What is the recommended management for multiple diverticula found at the mesenteric border of a jejunal loop during a laparotomy (surgical incision into the abdominal cavity) for hepatic (liver) resection?

Management of Multiple Jejunal Diverticula Found During Laparotomy

Resection of the jejunal loop containing the diverticula is the recommended management for multiple diverticula found at the mesenteric border of a jejunal loop during laparotomy for hepatic resection.

Understanding Jejunal Diverticula

Jejunal diverticula are uncommon compared to colonic diverticula, with reported incidence varying from 0.05% to 6%. They are typically false diverticula found along the mesenteric border of the jejunum, where blood vessels penetrate the intestinal wall, creating potential weak points.

Management Algorithm

1. Assessment of the Diverticula

• Evaluate for signs of acute complications:
  • Inflammation/diverticulitis
  • Perforation
  • Bleeding
  • Obstruction
  • Abscess formation

2. Decision-Making Process

• Asymptomatic incidental finding without complications:

  • If discovered during surgery for another indication (hepatic resection in this case), resection of the affected jejunal segment is recommended 1, 2
  • This prevents future complications that could require emergency surgery

• If complications are present:

  • Immediate resection is mandatory 3
  • In case of peritonitis or abscess, more extensive management may be required

Rationale for Resection

1. Prevention of future complications:

   • Jejunal diverticula can lead to serious complications in 10-30% of cases 4
   • Complications include diverticulitis, perforation, bleeding, obstruction, and bacterial overgrowth

2. Avoidance of future emergency surgery:

   • Emergency surgery for complicated jejunal diverticula carries higher morbidity and mortality 2
   • Poor prognostic factors include advanced age, delayed diagnosis, and time interval between perforation and surgery

3. Treatment of potential subclinical issues:

   • Even asymptomatic diverticula can harbor bacterial overgrowth leading to malabsorption and nutritional deficiencies 5

Surgical Technique

• Segmental resection of the affected jejunal loop with primary end-to-end anastomosis 3
• In case of extensive small bowel diverticulosis, resection should be limited to the segment with diverticula to avoid short bowel syndrome 2
• For hemodynamically stable patients, a laparoscopic approach can be considered if technical skills and equipment are available 1

Alternative Options and Why They Are Inferior

1. Biopsy alone (Option A):

   • Insufficient management as it leaves the diverticula in place
   • Does not prevent future complications
   • Only provides diagnostic information without therapeutic benefit

2. Postoperative antibiotics alone (Option C):

   • While antibiotics can temporarily suppress bacterial overgrowth in diverticula 5
   • They do not provide definitive treatment
   • Studies show that antibiotics alone do not provide prolonged relief of symptoms in patients with multiple diverticula 5

Special Considerations

• If the patient is hemodynamically unstable during the primary procedure, consider damage control surgery with staged approach 1
• In elderly patients or those with significant comorbidities, carefully weigh the risks of extended operative time against the benefits of resection
• Ensure proper assessment of bowel viability before and after resection

Conclusion

When multiple jejunal diverticula are discovered incidentally during laparotomy for hepatic resection, resection of the affected jejunal segment is the recommended management to prevent future complications that could require emergency surgery with higher associated morbidity and mortality.