Omental reinforcement of the thoracic esophagogastric anastomosis: An analysis of leak and reintervention rates in patients undergoing planned and salvage esophagectomy

Objective: An uncontained thoracic anastomotic leak may cause severe morbidity or mortality. Thoracic transposition of an omental flap along with the gastric conduit may decrease leak incidence, severity, or need for reoperations after esophagectomy. Methods: We identified 607 patients who underwent esophagectomy with thoracic anastomosis between January 2001 and August 2011. All patients were studied for leak postoperatively. Four leak grades were defined, ranging from radiographic leak to conduit loss. Univariate and multivariate analyses were performed to identify variables associated with anastomotic leak. Results: Omental reinforcement was used in 215 of 607 patients (35%). Anastomotic leak occurred in 51 of 607 patients (8.4%). Patients with omentum had a significantly lower (odds ratio [OR], 0.4; P = .014) anastomotic leak rate (4.7%) compared with patients without omentum (10.5%). Salvage resections were performed in 69 patients and 23 (32%) received omentum; the leak rate with omentum was 4.6% compared with 15% without (OR, 0.27; P = .24). Patients undergoing planned esophagectomy with omentum had a significantly lower leak rate than patients without omentum (4.7% vs 9.8%) (OR, 0.43; P = .04). Reoperations to rescue an anastomotic leak (Grade 3) was less common with omentum (OR, 0.26; P = .024). Multivariate analysis identified omental reinforcement (OR, 0.45; P = .034) and surgeon (OR, 3.4; P = .001) as variables predictive of an anastomotic leak. Conclusions: Omental reinforcement of thoracic esophagogastric anastomoses decreases overall leak rate and need for reoperation. We recommend pedicled omental transposition to reinforce all thoracic anastomoses. Endoscopic evaluation of significant anastomotic leaks is still warranted.