Clinical outcomes of conventional versus extended mesenteric resection in limited ileo-colonic Crohn's disease: a systematic review and meta-analysis.

Abstract

Background: The role of intestinal mesentery and the extent of its resection as a determinant of outcomes post-bowel resection in Crohn's disease (CD) remains a subject of debate. We evaluated outcomes of conventional mesenteric resection (CMR) and compared it with extended mesenteric resection (EMR) in patients undergoing ileo-colic excision for limited ileo-colonic CD.

Methods: A comprehensive search was conducted in accordance with PRISMA guidelines using Medline, Embase, PubMed, and Cochrane databases. Comparative studies of patients with limited ileo-colonic CD undergoing CMR and EMR for ileo-colic resection were included. Studies comparing anastomotic techniques, single-arm, case reports/series, study protocols and editorials were excluded. Primary outcomes were disease recurrence and re-operation. Secondary outcomes included post-operative complications, intra-operative blood loss, length of stay, total operative time and re-admission rate. Meta-analysis was performed using Cochrane RevMan Web on outcomes reported by two or more studies. Combined overall effect sizes were calculated using random-effects model and the Newcastle-Ottawa Scale and Cochrane risk-of-bias tools were used to assess bias.

Results: Five studies met our inclusion criteria (four retrospective cohort studies; one randomised controlled trial (RCT)) with a total of 4,358 patients (EMR: 993 vs. CMR: 3,365). No statistical difference was observed across any of the analysed outcomes: disease recurrence [OR: 0.49 CI 0.21-1.16, P = 0.10], re-operation [OR: 0.33 CI 0.06-1.65, P = 0.17], intra-operative blood loss [MD: -18.71 CI -76.65-39.23, P = 0.53], anastomotic leak [OR: 0.98 CI 0.34-2.82, P = 0.97], length of stay [MD: -0.06 CI -0.59-0.48, P = 0.83], post-operative morbidity [OR: 1.01 CI 0.82-1.24, P = 0.95], blood transfusion [OR: 1.16 CI 0.84-1.59, P = 0.36], Clavien-Dindo III + complications [OR: 0.83 CI 0.5-1.38, P = 0.47], post-operative ileus [OR: 0.97 CI 0.27-3.50, P = 0.96], intra-abdominal bleeding [OR: 0.85 CI 0.22-3.26, P = 0.81], re-admission [OR: 0.65 CI 0.24-1.78, P = 0.40], surgical site infection [OR: 1.00 CI 0.77-1.30, P = 0.99], post-operative adjuvant or prophylactic therapy [OR: 0.90 CI 0.54-1.51, P = 0.69] and total operative time [MD: 0.38 CI -4.42-5.19, P = 0.88].

Conclusion: Performing EMR during ileo-colic resection for patients with limited ileo-colonic CD does not seem to confer any additional benefit to conventional (limited resection) approaches. Robust, well-designed, large-scale RCTs are needed to better compare these techniques and demonstrate superiority in clinical outcomes.