Skip to main content
PMC home page
Annals of Surgery logoLink to Annals of Surgery
. 1998 Feb;227(2):179–186. doi: 10.1097/00000658-199802000-00005

Omentoplasty in the prevention of anastomotic leakage after colonic or rectal resection: a prospective randomized study in 712 patients. French Associations for Surgical Research.

F Merad 1, J M Hay 1, A Fingerhut 1, Y Flamant 1, J M Molkhou 1, Y Laborde 1
PMCID: PMC1191233  PMID: 9488514

Abstract

OBJECTIVE: To investigate the role of omentoplasty (OP) in the prevention of anastomotic leakage after colonic or rectal resection. SUMMARY BACKGROUND DATA: It has been proposed that OP--wrapping the omentum around the colonic or rectal anastomosis--reinforces intestinal sutures with the expectation of lowering the rate of anastomotic leakage. However, there are no prospective, randomized trials to date to prove this. METHODS: Between September 1989 and March 1994, a total of 705 patients (347 males and 358 females) with a mean age of 66 +/- 15 years (range, 15-101) originating from 20 centers were randomized to undergo either OP (n = 341) or not (NO, n = 364) to reinforce the colonic anastomosis after colectomy. Patients had carcinoma, benign tumor, colonic Crohn's disease, diverticular disease of the sigmoid colon, or another affliction located anywhere from the right colon to and including the midrectum. Patients undergoing emergency surgery were not included. Random allotment took place once the resection and anastomosis had been performed, the surgeon had tested the anastomosis for airtightness, and the omental flap was deemed feasible. Patients were divided into four strata: ileo- or colocolonic anastomosis, supraperitoneal ileo- or colorectal anastomosis, infraperitoneal ileo- or colorectal anastomosis, and ileo- or coloanal anastomosis. The primary end point was anastomotic leakage. Secondary end points included intra- and extraabdominal related morbidity and mortality. Severity of anastomotic leakage was based on the rate of repeat operations and related deaths. RESULTS: Both groups were comparable in terms of preoperative characteristics. Intraoperative findings were similar, except that there were significantly more septic operations and abdominal drainage performed in the NO group (p < 0.05 and p < 0.01, respectively). Thirty-five patients (4.9%) had postoperative anastomotic leakage, 16 in the OP group (4.7%) and 19 in the NO group (5.2%). There were 32 deaths (4.5%), 17 (4.9%) in the OP group and 15 (4.2%) in the NO group. Five patients with anastomotic leakage died (0.8%), 2 of whom had OP. There were 37 repeat operations (30%), 12 (6 in each group) for anastomotic leakage. Repeat operation was associated with fatal outcome in 14% of cases. The rate of these and the other intra- and extraabdominal complications did not differ significantly between the two groups. CONCLUSION: OP to reinforce colorectal anastomosis decreases neither the rate nor the severity of anastomotic failure.

Full text

PDF
185

Selected References

These references are in PubMed. This may not be the complete list of references from this article.

