SPICYCD · Surgery
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
van der Does de Willebois EML, et al.
Lancet Gastroenterol Hepatol 2024 · PMID 39025100 (PubMed, opens in a new tab) · doi 10.1016/S2468-1253(24)00097-9 (full paper, opens in a new tab)
| Endpoint | Extended | Sparing | Difference |
|---|---|---|---|
| Endoscopic recurrence, 6 months (primary endpoint) | 42% (28/66) | 43% (28/65) | Relative risk 0.985 (95% CI 0.663–1.464); P=1.0 |
| Anastomotic leak, Within 30 days | 8% (5/66) | 2% (1/65) | |
| Clavien-Dindo grade IIIa or higher, Postoperative complications | 11% | 8% |
Removing more mesentery did not lower recurrence, and leaks were numerically more common.
Source: van der Does de Willebois 2024, abstract (131 patients analysed for the primary outcome). Denominators for Clavien-Dindo complications are not printed.
Structured abstract
BackgroundRetrospective studies suggested that removing the affected mesentery at ileocolic resection might reduce Crohn's recurrence, but randomised data were scarce.
MethodsInternational randomised controlled trial (6 hospitals, Netherlands and Italy). 139 patients. Primary endpoint: Endoscopic recurrence 6 months after surgery.
ResultsPrimary result. 42% (28/66) with extended mesenteric resection vs 43% (28/65) with mesenteric-sparing resection; relative risk 0.985 (95% CI 0.663–1.464); P=1.0.
Take-homeRemoving more mesentery at primary ileocolic resection did not reduce 6-month endoscopic recurrence, and leaks were numerically more common.
| Patients | 139 |
|---|---|
| Population | Patients aged 16 or older with ileal or ileocolic Crohn's disease (L1 or L3) scheduled for primary ileocolic resection with anastomosis. Median age 36; 131 analysed for the primary outcome. |
| Comparison | Extended mesenteric resection vs conventional mesenteric-sparing resection |
| Drugs | Not applicable (surgical trial) |
| Classes | Surgery |
| Published | van der Does de Willebois EML, et al. Lancet Gastroenterol Hepatol 2024;9:793–801. |
Key points
- Anastomotic leak within 30 days: 8% (5/66) extended vs 2% (1/65) sparing.
- Clavien-Dindo grade IIIa or higher complications: 11% vs 8%.
- Supports the guideline-recommended mesenteric-sparing approach.
Limitations
- 6-month endpoint; longer-term recurrence is unknown.
- Six centres; surgical technique may vary elsewhere.
- Not powered for complication rates.
Commentary
SPICY tested the idea, from retrospective series, that the diseased mesentery drives recurrence. It did not reduce early endoscopic recurrence. Other surgical-technique trials (for example Kono-S anastomosis) are ongoing or reported; postoperative care should still follow risk stratification and endoscopic monitoring as in POCER.
Journal club
Design
International randomised controlled trial (6 hospitals, Netherlands and Italy). 139 patients.
Primary result. 42% (28/66) with extended mesenteric resection vs 43% (28/65) with mesenteric-sparing resection; relative risk 0.985 (95% CI 0.663–1.464); P=1.0.
Validity and applicability
- 6-month endpoint; longer-term recurrence is unknown.
- Six centres; surgical technique may vary elsewhere.
- Not powered for complication rates.
Where it sits now
Removing more mesentery at primary ileocolic resection did not reduce 6-month endoscopic recurrence, and leaks were numerically more common.
- POCER (2015): After resection, treating by risk and scoping at 6 months with step-up for recurrence beats drug prophylaxis alone; this is why we do a postoperative colonoscopy.
- REPREVIO (2025): Starting vedolizumab within 4 weeks of ileocolonic resection reduces early endoscopic recurrence in patients at risk.
- LIR!C (2017): For limited (40 cm or less), non-stricturing terminal ileal Crohn's disease that has failed conventional therapy, laparoscopic resection is a reasonable alternative to starting an anti-TNF.
- PREVENT (2016): In patients at increased risk, postoperative infliximab roughly halves endoscopic recurrence but did not significantly reduce clinical recurrence by week 76, so endoscopic monitoring is still needed.
Questions for discussion
- Endoscopic recurrence at 6 months is a surrogate. What longer-term outcomes would you want before closing the question?
- Leaks were 8% vs 2%, but the trial was not powered for complications. How should a numerically worse safety signal in a negative trial influence surgical practice?
- Does this result change postoperative prophylaxis or the timing of the first colonoscopy for any of your patients?