Potential roles of the mesentery in Crohn's disease

The mesentery is the organ that supports development of all abdominal digestive organs in the foetus, and which supports and maintains all abdominal digestive organs in systemic continuity in the adult. Mesenteric abnormalities such as creeping fat are pathognomic of Crohn's disease and point to a pathobiological role for the mesentery. As part of the standard operative approach to resection, the mesentery is normally retained. Recent observations suggest that if the mesentery is included in the resections for ileocolic Crohn's disease, postoperative requirements for re-operation may be reduced. This is supported by emerging observations related to excision of the mesorectum during proctectomy for Crohn's disease, and by observations on the Kono-S procedure. As part of the latter, the mesentery is retained but is circumferentially excluded from the intestinal anastomosis. Mesenteric resection may also provide a more oncologically sound approach, in patients who also harbour a malignancy. Concerns regarding mesenteric resection relate to the possibility of mesenteric haemorrhage, and the lack of surgical planes in a hostile operative setting. Reliable haemostatic techniques have emerged that enable safe mesenteric division. Emerging data that support a staged approach to mesenteric resection, in complex operative settings. Increasing studies characterise the cellular and molecular basis of the net pathogenic effects of the mesentery. These could provide pharmacotherapeutic opportunities for the future avoidance of surgery. This article discusses the position of the mesentery in the pathobiology of Crohn's disease, and surgical strategies that alter mesenteric inputs.