  1. Antonsen H. K., Kronborg O. Early complications after low anterior resection for rectal cancer using the EEA stapling device. A prospective trial. Dis Colon Rectum. 1987 Aug;30(8):579–583. doi: 10.1007/BF02554801. [DOI] [PubMed] [Google Scholar]
  2. BOYD J. T., DOLL R. Gastro-intestinal cancer and the use of liquid paraffin. Br J Cancer. 1954 Jun;8(2):231–237. doi: 10.1038/bjc.1954.23. [DOI] [PMC free article] [PubMed] [Google Scholar]
  3. Baum M. L., Anish D. S., Chalmers T. C., Sacks H. S., Smith H., Jr, Fagerstrom R. M. A survey of clinical trials of antibiotic prophylaxis in colon surgery: evidence against further use of no-treatment controls. N Engl J Med. 1981 Oct 1;305(14):795–799. doi: 10.1056/NEJM198110013051404. [DOI] [PubMed] [Google Scholar]
  4. Beard J. D., Nicholson M. L., Sayers R. D., Lloyd D., Everson N. W. Intraoperative air testing of colorectal anastomoses: a prospective, randomized trial. Br J Surg. 1990 Oct;77(10):1095–1097. doi: 10.1002/bjs.1800771006. [DOI] [PubMed] [Google Scholar]
  5. Brennan S. S., Pickford I. R., Evans M., Pollock A. V. Staples or sutures for colonic anastomoses--a controlled clinical trial. Br J Surg. 1982 Dec;69(12):722–724. doi: 10.1002/bjs.1800691212. [DOI] [PubMed] [Google Scholar]
  6. Carter D. C., Jenkins D. H., Whitfield H. N. Omental reinforcement of intestinal anastomoses. An experimental study in the rabbit. Br J Surg. 1972 Feb;59(2):129–133. doi: 10.1002/bjs.1800590214. [DOI] [PubMed] [Google Scholar]
  7. Condon R. E., Bartlett J. G., Greenlee H., Schulte W. J., Ochi S., Abbe R., Caruana J. A., Gordon H. E., Horsley J. S., Irvin G., 3rd Efficacy of oral and systemic antibiotic prophylaxis in colorectal operations. Arch Surg. 1983 Apr;118(4):496–502. doi: 10.1001/archsurg.1983.01390040100021. [DOI] [PubMed] [Google Scholar]
  8. Dixon A. R., Maxwell W. A., Holmes J. T. Carcinoma of the rectum: a 10-year experience. Br J Surg. 1991 Mar;78(3):308–311. doi: 10.1002/bjs.1800780314. [DOI] [PubMed] [Google Scholar]
  9. Evans M., Pollock A. V. Trials on trial. A review of trials of antibiotic prophylaxis. Arch Surg. 1984 Jan;119(1):109–113. doi: 10.1001/archsurg.1984.01390130091016. [DOI] [PubMed] [Google Scholar]
  10. Ferguson C. M. Use of omental pedicle grafts in abdominoperineal resection. Am Surg. 1990 May;56(5):310–312. [PubMed] [Google Scholar]
  11. Fielding L. P., Stewart-Brown S., Hittinger R., Blesovsky L. Covering stoma for elective anterior resection of the rectum: an outmoded operation? Am J Surg. 1984 Apr;147(4):524–530. doi: 10.1016/0002-9610(84)90016-3. [DOI] [PubMed] [Google Scholar]
  12. Fingerhut A., Elhadad A., Hay J. M., Lacaine F., Flamant Y. Infraperitoneal colorectal anastomosis: hand-sewn versus circular staples. A controlled clinical trial. French Associations for Surgical Research. Surgery. 1994 Sep;116(3):484–490. [PubMed] [Google Scholar]
  13. Fingerhut A., Hay J. M., Elhadad A., Lacaine F., Flamant Y. Supraperitoneal colorectal anastomosis: hand-sewn versus circular staples--a controlled clinical trial. French Associations for Surgical Research. Surgery. 1995 Sep;118(3):479–485. doi: 10.1016/s0039-6060(05)80362-9. [DOI] [PubMed] [Google Scholar]
  14. Fujita S., Teramoto T., Watanabe M., Kodaira S., Kitajima M. Anastomotic leakage after colorectal cancer surgery: a risk factor for recurrence and poor prognosis. Jpn J Clin Oncol. 1993 Oct;23(5):299–302. [PubMed] [Google Scholar]
