Surgery · Medical Literature
Resection of the mesentery vs Kono-S anastomosis in preventing surgical recurrence for primary Crohn disease: the REMEASURE prospective, randomized, controlled trial.
Abstract
Many authors have investigated whether a new functional end-to-end anastomosis, the Kono-S, or the resection of the mesentery could allow better results following primary ileocolic-resection for Crohn Disease. The Resection of the mesentery vs Kono-S anastomosis in preventing surgical recurrence (Remeasure)-trial aims at investigating if Kono-S-anastomosis or resection of the mesentery with functional end-to-end anastomosis could impact results in terms of postoperative complications and surgical, endoscopic and clinical recurrence. Randomized prospective trial at a tertiary referral Institution. Primary endpoint: endoscopic recurrence at 6 months (Rutgeerts score i2 or greater). Secondary endpoints: postoperative complications, clinical recurrence after 12 months, endoscopic-recurrence after 18 months, surgical recurrence after 24 months. 73 patients randomly assigned: 36 to Kono-S and 37 to mesenteric-resection. The two groups had similar peri-operative course. Surgical-recurrence occurred in two patients (1 following Kono-S, 1 following mesentery-resection). Six-months endoscopic-recurrence occurred in 12/36 (33%) of Kono-S patients and in 12/37 (32%) of the mesenteric-resection group. The 6-12- and 18-month time-to-event estimates showed no significant differences in endoscopic or clinical recurrence. In the Cox proportional hazards model, perforating behavior was a risk factor for late endoscopic recurrence (HR 1.70, p = 0.05), whereas adjuvant biologic therapy was protective (HR 1.32, p = 0.034). The Remeasure trial doesn't show significant advantages in terms of postoperative complications, surgical, endoscopic and clinical recurrence after Kono-S anastomosis or mesenteric-resection technique following primary ileocolic-resection in Crohn Disease.
Clinical relevance
In patients with primary ileocolic Crohn disease requiring surgical resection, does the Kono-S anastomosis (with mesentery preserved in situ) produce equivalent outcomes compared with standard functional end-to-end anastomosis performed after mesenteric resection, with respect to endoscopic recurrence and postoperative complications? __SNAPSHOT__ {"studyDesign":"Randomized controlled trial (prospective; single-center)","setting":"Tertiary referral institution; country not reported in the supplied abstract","sampleSize":"n=73 (Kono-S: n=36; mesenteric resection: n=37)","population":"Adults with primary ileocolic Crohn disease requiring ileocolic resection; patients with recurrent disease, multisite disease, or immediate postoperative biologic requirement were not the stated population (specific inclusion/exclusion criteria beyond 'primary' disease not fully detailed in the abstract)","intervention":"Kono-S anastomosis — antimesenteric, functional, hand-sewn end-to-end anastomosis with mesentery preserved in situ","comparator":"Functional end-to-end anastomosis performed after resection of the mesentery (stapled antimesenteric anastomosis with mesenteric excision)","primaryOutcome":"Endoscopic recurrence at 6 months post-resection, defined as Rutgeerts score i2 or greater on ileocolonoscopy","followUp":"Primary endpoint at 6 months; secondary endpoints at 12, 18, and 24 months (whether 24-month follow-up was complete for all participants is not reported in the abstract)","fundingSource":"Not reported"}
Key findings
Among 73 randomized patients, 6-month endoscopic recurrence (Rutgeerts score ≥i2) occurred in 12/36 (33.3%) patients in the Kono-S group and 12/37 (32.4%) patients in the mesenteric resection group. The absolute risk difference was 0.9 percentage points (calculated), with a relative risk of approximately 1.03 (calculated) — indicating no clinically or statistically meaningful difference for the primary endpoint, though formal p-values and confidence intervals are not reported in the supplied abstract. Surgical recurrence at 24 months occurred in 2 patients total: 1 in each group, suggesting a very low surgical recurrence rate in both arms over the study period, but the absolute numbers are too small to draw comparative conclusions. The two groups had similar perioperative courses, suggesting comparable short-term safety profiles. Results for secondary endpoints — clinical recurrence at 12 months and endoscopic recurrence at 18 months — are not reported in the available abstract. NNT and NNH cannot be calculated meaningfully given the near-identical primary outcome rates. No specific adverse event data (e.g., anastomotic leak rates, reoperation for complications) are detailed in the abstract beyond the statement of 'similar peri-operative course.'
