The Many Faces of Meckel's Diverticulum: Update on Management in Incidental and Symptomatic Patients

PURPOSE OF REVIEW

Meckel's diverticulum may be detected incidentally or present with symptoms from infancy and to old age. The presentation may be acute, with several complications associated with the condition. We aim to review the many faces with which a Meckel's diverticulum may present, either symptomatically or as an incidental finding.

RECENT FINDINGS

Due to its rarity, recent studies mainly include small retrospective series or case reports. Emphasis in the recent literature is on clinical presentation, the pathology of symptomatic cases, management options and risks of neoplasia. Symptoms are mainly caused by obstruction, bleeding or diverticulitis. Cross-sectional imaging is unspecific, although capsule endoscopy is reported of use in case series. Meckel's diverticulum presents with clinical features that are age-specific. Complicated Meckel's diverticulum is treated by resection. Optimal treatment of incidental cases remains debated. Meckel's diverticulum usually stays asymptomatic, and decision-making for management should be based on patient-specific factors. Use of minimal invasive techniques mandates refinement of the optimal treatment.

Torsion of Ileum Due To Giant Meckel's Diverticulum - A Case Report

BACKGROUND:

Meckel’s diverticulum (MD) is detected in approximately 2% of all individuals and only 2-4% MD patients may develop symptoms. Small intestinal obstruction is a frequent complication in adults.

CASE REPORT:

A 48-year-old male was admitted to emergency department for high intestinal obstruction symptoms. The imaging examinations were failed to detect the underlying causes. A median laparotomy revealed small bowel obstruction (SBO) due to a segment of ileum twisted around a giant MD axis.

CONCLUSION:

Thus, a giant MD generating torsion of ileum is an unusual complication. Preoperative diagnosis is challenging. Emergency surgery is preferred to make an accurate diagnosis and for treatment.

Rare cause of complicated Meckel's with Schistosoma infection: An unusual cause of acute intestinal obstruction in adults

INTRODUCTION

Small bowel obstruction (SBO) is a common surgical condition, while Meckel's diverticulum (MD) is the most common congenital anomaly of the gastrointestinal (GI) tract, for which differential diagnosis is considered among children. Intestinal parasitosis refers to a group of disease caused by one or more species of protozoa, cestodes, trematodes, and nematodes. Intestinal parasitic infections (IPIs) caused by pathogenic helminths and protozoan species are endemic throughout the world. The intestine is frequently involved during Schistosoma infection, especially with Schistosoma mansoni.

PRESENTATION OF CASE

A 41 years old Egyptian male with an unremarkable past medical or surgical history presented to the emergency department with two days history of abdominal pain associated with nausea, vomiting, and abdominal distention. The pain was colicky and started gradually without any bowel motion or flatus for two days. Patient had tachycardia with other vitals within the normal limit. The abdomen was found to be distended and tender all over with an empty rectum by digital rectal examination (DRE). Upright chest and abdominal X-rays showed multiple air fluid levels. CT abdomen showed dilated proximal small bowel loop and a picture of SBO at distal ileal loops. The patient was resuscitated with IV fluids and shifted to the operating room. Laparoscopic exploration showed dilated small bowel loops with collapsed distal ileum, and an inflammatory band was found 20 cm from ileocecal junction, originating from a small bowel diverticulum. The inflammatory band was released, and the diverticulum was resected at the base by gastrointestinal anastomosis (GIA). Postoperatively, the patient significantly improved, passed bowel motion and was discharged for home. The histopathology report showed MD with Schistosoma infection. The patient was then referred to the infectious disease department and praziquantel, a drug of choice for schistosomiasis, effective against all Schistosoma species was initiated.

DISCUSSION

Schistosomiasis is a parasitic disease that is transmitted through contact with contaminated water sources. Our patient had complete SBO with significant symptoms. He was treated with the surgical approach with diverticulum resection. Intestinal schistosomiasis was found on histopathology testing. In summary, we report a rare presentation of acute small bowel obstruction with an inflammatory band around MD harboring parasitic infection.

CONCLUSION

Diagnostic laparoscopy should be considered for all patients having virgin abdomen presenting with complete bowel obstruction. To the best of our knowledge from the literature review, this is the first case to be reported as acute SBO secondary to MD harbouring Schistosoma mansoni infection.

