Symptomatic Meckel's diverticulum in children: a 16-year review

Meckel's diverticulum mimicking acute appendicitis in children: a retrospective cohort study

BACKGROUND

The aims of this study were to summarize the clinical presentation and histological results of 20 cases of complicated Meckel diverticulum (MD) who were presumed to have acute appendicitis before surgery, as well as to improve the diagnosis and treatment of complicated MD in children.

MATERIALS AND METHODS

We retrospectively reviewed the records of 20 complicated MD admitted to our institution who were preoperatively diagnosed with acute appendicitis from January 2012 to January 2019. Patients were divided into the perforated MD group and the Meckel's diverticulitis group. Patient demographics, clinical manifestations, laboratory data, auxiliary examinations, surgical methods, and the result of heterotopic tissue were recorded.

RESULTS

A total of 20 cases of complicated MD (perforated or diverticulitis) were identified. Children were aged from 3 to 13 years, with a mean age of 7.75 years (median 7.75; range, 1-13 years). Perforated Meckel's diverticulum occurred in 5 of 20 (25%) cases. For perforated MD versus diverticulitis, no significant differences were found between age, time to intervention, length of hospital stay, and distance from the ileo-cecal valve. Heterotopic tissue was confirmed on histopathology in 75% of all patients, including 10 cases of gastric mucosa, 3 cases of coexistent gastric mucosa and pancreatic tissue, and 2 cases of pancreatic tissue. All patients underwent diverticulectomy or partial ileal resection under laparoscopy or laparotomy; two cases combined with appendectomy owing to slight inflammation of the appendix.

CONCLUSIONS

The most common presentation of symptomatic MD is painless rectal bleeding; however, it can present symptoms of acute abdomen mimicking acute appendicitis. The key point of diverticulectomy is to remove the ectopic mucosa completely.

Intestinal obstruction caused by mesodiverticular band in children: a cohort study

OBJECTIVE

To explore clinical characteristics, pathogenesis, diagnosis and treatment of intestinal obstruction due to mesodiverticular band (MDB) in children in a single center in China.

METHODS

The clinical data of 20 children with acute intestinal obstruction due to MDB between 1998 and 2020 were retrospectively analyzed.

RESULTS

The male-to-female ratio was 14:6 in 20 cases. Except one case of 7-month pregnant stillbirth, the cases were aged from 7 days to 14 years, at the median age of 4.31 years. The common symptoms were vomiting, abdominal pain and/or abdominal distension. About 40% (8/20) of patients had both MDB and Meckel's Diverticulum (MD), while 60% (12/20) of patients had MDB only. Only one case died because of total colonic aganglionosis, while other children recovered after surgery treatment. MDB led to the strangulation of necrotic bowel in six cases, intestinal perforation in one case, and intestinal rupture in one case. Pathologic examination showed thick-walled arteries and or thick venous vascular structures in the cord. All cases had no complications during 1-year follow-up.

CONCLUSION

MDB results from the remnant of vitelline vessel, and often causes acute intestinal obstruction without special clinical symptoms. Unexplained abdominal pain and distension without surgery history should be paid attention, especially for strangulated intestinal obstruction. Timely surgical exploration is beneficial to avoid intestinal necrosis or even sudden death, and the pathological examination is important for the diagnosis.

Meckel’s Diverticulum in Children: A Monocentric Experience and Mini-Review of Literature

Vitelline duct anomalies (VDA, including Meckel’s diverticulum (MD)) result from failed embryologic obliteration. This study aimed for characteristics in symptomatic versus asymptomatic VDA, analyzing clinico-laboratory data from 73 children, aged 1 day to 17 years, treated at a tertiary Pediatric Surgery Institution from 2002–2017. A male preponderance was obtained (ratio 3.6:1). MD accounted for 85% of VDA. Incidence of symptomatic VDA decreased with older age. Leading symptoms were intestinal obstruction and hemorrhage. Mucosal heterotopia (present in 39% of symptomatic MD) was associated with anemia and lowered CRP-levels. On ROC-analysis, hemoglobin < 8.6 g/dL, CRP < 0.6 mg/dL and MD distance to ileocecal valve >40 cm were predictors of ectopic tissue in symptomatic MD. Our data confirmed known characteristics as male preponderance, declined incidence of symptomatic cases with age and predominance of gastric ectopia in symptomatic MD. Moreover, anemia and prolonged distance of MD to ileocecal valve were predictors of ectopic mucosa in symptomatic MD.

Value of sonographic pseudogestational sac sign in the diagnosis of Meckel diverticulum in children presenting with bleeding per rectum: a 15-year prospective study

Background

Meckel diverticulum is the most common congenital abnormality of the gastrointestinal tract. Gastrointestinal bleeding is the most common complication of Meckel diverticulum in the paediatric population; the bleeding mostly occurs in the first 2 years of life. Because the diverticulum is seldom seen in clinical practice, misdiagnosis and delayed diagnosis are not uncommon. CT and nuclear studies are the most used diagnostic tools in clinical practice. However, radiation and sensitivity concerns remain an issue. Ultrasound has been suggested as an alternative diagnostic tool in diagnosing Meckel diverticulum with mixed results. The aim of our study is to assess the value of using a new sonographic sign, the pseudogestational sac sign in diagnosing Meckel diverticulum in children presenting with bleeding per rectum. Ultrasound was performed for all children. Results were correlated with nuclear studies, histopathology and clinical follow-up findings.

Results

Seventy-three children were included in our study. The pseudogestational sac sign was present in 46 (63%) and absent in 27 (37%) cases. Forty-five children were ultimately diagnosed as Meckel diverticulum. The age ranged from 2 months to 9 years with a mean of 2.3 years. The boy-to-girl ratio was 4.6:1 with 60% of children presenting during their first 2 years of life. The ultrasound performance using the pseudogestational sac sign revealed a sensitivity of 91.1%, specificity of 82.1%, positive predictive value of 89.1%, negative predictive value of 85.2%, positive likelihood ratio of 5.1, negative likelihood ratio of 0.11 and accuracy of 87.7%.

Conclusion

The sonographic pseudogestational sac sign is a reliable diagnostic tool for diagnosing Meckel diverticulum in children presenting with bleeding per rectum. The sonographic diagnosis of Meckel diverticulum complies with the international standards of “Image Gently”.

Management of Symptomatic Meckel's Diverticulum in Infants and Children

Objectives The primary objective of the present study was to review the demographics of infants and children operated upon for Meckel's diverticulum. The secondary objectives were to review the clinical characteristics, surgical procedures performed, postoperative complications, and the outcome.

Materials and Methods This study is a single-institutional, retrospective study and descriptive in nature. It consisted of infants and children below 12 years who were operated upon for Meckel's diverticulum. This study was conducted at the author's department of pediatric surgery, and it was performed for 21 years from January 1, 2000 to December 31, 2020.