Practice implications
The REMEASURE trial is, to this author's knowledge, the first RCT to directly compare Kono-S anastomosis (mesentery-sparing) against mesenteric resection with functional end-to-end anastomosis as head-to-head active comparators — a uniquely designed equivalence question, rather than the more common comparison of either technique against a standard stapled side-to-side anastomosis. The primary finding is that both techniques produced nearly identical 6-month endoscopic recurrence rates (~33% each), suggesting no superiority of either approach over the other for this endpoint. This result is contextually consistent with the SPICY trial (Lancet Gastroenterol Hepatol, 2024), which found that extended mesenteric resection was not superior to conventional mesenteric-sparing resection for endoscopic recurrence. Conversely, earlier retrospective data from the same group (REMEDY study, 2022) and the SuPREMe-CD RCT suggested potential advantages for mesenteric manipulation strategies. Critically, what the study does NOT establish: (1) whether either technique is superior to a standard stapled side-to-side anastomosis; (2) whether there is a difference in 12-month clinical recurrence, 18-month endoscopic recurrence, or 24-month surgical recurrence between groups, as these data are not available in the abstract; (3) the specific complication profile of each procedure; and (4) the combined effect of Kono-S plus mesenteric resection, which remains under evaluation in larger factorial trials (e.g., MEErKAT). The trial population — primary ileocolic CD at a single tertiary center — may not represent patients with recurrent, penetrating, or multisegment disease, or those managed at lower-volume centers where technical reproducibility of Kono-S may be lower. Because only an abstract is available, this summary is limited to reported aggregate results; subgroup analyses, covariate-adjusted analyses, and detailed safety data cannot be assessed. Practice change is not warranted on the basis of this single, modestly powered, single-center trial. __LIMITATIONS__ Small sample size (n=73) is likely underpowered to detect modest but clinically meaningful differences in recurrence rates; the trial protocol (NCT07164209) was powered assuming 45% endoscopic recurrence in the mesenteric resection group and 20% in the Kono-S group — the observed rates (~33% in both arms) fell between these assumptions, suggesting the power calculation was not met as expected,Single-center design limits generalizability and may reflect the expertise of a high-volume referral center rather than standard practice,Surgical blinding is inherently impossible; endoscopist and outcome assessor blinding status is not reported in the abstract,The abstract is truncated — secondary endpoint data at 12, 18, and 24 months, full safety data, and statistical inference (p-values, confidence intervals) are not available for this summary,No formal equivalence or non-inferiority margin is reported in the abstract, making interpretation of 'no difference' findings statistically ambiguous,Postoperative medical prophylaxis protocols (biologic use, immunomodulator use) are not described; differential postoperative treatment between arms could confound recurrence outcomes,The Rutgeerts score — while widely used — has recognized interobserver variability and lacks validation for the Kono-S anastomotic configuration, potentially introducing scoring bias,Selection bias cannot be excluded in a single-center trial; patients enrolled may differ systematically from community or lower-acuity populations,Funding source is not disclosed, limiting assessment of potential conflicts of interest,The abstract is truncated mid-sentence, raising the possibility that additional outcomes data exist in the full manuscript that are not captured here __BOTTOM_LINE_CATEGORY__ promising_but_preliminary __BOTTOM_LINE__ The REMEASURE RCT found nearly identical 6-month endoscopic recurrence rates (~33%) with Kono-S anastomosis (mesentery preserved) and mesenteric resection with functional end-to-end anastomosis in primary ileocolic Crohn disease, with similarly low 24-month surgical recurrence in both arms. However, the trial is single-center, modestly sized, and the abstract is incomplete — formal statistical inference, full safety data, and longer-term secondary outcomes are not yet available for review. Current evidence does not support preferentially selecting either technique over the other based on these data alone; surgeon expertise, institutional volume, and patient-specific factors should continue to guide anastomotic and mesenteric management decisions until larger factorial trials (e.g., MEErKAT) report their results.