Axial torsion of Meckel's diverticulum causing acute peritonitis in the first trimester of pregnancy: a case report

Background

Meckel’s diverticulum is considered the most prevalent congenital anomaly of the gastrointestinal tract. Approximately 4% of patients are symptomatic with complications such as bleeding, intestinal obstruction, and inflammation, while axial torsion of Meckel’s diverticulum is rare, particularly in pregnancy.

Case presentation

A 31-year-old woman in week 15 of pregnancy complained of epigastric pain, nausea and vomiting. Clinical diagnosis was severe hyperemesis gravidarum. Because the symptoms persisted during hospitalization, CT was performed and revealed dilated small bowel loops with multiple air-fluid levels. In the right mid-abdomen, there was a large part of air containing a cavity connected to the small intestine, which was considered a dilated bowel loop. Emergency laparotomy was performed and axial torsion of a large Meckel’s diverticulum measuring 11 cm was found at a few centimeters proximal to the ileocecal valve. Ileocecal resection including Meckel’s diverticulum was performed. The postoperative course was uneventful. At 40 weeks gestation, she had vaginal delivery of normal baby.

Conclusion

The physiological and anatomical changes in pregnancy can make a straightforward clinical diagnosis difficult. Prompt diagnosis and management were needed in order to avoid significant maternal and fetal risks. The use of imaging examinations, especially CT examination, with proper timing may be helpful to prevent delay in diagnosis and surgical intervention. Here, we report the case of a patient with axial torsion of Meckel’s diverticulum in pregnancy. To our knowledge, axial torsion of Meckel’s diverticulum in the first trimester of pregnancy has not been reported in the English medical literature.

Persistence of a vitelline artery on a Meckel's diverticulum as a cause of bowel infarction

Meckel's diverticulum is a congenital anomaly, resulting from incomplete obliteration of the most proximal portion of the omphalomesenteric duct. It generally remains silent, but life-threatening complications may arise in 4-6% of the patients. We present a case of a 16-year-old male, who arrived at the emergency room with crampy abdominal pain, nausea, and vomiting, suggestive of acute appendicitis. Surgical exploration revealed 150 cm of infarcted small bowel, secondary to a mesodiverticular band of a Meckel's diverticulum at the site of obstruction. The ischemic small bowel with Meckel's diverticulum was resected, and an ileo-ileal anastomosis was carried out. The postoperative course was uneventful, and the patient was discharged on the fifth postoperative day. He was seen 12 months after his initial surgery, with a favorable outcome.

Meckel's diverticulum in the adult: surgical treatment

Introduction: Management of asymptomatic Meckel's diverticulum (MD) incidentally discovered in adults remains controversial. The aim of this study was to determine if incidental diverticula should be removed. Materials and methods: We reviewed a consecutive series of patients surgically managed from January 1994 to December 2016. Patients were divided into two groups according to symptomatic or asymptomatic diverticula, and characteristics were compared. Results: The study included 66 patients: 30 in the symptomatic group (45%) and 36 in the incidental group (55%). We found 12 females (18.2%), and the ratio male:female was higher in the symptomatic group (14:1 vs. 2.6:1). Patients in the symptomatic group were significantly younger: 41.7 ± 18.1 vs. 54.7 ± 19.8 years (p = .007). MD in the symptomatic group tended to be longer (3.8 ± 1.9 vs. 2.6 ± 0.9 cm; p = .003). A MD-associated malignancy was present in three patients (4.5%), all neuroendocrine tumours. Major postoperative complications occurred in 6.6% of symptomatic patients and 0% within the incidental group, without specific morbidity related to prophylactic surgery. No mortality was observed. Conclusion: Resection of incidentally found Meckel's diverticulum can be made because of benefits outweigh the risks in this high-risk area for cancer.

Peritoneal carcinomatosis of unknown primary site may be an undiagnosed appendiceal adenocarcinoma. A case series

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Peritoneal carcinomatosis from unknown primary site must be a diagnosis of exclusion.

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Peritoneal metastases in the absence of a primary site by definitive radiologic and endoscopic tests does occur.

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An occult appendiceal adenocarcinoma may be the cause of the peritoneal carcinomatosis.

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Visualization of a normal appendix by exploratory laparotomy or laparoscopy is a new requirement for the diagnosis.

Background

Peritoneal carcinomatosis is sometimes diagnosed by cytology or by biopsy, but routine radiologic and endoscopic workup may not reveal a primary site. This clinical condition is called adenocarcinoma of unknown primary site.

