Surgical Techniques for Crohn's Disease

(SPARES Trial)

Recruiting at 6 trial locations

Overseen By Allison Bayles, AA

Age: 18+

Sex: Any

Trial Phase: Academic

Sponsor: The Cleveland Clinic

Disqualifiers: Repeat resection, Other disease locations, Cancer, others

No Placebo Group All trial participants will receive the active study treatment (no placebo)

Compensation: Varies

Number of Visits: 2

181 Participants Needed

Trial Summary

Will I have to stop taking my current medications?

The trial allows participants to continue taking their current medications, including corticosteroids, 5-ASA drugs, thiopurines, MTX, antibiotics, anti-TNF, vedolizumab, and ustekinumab.

What data supports the effectiveness of the treatment High Ligation of Ileocolic Artery, Mesenteric Non-Sparing Ileocolic Resection, and Mesenteric Sparing Ileocolic Resection for Crohn's Disease?

The research indicates that laparoscopic-assisted ileocolic resection for Crohn's disease is a safe and feasible procedure, although complications like mesenteric pseudoaneurysm can occur. Additionally, high ligation of arteries, while used in other conditions like rectal cancer, may affect blood flow, but this does not necessarily increase the risk of complications like anastomotic leakage. ^{1 2 3 4 5}

Is the surgical technique for Crohn's disease generally safe?

The surgical technique, including high ligation of the ileocolic artery, is generally considered safe, but there are potential risks such as pseudoaneurysms (abnormal bulging of blood vessels) and ischemia (reduced blood flow) if arteries are mistakenly ligated. These complications are rare and can often be managed effectively with prompt treatment. ^{1 2 6 7 8}

How is the treatment High Ligation of Ileocolic Artery, Mesenteric Sparing different from other treatments for Crohn's disease?

This treatment is unique because it involves high ligation (tying off) of the ileocolic artery and sparing the mesentery (the tissue that attaches the intestines to the abdominal wall), which is different from traditional surgeries that often remove diseased mesentery. This approach may help reduce postoperative recurrence of Crohn's disease. ^{2 9 10 11 12}

What is the purpose of this trial?

Study description - Patients will be randomized according to post-operative recurrence risk to either a high ligation of ileocolic artery or mesenteric sparing ileocolic resection for terminal ileal Crohn's disease. The primary endpoint 6-month endoscopic recurrence. Endpoints - Primary endpoint; 6 months Secondary endpoints at 1 and 5 years post ileocecal resection Study population - Adult Crohn's disease patients with medically refractory terminal ileal Crohn's disease undergoing a primary ileocecal resection. Study sites - Multicenter international study Description of study intervention - Randomized control trial of two operative techniques Operative approach of a high ligation of ileocolic artery as compared to mesenteric sparing for a primary ileocolic resection Participate duration - 5 years

Research Team

Amy Lightner, MD

Principal Investigator

The Cleveland Clinic

Eligibility Criteria

Adults aged 18-65 with Crohn's Disease affecting less than 30 cm of the terminal ileum and not responding to standard treatments can join. They must be able to follow the study protocol for 5 years and give consent. Excluded are those with a history of cancer, other significant medical conditions, or requiring additional surgeries beyond ileocolic resection.

Inclusion Criteria

My condition hasn't improved with current treatment or I can't tolerate it.

My Crohn's disease affects less than 30 cm of my ileocolic region.

Ability to comply with protocol

Exclusion Criteria

I have had cancer before, but not melanoma or any non-localized skin cancers.

I need surgery urgently.

I haven't had major heart issues or other serious health problems in the last 6 months.

Timeline

Screening

Participants are screened for eligibility to participate in the trial

2-4 weeks

Surgery

Participants undergo either a high ligation of ileocolic artery or mesenteric sparing ileocolic resection

1 week

1 visit (in-person)

Post-operative Monitoring

Participants are monitored for endoscopic recurrence using Rutgeerts score

6 months

1 visit (in-person)

Follow-up

Participants are monitored for clinical and surgical recurrence

5 years

Annual visits (in-person)

Treatment Details

Interventions

• High Ligation of Ileocolic Artery
• Mesenteric Sparing

Trial Overview The SPARES trial is testing two surgical methods in Crohn's patients: high ligation versus mesenteric sparing of the ileocolic artery during resection. It aims to see which technique better prevents disease recurrence after surgery, monitored over six months to five years.

Participant Groups

Group I: mesenteric sparing for a primary ileocolic resection Active Control 2 Interventions

Randomized control trial of two operative techniques Operative approach of a high ligation of ileocolic artery as compared to mesenteric sparing for a primary ileocolic resection

Group II: high ligation of ileocolic artery Active Control 2 Interventions

Randomized control trial of two operative techniques Operative approach of a high ligation of ileocolic artery as compared to mesenteric sparing for a primary ileocolic resection

Who Is Running the Clinical Trial?

