Medical Care
Although numerous retrospective studies have described trends in the diagnosis and treatment of Meckel diverticulum, the amount of cases has been insufficient to warrant official guidelines.
The emergency department evaluation and treatment of patients depends on the clinical presentation of Meckel diverticulum.
Because most symptomatic patients are acutely ill, establish an intravenous line immediately, start crystalloid fluids, and keep the patient on nothing by mouth (NPO) status. Obtain the blood investigations suggested earlier with a type and cross-match (see Workup, Laboratory Studies). If significant bleeding occurs, perform a transfusion of packed red blood cells.
A patient who presents with intestinal obstruction usually requires nasogastric (NG) decompression. After passing the NG tube, obtain plain radiography of the abdomen.
When a child presents with bleeding, specifically a dark tarry stool, perform a gastric lavage to rule out upper gastrointestinal bleeding. If the gastric lavage is negative for bleeding, consider performing an upper endoscopy and flexible sigmoidoscopy.
Meckel scan results may be negative despite a high clinical suspicion of Meckel diverticulum. Consult the surgery team to discuss the possible need for laparoscopy and/or laparotomy, even without a nuclear medicine diagnosis.
Consultations
Consultations with the following specialists may be appropriate:
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Radiologist
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Surgeon
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Gastroenterologist
Surgical Care
If the patient is bleeding but is hemodynamically stable, a Meckel scan is warranted. Alternatively, the presence of peritoneal signs or hemodynamic instability demands urgent surgical intervention. Signs of small bowel obstruction also require surgical intervention. [60]
A stationary foreign body within the right lower quadrant on imaging proximal to the ileocecal valve should raise suspicion for a Meckel diverticulum and prompt early surgical intervention. In a case report, a 6-year-old boy presented after having ingested a coin 2 days prior; serial abdominal radiographs demonstrated persistence of the coin in the right lower quadrant without a change in position over a 72-hour interval. [61] The coin led to both obstruction and perforation of a Meckel diverticulum.
Meckel diverticula containing gastric heterotopia predispose to local hyperacidity, mucosal ulceration, and gastrointestinal (GI) bleeding in children. Eradication of acid-producing oxyntic cells is always performed by segmental diverticulectomy, with or without segmental enterectomy. Definitive treatment of a complication, such as bleeding, is excision of the diverticulum along with the adjacent ileal segment. Excision is achieved by performing a wedge resection of the adjacent ileum and anastomosis with the use of a stapling device. [62] Adjacent ileum is included in the resection because ulcers frequently develop in the adjacent bowel and may continue to bleed. In those rare instances when the diverticulum is located on the mesenteric border, resection and anastomosis is preferred instead of a wedge resection.
Because of concern that ulcers in the adjacent bowel may continue to bleed if only the diverticulum is removed, a group compared whether a simple diverticulectomy rather than a segmental bowel resection is adequate treatment for GI bleeding secondary to Meckel diverticulum. [63] The primary outcome was postoperative bleeding during the initial hospitalization, whereas secondary outcomes included postdischarge bleeding, transfusion or additional procedure requirement, readmission, and overall complications. The study concluded that simple diverticulectomy is adequate for the treatment of GI bleeding caused by Meckel diverticulum. Furthermore, diverticulectomy appears to have a lower overall complication rate. [63]
In support of this finding, a retrospective review of all surgical resections of a bleeding Meckel diverticulum at a tertiary-referral children's hospital found that a diverticulectomy-only procedure completely eradicates gastric heterotopia without an increased risk of continued bleeding or complications and significantly shortens hospitalization. [64] Ultimately, real-time intraoperative findings by the surgeon should dictate how to proceed; although the pursuit of a less invasive procedure is desired, one should be careful not to treat a patient too conservatively and ultimately result in greater complications for the patient.
Laparoscopy
Successful resection of a Meckel diverticulum, even in children and infants, can also be accomplished through laparoscopy, using an endoscopically designed autostapling device. [65, 66, 67] A large series of national trends in the surgical management of Meckel diverticulum found that one fourth of cases are now treated laparoscopically. [7] This group was older (6.4 y ± 5.1 y vs 5.1 y ± 5.3 y), had shorter length of stay, and trended toward lower total hospital charges.
Minimally invasive surgery via laparoscopy in patients with Meckel diverticulum has been associated with faster recovery time without increasing complications, offering a safe alternative to open surgery. [68]
In some cases of Meckel diverticulum, a primitive persistent right vitelline artery originating from the mesentery has been found during operation. When present, the artery is noted to supply the Meckel diverticulum; therefore, it must be identified and ligated during the operation.
Diagnostic laparoscopy is now being used more commonly in cases where Meckel diverticulum is the cause of intestinal perforation, which is a less common presentation in young children. A case report described the use of laparoscopy in a neonate with pneumoperitoneum to diagnose and surgically resect the perforated Meckel diverticulum. [69] Using a multiuse single-site port in the umbilicus potentially reduces the preoperative and postoperative phases, allowing for earlier resumption of enteral nutrition, which is beneficial outcome in newborns.