Methods

The clinical findings of two patients with adenocarcinoma of unknown primary site were presented and the implications for management of similar patients were suggested.

Results

The patient had the diagnosis of adenocarcinoma of unknown primary site made when cancer was discovered at the time of umbilical hernia repair or laparoscopy. Radiologic and endoscopic tests were not definitive in providing the primary site for the malignancy. Exploratory laparotomy was performed which revealed an appendiceal mucinous adenocarcinoma as the cause of the peritoneal carcinomatosis. Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC) were used at the time of the exploratory laparotomy to treat the appendiceal adenocarcinoma with peritoneal metastases.

Conclusions

Peritoneal carcinomatosis of unknown primary site may be caused by an occult appendiceal adenocarcinoma. This error in diagnosis may lead to suboptimal treatment. Surgical exploration to visualize a normal appendix should occur prior to making a definitive diagnosis of peritoneal carcinomatosis of unknown primary site.

Recurrent intestinal inflammation with a perianal abscess is not always Crohn's disease: a patient with a complex Meckel's diverticulum diagnosed by double-balloon endoscopy

Recurrent intestinal inflammation and refractory perianal abscesses are typical manifestations of Crohn's disease. However, these conditions are not always due to Crohn's disease. A 25-year-old male with recurrent perianal abscesses for 1 year, suspected to be due to Crohn's disease, was referred for further evaluation. Computed tomography scan showed a perianal abscess abutting the small intestine. A complicated Meckel's diverticulum was suspected based on these findings. Meckel's diverticulum scintigraphy was negative. Bidirectional double-balloon endoscopy (DBE) identified a long diverticulum in the ileum. In this long diverticulum, a tight stricture was seen 5 cm distal to the diverticular opening. A selective contrast study showed a 10 cm diverticulum distal to the stricture, with three strictures in the long diverticulum. Inflammation of the Meckel's diverticulum due to bacterial overgrowth was suspected as a cause of the refractory perianal abscesses. Laparoscopic diverticulectomy was performed, and the specimen showed a 10 cm diverticulum containing post-inflammatory changes with scar formation. The perianal abscess was confirmed to be caused by an inflamed Meckel's diverticulum. The patient has been asymptomatic for 6 years after resection. DBE before exploratory laparotomy should be considered to investigate the cause of an abscess that could be secondary to small intestinal pathology.

Raoultella planticola associated with Meckel's diverticulum perforation and peritonitis in a child: Case report and systematic review of the paediatric literature

Raoultella planticola (R. planticola) is a Gram-negative, aerobic, rod bacteria found in water and soil that has been on rare occasions associated with clinical infections. However, in recent years, there has been both an increase in the frequency and severity of R. planticola infections. We present the first case of Meckel's diverticulum perforation and peritonitis in a child associated with R. planticola infection and a systematic review of the paediatric literature. At present, in the paediatric population, R. planticola presents good susceptibility to a variety of antibiotics with the exception of ampicillin.

Neuroendocrine Tumors in Meckel's Diverticulum: Recommendation for Lymphadenectomy Regardless of Tumor Size Based on the NCDB Experience

BACKGROUND

Meckel's diverticulum (MD) is an anomaly of the small intestine from which malignancy may arise. Among MD neoplasms, neuroendocrine tumors (NETs) are considered the most common. However, their metastatic potential and optimal surgical therapy remain ill-defined.

METHODS

In a retrospective analysis of the National Cancer Database (2004-2015), patients with a diagnosis of MD malignancy were identified. Clinicopathologic factors were extracted and tumors arising in MD were compared. In the subgroup of patients with NET, the association between tumor factors and node involvement was investigated.

RESULTS

Three hundred twenty primary MD malignancies were captured in the National Cancer Database, consisting of 280 (87.5%) NET. The median age at diagnosis was 64 years. Patients were predominantly male (207, 73.9%) and white (269, 96.1%). Most tumors were well-differentiated (118, 42.1%) and sub-centimeter (median size, 0.7 cm). Distant metastasis was present in a minority (16, 5.7%), and the median overall survival was 114 months in the entire cohort. The regional lymph node status was known in 87 NET patients, out of which 39 (44.8%) harbored node metastasis. Although the risk of node involvement increased with larger tumor size, it remained significant even among sub-centimeter (9 out of 34, 26.5%) and well-differentiated (18 out of 44, 41%) tumors. Regional node involvement was associated with the presence of distant metastasis (p < 0.001).

