Extended mesenteric resection in Crohn

Review by Prof. Vishal Sharma (India)

Study Summary 

A multicenter randomized trial (the SPICY trial) compared extended mesenteric resection to standard mesenteric sparing resection in patients with Crohn’s disease undergoing ileocolic resection with anastomosis. 139 patients were randomized into one of the two groups - and the primary outcome of endoscopic recurrence (defined as Rutgeert score of i2b or worse) was assessed six months after surgery. Endoscopic recurrence rates following the extended mesenteric resection (28 of 66, 42%) was similar to standard resection (28 of 65, 43%). Complications like anastomotic leakage or Clavien-Dindo Grade IIIa or higher surgical complications were numerically greater in the extended resection group.

Commentary 

Recent studies including the LIRIC trial as well as data from the Danish national cohort have increased interest in surgical management of Crohn’s disease. Upfront surgery is a reasonable option for many patients with Crohn’s disease including those with stricturing or limited ileocecal disease but comes with the risk of postoperative recurrence. Postoperative recurrence typically occurs at the neo-terminal ileum and the endoscopic recurrence precedes and serves as a proxy indicator for clinical or surgical recurrence. There is an interest in using medical therapy or surgical techniques to reduce postoperative recurrence. Some of the techniques which have garnered sufficient interest to justify randomized trials include end-to-end vs side-to-side anastomoses, the Kono-S anastomosis and mesenteric resection. The role of the mesentery in driving the inflammatory process in Crohn’ s disease is in focus and fueled interest in mesenteric resection. Previous retrospective studies had suggested some benefit, but the current RCT will temper enthusiasm for this strategy. The authors believe that the reasons for this difference from the retrospective studies is due to a less extensive mesenteric resection in the SPICY trial; a more radical excision may be beneficial but also comes with more surgical risks. Until more evidence and long-term data on clinical recurrence from this trial are available, it seems that the current guidance of mesenteric sparing surgery for patients with Crohn’s disease undergoing ileocolic resection will hold.

Citation

van der Does de Willebois EML, Bellato V, Duijvestein M, van der Bilt JDW, van Dongen K, Spinelli A, D'Haens GR, Mundt MW, Furfaro F, Danese S, Vignali A, Bemelman WA, Buskens CJ; SPICY collaborator group. 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. Lancet Gastroenterol Hepatol. 2024 Jul 15:S2468-1253(24)00097-9. doi: 10.1016/S2468-1253(24)00097-9. Epub ahead of print. PMID: 39025100.

Link

https://pubmed.ncbi.nlm.nih.gov/39025100/

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