Lancet Gastroenterol Hepatol. 2024 Sep;9(9):793-801.doi: 10.1016/S2468-1253(24)00097-9. Epub 2024 Jul 15.

Eline M L van der Does de Willebois ¹, Vittoria Bellato ², Marjolijn Duijvestein ³, Jarmila D W van der Bilt ⁴, Koen van Dongen ⁵, Antonino Spinelli ⁶, Geert R D'Haens ⁷, Marco W Mundt ⁸, Federica Furfaro ⁹, Silvio Danese ¹⁰, Andrea Vignali ¹¹, Willem A Bemelman ¹², Christianne J Buskens ¹³; SPICY collaborator group

Collaborators

• SPICY collaborator group: 

Michele Carvello, Susan Van Dieren, Alice Frontali, Johannes Govaert, Roel Hompes, Bart Koot, Wytze Lameris, Sander Van der Marel, Pierpaolo Sileri, Malaika Vlug, Manon Wildenberg, Jimme Wiggers, Sander Zwaveling

Author information

¹Department of Surgery, Amsterdam University Medical Centres, Amsterdam, Netherlands.

²Minimally Invasive Surgery Unit, Tor Vergata University Hospital, Rome.

³Department of Gastroenterology, Radboud University Medical Centre, Nijmegen, Netherlands.

⁴Department of Surgery, Flevoziekenhuis, Almere, Netherlands.

⁵Department of Surgery, Pantein Hospital Boxmeer, Beugen, Netherlands.

⁶IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy; Department of Biomedical Sciences, Humanitas University, Milan, Italy.

⁷Department of Gastroenterology and Hepatology, Amsterdam University Medical Centres, Amsterdam, Netherlands.

⁸Department of Gastroenterology and Hepatology, Flevoziekenhuis, Almere, Netherlands.

⁹Gastroenterology and Gastrointestinal Endoscopy Unit, IRCCS San Raffaele, Milan, Italy.

¹⁰Department of Gastroenterology, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy; Gastroenterology and Gastrointestinal Endoscopy Unit, IRCCS San Raffaele, Milan, Italy.

¹¹Unit of Coloproctology and IBD Surgery, IRCCS San Raffaele, Milan, Italy.

¹²Department of Surgery, Amsterdam University Medical Centres, Amsterdam, Netherlands; Unit of Coloproctology and IBD Surgery, IRCCS San Raffaele, Milan, Italy.

¹³Department of Surgery, Amsterdam University Medical Centres, Amsterdam, Netherlands. Electronic address: c.j.buskens@amsterdamumc.nl.

Abstract

Background: Retrospective research suggests that excision of the affected mesentery can improve outcomes after an ileocoecal resection in Crohn's disease. However, prospective data from randomised controlled trials are scarce. We aimed to compare rates of postoperative recurrence in patients with Crohn's disease who underwent extended mesenteric resection.

Methods: This international, randomised controlled trial was done in six hospitals and tertiary care centres in the Netherlands and Italy. Eligible patients were aged 16 years or older and had Crohn's disease that was previously confirmed by endoscopy in the terminal ileum or ileocolic region (L1 or L3 disease), with an imaging update in the past 3 months (ultrasound, MRI, or CT enterography). Eligible patients were scheduled to undergo primary ileocolic resection with ileocolic anastomosis. Enrolled patients were assigned by use of simple random allocation (1:1) to either extended mesenteric resection (intervention) or conventional mesenteric sparing resection (control). The primary endpoint was endoscopic recurrence 6 months after surgery. Analyses were done in all patients with primary endpoint data, excluding those who had no anastomosis, a postoperative diagnosis other than Crohn's disease, or withdrew consent. This trial was registered with ClinicalTrials.gov, NCT04538638.

Findings: Between Feb 19, 2020, and April 24, 2023, we assessed 217 patients for eligibility. 78 patients were excluded due to failure to meet the inclusion criteria or refusal to participate. 139 patients were enrolled and randomly assigned to either extended mesenteric resection (n=71) or mesenteric sparing resection (n=68). All 139 patients underwent surgery. Six patients were excluded after random assignment due to withdrawal of consent (n=2), postoperative diagnosis other than Crohn's disease (n=2) and no anastomosis performed (in case of a stoma; n=2). Two patients were lost to follow-up, and two more patients deviated from the protocol by undergoing investigations other than endoscopy 6 months after. 133 patients were included in the baseline analysis (67 in the extended resection group and 66 in the sparing resection group) of whom 57 (43%) were male. Baseline characteristics were similar between the groups, and median patient age was 36 years (IQR 25-54). 131 patients were analysed for the primary outcome. There was no difference between groups in the rate of endoscopic recurrence at 6 months after surgery (28 [42%] of 66 patients in the extended mesenteric resection group vs 28 [43%] of 65 patients in the mesenteric sparing resection group, relative risk 0·985, 95% CI 0·663-1·464; p=1·0). Five (8%) of 66 patients in the extended mesenteric resection group had anastomotic leakage within the 30 days after surgery, as did one (2%) of 65 in the mesenteric sparing group. Postoperative complications of Clavien-Dindo grade IIIa or higher were reported in seven (11%) patients in the mesenteric resection group and five (8%) in the mesenteric sparing group.

Interpretation: Extended mesenteric resection was not superior to conventional resection with regard to endoscopic Crohn's disease recurrence. These data support the guideline-recommended mesenteric sparing approach.

Funding: Topconsortia voor Kennis en Innovatie-Topsector Life Sciences & Health.