Results Eighty-four children below 12 years were operated upon for Meckel's diverticulum during the study period of 21 years. The ratio for males to females was 3:1. This study consisted of infants, (n = 22, 26.19%), children of 1 to 5 years of age (n =19, 22.61%), and children of 6 to 12 years of age (n = 43, 51.19%). Clinically, children with Meckel's diverticulum presented in the following order of frequency: (1) intestinal obstruction (n = 59, 70.23%), (2) perforation peritonitis (n = 17, 20.23%), (3) lower gastrointestinal bleeding (n = 4, 4.76%), and (4) incidental finding (n = 4, 4.76%). In 35 (41.66%) children, bowel gangrene was detected. One-fifth (n = 17) of Meckel's diverticulum was responsible for the secondary intussusception. In children (n = 84), for Meckel's diverticulum, surgical procedures were performed in the following order of frequency: (1) resection of Meckel's diverticulum, an adjacent segment of ileum and ileoileal anastomosis (n = 36, 42.85%); (2) Meckel's diverticulectomy (n = 32, 38.09%); (3) resection of Meckel's diverticulum, an adjacent segment of ileum with or without cecum and an ileostomy (n = 12, 14.28%); and (4) resection of Meckel's diverticulum, an adjacent segment of ileum, cecum, part of the colon, and ileocolic anastomosis (n = 4, 4.76%). In 8 (9.52%) children, complications were documented during the postoperative period. The present study observed three (3.57%) deaths during the postoperative period.

Conclusion Meckel's diverticulum was one of the common causes of acute intestinal obstruction in infants and older children. Ninety percent of children with Meckel's diverticulum presented with features of an acute abdomen. Forty percent of children evidenced bowel gangrene during the surgical procedures. In these children, early diagnosis, timely referral, and institution of surgical therapy for acute abdomen/intestinal obstruction may prevent the development of bowel gangrene and the requirement of bowel resections to some extent.

Omphalomesenteric Duct Anomalies in Children: A Multimodality Overview

The omphalomesenteric duct is an embryologic structure that connects the yolk sac with the primitive midgut of the developing fetus. Omphalomesenteric duct anomalies include a group of entities that result from failed resorption of the omphalomesenteric duct. These anomalies include Meckel diverticulum, omphalomesenteric fistula, fibrous bands, cysts, and umbilical polyps. Meckel diverticulum is the most common congenital anomaly of the gastrointestinal tract and is usually asymptomatic. Symptoms develop when Meckel diverticulum involves complications such as hemorrhage, inflammation, and perforation, or when it causes intussusception or bowel obstruction. Hemorrhage is the most common complication of Meckel diverticulum, and technetium 99m-pertechnetate scintigraphy is the imaging modality of choice for detecting acute bleeding. US and CT are commonly used for the evaluation of patients with other complications such as obstruction and inflammation. Nevertheless, the diagnosis of these complications can be challenging, as their clinical manifestations are usually nonspecific and can masquerade as other acute intraabdominal entities such as appendicitis, inflammatory bowel disease, or other causes of bowel obstruction. There are other umbilical disorders, such as urachal remnants and umbilical granuloma, that may present with symptoms and imaging findings similar to those of omphalomesenteric duct anomalies. An accurate preoperative diagnosis of omphalomesenteric duct anomaly is crucial for appropriate management and a better outcome, particularly when these anomalies manifest as a life-threatening condition. The authors review the anatomy, clinical features, and complications of omphalomesenteric duct anomalies in children, describing the relevant differential diagnoses and associated imaging findings seen with different imaging modalities. ^©RSNA, 2021.

Where Did the Blood Go?: A Meckel's Diverticulum Bleed Without Hematochezia or Melena

A 2-year-old patient with chronic abdominal pain presented with acutely worsening abdominal pain and acute anemia. The patient had no stigmata of bleeding including no hematemesis, melena or hematochezia, but had falling hemoglobin and hematocrit over the course of 24 hours. Abdominal ultrasound and computerized tomography showed a large cystic, fluid filled mass in the right midabdomen. The patient was taken to the operating room and a blood-filled mass arising from the ileum was identified and resected by the surgical team. Pathology was consistent with Meckel's diverticulum with heterotopic gastric mucosa. This is an atypical presentation of Meckel's diverticulum with bleeding contained within the diverticulum rather than bleeding in the intestinal lumen. Gastroenterologists must consider this unusual presentation when encountering progressive, acute anemia even in the absence of overt gastrointestinal blood loss.

Clinical diagnostic predictive score for Meckel diverticulum

BACKGROUND/PURPOSE

Meckel diverticulum (MD) is present in 2% of the population. Many practitioner feel the diagnosis relies upon technetium-99 m pertechnetate scintigraphy. When negative, patients undergo additional invasive procedures delaying definitive therapy. This study aims to identify features of bleeding MD and generate a risk score, which could preclude unnecessary testing and facilitate earlier operation.

METHODS

All patients <18-years-old who presented with hematochezia from 2005 to 2015 were identified. MD diagnosis was based on histopathology of operative tissue. Controls were patients with hematochezia undergoing colonoscopy. A points system was used generate a risk score.

RESULTS

A total of 215 patients presented with hematochezia out of which 42 patients with MD were identified. Predictive variables included infant (OR 7, 95%CI 2-29) and toddler (OR 20, 95%CI 8-50) age groups, duration <6 days (OR 18, 95%CI 8-43), presence of large blood volume (OR 16, 95% CI 7-36), hemoglobin <7 g/dL (OR 6, 95% CI 3-15) and transfusion requirement (OR 16, 95% CI 7-38). A score of 6 or higher is highly suggestive of MD.

CONCLUSIONS

This scoring system identifies children with bleeding MD who may benefit from exploratory surgery without undergoing endoscopy. This novel scoring system can be applied to provide accurate clinical diagnosis, reduce unnecessary tests and allow prompt surgical management.

The magnetic resonance enterography imaging features of symptomatic Meckel's diverticulum in pediatric patients: a retrospective observational study of 31 cases

BACKGROUND

The aim of this study was to explore the magnetic resonance enterography (MRE) imaging manifestations of a symptomatic Meckel's diverticulum (MD) in pediatric patients in order to provide a reference for the diagnosis of the condition.

METHODS

The medical records of 31 pediatric patients with MD from May 2014 to October 2020 were retrospectively analyzed. The inclusion criteria were patients with MD accompanied by unexplained gastrointestinal bleeding, anemia (except hematological diseases), chronic persistent abdominal pain, repeated intussusception, or intussusception in older pediatric patients during surgery. The clinical variables (age, sex, and hemoglobin) and imaging, surgical, and pathological findings were recorded.

