The Surgical Management of the Mesentery in Crohn's Disease

Abstract

Increasing evidence suggests that Crohn's disease is a primary mesenteropathy and that resection of the mesentery, or its exclusion from an anastomosis, may alter disease progression. If borne out in clinical trials, this observation would be welcome, as current pharmacotherapeutic approaches to Crohn's disease appear to have limited effect on disease progression. This article explores arguments for and against the alteration of mesenteric inputs by surgical means, in Crohn's disease.

Keywords

Crohn's disease - mesentery - resection - Kono-S - recurrence

Publication History

Article published online:
10 May 2024

• References

• 1 Crohn B, Ginzburg L, Oppenheimer GD. Regional ileitis—a clinical and pathologcal entity. JAMA 1932; 99 (16) 1323-1328
• 2 Turri G, Carvello M, Ben David N, Spinelli A. Intriguing role of the mesentery in ileocolic Crohn's disease. Clin Colon Rectal Surg 2022; 35 (04) 321-327
• 3 Bemelman WA, Warusavitarne J, Sampietro GM. et al. ECCO-ESCP consensus on surgery for Crohn's disease. J Crohn's Colitis 2018; 12 (01) 1-16
• 4 Coffey CJ, Kiernan MG, Sahebally SM. et al. Inclusion of the mesentery in ileocolic resection for Crohn's disease is associated with reduced surgical recurrence. J Crohn's Colitis 2018; 12 (10) 1139-1150
• 5 Coffey JC, O'Leary DP, Kiernan MG, Faul P. The mesentery in Crohn's disease: friend or foe?. Curr Opin Gastroenterol 2016; 32 (04) 267-273
• 6 Buskens CJ, de Groof EJ, Bemelman WA, Wildenberg ME. The role of the mesentery in Crohn's disease. Lancet Gastroenterol Hepatol 2017; 2 (04) 245-246
• 7 Coffey JC, O'Leary DP. The mesentery: structure, function, and role in disease. Lancet Gastroenterol Hepatol 2016; 1 (03) 238-247
• 8 Coffey JC, Byrnes KG, Walsh DJ, Cunningham RM. Update on the mesentery: structure, function, and role in disease. Lancet Gastroenterol Hepatol 2022; 7 (01) 96-106
• 9 Ehrenpreis ED, Alverdy JC, Wexner SD. The Mesenteric Organ in Health and Disease. Vol 1. Swtizerland AG: Springer Nature; 2021
• 10 Moore KL, Dalley AF, Agur AMR. Clinically Oriented Anatomy. 8 ed.. Philadelphia: Wolters Kluwer; 2018
• 11 Drake R. Anatomy of the Colon. In: Baker RJaFJE. ed. Mastery of Surgery. Vol 2. Tokyo: Lippincott Williams and Wilkins; 2001: 1461-1466
• 12 Carmichael JaMS. Anatomy and embryology of the colon, rectum and anus. In: Steel SRea. ed. The ASCRS Textbook of Colon and Rectal Surgery. Springer International Publishing; 2016: 3-26
• 13 Koshi R. Cunningham's manual of practical anatomy. Vol. 2, Thorax and Abdomen. 16 ed:. Oxford University Press; 2017
• 14 Kumar A, Faiq MA, Krishna H. et al. Development of a novel technique to dissect the mesentery that preserves mesenteric continuity and enables characterization of the ex vivo mesentery. Front Surg 2020; 6: 80
• 15 Kumar A, Kishan V, Jacob TG, Kant K, Faiq MA. Evidence of continuity of mesentery from duodenum to rectum from human cadaveric dissection—a video vignette. Colorectal Dis 2017; 19 (12) 1119-1120
• 16 D'Souza N, Lord A, Shaw A. et al. The sigmoid take-off: an anatomical imaging definition of the rectum validated on specimen analysis. Eur J Surg Oncol 2020; 46 (09) 1668-1672
• 17 D'Souza N, Lord AC, Shaw A. et al. Ex vivo specimen MRI and pathology confirm a rectosigmoid mesenteric waist at the junction of the mesorectum and mesocolon. Colorectal Dis 2020; 22 (02) 212-218
• 18 Byrnes KG, Walsh D, Walsh LG. et al. The development and structure of the mesentery. Commun Biol 2021; 4 (01) 982
• 19 Byrnes KG, Coffey JC. Embryology of the mesentery. In: Ehrenpreis ED, Alverdy JC, Wexner SD. eds. The Mesenteric Organ in Health and Disease. Cham: Springer International Publishing; 2021: 9-14
• 20 Coffey JC, Walsh D, Byrnes KG, Hohenberger W, Heald RJ. Mesentery—a 'New' organ. Emerg Top Life Sci 2020; 4 (02) 191-206
• 21 Coffey JC, Byrnes KG, Walsh D, Dockery P. The mesentery and the mesenteric model of abdominal compartmentalisation. Gray's Anatomy. Commentary 2020; 8: 1
