Objective: To compare long-term cost-effectiveness of laparoscopic nissen fundoplication (LNF) versus proton pump inhibitor (PPI) maintenance for severe gastro-oesophageal reflux disease (GORD). Methods: Patient level data on costs and outcomes up to 12-month follow up were obtained from the first 100 patients in a randomised control trial comparing LNF and PPI, based at the Norfolk and Norwich University Hospital. Detailed costing was performed from an NHS perspective. Costs were extrapolated to future years with one-way sensitivity analysis on modelling assumptions. Incremental cost-effectiveness ratios and confidence intervals were estimated using bootstrap simulation. Results: LNF was more effective than PPI and £2,166() more costly in year one, with a cost of £2,687() compared with £521(). LNF is cost saving by year 7, irrespective of changes in modelling assumptions such as the relapse rate and the future price of medication. A 10% change in surgical costs changes the "break-even" point by 1 year. In year 1, cost per patient returned to a normal DeMeester score (<13.9 at 3 months) was £5,515(), ranging from £3,655() to £13,400() and cost per percentage point improvement in Gastro-Intestinal and Psychological Well-being quality of life score was £430() with a range of £207() to £6,400(). By year 5, cost per physiologically normal patient was £1,146() and cost per percentage point improvement in quality of life was £93(). Conclusion: From the perspective of a public sector payer (UK National Health Service), LNF surgery in this trial was cost-effective at a time horizon of 3-5 years; and likely to become cost saving after 7 years.