RESULTS

MD was definitively identified in 28 patients, with the following characteristics: a blind-ending fluid-filled and/or gas-filled structure (n=23), an elongated shape (n=1), a dumbbell shape (n=1), and a solid mass (n=3). The diverticula were located in the right lower quadrant (n=16), the right abdomen at the level of the umbilicus (n=3), the right upper quadrant (n=2), the left upper quadrant (n=2), and the midline lower abdomen (n=5). Supply arteries were visualized in nine cases. In all cases, mural enhancement was comparable to that of the adjacent small-bowel (SB). Extravasation of the intravascular contrast medium was seen in two cases. Peripheral structural abnormalities included mesenteric fat stranding (n=7), hemorrhage in the adjacent lumen (n=3), free intraperitoneal gas (n=1), abnormal fluid retention (n=2), intestinal obstruction (n=1), and lymph node enlargement (n=7). A normal appendix was identified in 18 cases.

CONCLUSIONS

MRE is an appropriate method of diagnosing symptomatic MD in pediatric patients and is particularly useful in the assessment of complications.

STUDY IN PAEDIATRIC AGE GROUP UNDERGOING EMERGENCY LAPAROTOMY : OBSERVATIONAL STUDY

INTRODUCTION: Acute abdomen can be defined as “syndrome included by wide variety of pathological conditions that require emergent medical or more often surgical management.” Acute abdomen is caused due to gastrointestinal diseases such as intestinal obstruction and perforation peritonitis. AIM: The aim of our study was to observe the common cause in paediatric age group undergoing emergency laprotomy in our institutions. MATERIAL AND METHODS:This prospective study included 77children aged below or equal to 15years, underwent emergency laprotomy for acute intestinal conditions between January 2019 to December 2019 in RIMS,RANCHI. We excluded neonates ,patients of jejunoileal colonic atresia and stenosis, anorectal malformation(ARM), congenital pouch colon, neonatal necrotizing enterocolitis(NEC), hirschprung’s disease, gastrointestinal tumor. RESULTS: Total of 77 laprotomies were performed in emergency in children below or equal to 15 years age,59(76.62% ) were boys and 18(23.37% )were girls with male:female ratio of 3.2:1. 36(46.75%) cases were done for acute intestinal obstruction and 41(53.24%) cases were done for perforation peritonitis.20(25.97%)emergency laprotomy was performed in the age group 1-5 years and 57(74.02% ) were performed in the age group 5-15 years. Causes in order of frequency for intestinal obstruction were intussusceptions, post operative band/adhesion, abdominal tb obstruction, meckel’s diverticulum and worm obstruction. Causes in order of frequency for perforation peritonitis were typhoid, abdominal tb, appendicular perforation and abdominal trauma. CONCLUSION: In our study maximum emergency laprotomy was performed in male patients with male:female ratio of 3.2:1. Perforation peritonitis was more common than acute intestinal obstruction. 5-15 year age group were more commonly affected. Typhoid ileal perforation was the most common cause for emergency laprotomy followed by intussusception.

Meckel's Diverticulum: A National Surgical Quality Improvement Program Survey in Adults Comparing Diverticulectomy and Small Bowel Resection

BACKGROUND

Meckel's diverticulum is a congenital abnormality often associated with the pediatric population. When seen in the adult population, management is controversial. This study sought to determine demographic and outcome differences between diverticulectomy and small bowel resection in adults diagnosed with Meckel's diverticulum.

METHODS

An analysis of the American College of Surgeons National Surgical Quality Improvement database (2015-2018) was performed, capturing patients with a postoperative diagnosis of Meckel's diverticulum. Inclusion criteria included diverticulectomy or small bowel resection, and exclusion criteria included other major procedures such as colectomy or concomitant diverticulectomy and a small bowel resection. Demographics and outcomes were analyzed between those receiving diverticulectomy or resection.

RESULTS

506 patients undergoing surgical treatment of Meckel's diverticulum were captured. The majority of these patients were white (79.05%), male (68.77%), and averaged 46 years old. The 2 populations were homogenous, with no significant differences in demographics or comorbidities between populations. Mean operative time was shorter in the diverticulectomy group than the resection group (68.92 ± 35.89 vs. 89.33 ± 40.16 minutes, P < .0001). There were no deaths at 30 days. Length of stay, readmission rate, wound infection, and discharge destination were similar among both groups.

DISCUSSION

Our analysis of a national database reveals no difference in outcomes between patients receiving a diverticulectomy or resection for Meckel's diverticulum. Operating time may be slightly increased for resection. However, decision to excise the diverticulum vs. the segment of small bowel should be individualized to each patient, their pathology, and clinical picture.

Laparoscopic Management of Mechanical Small Bowel Obstruction Secondary to Meckel's Diverticulum with a Double Basis. A Rare Anatomic Presentation

Meckel's diverticulum (MD) is the most common congenital abnormality of the gastrointestinal tract. Intestinal occlusion due to MD is a commonly observed consequence of intussusception or volvulus. Here, we report a case of an 11-year-old boy who presented to the emergency department with acute abdominal pain, bilious vomiting, and abdominal rebound tenderness. Computed tomography scan concluded a diagnosis of intestinal occlusion with no apparent cause. The patient was submitted to diagnostic laparoscopy, and mechanical occlusion by the permeable Meckel with double base was identified. A diverticulectomy by staplers was performed, and occlusion was alleviated. MD is a rare disease (for only 0.3–2.9% of the general population), and only 4.2 to 9% of patients diagnosed with MD have associated complications. MD can be a large base or a narrow base, with a mesodiverticular band but the diverticulum is usually a blind recess. In our case, the tube connected two intestinal segments. To the best of our knowledge, we have reported the first case of an MD-like permeable tube with a double basis.

Clinical outcomes of minimally invasive surgery for Meckel diverticulum: a multicenter study

Purpose

Meckel diverticulum (MD), caused by an obliteration defect of the omphalomesenteric duct, is one of the most common congenital anomalies of small intestines. The objective of this study was to review surgical outcomes of MD and evaluate the feasibility of minimally invasive surgery (MIS) in MD.

Methods

We performed a retrospective analysis of the medical records of patients who underwent diverticulectomy for MD at 6 Hallym University-affiliated hospitals between January 2008 and December 2017. All patients underwent either open surgery or MIS. Patients who underwent MIS were subdivided into laparoscopic only diverticulectomy (LOD) or laparoscopic-assisted diverticulectomy (LAD).

Results

Of 64 patients, 21 underwent open surgery and 43 underwent MIS. Time to flatus, time to soft food intake, and length of hospital stay were shorter in the MIS group than in the open surgery group (P = 0.047, P = 0.005, and P = 0.015, respectively). Among patients who underwent MIS, the time to flatus and time to soft food intake were longer in the LAD group than in the LOD group (0.3 and 0.9 days, respectively). Multivariate analysis showed that old age and preoperative ileus were independent predictors of complications (P = 0.030 and P = 0.013, respectively). Operation type (open surgery, LOD, or LAD) was not associated with complications.

