The initial treatment for achalasia in most centers is pneumatic dilation (PD). The most significant complication of PD is esophageal perforation (EP). During the past ten years, six patients were noted to have EP after PD at St. Luke's-Roosevelt Hospital Center. The cornerstone of treatment is early diagnosis. Operative repair, including suture of the perforation and modified Heller esophagomyotomy without anti-reflux procedure, is preferred. Details of this operation are presented. We have successfully managed five patients with EP after PD. A sixth patient died of unrecognized EP.