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Introduction Gastroesophageal reflux disease (GERD) is increasingly being managed with interventions beyond pharmacotherapy. While Nissen’s fundoplication remains the gold-standard surgical option, emerging endoscopic approaches such as transoral incisionless fundoplication and anti-reflux mucosal interventions offer less invasive alternatives for patients without a hiatal hernia requiring anatomical repair. Their adoption, however, is limited partly due to reliance on surgical outcome data. Published evidence from fundoplication comes from controlled trials with narrow inclusion criteria, which may not reflect the broader and more complex patient populations seen in routine NHS practice. The study aimed to assess the real-world fundoplication outcomes as a benchmark for evaluating endoscopic strategies.Methods A retrospective audit was performed on 100 adult patients who underwent anti-reflux surgery between January 2019 and December 2023 within a surgical service comprising approximately ten surgeons. Data was extracted from electronic patient records, including demographics, diagnostics, operative details and follow-up outcomes. Five predefined endpoints were assessed at final patient follow-up: PPI cessation, persistent reflux symptoms, swallowing problems, patient satisfaction and discharge from GI services. Subgroup analysis and univariate logistic regression explored associations between clinical variables and surgical outcomes, to identify patients better suited to endoscopic therapy.Results At final follow-up, 53% of patients had discontinued proton pump inhibitors while 64% were not discharged. Only 40% of patients were satisfied after treatment, with persistent reflux symptoms and dysphagia reported in 30%. Re-intervention was required in 16% of patients, predominantly via endoscopic dilatation (10%), with 6% requiring revisional surgery. Mean hospital stay following surgery was 1.67 days. While no subgroup differences reached statistical significance, patients with BRAVO-confirmed reflux were associated with better outcomes than catheter-based testing. Patients with atypical reflux symptoms had marginally poorer outcomes, and those receiving a 270-degree wrap were less likely to achieve PPI cessation.Conclusions Real-world PPI cessation after fundoplication was lower than clinical trial data, with a substantial burden of dysphagia requiring re-intervention. Dysphagia following endoscopic intervention is rare and usually managed conservatively. Endoscopic anti-reflux procedures, performed as day cases, provide comparable reflux control in carefully selected candidates with minimal inpatient burden. In an NHS under capacity pressure, delivering definitive reflux management without admission demonstrates meaningful resource savings. These findings underline the real-world limitations of fundoplication and support broader NHS adoption of endoscopic therapies, which offer clear advantages in cost-effectiveness and tolerability.