Conclusion

The present study showed that MIS is associated with quicker recovery without increasing complications. Therefore, MIS may be a safe alternative to open surgery for MD. An old age and preoperative ileus were associated with a risk of postoperative complications.

Perforated Meckel Diverticulum: A Rare Cause of Acute Abdomen in Children

Meckel diverticulum (MD) is the most common congenital anomaly of the gastrointestinal tract and the most common cause of gastrointestinal bleeding in children. Although it usually follows the rule of 2's, exceptions to this rule are reported in the literature. Often asymptomatic, MD is commonly an incidental finding during surgical interventions. When symptomatic, the most common presentation of this condition is painless rectal bleeding. A myriad of other nonspecific symptoms are however possible, especially in adults, thus making this diagnosis difficult. Meckel diverticulum has been reported to mimic other abdominal pathologies like appendicitis, inflammatory bowel disease, and pancreatitis to name a few.We report a patient with acute abdomen in whom the more common causes of acute abdomen were ruled out and a diagnosis of MD was established on exploratory laparoscopy, only after he developed perforation. This report emphasizes the need for maintaining a high index of suspicion towards a possibility of a complicated MD in patients presenting with an acute abdomen, once other causes of acute abdomen are ruled out.

The rule of two's didn't work: Meckel's diverticulum with hemorrhagic shock in an adolescent

Meckel's diverticulum classically follows the rule of two's; presenting before the age of two years, found 2 ft. from the ileocecal valve, approximately 2 in. in length, and present in roughly 2% of the population. To our knowledge, there are few cases detailing emergent medicine management of hemorrhagic shock in patients with acute blood loss from a Meckel's diverticulum. We report the case of a 13-year-old male presenting in hemorrhagic shock secondary to an undifferentiated gastrointestinal bleed who was effectively resuscitated in a children's emergency department. Meckel's scan revealed abnormal tracer uptake consistent with Meckel's diverticulum and the patient underwent surgical resection of the diverticulum. This case report details the importance of prompt recognition and appropriate volume resuscitation in a pediatric patient suffering from hemorrhagic shock. Emergency medicine physicians should maintain an index of suspicion for Meckel's diverticulum in any pediatric patient presenting with undifferentiated gastrointestinal hemorrhage.

Unusual presentation of a curve-shaped Meckel's diverticulum detected on technetium-99m Meckel's scintigraphy

Complicated Meckel's diverticulum (MD) in pediatric age group may not present with classic symptoms or signs. The routine modalities of investigations for the detection of MD are ultrasonography (US), computerized tomography, and air enema. However, these may miss the diagnosis in cases of atypical patterns of presentation. In such situations, the radionuclide Meckel scan helps to narrow down the diagnosis. The objective of this case report was to present an unusual presentation of MD where the diagnosis was established by a radionuclide scan against other methods which were equivocal. An 8-year-old boy was admitted with features of intestinal obstruction. ^99mTc-pertechnetate Meckel's scintigraphy showed localization of tracer in ectopic gastric mucosa. The surgical exploration after the Meckel's scan revealed a curve-shaped MD localized 50 cm proximal to the ileocecal valve. The surgery was completed after a diverticulectomy, and the patient was relived of symptoms. MD scintigraphy can help detect ectopic gastric mucosa in cases of unusual presentation by considering the atypical presentation, variation in shape, and location on Meckel's scan and improve the disease management.

[Complications of Meckel's diverticulum in children: about 18 cases]

Meckel's diverticulum (MD) is a remnant of omphalomesenteric channel. It is often asymptomatic but it can be responsible for various clinical complications and variable clinical status especially in children. We conducted a retrospective study on complications of MD among children hospitalized in the division of Paediatric Surgery at the University Hospital Hassan II, Fez, Morocco. The study aimed to describe the clinical, radiological and therapeutic features of MD. The study was conducted over a period of 10 years (January 2009 - December 2018) and involved 18 children (15 boys and 3 girls) aged 1 day - 15 years (with an average age of 5 years) who had undergone surgery for complications of MD. Acute intussusception and intestinal occlusion were the most frequent complications. Other complications included: infection of the MD (1 case) and digestive hemorrhage (2 cases). Two rare types of neonatal Meckel's diverticulum were described (neonatal occlusion and fistula associated with omphalocele). In no case, abdominal X-ray without treatment, ultrasound and CT scan showed MD. Scintigraphy was performed in 2 patients with hematochezia and it helped to make the diagnosis of MD in one case. Three patients underwent laparoscopic surgery with resection of the MD and intestinal anastomosis with laparoscopy. The other patients underwent laparotomy. Ileostomy was performed in one case, followed by secondary recovery. Patient's outcome was good, except for one case of anastomotic leakage. Anatomopathological examination showed two cases of heterotopia.

Predictive model of heterotopy in Meckel's diverticulum in children

BACKGROUND

The presence of heterotopic tissue in Meckel's diverticulum (MD) increases the incidence of future complications. Based on this concept, this study aimed to detect clinical and morphological parameters able to predict the probability of heterotopy in incidentally discovered uncomplicated MD and to develop a risk-based classification tool.

METHODS

The clinical records of 146 patients who underwent MD resection were reviewed. MD complications (bleeding, inflammation, perforation or involvement in pathological processes such as intussusception) and MD dimensions (width, length and the product width × length) were evaluated in association with heterotopy. Regression analysis was used to explore the discrete effect of clinically relevant parameters, which were subsequently combined in a Classification and Regression Tree.

RESULTS

The probability of heterotopy was higher in complicated MDs. The width of the base of the MD and the product width × length were also significant predictors of heterotopy. A stepwise combination (Classification and Regression Tree model) of (i) uncomplicated macroscopic presentation, (ii) width <2.5 cm, (iii) age <10 years and (iv) product width × length <4 cm² resulted in a null probability of heterotopy in our study group.

CONCLUSION

The combination of MD-related clinical and morphological parameters using advanced statistical tools may assist in estimating the probability of heterotopy. This may be applied in incidentally discovered uncomplicated MDs during abdominal surgery for other morbidities. Prospective studies are required to confirm our findings and test the practical usefulness of the classification tool developed here.

Cutaneous presentations of omphalomesenteric duct remnant: A systematic review of the literature

BACKGROUND

Disorders of the umbilicus are commonly seen in infancy, including hernias, infections, anomalies, granulomas, and malignancies. Meticulous inspection of the umbilicus at birth might reveal a persisting embryonic remnant, such as an omphalomesenteric duct (OMD), manifested by a variety of cutaneous signs, such as an umbilical mass, granulation tissue, or discharge.

OBJECTIVE

To systematically review the available data regarding the presence and management of OMD remnant with cutaneous involvement to suggest a practical approach for diagnosis and treatment.

