Ahmed Farag
Emeritus Professor of General Surgery. Kasr El-Ainy University hospital Cairo University, Egypt.
*Correspondence to: Ahmed Farag, Emeritus Professor of General Surgery. Kasr El-Ainy University hospital Cairo University, Egypt.
Received: May 09, 2024; Accepted: May 20, 2024; Published: May 24, 2024
Citation: Farag A (2024) Immune-modulating Surgery in IBD: A New Trend in Surgical Management of IBD?. Journal of Anatomical Variation and Clinical Case Report 2:108. DOI: https://doi.org/10.61309/javccr.100010
Copyright: ©2024 Farag A. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
EDITORIAL
Crohn’s disease is a chronic inflammatory bowel disease that affects the gastrointestinal tract. It is characterized by periods of remission and relapse, and can lead to complications such as strictures, fistulas, and abscesses. Surgical intervention is often necessary in cases of severe or refractory disease. Excision of the mesentery of the bowel has been proposed as a potential strategy to reduce the incidence of recurrence and improve the response to immune-modulating treatment or biologics after surgery [1-3]. Several studies have investigated the role of mesenteric excision in Crohn’s disease, with varying results.
Those who supports the approach of Mesenteric excision argue for improved surgical outcomes: Mesenteric excision has been shown to improve surgical outcomes in patients with Crohn’s disease by reducing the risk of postoperative complications such as anastomotic leakage and wound infections [4-6]. Reduced risk of recurrence: Mesenteric excision can also reduce the risk of disease recurrence by removing the inflamed mesentery, which is thought to be a source of disease activity [7]. Better disease control: Mesenteric excision can improve disease control by removing the inflamed tissue and reducing the risk of complications such as strictures and fistulas [8].
According to basic scientific research, the mesentery may have a role in IBD, but the exact mechanism is still unclear [9]. In 2018, Coffey et al. conducted a retrospective review comparing two groups of patients with CD who underwent different types of ileocolic resection. The first group (n = 30) had conventional ileocolic resection with mesenteric division close to the intestine, while the second group (n = 34) had a more extended excision of the adjacent mesentery. The reoperation rates for CD were significantly lower in the extended mesenteric excision group (2.9%) compared to the standard group (40%) with a mean follow-up duration of 52 and 70 months, respectively. The authors also found that advanced mesenteric disease predicted increased surgical recurrence.
Preliminary data from a trial involving the Kono-S anastomosis has also questioned the underlying theory behind the Coffey study, as it showed a decreased risk of endoscopic CD recurrence six months postoperatively with a limited mesenteric excision [10-11].
On the other hand those who argue against Mesenteric excision argue by increased surgical complexity: Mesenteric excision is a technically challenging procedure that requires specialized training and expertise. It can also increase the duration of surgery and the risk of intraoperative complications [12]. Mesenteric excision can cause damage to nearby structures such as blood vessels and nerves, which can lead to complications such as bleeding and nerve injury [13]. Another important point of argument is the Limited evidence: While mesenteric excision has been shown to improve outcomes in some studies, there is limited high-quality evidence to support its routine use in all patients with Crohn’s disease [14].
A different study, the Remedy trial, found no advantage to removing more mesentery (extended mesenteric resection) compared to preserving it (mesentery-sparing resection) in preventing Crohn’s disease recurrence after 5 years. This was true for both stricturing and penetrating forms of the disease. Interestingly, the study also showed that using immunosuppressive drugs after surgery greatly reduced the need for repeat surgery (surgical recurrence) to only 4% [15].
In a recent review by Meijer et al 2023, they concluded that A recent review suggests the mesentery plays a bigger role in Crohn’s disease (CD) than previously thought, with just managing the bowel potentially not enough. The study by Meijer et al (2023) highlights the importance of mesentery resection extent, postoperative monitoring, and potentially the Kono-S reconstruction technique in reducing disease recurrence. Three ongoing clinical trials are comparing different mesenteric removal approaches and anastomosis types to guide future surgical decisions for CD [16].
Similarly, Appendectomy is the surgical removal of the appendix, and it has been suggested as a potential treatment for ulcerative colitis (UC), a chronic inflammatory bowel disease that affects the colon and rectum. The idea behind this is that the appendix may be a reservoir for harmful bacteria that can trigger inflammation in the gut, and removing it may reduce the risk of UC or improve symptoms in those who already have the disease [14,17-18].
Several studies have investigated the role of appendectomy in UC, and while the results have been mixed, some have suggested that it may be beneficial in certain cases. For example, 2010 study published in the journal Inflammatory Bowel Diseases found that patients with UC who had undergone appendectomy had a lower risk of developing complications such as toxic megacolon and a lower likelihood of requiring total proctocolectomy (surgical removal of the colon and rectum) compared to those who had not had the procedure [19-21].
Similarly, In a prospective study of 30 patients with medically refractory UC who were referred for proctocolectomy, but who instead underwent laparoscopic appendectomy, 9 patients (30%) had a sustained clinical response and 5 patients (17%) experienced endoscopic remission at 12 months. In this study, the degree of appendiceal inflammation was significantly associated with clinical and endoscopic response [22]. In another prospective, multicenter study of 28 patients with medically refractory UC who underwent a laparoscopic appendectomy rather than proctocolectomy, 13 patients (46%) had a clinical response, 5 patients (18%) had endoscopic remission, and 9 patients (32%) required a colectomy or new experimental medical therapy within 12 months of appendectomy [23].
Based on the above mentioned data we can suggest a new trend in treatment of IBD which is based on minimal surgical procedures which improves the patients response to medical treatment and brings more patients under control which decreases the incidence of recurrence and the need of repeated surgery in Crohn’s disease and avoids major surgery in Patients with ulcerative colitis.
While the idea of using minimal surgical procedures to treat IBD is intriguing, it is important to note that appendectomy is not a standard treatment for UC and the weak evidence supporting the addition of Mesenteric excision to resection of localized Crohn’s disease, the suggested approach should only be considered on a case-by-case basis. More research is needed to fully understand the potential benefits and risks of this approach, and it should be evaluated in the context of other available treatments for IBD, such as medication and lifestyle changes. Additionally, any surgical procedure carries risks and should only be performed when the potential benefits outweigh the risks for the individual patient.
The suggested Immune-modulating surgical approach is characterized by being Limited Surgeries which are targeted to modulate the Immune system of IBD patients in order to improve response to Medical treatment including Biologics.
The aim of this editorial is to suggest a Multicenter Trial on the immune-modulating effect of Mesenteric excision and Appendectomy on the course of CD and UC respectively.
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