Pioneering Limerick surgeon outlines developments in Crohn’s surgery

Surgeons should increasingly consider mesentery-based approaches in the surgical management of Crohn’s disease (CD), supported by an expanding evidence base, delegates at the Irish Society of Gastroenterology (ISG) 2026 Summer Meeting heard.

Prof J Calvin Coffey, Foundation Chair of Surgery, University of Limerick School of Medicine and Consultant General and Colorectal Surgeon, University Hospital Limerick, delivered a detailed presentation on optimal mesenteric approaches in CD surgery.

The mesentery was reclassified as an organ following discoveries by Prof Coffey and collaborators in 2016. His subsequent research into its role in CD and the development of mesentery-based surgical approaches has gained international recognition.

Postoperative anastomotic recurrence of CD remains a major clinical challenge and frequently leads to symptom recurrence and repeat surgery, Prof Coffey told the meeting.

Macroscopic recurrence initially occurs at the mesenteric pole of the intestine, and accumulating evidence suggests that mesenteric changes are closely linked to disease recurrence following resection.

Consequently, mesentery-based surgery has attracted increasing interest in recent years. However, the precise role of the mesentery in postoperative recurrence remains controversial.

“There remains ongoing debate and lack of consensus regarding the benefit of extended mesenteric excision (EME) compared to limited mesenteric excision (LME) in the surgical management of CD,” Prof Coffey said.

He discussed the findings of the landmark SPICY (Mesenteric SParIng versus extensive mesentereCtomY in primary ileocolic resection for Crohn’s disease) randomised controlled trial (RCT), which investigated whether removing the entire mesentery, up to the ileocolic trunk, reduced CD recurrence compared with traditional LME.

The SPICY trial results (2024) found that EME was not superior to traditional LME in preventing postoperative endoscopic recurrence at six months. However, the findings were controversial, with conflicting data from other trials and uncertainty regarding the exact nature and classification of the surgeries performed.

Therefore, further research was undertaken, most notably the recently published MESOCOLIC (Mesenteric excision surgery or conservative limited resection in Crohn’s disease) multicentre RCT involving Prof Coffey and local and international colleagues.

Prof Coffey reported the key findings of the MESOCOLIC trial at the ISG meeting, most notably that EME reduced overall endoscopic recurrence in CD and was associated with reduced requirements for CD medication at long-term follow-up.

“EME results in an early and durable reduction in overall endoscopic recurrence and all categories of endoscopic recurrence.”

The MESOCOLIC trial also suggested that events occurring within the mesentery are net pathogenic in CD, he noted. “We need to characterise these events; doing so could improve our pharmacology.”

The evidence is increasingly favouring mesenteric excision in CD, although Prof Coffey cautioned that it should not yet be considered standard practice.

Instead, surgeons should determine the most appropriate mesentery-based strategy for each individual patient, whether that involves mesenteric resection, exclusion, or reconfiguration.

Prof Coffey acknowledged that many surgeons remain reluctant to remove the mesentery but said the growing body of evidence is reassuring regarding the safety and efficacy of mesentery-based approaches compared with traditional techniques.

He also noted that staged EME appears safe when complete mesenteric excision cannot be performed during a single procedure.