Barrett's metaplasia can develop in patients with gastroesophageal reflux disease (GERD), and metaplasia can evolve into dysplasia and adenocarcinoma. The optimal treatment for Barrett's metaplasia and dysplasia is still being debated. The study reported herein was designed to assess the following: (1) the incidence of Barrett's metaplasia among patients with GERD; (2) the ability of laparoscopic fundoplication to control symptoms in patients with Barrett's metaplasia; (3) the results of esophagectomy in patients with high-grade dysplasia; and (4) the character of endoscopic follow-up programs of patients with Barrett's disease being managed by physicians throughout a large geographic region (northern California). Five-hundred thirty-five patients evaluated between October 1989 and February 1997 at the University of California San Francisco Swallowing Center had a diagnosis of GERD established by upper gastrointestinal series, endoscopy, manometry, and pH monitoring. Thirty-eight symptomatic patients with GERD and Barrett's metaplasia underwent laparoscopic fundoplication. Eleven other consecutive patients with high-grade dysplasia underwent transhiatal esophagectomies. Barrett's metaplasia was present in 72 (13%) of the 535 patients with GERD. The following results were achieved in patients who underwent laparoscopic fundoplication (n = 38): Heartburn resolved in 95% of patients, regurgitation in 93% of patients, and cough in 100% of patients. With regard to transhiatal esophagectomy (n = 11), the average duration of the operation was 339 +/- 89 minutes. The only significant complications were two esophageal anastomotic leaks, both of which resolved without sequelae. Mean hospital stay was 14 +/- 5 days. There were no deaths. The specimens showed high-grade dysplasia in seven patients and invasive adenocarcinoma (undiagnosed preoperatively) in four (36%). These results can be summarized as follows: (1) Barrett's metaplasia was present in 13% of patients with GERD being evaluated at a busy diagnostic center; (2) laparoscopic fundoplication was highly successful in controlling symptoms of GERD in patients with Barrett's metaplasia; (3) in patients with high-grade dysplasia esophagectomy was performed safely (invasive cancer had eluded preoperative endoscopic biopsies in one third of these patients); and (4) even though periodic endoscopic examination of Barrett's disease is universally recommended, this was actually done in fewer than two thirds of patients being managed by a large number of independent physicians in this geographic area.