  15. Goldsmith H. S. Protection of low rectal anastomosis with intact omentum. Surg Gynecol Obstet. 1977 Apr;144(4):584–586. [PubMed] [Google Scholar]
  16. Greenberg B. M., Low D., Rosato E. F. The use of omental grafts in operations performed upon the colon and rectum. Surg Gynecol Obstet. 1985 Nov;161(5):486–488. [PubMed] [Google Scholar]
  17. Heald R. J., Leicester R. J. The low stapled anastomosis. Br J Surg. 1981 May;68(5):333–337. doi: 10.1002/bjs.1800680514. [DOI] [PubMed] [Google Scholar]
  18. Jakowatz J. G., Porudominsky D., Riihimaki D. U., Kemeny M., Kokal W. A., Braly P. S., Terz J. J., Beatty J. D. Complications of pelvic exenteration. Arch Surg. 1985 Nov;120(11):1261–1265. doi: 10.1001/archsurg.1985.01390350043009. [DOI] [PubMed] [Google Scholar]
  19. John H., Buchmann P. Improved perineal wound healing with the omental pedicle graft after rectal excision. Int J Colorectal Dis. 1991 Nov;6(4):193–196. doi: 10.1007/BF00341389. [DOI] [PubMed] [Google Scholar]
  20. Katsikas D., Sechas M., Antypas G., Floudas P., Moshovos K., Gogas J., Rigas A., Papacharalambous N., Skalkeas G. Beneficial effect of omental wrapping of unsafe intestinal anastomoses. An experimental study in dogs. Int Surg. 1977 Aug;62(8):435–437. [PubMed] [Google Scholar]
  21. Kiricuta I., Goldstein A. M. The repair of extensive vesicovaginal fistulas with pedicled omentum: a review of 27 cases. J Urol. 1972 Nov;108(5):724–727. doi: 10.1016/s0022-5347(17)60851-6. [DOI] [PubMed] [Google Scholar]
  22. Kracht M., Hay J. M., Fagniez P. L., Fingerhut A. Ileocolonic anastomosis after right hemicolectomy for carcinoma: stapled or hand-sewn? A prospective, multicenter, randomized trial. Int J Colorectal Dis. 1993 Mar;8(1):29–33. doi: 10.1007/BF00341273. [DOI] [PubMed] [Google Scholar]
  23. Lanter B., Mason R. A. Use of omental pedicle graft to protect low anterior colonic anastomosis. Dis Colon Rectum. 1979 Oct;22(7):448–451. doi: 10.1007/BF02586925. [DOI] [PubMed] [Google Scholar]
  24. Lawrance R. J., Loizidou M., Cooper A. J., Alexander P., Taylor I. Importance of the omentum in the development of intra-abdominal metastases. Br J Surg. 1991 Jan;78(1):117–119. doi: 10.1002/bjs.1800780135. [DOI] [PubMed] [Google Scholar]
  25. Manz C. W., LaTendresse C., Sako Y. The detrimental effects of drains on colonic anastomoses: an experimental study. Dis Colon Rectum. 1970 Jan-Feb;13(1):17–25. doi: 10.1007/BF02617675. [DOI] [PubMed] [Google Scholar]
  26. Matheson N. A., McIntosh C. A., Krukowski Z. H. Continuing experience with single layer appositional anastomosis in the large bowel. Br J Surg. 1985 Sep;72 (Suppl):S104–S106. doi: 10.1002/bjs.1800721351. [DOI] [PubMed] [Google Scholar]
  27. Max E., Sweeney W. B., Bailey H. R., Oommen S. C., Butts D. R., Smith K. W., Zamora L. F., Skakun G. B. Results of 1,000 single-layer continuous polypropylene intestinal anastomoses. Am J Surg. 1991 Nov;162(5):461–467. doi: 10.1016/0002-9610(91)90262-c. [DOI] [PubMed] [Google Scholar]
  28. McLachlin A. D., Denton D. W. Omental protection of intestinal anastomoses. Am J Surg. 1973 Jan;125(1):134–140. doi: 10.1016/0002-9610(73)90018-4. [DOI] [PubMed] [Google Scholar]
