What is the recommended management for a patient with symptomatic Meckel's diverticulum?

From the Guidelines

Surgical resection is the recommended management for symptomatic Meckel's diverticulum. The procedure typically involves a diverticulectomy or segmental resection of the small bowel containing the diverticulum, which can be performed via laparoscopic or open surgical approaches depending on the patient's condition and surgeon expertise.

Key Considerations

• Preoperative preparation includes NPO status, intravenous fluid resuscitation, correction of electrolyte abnormalities, and administration of broad-spectrum antibiotics (such as cefazolin 1-2g IV and metronidazole 500mg IV) 1.
• Technetium-99m pertechnetate scintigraphy (Meckel's scan) may be performed preoperatively to confirm the diagnosis, particularly in patients presenting with gastrointestinal bleeding.
• Surgery is necessary because Meckel's diverticulum represents a true diverticulum containing all layers of the intestinal wall, often with heterotopic gastric or pancreatic tissue that can cause complications including hemorrhage, obstruction, inflammation, or perforation.
• Conservative management is not recommended for symptomatic cases as symptoms indicate complications that typically do not resolve without intervention and carry significant morbidity risks.
• Postoperative care includes gradual diet advancement, pain management, and monitoring for surgical complications.

Rationale

• The provided evidence primarily discusses colonic diverticulitis, which is distinct from Meckel's diverticulum in terms of location and management 1.
• However, the principle of personalized management considering severity of disease, patient preferences, and risks and benefits, including quality of life, can be applied to Meckel's diverticulum as well 1.
• Given the potential for significant morbidity associated with symptomatic Meckel's diverticulum, a proactive approach with surgical resection is generally recommended to prevent complications and improve quality of life.

From the Research

Recommended Management for Symptomatic Meckel's Diverticulum

The recommended management for a patient with symptomatic Meckel's diverticulum includes:

• Surgical resection as the definitive treatment 2, 3, 4, 5
• The type of procedure depends on the integrity of the diverticulum base and adjacent ileum, as well as the presence and location of ectopic tissue within the diverticulum 3
• Diverticulectomy, wedge resection, and segmental resection are common surgical procedures used to treat symptomatic Meckel's diverticulum 3, 6

Factors Influencing Management Decisions

The decision to resect an incidental Meckel's diverticulum is based on several factors, including:

• Patient age, with younger patients being at higher risk for developing complications 3, 6
• Diverticulum length, with longer diverticula being more prone to complications 3, 6
• Presence of ectopic tissue or abnormal features within the diverticulum 3, 6
• Male sex, which is associated with a higher risk of complications 6

Diagnostic Approaches

Diagnosing Meckel's diverticulum can be challenging, and a multimodality approach is often required, including:

• Meckel's scan, which has a sensitivity of 80-92% in children but 62-88% in adults 2
• Small bowel capsule endoscopy (SBCE), which has a diagnostic yield of up to 50% 2
• Device-assisted enteroscopy (DAE), which has a sensitivity of 84-100% for Meckel's diverticulum but is invasive 2
• Cross-sectional imaging, which is unspecific but can be useful in certain cases 4, 5