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The data that support the findings of this study are available from the corresponding author upon reasonable request.

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Objectives Gastroesophageal reflux disease after lung transplantation may be associated with chronic lung allograft dysfunction. Aspiration may continue on medical management of reflux, but antireflux surgery potentially reduces all reflux. We compared outcomes between medical and surgical management of reflux in lung recipients. Methods Lung recipients with an elevated DeMeester score (≥14.72) on posttransplant reflux testing between 2015 and 2020 were included. Patients were divided into two groups: group A (underwent surgery) and group B (medically managed). Endpoints were pulmonary function, allograft dysfunction-free survival, and overall survival. Further analysis included subgroups: A1 (early surgery, <6 months) and A2 (late surgery, >6 months), and B1 (DeMeester <29.9) and B2 (DeMeester ≥30). Results A total of 186 included subjects were divided into groups A (n = 46 [A1, n = 36; A2, n = 10]) and B (n = 140 [B1, n = 78; B2, n = 62]). Compared to medically managed patients, patients who underwent surgery had a higher prevalence of hiatal hernia (p < 0.001) and a lower prevalence of esophageal motility disorders (p = 0.036). Recipients who underwent surgery had superior pulmonary function at 5 years compared to group B (p < 0.05) and longer allograft dysfunction-free survival than subgroup B2 (p = 0.028). Furthermore, early surgery was associated with longer survival than late surgery (p = 0.021). Conclusions Antireflux surgery in recipients with reflux improved long-term allograft function, and early surgery showed a survival benefit. Allograft dysfunction-free survival of lung recipients who underwent surgery was significantly better than that of medically managed patients with DeMeester ≥30. We present an algorithm for appropriate selection of candidates for antireflux surgery after LT.