Both laparoscopic Nissen fundoplication and proton pump inhibitors are effective modern therapies for reflux disease that have yet to be directly compared in a well-designed clinical trial. In terms of a risk/benefit analysis, the risk of an undesirable outcome or death from laparoscopic Nissen fundoplication exceeds that of maintenance treatment with proton pump inhibitors making the later the preferable therapy. Neither therapy increases or reduces the risk of death from cancer and there are no compelling economic arguments favoring surgical management. Instances in which laparoscopic Nissen fundoplication should be considered include: 1) Individuals who are intolerant of proton pump inhibitor therapy because of side effects, 2) When patients are inadequately responsive to proton pump inhibitor therapy even after dosage and dose interval have been optimized, and 3) When a patient desires a permanent solution to their reflux problem that frees them of the need to chronically consume pharmaceuticals. However, regardless of the motivation for pursuing surgical management, patients must be advised of potential suboptimal results and the irreversibility of the procedure.