CONCLUSION

Lymph node involvement was common irrespective of the size and grade of NET arising from Meckel's diverticulum. Therefore, regional lymphadenectomy should be considered in the curative-intent surgical management of these neoplasms regardless of tumor size and grade.

Perforation of the Meckel's diverticulum with a chicken bone: a case report and literature review

Background

Meckel’s diverticulum (MD) is the most common congenital abnormality of the gastrointestinal (GI) tract. Most of the people remain asymptomatic during their lifetime, but some can develop complications such as inflammation, haemorrhage or obstruction. Perforation of Meckel’s diverticulum is very rare, and we present a case of perforation by a chicken bone.

Case presentation

A 19-year-old man presented to the emergency department with abdominal pain, and based on examination and laboratory findings, he was diagnosed with appendicitis initially. Meanwhile, a CT scan was requested and a foreign object inside the Meckel’s diverticulum was noted, and on further questioning, he mentioned that he had chicken with bones 2 days ago. He was taken to the operating theatre, and during laparotomy, the perforated Meckel’s diverticulum was found, and it was resected with primary anastomosis.

Conclusion

Meckel’s diverticulum follows the ‘rule of twos’, and perforation of it with foreign object is rare. Patients usually present with signs and symptoms of acute abdomen, and appendicitis is the first diagnosis, and the final diagnosis is usually made intraoperatively. Perforation of Meckel’s diverticulum should be considered for the patients who present with acute abdomen, and with precise history taking and investigations, preoperative diagnosis can be achieved.

Congenital fistulisation of Meckel's diverticulum in omphalocele sac: case report

Fistulisation of Meckel's diverticulum in the top of an omphalocele sac is very rare. To our Knowledge, three cases were reported in the literature. We presente in this report a new case of this uncommon presentation.

Capsule endoscopy as a diagnostic test for Meckel's diverticulum

OBJECTIVE

We described a case series of patients diagnosed with Meckel's diverticulum using capsule endoscopy (CE), reviewed the literature, and aimed to reveal the common CE characteristics of Meckel's diverticulum.

MATERIALS AND METHODS

We reviewed a case series of Meckel's diverticulum in the Department of Gastroenterology, Beijing Shijitan Hospital Affliated to the Capital Medical University. In each case, primary upper endoscopy and colonoscopy failed to reveal a reason to explain the complaints (hematochezia in three cases and abdominal pain in one). CE (Pillcam SB2, Given Imaging, Yoqneam, Israel) was chosen as the next diagnostic test of choice and Meckel's diverticulum was detected by CE. Then, endoscopic characteristics and follow-up of Meckel's diverticulum were analyzed.

RESULTS

4 patients were enrolled. CE revealed Meckel's diverticulum in patients with different features. In case 1, CE revealed a typically double lumen sign and diaphragm sign, with visible blood. In case 2 and case 3, CE revealed a protruding lesion with/without erosion. In case 4, CE revealed multiple caved lesions, double lumen sign and capsule retention in an abnormal blind end for over 2 hours.

CONCLUSION

Except double lumen sign, partial disappearance of normal mucosa and capsule retention, other CE findings could be used for the diagnosis of Meckel's diverticulum, such as protruding lesion, caved lesion, solitary polyp and stenosing lesion.

Littre's hernia: a systematic review of the literature

PURPOSE

A hernia containing Meckel's diverticulum is called a Littre's Hernia. It's a rare entity and its diagnosis is often incidental during routine hernia repair surgery. The objective of this study is the evaluation of the current evidence on Littre's hernias regarding their clinical presentation and optimal treatment approach.

METHODS

PubMed and Cochrane bibliographical databases were searched from the beginning of time (last search: August 1st, 2018) for studies reporting on Littre's hernias in adult population.

RESULTS

Forty-five studies met our inclusion criteria and reported collectively on 53 patients (21 males and 32 females) presenting at health care units with a Littre's hernia. The most common sites of occurrence were femoral (39.6%) and inguinal (34%). The vast majority of cases (77.4%) concerned incarcerated hernias. All patients underwent surgical hernia repair accompanied by a diverticulectomy and 16.9% of them received mesh. Only 7.5% of patients experienced immediate postoperative complications.

