Omental wrapping of the pancreaticojejunostomy during pancreatoduodenectomy to prevent clinically relevant POPF: a GRADE-assessed systematic review and meta-analysis featuring geographic subgroup analysis.

backgroundPostoperative pancreatic fistula (POPF) is the principal cause of morbidity after pancreatoduodenectomy (PD). Omental wrapping of the pancreaticojejunostomy (PJ) has been proposed to reduce fistula risk; however, prior syntheses often pooled arterial and anastomotic targets, obscuring the PJ-specific effect relevant to surgical decision-making.

methodsThis systematic review and meta-analysis was registered in PROSPERO (ID: CRD420251176513) on October 26, 2025. We searched the PubMed, Embase, Web of Science, Cochrane CENTRAL, Scopus, and ClinicalTrials databases. gov, and WHO ICTRP from inception to October 24, 2025, for comparative studies evaluating omental wrapping of the PJ versus no wrap during PD. The primary outcome was clinically relevant POPF (CR-POPF; ISGPS grades B/C). Secondary outcomes included delayed gastric emptying, post-pancreatectomy hemorrhage, reoperation, length of stay (LOS), operative time, estimated blood loss (EBL), and time to oral intake. Random-effects meta-analyses were used to calculate risk ratios (RR) and mean differences (MD) with 95% confidence intervals. The risk of bias was assessed using RoB 2 for randomized controlled trials and ROBINS-I for non-randomized studies. The certainty of the evidence was appraised using the GRADE.

resultsSix comparative studies (two RCTs and four cohorts; 254 patients with omental wrapping of the PJ and 275 control patients) were included. Omental wrapping of the PJ significantly reduced CR-POPF (RR 0.44, 95% CI, 0.28-0.71; I²=0%; P = 0.0008; moderate certainty), corresponding to 125 fewer events per 1,000 treated patients than non-wrapped PJ. Wrapping also reduced LOS (MD - 2.56 days, 95% CI, - 4.37 to - 0.76; I²=52%; P = 0.005; moderate certainty), EBL (MD - 103.86 mL, 95% CI - 160.50 - 47.22; I²=0%; P = 0.0003; moderate certainty), and time to oral intake (MD - 2.30 days, 95% CI - 3.60 to - 1.00; P = 0.0005; very low certainty). No significant differences were observed in terms of delayed gastric emptying, post-pancreatectomy hemorrhage, reoperation, or operative time. The leave-one-out sensitivity analysis confirmed the robustness of the results. Geographic subgroup analysis showed consistent benefits in East Asia, with no significant regional interactions.

conclusionOmental wrapping of PJ reduces CR-POPF and improves perioperative recovery without prolonging surgery, supporting selective adoption in anatomically high-risk contexts within standardized care pathways.