Presurgery emotional distress has had variable associations with outcomes of surgery in past narrative reviews. This meta-analysis was designed to evaluate the overall strengths of relations between presurgical emotional distress and key postsurgical pain outcomes (ie, pain intensity, analgesic use, functional impairment) and to identify moderators that might explain effect size heterogeneity between studies. PubMed, Web of Science, PsychINFO, Google Scholar, and Science Direct databases were searched to identify studies subjected to meta-analysis. Forty-seven studies of 6,207 patients met all 10 inclusion criteria. High presurgery emotional distress levels were associated with significantly more postsurgical pain, analgesic use, and impairment after surgery, with small to medium average effect sizes. Moderator analyses for relations between distress and pain intensity indicated effect sizes were larger in studies that assessed catastrophizing, anxiety, and/or depression than other types of emotional distress as well as those with lower rather than higher quality scores. Associations between presurgery distress and postoperative impairment were moderated by type of surgery. Heterogeneity in these relations was reduced or no longer significant after statistically controlling for moderators. Moderator analyses also supported the role of presurgery emotional distress as a risk factor for, rather than simply a correlate of, elevations in postoperative pain and disability. Perspective: This meta-analysis indicates presurgery emotional distress has significant associations with postoperative outcomes but specific methodological factors and sample characteristics contribute to effect size variability in the literature. Considering emotional distress within presurgical assessment protocols may aid in identifying vulnerable patients who can benefit from interventions targeting distress reductions.