  29. Mealy K., Burke P., Hyland J. Anterior resection without a defunctioning colostomy: questions of safety. Br J Surg. 1992 Apr;79(4):305–307. doi: 10.1002/bjs.1800790406. [DOI] [PubMed] [Google Scholar]
  30. Montesani C., De Milito R., Chiappalone S., Narilli P., D'Amato A., Ribotta G. Critical evaluation of the anastomoses in large bowel surgery: experience gained in 533 cases. Hepatogastroenterology. 1992 Aug;39(4):304–308. [PubMed] [Google Scholar]
  31. Moreaux J., Horiot A., Barrat F., Mabille J. Obliteration of the pelvic space with pedicled omentum after excision of the rectum for cancer. Am J Surg. 1984 Nov;148(5):640–644. doi: 10.1016/0002-9610(84)90342-8. [DOI] [PubMed] [Google Scholar]
  32. Morgenstern L., Yamakawa T., Ben-Shoshan M., Lippman H. Anastomotic leakage after low colonic anastomosis. Clinical and experimental aspects. Am J Surg. 1972 Jan;123(1):104–109. doi: 10.1016/0002-9610(72)90317-0. [DOI] [PubMed] [Google Scholar]
  33. Murray G. D. Statistical aspects of research methodology. Br J Surg. 1991 Jul;78(7):777–781. doi: 10.1002/bjs.1800780704. [DOI] [PubMed] [Google Scholar]
  34. Novell J. R., Lewis A. A. Peroperative observation of marginal artery bleeding: a predictor of anastomotic leakage. Br J Surg. 1990 Feb;77(2):137–138. doi: 10.1002/bjs.1800770206. [DOI] [PubMed] [Google Scholar]
  35. PETTET J. R., JUDD E. S., WOOLNER L. B. Free omental grafts applied to intestinal anastomoses; results of an experimental study. AMA Arch Surg. 1956 Jun;72(6):925–930. doi: 10.1001/archsurg.1956.01270240037006. [DOI] [PubMed] [Google Scholar]
  36. POTH E. J. The role of intestinal antisepsis in the preoperative preparation of the colon. Surgery. 1960 Jun;47:1018–1028. [PubMed] [Google Scholar]
  37. Phillips E. H., Franklin M., Carroll B. J., Fallas M. J., Ramos R., Rosenthal D. Laparoscopic colectomy. Ann Surg. 1992 Dec;216(6):703–707. doi: 10.1097/00000658-199212000-00015. [DOI] [PMC free article] [PubMed] [Google Scholar]
  38. Polk H. C., Jr, Lopez-Mayor J. F. Postoperative wound infection: a prospective study of determinant factors and prevention. Surgery. 1969 Jul;66(1):97–103. [PubMed] [Google Scholar]
  39. Schrock T. R., Deveney C. W., Dunphy J. E. Factor contributing to leakage of colonic anastomoses. Ann Surg. 1973 May;177(5):513–518. doi: 10.1097/00000658-197305000-00002. [DOI] [PMC free article] [PubMed] [Google Scholar]
  40. Shorthouse A. J., Bartram C. I., Eyers A. A., Thomson J. P. The water soluble contrast enema after rectal anastomosis. Br J Surg. 1982 Dec;69(12):714–717. doi: 10.1002/bjs.1800691210. [DOI] [PubMed] [Google Scholar]
  41. Smith S. R., Swift I., Gompertz H., Baker W. N. Abdominoperineal and anterior resection of the rectum with retrocolic omentoplasty and no drainage. Br J Surg. 1988 Oct;75(10):1012–1015. doi: 10.1002/bjs.1800751020. [DOI] [PubMed] [Google Scholar]
  42. Trimpi H. D., Khubchandani I. T., Sheets J. A., Stasik J. J., Jr Advances in intestinal anastomosis: experimental study and an analysis of 984 patients. Dis Colon Rectum. 1977 Mar;20(2):107–117. doi: 10.1007/BF02587325. [DOI] [PubMed] [Google Scholar]
  43. Tuson J. R., Everett W. G. A retrospective study of colostomies, leaks and strictures after colorectal anastomosis. Int J Colorectal Dis. 1990 Feb;5(1):44–48. doi: 10.1007/BF00496150. [DOI] [PubMed] [Google Scholar]

Articles from Annals of Surgery are provided here courtesy of Lippincott, Williams, and Wilkins

RESOURCES