• 22 Coffey JC, Walsh D, Rausei S. Il “Meso” com nuovo organo. In: Dionigi R. ed. Dionigi Chirurgia. 7 ed.. Milan: Edra; 2022: 367-373
• 23 Heald RJ. The 'Holy Plane' of rectal surgery. J R Soc Med 1988; 81 (09) 503-508
• 24 Hohenberger W, Weber K, Matzel K, Papadopoulos T, Merkel S. Standardized surgery for colonic cancer: complete mesocolic excision and central ligation—technical notes and outcome. Colorectal Dis 2009; 11 (04) 354-364 , discussion 364–365
• 25 Choi S, Prien C, Connelly T, Holubar SD. Targeting the mesentery with surgery. In: Coffey JC. ed. The Mesentery and Inflammation. Cham: Springer International Publishing; 2023: 179-212
• 26 Becker MAJ, Does de Willebois EMLV, Bemelman WA, Wildenberg ME, Buskens CJ. Role of the mesentery in Crohn's terminal ileitis. Clin Colon Rectal Surg 2022; 35 (04) 316-320
• 27 Alshantti A, Hind D, Hancock L, Brown SR. The role of Kono-S anastomosis and mesenteric resection in reducing recurrence after surgery for Crohn's disease: a systematic review. Colorectal Dis 2021; 23 (01) 7-17
• 28 Kono T, Ashida T, Ebisawa Y. et al. A new antimesenteric functional end-to-end handsewn anastomosis: surgical prevention of anastomotic recurrence in Crohn's disease. Dis Colon Rectum 2011; 54 (05) 586-592
• 29 Shimada N, Ohge H, Kono T. et al. Surgical recurrence at anastomotic site after bowel resection in Crohn's disease: comparison of Kono-S and end-to-end anastomosis. J Gastrointest Surg 2019; 23 (02) 312-319
• 30 de Groof EJ, van der Meer JHM, Tanis PJ. et al. Persistent mesorectal inflammatory activity is associated with complications after proctectomy in Crohn's disease. J Crohn's Colitis 2019; 13 (03) 285-293
• 31 Zhu Y, Qian W, Huang L. et al. Role of extended mesenteric excision in postoperative recurrence of Crohn's colitis: a single-center study. Clin Transl Gastroenterol 2021; 12 (10) e00407
• 32 Holubar SD, Gunter RL, Click BH. et al. Mesenteric excision and exclusion for ileocolic Crohn's disease: feasibility and safety of an innovative, combined surgical approach with extended mesenteric excision and Kono-S anastomosis. Dis Colon Rectum 2022; 65 (01) e5-e13
• 33 Ewe K, Herfarth C, Malchow H, Jesdinsky HJ. Postoperative recurrence of Crohn's disease in relation to radicality of operation and sulfasalazine prophylaxis: a multicenter trial. Digestion 1989; 42 (04) 224-232
• 34 Mineccia M, Maconi G, Daperno M. et al. Has the removing of the mesentery during ileo-colic resection an impact on post-operative complications and recurrence in Crohn's disease? results from the resection of the mesentery study (remedy). J Clin Med 2022; 11 (07) 1961
• 35 van der Does de Willebois EML. SPICY study group. Mesenteric SParIng versus extensive mesentereCtomY in primary ileocolic resection for ileocaecal Crohn's disease (SPICY): study protocol for randomized controlled trial. BJS Open 2022; 6 (01) zrab136
• 36 Li Y, Mohan H, Lan N. et al. Mesenteric excision surgery or conservative limited resection in Crohn's disease: study protocol for an international, multicenter, randomized controlled trial. Trials 2020; 21 (01) 210
• 37 Fleming CA, Mohan HM, Kiernan M. et al. Surgical morbidity is acceptable following a one or two stage mesentery-including surgery for Crohn's disease and comparable to mesentery-sparing surge. Mesentery Peritoneum 2023; 7: 1
• 38 Holubar SD, Lipman J, Steele SR. et al. Safety & feasibility of targeted mesenteric approaches with Kono-S anastomosis and extended mesenteric excision in ileocolic resection and anastomosis in Crohn's disease. Am J Surg 2024; 230: 16-20
• 39 Coffey JC, Lipman J. General techniques in mesenteric based colorectal surgery. In: Coffey JC. ed. Mesenteric principles of gastrointestinal surgery. Vol 1. Florida: Taylor and Francis; 2017: 211-233
