Anastomotic reinforcement with omentoplasty following gastrointestinal anastomosis: A systematic review and meta-analysis

doi:10.1016/j.suronc.2015.06.011

Surgical Oncology

Volume 24, Issue 3, September 2015, Pages 181-186

https://doi.org/10.1016/j.suronc.2015.06.011 Get rights and content

Highlights

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Pooled analysis of nine studies (six esophageal and three colorectal).
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Omentoplasty reduced anastomotic leak rate in esophageal anastomosis.
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Omentoplasty did not significantly reduce leak rate with colorectal anastomosis.

Abstract

Anastomotic leak is a potentially devastating complication following gastrointestinal anastomosis. Some surgeons believe that reinforcing the anastomosis with omentum reduces the incidence and severity of anastomotic leak. A comprehensive electronic search of EMBASE, Medline, Web of Science and Cochrane databases was performed. Pooled odds ratios (POR) were calculated for discrete variables. There were six studies investigating esophageal anastomosis and 3 studies investigating colorectal anastomosis identified by the literature search. A total of 2296 patients were included, 1073 with omentoplasty and 1223 without. In esophageal surgery omentoplasty significantly reduced the rate of anastomotic leak (2.9% vs 10.5% (POR = 0.28; 95% CI = 0.17 to 0.47; P < 0.0001), but there was no significant effect upon in-hospital mortality (2.3% vs. 2.5%; POR = 0.911 [95% CI 0.439–1.887]; P = 0.802) or anastomotic stricture between the two groups (6.6% vs 9.1%; POR = 0.842 [95% CI 0.331 to 2.145]; P = 0.720). In colorectal surgery there was no significant difference in anastomotic leak rate (5.0% vs 8.4%; POR: 0.50; 95% CI 0.21 to 1.17) or in-hospital mortality (4.2% vs 4.1%; POR: 0.90; 95% CI 0.34 to 2.41). The results of this analysis show that omentoplasty significantly reduced the rate of anastomotic leak following esophageal anastomosis but these results were not observed in colorectal anastomosis. Omentoplasty could be used as an adjunct technique to reduce the incidence of anastomotic leak in oesophageal anastomosis.

Introduction

Anastomotic leak is a potentially devastating complication following gastrointestinal anastomosis. The causes of anastomotic leak can be multi-factorial but major contributing factors include surgical technique or inadequacy of blood supply [1], [2], coupled with patient-related influences such as malnutrition, smoking or use of non-steroidal anti-inflammatories. The risk of anastomotic leak is variable depending upon the type of gastrointestinal anastomosis performed. In general the risk is greatest in esophageal or rectal anastomosis where the risk of leak is between 5 and 10% [3], [4]. There is an increasing rate of anastomotic leak for procedures on the left side of the colon compared to right [5], particularly when anastomosis is performed within 10 cm of the anal verge [6]. Anastomotic leak has been associated with an increased patient mortality in both esophageal and colorectal surgery [2], [4]. This complication is particularly feared in relation to intra-thoracic esophageal anastomosis where mediastinal contamination can lead to rapid patient deterioration.

Various techniques have been attempted to reduce the rate of anastomotic leak, including the use of stapling devices and anastomotic reinforcement with synthetic material [7]. However, none of these practises have shown a definitive reduction in the rate of leak. One technique that some surgeons believe reduces anastomotic leak is the utilization of an omentoplasty. This procedure involves using a pedicle of omentum along with its vascular supply to cover the area of anastomosis. The role of the omentum in localising inflammatory processes or sealing visceral perforations is a very common observation in emergency surgical practice with the omentum being referred to as the ‘policeman of the abdomen’ in surgical education.

Omentoplasty is thought to assist in re-enforcing the anastomotic line thereby providing additional support particularly in the first few days following surgery when the risk of anastomotic leak due to surgical failure is greatest. In addition omentoplasty increases neovascularisation at the anastomotic site which further reduces the risk of leak [8]. However, omentoplasty has not been universally adopted during gastrointestinal anastomosis in part due to concerns regarding the potential for omental necrosis [9]. There have also been concerns in esophageal surgery that the right gastro-epiploic artery is required to contribute towards the vascular supply of the omental pedicle, which could theoretically affect the supply from this artery towards the gastric conduit.