METHODS

A systematic review of the literature evaluating OMD anomalies presenting with cutaneous symptoms was performed. In addition, an index case of an 11-month-old patient is presented.

RESULTS

We included 59 publications reporting 536 cases; 97% of the patients whose age was noted were infants (mean age 11 months). In 7.5% of the cases, diagnosis was established only after treatment failure. In 6.4% of patients, nonlethal complications were reported, and in 10.3%, the outcome was death, partly due to delayed diagnosis or mismanagement.

LIMITATIONS

Limited quality of the collected data, reporting bias.

CONCLUSION

OMD is relatively rare; however, the clinician must consider this remnant while examining patients with umbilical abnormalities because mismanagement could cause severe morbidity and mortality.

Symptomatic Meckel's Diverticulum in Pediatric Patients-Case Reports and Systematic Review of the Literature

Introduction: Our aim was to highlight the characteristics of pediatric Meckel's diverticulum with a special focus on its complications. Methods: We report a group of seven patients with Meckel's diverticulum and its resection from the Department of Pediatric Surgery between 2012 and 2017. We reviewed all patient records, clinical presentation, and intraoperative findings. The diagnosis was confirmed by surgery and pathology. For a systematic literature review, we used PubMed, Medline and Google Scholar search engines to locate articles containing terms such as Meckel's diverticulum, children, pediatric, complications and symptomatic. We included article reporting on case series in English and German on pediatric patients only. Results: All included patients (n = 7) were symptomatic. Some patients showed isolated symptoms, and others presented with a combination of symptoms that consisted of abdominal pain, bloody stool or vomiting. The median age of our seven cases was 3.5 years, including 4 male and 3 female patients. Intestinal obstruction was the most common complication; it was seen in 5 out of 7 patients (intussusception in 4 cases, volvulus in 1 case). Ectopic gastric tissue was identified in 3 cases, and inclusion of pancreatic tissue was observed in 1 case. The literature review identified 8 articles for a total of 641 patients aged between 1 day and 17 years and a male:female ratio of 2.6:1. From this group, 528 patients showed clinical symptoms related to Meckel's diverticulum. The most common symptom was abdominal pain and bloody stool. The most common surgical finding in symptomatic patients was intestinal obstruction (41%), followed by intestinal hemorrhage (34%). Complications such as perforation (10%) and diverticulitis (13%) were less frequently reported. Heterotopic tissue was confirmed on histopathology in 53% of all patients enclosing gastric, pancreatic, and both gastric and pancreatic mucosae. In one case, large intestine tissue could be found. Overall, one death was reported. Conclusion: The presented case series and literature review found similar clinical presentations and complications of Meckel's diverticulum in children. Intestinal obstruction and bleeding are more frequent than inflammation in pediatric Meckel's diverticulum. Bowel obstruction is the leading cause for complicated Meckel's diverticulum in patients younger than 12 years.

Complicated Meckel's diverticulum: Presentation modes in adults

Complicated Meckel's diverticulum represents a common etiology of acute abdomen in children. However, this condition is less frequent in adults. We reviewed the records of adult patients who underwent the surgical removal of complicated Meckel's diverticulum between 2001 and 2017 at 2 tertiary French medical centers. We then analyzed the clinical characteristics, mode of presentation, and management for all patients.The Meckel's diverticulum was resected in 37 patients (24 males and 13 females). The mean patient age was 46.1 ± 21.4 years. The most common clinical presentations of complicated Meckel's diverticulum were diverticulitis (35.1%, n = 13), small-bowel obstruction (35.1%, n = 13), and gastrointestinal bleeding (29.8%, n = 11) (anemia, n = 1; hematochezia, n = 10). Age distribution was significantly different (P = .02) according to the 3 Meckel's diverticulum complications: patients with diverticulitis (P = .02) were statistically more frequently over 40 (P = .05), significantly older than patients with gastrointestinal bleeding who were more frequently <40 (P = .05). There was a preoperative diagnosis available for 15 of the 37 patients (40%). An exploratory laparoscopy was necessary to determine the cause of disease for the other 22 patients (60%). An intestinal resection was performed in 33 patients (89%) and diverticulectomy was performed in 4 patients (11%). There was heterotopic tissue found in only 6 patients (16%). Postoperative complications were as follows: 1 death by cardiac failure in a 92-year-old patient and 2 patients with postoperative wound infections. The follow-up time was 3 to 12 months.The correct diagnosis of complicated Meckel's diverticulum in adults is difficult due to the lack of specific clinical presentation. As a result, exploratory laparoscopy appears to play a central role in cases of acute abdomen with uncertain diagnosis.

Systematic review of epidemiology, presentation, and management of Meckel's diverticulum in the 21st century

BACKGROUND

The contemporary demographics and prevalence of Meckel's diverticulum, clinical presentation and management is not well described. Thus, this article aims to review the recent literature concerning Meckel's diverticulum.

METHODS

A systematic PubMed/Medline database search using the terms "Meckel" and "Meckel's" combined with "diverticulum." English language articles published from January 1, 2000 to July 31, 2017 were considered. Studies reporting on the epidemiology of Meckel's diverticulum were included.

RESULTS

Of 857 articles meeting the initial search criteria, 92 articles were selected. Only 4 studies were prospective. The prevalence is reported between 0.3% and 2.9% in the general population. Meckels' diverticulum is located 7 to 200 cm proximal to the ileocecal valve (mean 52.4 cm), it is 0.4 to 11.0 cm long (mean 3.05 cm), 0.3 to 7.0 cm in diameter (mean 1.58 cm), and presents with symptoms in 4% to 9% of patients. The male-to-female (M:F 1.5-4:1) gender distribution is reported up to 4 times more frequent in men. Symptomatic patients are usually young. Of the pediatric symptomatic patients, 46.7% have obstruction, 25.3% have hemorrhage, and 19.5% have inflammation as presenting symptom. Corresponding values for adults are 35.6%, 27.3%, and 29.4%. Ectopic gastric tissue is present in 24.2% to 71.0% of symptomatic Meckel's diverticulum, is associated with hemorrhage and is the most common form of ectopic tissue, followed by ectopic pancreatic tissue present in 0% to 12.0%.

CONCLUSION

The epidemiological patterns and clinical presentation appears stable in the 21st century. A symptomatic Meckel's diverticulum is managed by resection. The issue of prophylactic in incidental Meckel's diverticulum resection remains controversial.

Multifaceted behavior of Meckel's diverticulum in children

PURPOSE/BACKGROUND

Meckel's diverticulum (MD) is one of the most common congenital malformations of gastrointestinal tract in children. However, the nonspecific clinical manifestations of MD often cause a diagnostic as well as therapeutic challenge to pediatric surgeon. This study aimed to review our experience in managing this disease while evaluating the management strategies.