Enteroscopy
Double-balloon enteroscopy (DBE) is a relatively new technique used to diagnose a bleeding Meckel diverticulum and to assist in a minimally invasive standard surgical resection. Previously, DBE has been used as a diagnostic tool followed by laparoscopic treatment of Meckel diverticulum.
In a retrospective study (2011-2014) of 21 pediatric patients with melena and or/maroon-colored stools who underwent retrograde transanal DBE, 14 children had Meckel diverticulum that were all successfully treated with standard resection through an umbilical incision with exteroscopic light guidance, 5 children had a negative DBE study, and 2 had a lesion that prevented insertion of the enteroscope. [70] A clear advantage of this technique is that direct visualization of the distal small bowel lumen permits easy identification of the bleeding source. Noninvasive diagnostic methods such as ultrasonography, scintigraphy, and computed tomography (CT) scanning often yield false-positive or false-negative results, which may delay laparoscopy and treatment in pediatric patients. Note that a potential significant limitation of DBE is that the upper small bowel is not examined. Thus, DBE should not be routinely used as the first investigation to diagnose GI bleeding in patients presenting with a large quantity of melena and/or maroon-colored stools. [70]
Conversely, a case report described how retrograde DBE was employed to reduce an intussusception with an inverted Meckel diverticulum as the lead point. [71] Pressure was successfully applied to the protruding lesion using a contrast medium injection after wedging the lumen with a balloon to prevent distal flow, relieving the obstruction. By reducing the intussusception, emergent surgery was avoided. Endoscopic tattooing enabled elective laparoscopy-assisted surgery with minimum laparotomy to resect the inverted Meckel diverticulum. [71] In those with advanced endoscopic techniques along with a multidisciplinary surgical team, retrograde DBE can be useful for the investigation and treatment of ileal intussusception. It is important to note that this method does not necessarily entirely eliminate the need for surgery, and further studies are required before its benefit is fully established.
Mizutani et al determined the specific characteristics of hemorrhagic Meckel diverticulum and incidental Meckel diverticulum at DBE. [72] Findings during the procedure were classified into either major (ectopic gastric mucosa and/or open ulcer) or minor (ringlike scar). Hemorrhagic Meckel diverticulum correlated more with these findings. Specificity of major findings was 100%, and specificity of major and/or minor findings was 96%. These results allowed identification of asymptomatic Meckel diverticulum, thus avoiding unnecessary laparotomy/laparoscopy and diverticulectomy. [72]
The most common postoperative complication after Meckel’s diverticulectomy is adhesive intestinal obstruction. This usually presents with GI bleeding, and has been most often reported in patients with an ischemic and congested intestine. [73]
Management of Meckel diverticulum in asymptomatic patients is controversial. In the past, if a Meckel diverticulum was encountered in a patient undergoing abdominal surgery for some other intra-abdominal condition, many surgeons recommended its removal. This practice was questioned when a large case series described an overall 4.2% likelihood of complications in Meckel diverticulum and a decreasing risk with increasing age. [74] The investigators concluded that, assuming a 6% mortality rate from Meckel diverticulum complications, 400 asymptomatic diverticula would have to be excised to save one patient.
Another faction favors prophylactic removal of a diverticulum, which is a simple operation. This view is supported by data that demonstrate managing a complication of Meckel diverticulum is associated with high morbidity and mortality. Other authors feel the only exception to universal excision is if the diverticulum is so broad based or so short that stapled excision cannot be performed technically. Fortunately, patients are less likely to develop complications in both of these situations.
One small case series suggested that only patients younger than 50 years clearly benefited from removal if Meckel diverticulum was discovered unintentionally. [75]
Another study examined whether the appearance of the Meckel diverticulum was able to predict the need for resection based on the potential for complications. [76] Using age, sex, clinical features, laboratory data, perioperative findings (diverticulum length, diameter, depth, thickening, height-to-diameter ratio [HDR]), pathology, and postoperative follow-up for evaluation, the authors found a correlation between the age of the patient and the size (length, diameter, and depth) of the Meckel diverticulum. With increasing age, Meckel diverticulum reaches larger sizes. The macroscopic appearance of the Meckel diverticulum did not predict the presence of heterotopic gastric mucosa and could not be used to guide subsequent surgery. Specifically, a thickened diverticulum had the same (68%) chance of containing heterotopic gastric mucosa as one without this finding (63%). [76] The study authors concluded that, regardless of appearance, Meckel diverticulum should be removed, except in certain situations unrelated to complications, such as peritonitis due to appendicitis or bowel perforation.
The limitations of this study were that it had a small sample size (50 children) and that macroscopic thickening is a subjective criterion, which differs among clinicians. [76] The study also found that resection of incidental Meckel diverticulum is not associated with higher operative morbidity or mortality than resection of symptomatic Meckel diverticulum, and thus all Meckel diverticulum should be removed.
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Pediatric Meckel Diverticulum. Anteroposterior view of an abdominal radiograph showing multiple dilated loops of a small bowel with air-fluid levels.