CONCLUSIONS

A Littre hernia is a rare complication of Meckel's diverticulum. It requires surgical attention and all medical professionals should be encouraged to report such cases to expand our experience and optimize the therapeutic approach.

Meckel’s diverticulum diagnosis by video capsule endoscopy: A case report and review of literature

BACKGROUND

Meckel’s diverticulum (MD) occurs predominantly in children and adolescents. It is rarely diagnosed in adults. Preoperative diagnosis is difficult due to low sensitivity of the radiological imaging studies. The role of video capsule endoscopy (VCE) in the diagnosis of MD is unknown, and the endoscopic patterns are not defined. We will describe four of our cases of MD evaluated with VCE and make a review of the literature focusing on the endoscopic characteristics.

CASE SUMMARY

We present four cases of MD confirmed by surgery. They were all adult males with ages going from 18 to 50 years, referred to our service from 2004 to 2018, due to obscure gastrointestinal bleeding (OGIB). They had a history of 1 mo to 10 years of overt and occult bleeding episodes. Laboratory blood test showed an iron-deficiency anemia from 4 to 9 g/dL of hemoglobin that required multiple hospitalizations and blood transfusions in all cases. Repeated upper digestive endoscopies and colonoscopies were negative. Small bowel was examined with VCE, which revealed double lumen images in all cases, one with polyps and three with circumferential ulcers in the diverticulum. However, based on VCE findings, preoperative diagnosis of MD was suggested only in two patients. Capsule was retained in one patient, which was recovered with surgery. The anatomopathological report revealed ulcerated ectopic gastric mucosa in all cases.

CONCLUSION

VCE is useful for the diagnosis of MD. However, endoscopic characteristics must be recognized in order to establish preoperative diagnosis.

Spontaneous perforation of Meckel's diverticulum in an adult female with literature review

BACKGROUND

Perforated Meckel's diverticulum is a rare complication of an already rare disease process, which often mimics a perforated appendix on presentation and diagnosis. The majority of case reports for perforation involve either a foreign body or fecalith.

CASE PRESENTATION

We report the case of a 54-year-old female who initially presented at another institution with signs and symptoms of acute appendicitis and underwent appendectomy with a drain left in place. Subsequently, she underwent exploratory laparotomy at our institution for a perceived stump leak or incidental perforation and was found to have a perforated Meckel's, with no evidence of foreign body or fecalith.

CONCLUSION

The literature of Meckel's diverticulum is reviewed, and we discuss the difficulty in diagnosis as well as the quandary of incidental resection.

Significant bleeding from Meckel's diverticulum after blunt abdominal trauma: a case report

Background

Meckel’s diverticulum, with an incidence of 2%, is the most common congenital anomaly in the gastrointestinal tract. Its main complications are perforation, obstruction, and bleeding. A few studies have reported that blunt abdominal trauma may result in perforation or obstruction to Meckel’s diverticulum. However, reports of significant major intestinal bleeding from Meckel’s diverticulum as a complication of blunt abdominal trauma is rare. This paper present what we believe to be the first reported case of significant intestinal bleeding from a Meckel’s diverticulum following blunt abdominal trauma.

Case presentation

A 12-year-old Saudi boy of Arab ethnicity presented to the King Saud Medical City emergency department with bleeding per rectum and mild abdominal pain following blunt trauma to his abdomen. On examination, his abdomen was slightly tender, bowel sounds were present, and he was hemodynamically stable. During admission, rectal bleeding was ongoing. On day 3 he deteriorated with decreasing blood pressure and hemoglobin, and increasing pulse rate with fever. After resuscitation and stabilization, he was urgently taken to the operating room for further diagnostic management and treatment. His nasogastric tube revealed bile without blood, and an intraoperative colonoscopy revealed altered blood within his whole colon and terminal ileum without a definite bleeding site. A laparotomy was performed, and an injured branch of the mesenteric artery supplying the Meckel’s diverticulum was identified as the source of the significant arterial bleeding. Suture ligation controlled the bleeding, and the Meckel’s diverticulum was resected. The patient remained stable after that until discharge without any further intestinal bleeding.

Conclusion

Identifying bleeding as a complicated Meckel’s diverticulum following blunt trauma to the abdomen can be challenging due to its low incidence and difficulties while making the diagnosis.