The Cleveland Clinic

Lead Sponsor

Trials

1,072

Recruited

1,377,000+

Findings from Research

In a study of 75 patients undergoing ileocecal resection or anterior rectal resection, high ligation of the inferior mesenteric artery was found to significantly prolong blood flow time in the sigmoid colon, indicating potential hypoperfusion issues.

Despite the differences in vascular perfusion, the rates of anastomotic leakage were similar between high and low ligation techniques, suggesting that low vascular perfusion may not be a definitive risk factor for leakage.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

High Ligation of the Inferior Mesenteric Artery Induces Hypoperfusion of the Sigmoid Colon Stump During Anterior Resection. Higashijima, J., Kono, T., Shimada, M., et al.[2021]

Laparoscopic-assisted ileocolic resection for Crohn's disease is a safe and feasible procedure, as demonstrated by the uneventful postoperative course of a 32-year-old patient.

A rare complication, a mesenteric pseudoaneurysm, was identified post-surgery, likely due to the patient's thick vascular mesentery, highlighting the need for awareness of this potential risk in similar cases.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Endovascular treatment of ileocolic pseudoaneurysm after a laparoscopic-assisted bowel resection for Crohn disease. Edden, Y., Shussman, N., Cohen, MJ., et al.[2016]

In a study of 104 rectal cancer patients, precision low inferior mesenteric artery (IMA) ligation with left colonic artery (LCA) preservation led to a significant increase in the number of harvested lymph nodes compared to traditional high IMA ligation (24.9 vs. 16.9 nodes).

The precision technique also resulted in fewer postoperative complications (5.8% vs. 9.6%) while maintaining safety, as there were no significant differences in operative time or other recovery metrics between the two surgical methods.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

[Accurate low ligation of inferior mesenteric artery and root lymph node dissection according to different vascular typing in laparoscopic radical resection of rectal cancer]. Zhou, J., Zhang, S., Huang, J., et al.[2018]

In a randomized trial involving 331 patients with rectal cancer, the method of inferior mesenteric artery ligation (high tie vs. low tie) did not significantly affect the incidence of anastomotic leakage, with rates of 17.7% for high tie and 16.3% for low tie.

There were no significant differences in overall survival (87.2% vs. 89.4%) or disease-free survival (76.3% vs. 77.6%) at 5 years between the two ligation methods, indicating that the choice of ligation level does not impact long-term outcomes.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Randomized clinical trial of high versus low inferior mesenteric artery ligation during anterior resection for rectal cancer. Fujii, S., Ishibe, A., Ota, M., et al.[2022]

In a study of 92 rectal cancer patients undergoing laparoscopic radical resection, type III inferior mesenteric artery (IMA) was associated with significantly higher intraoperative blood loss and a greater incidence of postoperative anastomotic fistula compared to type I and II IMAs.

Despite the increased bleeding and fistula rates in type III IMA patients, the overall risk of postoperative complications did not differ significantly among the three IMA types, suggesting that while type III may pose specific challenges, it does not lead to a higher overall complication rate.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

A clinical study of inferior mesenteric artery typing in laparoscopic radical resections with left colonic artery preservation of rectal cancer. Chen, J., Wang, M., Chen, Y., et al.[2022]

A rare case of ileal ischemia occurred due to the unintentional ligation of a variant ileal branch of the superior mesenteric artery during laparoscopic surgery, highlighting the risk of confusing this branch with the ileocolic artery.

The use of intraoperative real-time monitoring techniques, such as indocyanine green (ICG) angiography and hyperspectral imaging (HSI), can effectively detect hypoperfusion and potentially prevent complications related to inadequate blood supply during surgery.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Ileal long-segment ischemia after the unintended ligation of variant ileal branch during laparoscopic right hemicolectomy. Son, GM., Kim, TU., Shin, DH., et al.[2022]

In a study of 409 patients undergoing high or low ligation for sigmoid colon and rectal cancer, 2.0% of those who had high ligation developed proximal bowel necrosis, a serious complication that required secondary surgery.

Advanced age, cerebrovascular disease, and hypertension were identified as significant risk factors for developing proximal bowel necrosis, with cerebrovascular disease being an independent predictor of this complication.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Proximal bowel necrosis after high ligation of the inferior mesenteric artery in colorectal surgery. Tsujinaka, S., Kawamura, YJ., Tan, KY., et al.[2022]

The case report highlights a rare instance of an ileocolic artery pseudoaneurysm, which is a serious condition that can lead to severe bleeding or bowel ischemia if not promptly diagnosed and treated.