METHODS

We retrospectively analyzed the clinical data of all patients diagnosed with MD admitted to our center between January 2010 and December 2015. Factors documented including demographic criteria, clinical manifestations, preoperative examinations, surgical methods, histopathological characteristics, postoperative complications, and outcomes.

RESULTS

The patients included 210 males and 76 females, aged from 1day to 15years. In fifty three patients, the MD was an incidental finding at laparotomy or laparoscopy. The remaining 233 patients were symptomatic and presented with various clinical features. Ninety nine patients presented with episodes of bleeding per rectum or melena. Fifty six patients demonstrated symptoms of diverticulitis or perforated MD. Forty patients were diagnosed as intestinal obstruction, and 35 patients with intussusception requiring surgical reduction. Two cases of Littre hernia and one case of foreign body trapped in MD were also observed in this group. Six patients misdiagnosed as appendicitis at another institution were reoperated in our department. Among the 99 patients with bleeding per rectum, 78 underwent a Tc-99m scan that showed a positive tracer in 55 patients and negative in 23. All patients underwent resection of the diverticulum, except for 2 cases of postponed resection. Histology revealed ectopic gastric mucosa or ectopic pancreatic tissue in 154 patients; significant differences were observed between the symptomatic group and the accidentally found group. One patient died of peritonitis and sepsis postoperatively; one case of anastomotic leak and one case of adhesive intestinal obstruction were reoperated.

CONCLUSION

Meckel's diverticulum has various clinical presentations and it is difficult to make a precise diagnosis preoperatively. It is necessary to maintain a high suspicion of MD in the pediatric age group with symptoms of abdominal pain, gastrointestinal hemorrhage or intestinal obstruction. Heterotopic tissue is the main cause of complicated diverticulum, and it is safe and feasible to remove the incidentally found MD. Laparoscopy should become the first choice of methods in diagnosis and treatment of MD.

TYPE OF STUDY

Treatment study.

LEVEL OF EVIDENCE

Level IV.

Clinical characteristics of Meckel diverticulum in children: A retrospective review of a 15-year single-center experience

Meckel diverticulum is the most prevalent congenital abnormality of the gastrointestinal tract in children. The aim of this study was to review and analyze clinical data on the diagnosis and management of Meckel diverticulum in pediatric patients. The records of 102 pediatric patients (<14 years old) who underwent surgery for Meckel diverticulum at our institute between 2001 and 2015 were reviewed. Clinical, imaging, laboratory, surgical, and pathological data were recorded. The series comprised 65 males and 37 females with a median age of 5.6 years. Lower gastrointestinal bleeding was the most frequently identified clinical manifestation of Meckel diverticulum, and this manifestation was observed in 41 patients. Intussusception secondary to Meckel diverticulum was identified in 32 patients. Twelve patients presented clinical features of peritonitis; of these patients, 8 had perforated Meckel diverticulum and 4 had Meckel diverticulitis. In 10 patients, Meckel diverticulum was incidentally diagnosed during other surgeries, including appendectomy and neonatal enterostomy. Seven patients were diagnosed with intestinal obstruction. Technetium-99m pertechnetate imaging offered high diagnostic yield. Open surgery was performed on 59 patients, while a laparoscopic approach was employed in 35 patients. The remaining 8 patients did not undergo resection of the Meckel diverticulum. Histology revealed ectopic gastric mucosa in 42 patients (44.7%), ectopic pancreatic tissue in 35 patients (37.2%), mucosa of the small intestine in 15 patients (16.0%), and both gastric and pancreatic ectopic tissue in 2 patients (2.1%). All patients recovered uneventfully except 2 patients in whom an intestinal adhesion obstruction was identified after discharge. Meckel diverticulum had various clinical manifestations in children. Technetium-99m pertechnetate imaging may be useful for diagnosing Meckel diverticulum. Surgical excision of the Meckel diverticulum may be safe and effective in symptomatic patients, and relatively better outcomes can be achieved using this approach.

Male predominance in Meckel's diverticulum: A hyperacidity hypotheses

The symptomatic presentation of Meckel's diverticulum (MD) depends on a person's age, sex, and presence or absence of ectopic gastric tissue. There are no differences in the prevalence of asymptomatic MD between males and females; however, symptomatic MD has a distinct male predominance with a male-to-female ratio ranging from 2:1 to 5:1 in children. Furthermore, if the ectopic tissue contains gastric mucosa, MD has a greater chance of becoming symptomatic. Studies have shown that acid secretion is more likely to occur in male infants compared to female infants. In adults, men are known to have a higher level of acid production compared to women. Peptic ulcers (PU) are more common in males due to high acid secretion, and gastric tissues are affected by gastrin secretion in both conditions. MD is typically accompanied by ectopic gastric tissue, and could therefore be affected by gastrin and acid secretion in a similar manner to PU. Some of the major complications of MD are diverticulitis, ulcers, and bleeding from adjacent ectopic gastric tissue, and such complications resemble PU. PU also have male to female ratios ranging from 2:1 to 5:1, which is again similar to MD. Since the secretion of both gastrin and acid decrease with age, symptomatic presentation of MD also declines with age. Therefore, we hypothesize that higher gastrin and acid levels in males affect the ectopic gastric mucosa and lead to an increase in MD symptoms, which result an increased incidence of MD in males.

Vitelline duct pathologies in neonates

OBJECTIVE

The aim of this study was to review the management of pediatric cases of vitelline duct pathology (VDP) detected surgically or incidentally during the neonatal period and the outcomes.

METHODS

The data of newborns who were symptomatic and underwent VDP resection or who were incidentally diagnosed with VDP at a single institution between 1985 and 2015 were retrospectively analyzed in terms of age, sex, clinical features, treatment, perioperative findings, ectopic tissue pathology, and postoperative follow-up information.

RESULTS

Among the 36 newborns enrolled in this study, 26 were male and 10 were female (2.6:1). The median weight was 2400 g (range: 800-3090 g). In 16 cases (14 males and 2 females; 7:1) the VDP was surgically repaired. Pathological evaluation indicated that 43% (n=7) of the cases had ectopic gastric mucosa. VDP was incidentally discovered in 12 males and 8 females (1.5:1). VDP was removed in 10 cases (50%) and left intact in others. Ectopic gastric mucosa was observed in 10% of the VDP removal cases. Ectopic gastric tissue was more prevalent in the surgical VDP cases than in the incidentally discovered and VDP removal cases (p<0.05). Male predominance was greater in the surgically repaired cases than in the incidentally discovered cases (p<0.05). One patient whose VDP was discovered incidentally was admitted 3 years later with obstruction due to intussusception caused by Meckel's diverticulum, and 1 patient was admitted with rectal bleeding at 11 years of age.

CONCLUSION

Symptomatic VDP in the newborn demonstrates a significant gender difference. Symptomatic cases are more likely to have ectopic gastric tissue than non-symptomatic cases. Incidentally detected cases without removal should be followed closely for future complications.

