Abstract
BACKGROUND: Pulmonary complications remain a major challenge after esophagectomy for esophageal cancer. While rehabilitation interventions aligned with Enhanced Recovery After Surgery (ERAS) principles show promise, the term "rehabilitation" is often applied to highly variable approaches-from isolated breathing exercises to comprehensive multimodal programs-raising concerns about clinical interpretability and generalizability. This systematic review evaluates the effectiveness of structured perioperative rehabilitation, with emphasis on intervention comprehensiveness, timing, and implications for real-world implementation. METHODS: We systematically searched PubMed, CINAHL, Cochrane Library, Web of Science, CNKI, Wanfang, and CBM from inception to October 31, 2024. Of 37 included studies, only 12 delivered interventions integrating ≥2 core components (e.g., exercise plus nutrition or education). Due to high clinical and statistical heterogeneity (I(2) > 90% for most outcomes), we prioritized narrative synthesis and conducted meta-analyses only within homogeneous subgroups-particularly those delivering continuous care across both preoperative and postoperative periods. Outcomes included functional capacity (6-min walk distance), cardiopulmonary function, pneumonia incidence, length of hospital stay (LOS), and health-related quality of life (HRQoL). RESULTS: Comprehensive perioperative rehabilitation (integrating prehabilitation and postoperative rehabilitation) was uniquely associated with a significant reduction in postoperative pneumonia [RR = 0.34, 95% CI (0.19, 0.61); p < 0.0001]. In contrast, the pooled effect across all rehabilitation interventions showed a modest but statistically significant benefit [RR = 0.70, 95% CI (0.52, 0.96); p = 0.02], suggesting that while even simplified protocols may confer some protection, maximal risk reduction requires continuous, multimodal support spanning the entire surgical trajectory. In contrast, prehabilitation alone achieved the greatest reduction in hospital length of stay [MD = -2.94 days, 95% CI (-5.50, -0.37)] and significantly improved FEV₁ (SMD = 0.60). Multimodal programs consistently enhanced health-related quality of life [SMD = 0.76, 95% CI (0.60, 0.92)] and functional capacity (6-min walk distance, SMD = 0.90). Single-component interventions (e.g., respiratory training alone) showed inconsistent or negligible effects. The current evidence base is predominantly derived from studies conducted in China, reflecting strong regional research momentum while highlighting the need to validate these findings in other healthcare contexts. CONCLUSION: Multimodal, multi-phase rehabilitation may meaningfully improve short-term recovery after esophagectomy, but its benefits are outcome-specific and contingent on intervention design: pneumonia prevention requires integrated perioperative care, while reductions in resource use and improvements in baseline physiology are primarily driven by prehabilitation. The current literature suffers from conceptual dilution of "rehabilitation," methodological variability, and limited long-term data. To enhance public health impact, future efforts should focus on scalable, standardized delivery models-such as community-integrated or telehealth-supported pathways-that extend support beyond hospital discharge, particularly in resource-constrained settings. SYSTEMATIC REVIEW REGISTRATION: PROSPERO registration number: CRD42024617815.