A systematic review and meta-analysis of the prevalence of reflux symptoms after esophagectomy: patient-reported outcomes and management

BACKGROUND: Esophageal cancer predominantly affects middle-aged and older adults, and postoperative reflux is one of the most common long-term complications after curative esophagectomy. It can persist for years and impair quality of life. However, no previous review has quantified the incidence of postoperative reflux or its related factors. This study aimed to summarize the prevalence and time course of reflux after esophagectomy and to explore associated determinants. METHODS: We systematically searched PubMed, Embase, Web of Science and other major databases from inception, without time limits. We included original studies reporting postoperative reflux symptoms or reflux esophagitis after curative esophagectomy for primary esophageal cancer. Patient-reported reflux symptoms were the primary outcome, and endoscopically confirmed reflux esophagitis was the secondary outcome. We used random-effects models to pool prevalence, restricted cubic splines to model time trends, and meta-regression to explore heterogeneity and publication bias. RESULTS: We included 28 studies with 5,276 patients. Pooled prevalence was 38% for symptomatic reflux and 33% for reflux esophagitis, with high heterogeneity. Symptoms peaked at about 30 months, while reflux esophagitis peaked at about 35 months and then plateaued. Mean age, questionnaire threshold, medication coverage, and the timing of endoscopic assessment explained part of the heterogeneity. DISCUSSION: Reflux is a common long-term problem in survivors after esophagectomy for esophageal cancer. The trajectory of patient-reported symptoms does not fully mirror changes in endoscopic mucosal injury. CONCLUSIONS AND IMPLICATIONS: Reflux is common after esophagectomy and may affect long-term recovery. Symptom patterns do not fully match mucosal injury, so symptoms alone cannot reflect esophageal damage well. Follow-up should focus on the first 3 years after surgery, with standardized symptom assessment, planned endoscopic monitoring, and clear recording of acid-suppressive therapy and other key clinical factors to support risk stratification and targeted care.