Double simultaneous intussusception caused by Meckel's diverticulum and intestinal duplication in a child

Intussusception is common in children. Double simultaneous intussusception is a peculiar variety of intussusception with only 14 previously reported cases. We report a unique case of a child who suffered from double simultaneous intussusception with two lead points (Meckel's diverticulum and intestinal duplication). The patient was successfully treated with manual reduction along with resection of Meckel's diverticulum and intestinal duplication. The child recovered well.

Laparoscopic treatment of a vesicointestinal fistula due to a Meckel's diverticulum: a case report and review of the literature

While there have been numerous reports about colovesical fistulas and ruptured intestinal diverticula, there have been far fewer reports about vesicointestinal fistulas caused by Meckel's diverticula. Most Meckel's diverticula are asymptomatic. Furthermore, they seldom cause vesicointestinal fistulas, and the associated complications are non-specific. Thus, their preoperative diagnosis is difficult. We experienced a case in which a vesicointestinal fistula was caused by a Meckel's diverticulum and was treated with laparoscopic surgery. A 46-year-old male was referred to our hospital after exhibiting hematuria. Cystoscopy revealed a fistula between the small intestine and bladder. Contrast-enhanced computed tomography and magnetic resonance imaging showed a diverticulum in the ileum and a fistula between the ileum and bladder, which passed through the diverticulum. A Meckel's diverticulum was suspected. We conducted a laparoscopic operation. We dissected the Meckel's diverticulum with an automatic suturing device and removed it together with part of the ileum. The patient's postoperative course was good. We experienced a case in which a vesicointestinal fistula was caused by a Meckel's diverticulum and was successfully treated with laparoscopic surgery. In selected cases of Meckel's diverticulum, the dissection of the diverticulum with an automatic suturing device is appropriate.

Heterotopic pancreas without Meckel's diverticulum in children as unique cause of gastrointestinal bleeding: think about it!

Ectopic pancreas also known as heterotopic pancreas (HP) is a rare congenital anomaly, mainly found as incidental finding during autopsy or abdominal exploration for an other condition. Incidence rate is probably underestimated as patients are mostly asymptomatic; otherwise, it is capable of producing symptoms depending on its location, size, often appearing in the 4th-to-6th decades. Complications such as inflammation, obstruction, bleeding, and malignancy degeneration must be considered. Pediatrics cases are very rare, generally concerning HP within Meckel's diverticulum, manifesting by gastrointestinal bleeding and intussusception. We report a rare case of jejunum bleeding, due to an isolated HP in a 15-year-old adolescent. Endoscopic and computed tomographic scan were normal, in particular did not found Meckel's diverticulum. Diagnosis and treatment have been apprehended performing a laparoscopic exploration. It is a singular location for HP, predominantly found in upper gastrointestinal tractus. So far, there have been no case reports of jejunal bleeding from ectopic pancreas without Meckel's diverticulum in children.

Neuroendocrine Tumor Arising From Meckel's Diverticulum Unexpectedly Diagnosed After Diverticulectomy and in Which Multiple Lymph Node Metastases Were Found After Reoperation: A Case Report

A 47-year-old man with progressive anemia possibly due to digestive tract bleeding was referred to our hospital. Contrast-enhanced computed tomography of the abdomen showed a 2-cm tumor lesion arising near the small intestine. Enteroscopy revealed a 3-cm submucosal tumor at the ileum. A gastrointestinal stromal tumor of the small intestine was suspected, and the patient underwent surgery. During the operation, a diverticulum approximately 60 cm orad to the terminal ileum and a tumor at the top of the diverticulum were observed. Considering the location, Meckel's diverticulum was suspected. No lymphadenopathy was present in the mesentery. Laparoscopy-assisted resection of the diverticulum without lymph node dissection was performed. The histological diagnosis of the tumor was a well-differentiated neuroendocrine tumor. Given the possibility of lymph node metastasis, we performed a second operation to remove the small intestine and lymph nodes. Histologically, 7 of the 18 dissected lymph nodes were metastatic. The postoperative course was uneventful, and the patient survived without tumor recurrence for another 2 years 8 months. Neuroendocrine tumors of Meckel's diverticulum are aggressive. Therefore, small intestinal resection along with lymph node dissection might be necessary as part of the surgical strategy.