At present there is no definitive evidence for or against the use of omentoplasty in gastrointestinal anastomosis. Therefore, this systematic review and pooled analysis will compare the outcomes of gastrointestinal anastomosis with and without the use of omentoplasty.

Section snippets

Materials and methods

A systematic literature search of Medline, EMBASE, Web of Science and the Cochrane Library was performed. The search terms used were; ’esophagectomy’, ‘oesophagectomy’, ‘colorectal’, ‘colon’, ‘rectum’, ‘anterior resection’, ‘omentoplasty’, ‘omentum’, ‘omental’, and ‘pedicle’. Additionally the medical subject headings (MeSH) ‘esophagectomy’, ‘colorectal surgery’, and ‘omentum’ were used in combination with Boolean operators AND or. The electronic search was supplemented by a hand-search of

Results

The literature search identified nine studies that were included for analysis. There were six studies investigating omentoplasty in esophageal surgery (three RCT's [11], [12], [13], and three comparative studies [14], [15], [16]) as well as three randomized trials studies investigating omentoplasty in colorectal anastomosis [17], [18], [19]. Fig. 1 shows the PRISMA flowchart for the literature search. In total there were 2296 patients included, 1073 with omentoplasty (617 esophageal and 456

Discussion

This meta-analysis has shown that omentoplasty provides a three-fold improvement in the leak rate for thoracic esophageal anastomosis, and four-fold for cervical anastomosis. It was not possible to identify a similar effect in colorectal anastomosis. The incidence of conduit necrosis was only reported in the largest case series by Sepesi et al. [16], which found no significant difference with or without omentoplasty.

There are few explanations for the improved leak rate with omentoplasty in

Conclusion

In conclusion, omentoplasty may be used as an adjunctive procedure to reduce anastomotic leak rate in esophageal surgery. From the available data it was not possible to show any difference in leak rate for colorectal anastomosis. Further studies are required to fully appreciate the full effect of omentoplasty upon leak rate and its severity before advocating its routine use in clinical practice.

Funding

Sheraz R Markar is supported by the NIHR.

Conflict of interests

None.

Acknowledgements

Sheraz R Markar is supported by the NIHR (DRF-2014-07-088).

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There is a heavy existing literature supporting systematic diverting stoma creation after low colorectal anastomosis for rectal cancer. Keeping in mind the important differences between the two situations, the conclusions cannot be directly extrapolated. In endometriosis surgery after low rectal resection, stoma creation must be discussed and the patient must be informed and educated about this possibility.
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ReviewAnastomotic reinforcement with omentoplasty following gastrointestinal anastomosis: A systematic review and meta-analysis

Highlights

Abstract

Introduction

Section snippets

Materials and methods

Results

Discussion

Conclusion

Funding

Conflict of interests

Acknowledgements

Ann. Thorac. Surg.

J. Pediatr. Surg.

Control Clin. Trials

Ann. Thorac. Surg.

Surgery

J. Surg. Res.

J. Am. Coll. Surg.

J. Gastrointest. Surg.

Intraoperative assessment of perfusion of the gastric graft and correlation with anastomotic leaks after Esophagectomy

Ann. Surg.

Risk factors for anastomotic leak after colon resection for cancer: multivariate analysis and nomogram from a multicentre, prospective, national study with 3193 patients

Ann. Surg.

Systematic review of anastomotic leakage rate according to an international grading system following anterior resection for rectal cancer

PLoS One

Risk factors for anastomotic leakage and leak-related mortality after colonic cancer surgery in a nationwide audit

Br. J. Surg.

Identifying important predictors for anastomotic leak after colon and rectal resection: prospective study on 616 patients

Ann. Surg.

Preventing complications in colorectal anastomosis: results of a randomized controlled trial using bioabsorbable staple line reinforcement for circular stapler

Dis. Colon Rectum

Complications of the pedicled omentoplasty

Neth J. Surg.

Omentoplasty in preventing anastomotic leakage of oesophagogastrostomy following radical oesophagectomy with three-field lymphadenectomy

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Review
Anastomotic reinforcement with omentoplasty following gastrointestinal anastomosis: A systematic review and meta-analysis