INTRODUCTION: The evidence has suggested that anti-reflux surgery is beneficial in patients with proton-pump inhibitor (PPI) refractory erosive gastroesophageal reflux disease (ERD). The outcomes of surgical intervention in patients with PPI refractory non-erosive reflux disease (NERD) compared to ERD remains unclear. METHODS: 5 prospective observational studies investigating the outcomes of anti-reflux surgery in PPI refractory-NERD and -ERD were selected using PubMed, EMBASE and MEDLINE databases (inception April 2020). The primary endpoint was post-surgical GERD symptom resolution. The secondary endpoints were short-term (≤1-year) and long-term (>1-year) mean improvement in quality of life (QOL). The outcomes were measured as relative risk (RR) and standardized mean difference (SMD) with a 95% confidence interval (CI) using the fixed effect model. RESULTS: In analysis comprising of 670 patients with a mean age of 47.6 ± 3.1 years and 60.5% males, the anti-reflux surgery led to significantly higher GERD symptom resolution in the ERD group as compared to the NERD group as shown in Figure 1 (RR: 1.15, 95% Cl 1.01–1.31, P = 0.04, I2 = 0). There was significant improvement in short-term QOL in both NERD (SMD: 0.28, 95% Cl 0.13-0.44, P < 0.001, I2 = 0) and ERD groups (SDM: 0.34, 95% Cl 0.18–0.50, P < 0.001, I2 = 0). Similarly, long-term QOL significantly improved after surgery in both NERD (SDM: 0.30, 95% Cl 0.14–0.45, P < 0.001, I2 = 13) and ERD groups (SDM: 0.23, 95% Cl 0.07–0.39, P = 0.005, I2 = 0). CONCLUSION: Anti-reflux surgery achieved greater GERD symptom resolution in patients with PPI-refractory ERD as compared to NERD, however, improved short- and long-term QOL in PPI refractory GERD irrespective of mucosal changes evidenced on endoscopy. Randomized controlled trials are required to further validate this data.Figure 1.: Forest Plot demonstrating GERD symptom resolution after anti-reflux surgery in PPI refractory non-erosive gastroesophageal reflux disease (NERD) and erosive esophageal reflux disease (ERD).