Neuroendocrine tumours within a Meckel's diverticulum

A Meckel's diverticulum is a common anomaly of the gastrointestinal tract. Although the majority of patients do not have any symptoms, malignancies can develop inside these diverticula, with neuroendocrine tumours being the most common. Diverticulectomy is the best option for complicated diverticula but prophylactic resection of asymptomatic diverticula in adults remains controversial. We present a case series of three patients with a neuroendocrine tumour found in a Meckel's diverticulum. Given the number of asymptomatic diverticula not resected, it seems likely that incidental neuroendocrine tumours are more prevalent than thought previously. With the minimally invasive techniques now available and the low complication rate for incidental diverticulectomy, we believe that the benefits of resection of this high risk area for cancer outweigh the risks of surgery.

Neuroendocrine tumours within a Meckel's diverticulum

A Meckel's diverticulum is a common anomaly of the gastrointestinal tract. Although the majority of patients do not have any symptoms, malignancies can develop inside these diverticula, with neuroendocrine tumours being the most common. Diverticulectomy is the best option for complicated diverticula but prophylactic resection of asymptomatic diverticula in adults remains controversial. We present a case series of three patients with a neuroendocrine tumour found in a Meckel's diverticulum. Given the number of asymptomatic diverticula not resected, it seems likely that incidental neuroendocrine tumours are more prevalent than thought previously. With the minimally invasive techniques now available and the low complication rate for incidental diverticulectomy, we believe that the benefits of resection of this high risk area for cancer outweigh the risks of surgery.

A faster and simpler way of operation for Meckel's diverticulum: basal ligation combined with intraoperative frozen section

BACKGROUND

The key step in Meckel's diverticulectomy (MD) is to achieve complete resection of MD along with the ectopic epithelium. Currently main treatment methods for Meckel's diverticulum are either intestinal resection and anastomosis or wedge resection. Here we introduced a new method to treat MD. The goal of this study was to investigate the clinical effects and advantages of a new operation method for Meckel's diverticulum: basal ligation combined with intraoperative frozen section.

METHODS

262 cases of Meckel's diverticulum were resected with simple basal ligation operation. Intraoperative frozen pathological section was performed to determine surgery strategies. Based on the existence of basal residual ectopic mucosa, surgery was either terminated or further wedge intestinal resection or bowel resection was performed.

RESULTS

All 262 surgeries were successfully completed. Additional wedge resection or bowel resection was performed in only 23 of them due to the presence of ectopic basal residual gastric mucosa. No ectopic mucosa was found for the other cases, and the operation ended after basal ligation. All patients had no complications such as intestinal fistula, bleeding for 6 months-7.6 years after surgery.

CONCLUSIONS

Intraoperative frozen pathological examination can well determine whether ectopic Meckel's diverticulum mucosa locates at the basal part. Basal ligation is a safe and effective operation method, and it can significantly shorten the operation time and postoperative fasting time.

Giant Meckel's diverticulum compressing root of mesentery - A rare cause of ileal gangrene - Case report and review of literature

INTRODUCTION

Meckel's diverticulum (MD) commonly presents as gastrointestinal bleeding in the pediatric population and intestinal obstruction in adults. There is no consensus for surgical excision of an incidentally diagnosed MD. We present a hitherto unreported vascular cause of intestinal gangrene due to MD.

CASE PRESENTATION

A 16year old boy was referred as an acute abdomen for tertiary hospital management. Clinical examination and CT suggested small bowel obstruction and emergency laparotomy was performed. A giant MD compressing the root of mesentery, causing critical occlusion of the ileal vessels and extensive ileal gangrene was found. The gangrenous bowel was resected and a jejuno-ascending colon anastamosis was done. Postoperative recovery was uneventful.

DISCUSSION

This case report highlights an unrecognized complication of a giant Meckel's diverticulum. There are no clear guidelines on the management of an incidentally discovered MD though certain studies recommend resection of an incidental MD in males and individuals less than 50 years of age or when the MD is larger than 2cm or contains histologically abnormal tissue. Other meta-analyses do not recommend routine resection. MD has been identified as a high risk region for ileal malignancy and its resection usually has minimal morbidity. A valid consent for opportunistic resection of a Meckel's diverticulum in any laparotomy would be discerning.

CONCLUSION

Appropriate opportunistic resection of an incidental Meckel's diverticulum may prevent extensive surgical morbidity later. This case highlights the need to revisit guidelines for management of incidentally identified MD.