two myotomies were performed endoscopically (POEM group) and 42 were performed laparoscopically with a 180° anterior fundoplication (surgical myotomy [SM] group). Operative time was significantly shorter for the POEM group (63 [range: 32–114] vs. 76 minutes [54–152]; P = 0.0005). Myotomy was significantly longer for the POEM group (12 [range: 10–15] vs. 9 cm [range: 7–10]; P = 0.0001). Postoperative morbidity occurred in two patients (4.7%) in the SM group; no complications (P = not significant) were recorded for the POEM group. The median Eckardt score at last follow-up decreased for each group from 6 to 1 (P < 0.001). Morphological evaluation was performed for 20 patients and functional evaluation was performed in 18 patients of each group. Lower esophageal sphincter resting and relaxation pressures were significantly reduced in both groups (P < 0.001). Eight patients in the POEM group (40%) had esophagitis at endoscopy: 4 (20%) with Los Angeles (LA) grade A, 3 (15%) with LA grade B, and 1 patient with LA grade D (5%). Five patients in POEM group (28%) had a pathologic DeMeester score. In the SM group, one patient (5%) had esophagitis (P = 0.04; 95% CI) and 4 patients (22%) presented a pathological DeMeester score. Perioperative results for POEM and SM are similar. The absence of an antireflux wrap leads to an increased risk of reflux with consequent esophagitis. SM with an antireflux wrap could be a preferred choice when a long standing gastroesophageal reflux could potentially lead to a damage as, for example, in young patients. © 2017, © The Authors 2017. Published by Oxford University Press on behalf of International Society for Diseases of the Esophagus. All rights reserved. For permissions, please e-mail: email@example.com.