Meckel's diverticulum in children: Our 12-year experience

BACKGROUND

Meckel's diverticulum (MD) is the one of the most common congenital malformation of gastrointestinal tract and has varied clinical presentations. We are presenting here our 12-year experiences with MD in children at tertiary care hospital in North India. It highlights the fact that isolated gangrene of MD can occur, and it is associated with increased morbidity.

MATERIALS AND METHODS

This retrospective study is conducted by analysing the medical records of the patients who were operated for MD in the last 12 years in paediatric surgery department at our hospital.

RESULTS

Sixty-five patients were operated for MD in study period; in this 52 were males and 13 were females with mean age of presentation 3.2 years. The most common presentation was intestinal obstruction seen in 86.1% (56 cases). Intestinal haemorrhage was seen in 4.6% (3 cases) and diverticulitis in 3% (2 cases). Perforation of the gut with peritonitis was present in 6.1% (four cases). Cause of obstruction was intussusception in 21.4% (12 cases), fibrous band connected to umbilicus in 17.8% (10 cases), volvulus in 17.8% (10 cases), kinking in 16.0% (9 cases), knotting in 14.2% (8 cases) and herniation of gut below in 12.5% (7 cases). Isolated gangrene of MD was present in ten cases with intestinal obstruction. The ectopic gastric mucosa was seen in three and pancreatic mucosa in two cases. Mortality and morbidity during the study were one and three cases, respectively.

CONCLUSION

MD may remain clinically silent for lifetime, or it may have life-threatening complications. In our series, intestinal obstruction and not the haemorrhage was the most common presentation. Isolated gangrene of MD with obstruction was present in significant numbers, which we failed to find in literature.

[A pseudotumoral lesion revealing Meckel's diverticulum]

INTRODUCTION

Meckel's diverticulum is a common malformation in children, usually asymptomatic, with complications in only 20% of cases. Exceptionally, a tumor can develop in Meckel's diverticulum in children, particularly Burkitt's lymphoma; in adults it can develop into a gastrointestinal stromal tumor, a leiomyosarcoma, or a neuroendocrine tumor such as a carcinoid tumor. The diagnosis of inflammatory pseudotumor following an insidious perforation is rare.

OBSERVATION

We report the case of a 14-month-old boy who presented with fever, asthenia, food refusal, and digestive complaints such as vomiting and tender abdomen suggesting appendicitis. Computed tomography showed an ileal mass of 3cm in diameter, which led to the suspicion of Burkitt's lymphoma. Laparoscopy showed Meckel's diverticulum with a mass of 3×2.8×2cm. Histological examination confirmed the diagnosis of Meckel's diverticulum with gastric heterotopia and showed a proliferation of spindle cells in a myxoid background, with an inflammatory infiltrate made of lymphocytes and plasmocytes. Immunostaining ruled out a malignant tumor. The diagnosis of an inflammatory pseudotumor developing on a Meckel diverticulum with gastric heterotopias was made. The outcome was favorable after surgical resection.

CONCLUSION

While perforation of a Meckel diverticulum with gastric heterotopia is a common finding, the discovery of an inflammatory pseudotumor following a perforation is rare; the differential diagnosis should include Burkitt's lymphoma.

Incremental value of SPECT/CT in detection of Meckel's diverticulum in a 10-year-old child

Introduction

Meckel’s diverticulum is a common congenital abnormality of gastrointestinal tract in children. Planar scintigraphy using Technetium-99m pertechnetate is widely used in the diagnosis of Meckel’s diverticulum. Single photon emission computed tomography/computed tomography (SPECT/CT) fusion imaging may help to locate the Meckel’s diverticulum lesion. We now present a Meckel’s diverticulum case which tends to be missed.

Case description

The patient was diagnosed with Mecke’s diverticulum by planar scintigraphy in 2007. After seven years, a recurrence of hematochezia made the patient undergo planar scintigraphy again. However, the concentration on planar image was located at the right kidney level, we could not determine whether it was caused by physiological uptake of the right kidney or by an ectopic gastric mucosa. Using SPECT/CT technique, we confirmed that the lower part of the concentration was from a Meckel’s diverticulum from the small intestine based on the functional and anatomical information together.

Discussion and Evaluation

For concentrations about the kidney level, planar scintigraphy is not enough to be diagnostic of Meckel’s diverticulum. SPECT/CT imaging may be beneficial for a definitive diagnosis. Also, fusion images may provide precise localization of the lesion. To make sure that patients obtain optimal benefit from a SPECT/CT examination, we have to balance the priority between information of anatomic location and avoiding redundant radiation to the patients.

Conclusions

Our case study suggest that for cases with ambiguous planar scintigraphy images, SPECT/CT imaging should be performed to obtain a definitive diagnosis.

Electronic supplementary material

The online version of this article (doi:10.1186/s40064-016-2928-4) contains supplementary material, which is available to authorized users.

Simultaneous occurrence of Meckel's diverticulum and patent urachus

The simultaneous occurrence of a Meckel's diverticulum and a patent urachus is very uncommon. We describe the occurrence and surgical treatment of Meckel's diverticulum and an urachal anomaly in a 1-year-old boy. The patient had intermittent production of clear fluid from the patent urachus, which disappeared after surgical resection.

Symptomatic paediatric Meckel's diverticulum: stratified diagnostic indicators and accuracy of Meckel's scan

PURPOSE

The aim of the study was to delineate stratified diagnostic indicants and evaluate the diagnostic accuracy of technetium-99m (Tc)-pertechnetate scintigraphy in children with symptomatic Meckel's diverticulum (MD).

MATERIALS AND METHODS

This was a prospective linear observational study conducted over a period of 5 years on 73 children with a diagnosis of symptomatic MD. The independent variables assessed were age, sex, weight-for-age z-scores, clinical presentation, complications of MD, laparoscopic findings, haematologic and biochemical results, radiological results, and histological findings. Stepwise multiple logistic regression analysis was performed to determine the diagnostic markers. The sensitivity and specificity of Tc-pertechnetate scintigraphy were assessed.

RESULTS

The incidence of MD with complications was 44%. The prevalence of ectopic gastric mucosa in histological specimens was 84%. There was a good correlation between rectal bleeding and the presence of ectopic gastric mucosa [r=0.94; 95% confidence interval (CI): 0.77-0.98]. Haematochezia associated with a drop in haemoglobin (>2 g/dl) was diagnostic of MD with ectopic gastric mucosa in children (n=42, 58%; P=0.006; odds ratio 1.99; 95% CI: 1.14-2.42). Bilious vomiting was diagnostic of complicated MD (n=12, 16%; P=0.007; odds ratio 1.89; 95% CI: 1.12-3.22). The sensitivity of Tc-pertechnetate scintigraphy was 84% and specificity was 22%. The positive predictive value was 0.64 and the negative predictive value was 0.22. The sensitivity and specificity of Tc-pertechnetate scintigraphy were dependent on the quantity and functional quality of the heterotopic gastric mucosa. The preoperative median z-score was -1.4 and the postoperative median z-score was -1.2.

