Pancreatic Exocrine Insufficiency Following Esophagectomy, Gastrectomy and Bariatric Surgery: A Systematic Review and Narrative Synthesis

Background Pancreatic exocrine insufficiency (PEI) is an increasingly recognised consequence of esophagogastric surgery; however, its prevalence, burden across different surgical procedures, and optimal approaches to diagnosis and management remain incompletely characterized. This review aims to systematically evaluate the prevalence, diagnosis, clinical manifestations, nutritional consequences and management of PEI following esophagogastric surgery in adults. Methods A systematic review and meta‐analysis was conducted according to Joanna Briggs Institute methodology and reported in accordance with PRISMA 2020. PubMed, Scopus, Web of Science and Embase were searched from January 2011 to May 2026. Eligible studies reported PEI following esophagectomy, gastrectomy, or bariatric surgery. Owing to substantial clinical and methodological heterogeneity, findings were synthesized narratively by surgical group and procedure. Risk of bias was evaluated using JBI critical appraisal tools. Results Seventeen studies comprising 1397 patients were included. Reported PEI prevalence varied substantially across surgical populations, ranging from 3.2% to 22.0% following esophagectomy, 25.0%–63.8% following gastrectomy, and 9.1%–32.6% in bariatric cohorts. Procedure‐specific estimates varied considerably, with rates of 4.2%–17.2% following sleeve gastrectomy, 8.3%–10.3% following RYGB, 48.1% following distal RYGB and 75.0% following biliopancreatic diversion with duodenal switch. Fecal elastase‐1 was the most frequently used diagnostic test, although diagnostic criteria and timing of assessment varied between studies. Gastrointestinal symptoms, weight loss, nutritional deficiencies and impaired quality of life were reported, while limited observational evidence suggested symptomatic improvement following pancreatic enzyme replacement therapy. Conclusions PEI is an under‐recognised consequence of esophagectomy, gastrectomy and bariatric surgery, with reported prevalence varying substantially between procedures and studies. Greater clinical awareness and standardised approaches to diagnosis are required, alongside prospective studies to better define postoperative screening and management. Trial Registration This review was prospectively registered in PROSPERO (CRD420261369499)