• 40 Xu L, Su X, He Z. et al; RELARC Study Group. Short-term outcomes of complete mesocolic excision versus D2 dissection in patients undergoing laparoscopic colectomy for right colon cancer (RELARC): a randomised, controlled, phase 3, superiority trial. Lancet Oncol 2021; 22 (03) 391-401
• 41 Weidinger C, Hegazy AN, Siegmund B. The role of adipose tissue in inflammatory bowel diseases. Curr Opin Gastroenterol 2018; 34 (04) 183-186
• 42 Behr MA. The path to Crohn's disease: is mucosal pathology a secondary event?. Inflamm Bowel Dis 2010; 16 (05) 896-902
• 43 Weidinger C, Siegmund B. The immunological importance of the mesentery. In: Coffey JC. ed. The Mesentery and Inflammation. Cham: Springer International Publishing; 2023: 77-91
• 44 Mao R, Kurada S, Gordon IO. et al. The mesenteric fat and intestinal muscle interface: creeping fat influencing stricture formation in Crohn's disease. Inflamm Bowel Dis 2019; 25 (03) 421-426
• 45 Huang L, Li Y. Mesenteric organ lymphatics in abdominal inflammation. In: Coffey JC. ed. The Mesentery and Inflammation. Cham: Springer International Publishing; 2023: 57-75
• 46 Kiernan MG, Coffey JC, McDermott K. et al. The human mesenteric lymph node microbiome differentiates between Crohn's disease and ulcerative colitis. J Crohn's Colitis 2019; 13 (01) 58-66
• 47 Ha CWY, Devkota S. Bacterial translocation to the mesentery. In: Coffey JC. ed. The Mesentery and Inflammation. Cham: Springer International Publishing; 2023: 93-109
• 48 Ha CWY, Martin A, Sepich-Poore GD. et al. Translocation of viable gut microbiota to mesenteric adipose drives formation of creeping fat in humans. Cell 2020; 183 (03) 666-683.e17
• 49 Mao R, Liao WD, He Y. et al. Computed tomographic enterography adds value to colonoscopy in differentiating Crohn's disease from intestinal tuberculosis: a potential diagnostic algorithm. Endoscopy 2015; 47 (04) 322-329
• 50 Pulido CG, Ehrenpreis ED. Role of the mesentery in systemic inflammation response syndrome (SIRS) and multiple organ dysfunction syndrome (MODS). In: Ehrenpreis ED, Alverdy JC, Wexner SD. eds. The Mesenteric Organ in Health and Disease. Cham: Springer International Publishing; 2021: 157-167
• 51 Sorrentino D. Fibrocytes, inflammation, and fibrosis in Crohn's disease: another piece of the puzzle. Dig Dis Sci 2014; 59 (04) 699-701
• 52 Sahebally SM, Burke JP, Chang KH, Kiernan MG, O'Connell PR, Coffey JC. Circulating fibrocytes and Crohn's disease. Br J Surg 2013; 100 (12) 1549-1556
• 53 Sazuka S, Katsuno T, Nakagawa T. et al. Fibrocytes are involved in inflammation as well as fibrosis in the pathogenesis of Crohn's disease. Dig Dis Sci 2014; 59 (04) 760-768
• 54 Ueno A, Jijon HB, Peng R. et al. Association of circulating fibrocytes with fibrostenotic small bowel Crohn's disease. Inflamm Bowel Dis 2022; 28 (02) 246-258
• 55 Cenaj O, Allison DHR, Imam R. et al. Evidence for continuity of interstitial spaces across tissue and organ boundaries in humans. Commun Biol 2021; 4 (01) 436
• 56 Theise ND, de Jong IEM, Wells RG. The interstitium of the mesentery: contents and inter-organ connections. In: Coffey JC. ed. The Mesentery and Inflammation. Cham: Springer International Publishing; 2023: 37-55
• 57 Argikar AA, Argikar UA. The mesentery: an ADME perspective on a 'new' organ. Drug Metab Rev 2018; 50 (03) 398-405
• 58 Argikar AA, Argikar UA. Drug metabolizing enzymes and transporters of the mesentery. In: Coffey JC. ed. The Mesentery and Inflammation. Cham: Springer International Publishing; 2023: 165-178
• 59 Mao R, Doyon G, Gordon IO. et al. Activated intestinal muscle cells promote preadipocyte migration: a novel mechanism for creeping fat formation in Crohn's disease. Gut 2022; 71 (01) 55-67
• 60 Mao R, Liu Z, Rieder F. The effects of mesenteric inflammation on intestinal fibrosis. In: Coffey JC. ed. The Mesentery and Inflammation. Cham: Springer International Publishing; 2023: 149-163
• 61 Celentano V, Adamina M, Spinelli A. et al. SupportiNg operAtive Photographic documentation in ileocolonic CROHN's disease surgery: the SNAPCROHN study. Colorectal Dis 2023; 25 (02) 282-288