Extended Mesenteric Resection Not Superior for Reducing Crohn's Disease Recurrence, reveals research

Some retrospective data have shown that conduct of resection of involved mesentery in an ileocolic resection may lead to better outcomes in Crohn's disease. However, no prospective data have been available based on controlled trials. This is a controlled international trial conducted to compare conventional mesenteric sparing resection with extended mesenteric resection in terms of their impact on recurrence postoperatively in Crohn's disease patients.

The trial was conducted in six hospitals and tertiary care centers of the Netherlands and Italy. The study included patients more than 16 years old proven to have Crohn's disease of the terminal ileum or ileocolic region (L1 or L3 disease) from endoscopy. Availability of recent imaging (ultrasound, MRI, or CT enterography) within the last three months was mandatory. And patients with the prospect of undergoing primary ileocolic resection with ileocolic anastomosis were also at random 1:1 to either extended mesenteric resection or conventional mesenteric sparing resection. The primary endpoint 6 months post-surgery is an endoscopic recurrence. Analyses excluded patients without an anastomosis, with postoperative diagnosis other than Crohn's disease, or who withdrew consent.

The key findings of the study were:

• From February 19, 2020, to April 24, 2023, 217 patients were assessed for eligibility.

• Seventy-eight were excluded, leaving 139 enrolled patients who were randomized to extended mesenteric resection (n=71) or mesenteric sparing resection (n=68).

• Post-randomization exclusions included withdrawal of consent (n=2), postoperative non-Crohn's diagnosis (n=2), and no anastomosis (n=2).

• Two patients were lost to follow-up, and two deviated from the protocol. The baseline analysis included 133 patients (67 in the extended group and 66 in the sparing group), with a median age of 36 years (IQR 25–54), and 43% were male.

• No difference at 6 months post-surgery (42% in extended group vs. 43% in sparing group; relative risk 0.985, 95% CI 0.663–1.464; p=1.0).

• Anastomotic leakage occurred in 8% of extended resection patients versus 2% in the sparing group within 30 days post-surgery.

• Clavien-Dindo grade IIIa or higher complications were reported in 11% of extended resection patients and 8% of sparing resection patients.

The conclusion was that there was no benefit or advantage to an extended mesenteric resection in preventing recurrences over and above conventional mesenteric-sparing resections. Recurrence rates, endoscopy, and anastomotic leakages were balanced in both groups, and the rate of severe complications supported the safety and efficacy of the MR resection recommended in the current guidelines.

Extended mesenteric resection is not better than conventional mesenteric-sparing resection with respect to the reduction of endoscopic recurrence in Crohn's disease. The results of this study would further strengthen the recommendation of mesenteric-sparing resection as the elective method of managing Crohn's disease, and wherein effective treatment is achieved with decreased complications.

Reference:

van der Does de Willebois, E. M. L., Bellato, V., Duijvestein, M., van der Bilt, J. D. W., van Dongen, K., Spinelli, A., D’Haens, G. R., Mundt, M. W., Furfaro, F., Danese, S., Vignali, A., Bemelman, W. A., Buskens, C. J., Carvello, M., Van Dieren, S., Frontali, A., Govaert, J., Hompes, R., Koot, B., … Zwaveling, S. (2024). Effect of mesenteric sparing or extended resection in primary ileocolic resection for Crohn’s disease on postoperative endoscopic recurrence (SPICY): an international, randomised controlled trial. The Lancet. Gastroenterology & Hepatology. https://doi.org/10.1016/s2468-1253(24)00097-9