Background Gastroesophageal reflux disease is a common gastrointestinal condition managed medically and surgically. With an ageing population, increasing numbers of elderly patients are undergoing or being considered for anti-reflux surgery. This systematic review and meta-analysis aimed to evaluate surgical outcomes in elderly patients undergoing anti-reflux procedures. Methods This review followed PRISMA guidelines and included studies published between 1 January 1990 and 12 September 2025. The protocol was prospectively registered with PROSPERO (CRD42024561534). Elderly patients were defined as aged ≥65 years, and anti-reflux surgery was defined as hiatus hernia repair, fundoplication, or gastropexy. Outcomes assessed included mortality, postoperative complications, reoperation, and readmission. Results Of 5,937 records identified, 168 full-text articles were reviewed, and 36 studies met inclusion criteria. For mortality analysis, the meta-analysis included a younger cohort (n = 53,074) and an older cohort (n = 11,945). Mortality was significantly lower in the younger cohort (0.2%) compared to the older cohort (1.0%) (OR 0.19, 95% CI: 0.14–0.26, p < 0.00001). Pneumonia rates were 1.2% (n = 41,092) and 1.9% (n = 8,754), respectively (OR 0.62, 95% CI: 0.50–0.75, p < 0.00001). Cardiovascular complications occurred in 5.9% (n = 36,385) of younger patients and 19.2% (n = 3,579) of older patients (OR 0.25, 95% CI: 0.10–0.64, p = 0.004). No significant differences were found in reoperation, pneumothorax, Clavien–Dindo grade ≥ III complications, or readmission. Conclusion Although overall complication rates were low, elderly patients demonstrated higher surgical risk. Individualised assessment and case-by-case evaluation are essential to ensure optimal surgical outcomes.