CONCLUSION

Tc-pertechnetate scintigraphy had a truncated predictive value. Its contribution in clinical decision making was poor. Clinical suspicion of MD should be high in children presenting with haematochezia associated with a drop in haemoglobin by more than 2 g/dl. Laparoscopy is an effective diagnostic and therapeutic tool.

Suppurative meckel diiverticulum in a 3-year-old girl presenting with periumbilical cellulitis

Meckel diverticulum (MD) is one of the most common congenital gastrointestinal anomalies and occurs in 1.2-2% of the general population. MD usually presents with massive painless rectal bleeding, intestinal obstruction or inflammation in children and adults. Suppurative Meckel diverticulitis is uncommon in children. An experience is described of a 3-year-old girl with suppurative inflammation in a tip of MD. She complained of acute colicky abdominal pain, vomiting and periumbilical erythema. Laparoscopic surgery found a relatively long MD with necrotic and fluid-filled cystic end, which was attatched to abdominal wall caused by inflammation. Herein, we report an interesting and unusual case of a suppurative Meckel diverticulitis presenting as periumbilical cellulitis in a child. Because of its varied presentations, MD might always be considered as one of the differential diagonosis.

Imaging of omphalomesenteric duct remnants and related pathologies in children

The omphalomesenteric duct (OMD) or the vitelline duct (VD) is the embryologic communication between the yolk sac and the primitive midgut. OMD or VD anomalies are a group of defects resulting from failure of involution of the OMD. Meckel diverticulum is the most common anomaly that results from failure of resorption of the OMD. Other less common anomalies seen in children include OMD fibrous band, fistula, sinus tract, cyst, and umbilical polyps. These OMD remnants can have variable clinical manifestations such as umbilical discharge, small bowel obstruction, gastrointestinal tract bleeding, or acute abdomen. This pictorial essay reviews the clinical presentation and imaging findings of the common and not so common complications of OMD remnants in the pediatric population.

CT diagnosis of a post-embolization ischemic diverticulitis of Meckel

A 23-year-old man presented with hypovolemic shock due to a lower gastrointestinal bleeding. Radiological and endoscopic investigation did not reveal the bleeding site. Emergency visceral angiography showed contrast extravasation at a right-sided branch of the superior mesenteric artery (SMA). Embolization of the bleeding point was performed, resulting in bleeding cessation. One week later, the patient presented with a new episode of moderate anal blood loss associated with diffuse abdominal pain. Computed tomography (CT) revealed an ischemic small bowel diverticulum that was treated by a laparoscopically-assisted segmental small bowel resection. Intraoperative and pathologic analysis confirmed a post-embolization ischemic diverticulitis of Meckel.

Diverse presentations in pediatric Meckel's diverticulum: a review of 100 cases

BACKGROUND

Our objective was to analyze demographics and characteristics of Meckel's diverticulum with different manifestations in pediatric patients.

METHODS

This is a retrospective study in children with symptomatic Meckel's diverticulum who underwent resection between September 1998 and October 2010. The diagnosis was confirmed by surgery and pathology. Demographic characteristics, manifestations, Meckel's scan results, surgical and histological findings were analyzed.

RESULTS

One hundred symptomatic Meckel's diverticula were identified in 74 boys and 26 girls aged from one day to 18 years old over 13 years. Depending on whether or not obstruction occurred, the patients were classified into two categories. Each category was further subdivided into two diagnostic groups: 17 intussusception and 24 non-intussusception bowel obstruction in the obstructive category and 44 gastrointestinal bleeding and 15 diverticulitis and/or perforation in the non-obstructive category. The sex discrepancy was higher in the non-obstructive category than in the obstructive category (male-to-female, 4.36 vs. 1.73, p < 0.05). Forty-one of 44 patients with gastrointestinal bleeding underwent a Meckel's scan with a high positive rate (92.7%). The ectopic tissues were identified in 73 patients and included 61 gastric type, two pancreatic type and 10 mixed type. Ectopic tissues were more prevalent in non-obstructive category (p < 0.05) with ectopic gastric tissue even more pronounced (p < 0.01). Ectopic pancreatic tissue was significantly more prevalent in intussusception (p < 0.01). Laparoscopic surgery was performed more frequently in Meckel's diverticulum with non-obstructive symptoms (p < 0.001).

CONCLUSION

Diverse presentations in pediatric Meckel's diverticulum are affected by different ectopic tissue types and male sex. Laparoscopic surgery is widely used for children with non-obstructive symptoms.

Laparoscopic approach to Meckel's diverticulum

AIM: To retrospective review the laparoscopic management of Meckel Diverticulum (MD) in two Italian Pediatric Surgery Centers.

METHODS: Between January 2002 and December 2012, 19 trans-umbilical laparoscopic-assisted (TULA) procedures were performed for suspected MD. The children were hospitalized for gastrointestinal bleeding and/or recurrent abdominal pain. Median age at diagnosis was 5.4 years (range 6 mo-15 years). The study included 15 boys and 4 girls. All patients underwent clinical examination, routine laboratory tests, abdominal ultrasound and technetium-99m pertechnetate scan, and patients with bleeding underwent gastrointestinal endoscopy. The abdominal exploration was performed with a 10 mm operative laparoscope. Pneumoperitoneum was established based on the body weight. Systematic overview of the peritoneal cavity allowed the ileum to be grasped with an atraumatic instrument. The complete exploration and surgical treatment of MD were performed extracorporeally, after intestinal exteriorization through the umbilicus. All patients’ demographics, main clinical features, diagnostic investigations, operative time, histopathology reports, conversion rate, hospital stay and complications were registered and analyzed.

RESULTS: MD was identified in 17 patients, while 1 had an ileal duplication and 1 a jejunal hemangioma. Fifteen patients had painless intestinal bleeding, while 4 had recurrent abdominal pain and exhibited cyst like structures in an ultrasound study. Eleven patients had a positive technetium-99m pertechnetate scan. In the patients with bleeding, gastrointestinal endoscopy did not name the source of hemorrhage. All patients were subjected to a TULA surgical procedure. An intestinal resection/anastomosis was performed in 14 patients, while 4 had a wedge resection of the diverticulum and 1 underwent stapling diverticulectomy. All surgical procedures were performed without conversion to open laparotomy. Mean operative time was 75 min (range 40-115 min). No major surgical complications were recorded. The median hospital stay was 5-7 d (range 4-13 d). All patients are asymptomatic at a median follow up of 4, 5 years (range 10 mo-10 years).

CONCLUSION: Trans-umbilical laparoscopic-assisted Meckel’s diverticulectomy is safe and effective in the treatment of MD, with excellent results.