Gastroesophageal reflux disease is one of the most challenging diagnostic and therapeutic problems in benign esophageal disease. Symptoms alone are not a reliable guide to the diagnosis of the disease. Of patients thought to have gastroesophageal reflux disease based on symptoms alone, 25% to 30% do not have increased esophageal exposure to gastric juice on 24-hour pH study. The presence and severity of reflux complications,ie, esophagitis, stricture, and Barrett's esophagus, are related to the presence of a mechanically defective sphincter and an increased esophageal exposure to both acid and alkalinity. Antireflux surgery has been shown to be superior to medical therapy in a recent prospective multicenter randomized trial. Optimal surgical results, however, require the selection of the appropriate antireflux procedure. Options include transabdominal and transthoracic Nissen fundoplication, a Belsey partial fundoplication, often in combination with a Collis gastroplasty as an esophageal lengthening procedure, or rarely an esophageal resection and reconstruction. Twenty-four hour ambulatory manometry improves the diagnostic sensitivity in esophageal motility disorders. Excellent results are obtained with surgical myotomy for achalasia, most recently performed with video-assisted endosurgical techniques. A long esophageal myotomy is a valid treatment alternative in select patients with diffuse esophageal spasm. Technical aspects of esophageal surgery continue to challenge clinicians. Despite difficulties in demonstrating objective benefit, transhiatal esophagectomy has gained widespread acceptance as an alternative to the traditional combined laparotomy and right thoracotomy approach, particularly in the setting of benign esophageal disease and in the palliation of esophageal cancer. Respiratory complications are the most troublesome problems postoperatively. Antireflux surgery may also be superior to medical therapy in preventing complications of Barrett's esophagus, including the development of dysplasia and carcinoma. Endoscopic surveillance of Barrett's esophagus allows early detection of adenocarcinoma and may decrease the mortality rate for esophageal cancer in these patients. Increasing evidence suggests that survival of patients undergoing en bloc esophagogastrectomy for carcinoma of the lower esophagus is improved when compared with standard esophagectomy. Adjuvant radiotherapy alone has now been shown conclusively to be of no benefit for patients with carcinoma of the esophagus.