Impact of omental flap reinforcement on anastomotic leak after esophagectomy: updated evidence incorporating minimally invasive and high-volume contemporary series.

Abstract / Summary

Anastomotic leak is a serious complication following esophagectomy, contributing to substantial morbidity and mortality. Omental reinforcement of the esophagogastric anastomosis has been proposed as an adjunct to reduce the risk of leakage. This systematic review and meta-analysis evaluated the impact of omental reinforcement following esophagectomy. A PRISMA-guided search of PubMed, Embase, and Web of Science till December 2025 identified comparative studies evaluating esophagectomy with versus without omental reinforcement in adults. The primary outcome was anastomotic leak; secondary outcomes included severe leaks, stricture, and postoperative mortality. Random-effects meta-analysis was performed, with prespecified subgroup and sensitivity analyses. Certainty of evidence was assessed using GRADE. Nine comparative studies involving 2227 patients were included (1170 with reinforcement; 1057 controls), comprising four randomized trials and five observational cohorts. Omental reinforcement significantly reduced anastomotic leak (risk ratio [RR] 0.32, 95% CI 0.23-0.44; I2 = 0%), corresponding to Absolute Risk Reduction (ARR) 7.9% (95% CI 7.1-9.7%) and Number Needed to Treat (NNT) 13 (95% CI 11-15). The effect remained robust across randomized trials, cervical and intrathoracic anastomoses, and both open and minimally invasive/robotic approaches. Severe leaks requiring reoperation were also reduced (RR ≈ 0.22). Stricture formation (RR 0.78) and mortality (RR 0.71) favored reinforcement but were not statistically significant. Certainty of evidence for the primary outcome was moderate. Omental reinforcement substantially reduces the incidence and severity of anastomotic leak following esophagectomy, with consistent benefit across surgical approaches and anastomotic locations. Given its biological rationale, low cost, and favorable safety profile, omental reinforcement (omentoplasty) represents a valuable adjunct in esophagogastric reconstruction.

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