The diagnosis was successfully made using delayed CT imaging, and the condition was effectively treated through transcatheter embolization, demonstrating a minimally invasive approach to managing such vascular injuries.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Traumatic ileocolic pseudoaneurysm: diagnosis and transcatheter treatment. Rundback, JH., Chughtai, S., Rozenblit, G., et al.[2019]

A novel surgical technique combining mesenteric excision and exclusion was performed on 22 patients with ileocolic Crohn's disease, showing high feasibility and safety with no cases of intra-abdominal sepsis or anastomotic leak.

The median postoperative stay was only 4 days, and while there were 2 readmissions for reintervention, the overall outcomes suggest this approach could potentially reduce postoperative recurrence of Crohn's disease, warranting further investigation.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

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. Holubar, SD., Gunter, RL., Click, BH., et al.[2023]

A limited resection of the terminal ileum and ileocecal valve, followed by ileocecal anastomosis, was successfully performed on three patients with Crohn's disease, resulting in symptom resolution and no mucosal changes at 6 and 12 months post-surgery.

This approach minimizes the extent of surgery compared to standard ileocolic resection, potentially reducing the risk of post-surgical relapses and preserving more of the bowel, making it a viable alternative for select patients.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Minimally invasive ileocecal valve resection in ileocecal Crohn's disease. Benassai, G., Serra, C., Romeo, G., et al.[2023]

In a study of 80 patients undergoing laparoscopic ileocolic resection for terminal ileal Crohn's disease, the procedure had a low conversion rate of 1.2% and a complication rate of only 7.5%, indicating it is a safe surgical option.

The surgery resulted in a recurrence rate of 30% over a median follow-up of 64 months, suggesting that while effective, some patients may experience a return of symptoms after the procedure.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Laparoscopic intracorporeal ileocolic resection for Crohn's disease: is it safe? Bergamaschi, R., Haughn, C., Reed, JF., et al.[2009]

In a study of 207 patients undergoing ileocecal or ileocolic resections for Crohn's disease, steroid use and preoperative abscess formation were identified as significant independent risk factors for anastomotic complications, with complication rates reaching 40% when both factors were present.

The overall risk of anastomotic complications was 6% in patients without these risk factors, but increased to 14% with one risk factor, highlighting the importance of assessing these conditions before surgery.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Influence of risk factors on the safety of ileocolic anastomosis in Crohn's disease surgery. Tzivanakis, A., Singh, JC., Guy, RJ., et al.[2022]

References

1. Switzerland pubmed.ncbi.nlm.nih.gov

High Ligation of the Inferior Mesenteric Artery Induces Hypoperfusion of the Sigmoid Colon Stump During Anterior Resection. [2021]

2. United States pubmed.ncbi.nlm.nih.gov

Endovascular treatment of ileocolic pseudoaneurysm after a laparoscopic-assisted bowel resection for Crohn disease. [2016]

3. China pubmed.ncbi.nlm.nih.gov

[Accurate low ligation of inferior mesenteric artery and root lymph node dissection according to different vascular typing in laparoscopic radical resection of rectal cancer]. [2018]

4. England pubmed.ncbi.nlm.nih.gov

Randomized clinical trial of high versus low inferior mesenteric artery ligation during anterior resection for rectal cancer. [2022]

5. England pubmed.ncbi.nlm.nih.gov

A clinical study of inferior mesenteric artery typing in laparoscopic radical resections with left colonic artery preservation of rectal cancer. [2022]

6. Korea (South) pubmed.ncbi.nlm.nih.gov

Ileal long-segment ischemia after the unintended ligation of variant ileal branch during laparoscopic right hemicolectomy. [2022]

7. England pubmed.ncbi.nlm.nih.gov

Proximal bowel necrosis after high ligation of the inferior mesenteric artery in colorectal surgery. [2022]

8. United States pubmed.ncbi.nlm.nih.gov

Traumatic ileocolic pseudoaneurysm: diagnosis and transcatheter treatment. [2019]

9. United States pubmed.ncbi.nlm.nih.gov

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. [2023]

10. Italy pubmed.ncbi.nlm.nih.gov

Minimally invasive ileocecal valve resection in ileocecal Crohn's disease. [2023]

11. United States pubmed.ncbi.nlm.nih.gov

Laparoscopic intracorporeal ileocolic resection for Crohn's disease: is it safe? [2009]

12. United States pubmed.ncbi.nlm.nih.gov

Influence of risk factors on the safety of ileocolic anastomosis in Crohn's disease surgery. [2022]