What is the treatment for Meckel's (Meckel's diverticulum) diverticulum?

Treatment of Meckel's Diverticulum

Surgical resection is the definitive treatment for symptomatic Meckel's diverticulum, with either diverticulectomy or segmental small bowel resection depending on the base width and presence of complications.

Clinical Presentation and Diagnosis

Meckel's diverticulum is the most common congenital abnormality of the gastrointestinal tract. Before determining treatment, proper diagnosis is essential:

• Presenting symptoms may include:

  • Gastrointestinal bleeding (especially in children)
  • Small bowel obstruction
  • Diverticulitis
  • Perforation
  • Volvulus

• Diagnostic methods:

  • Meckel scan (technetium-99m pertechnetate) - most sensitive test for detecting ectopic gastric mucosa with 85% sensitivity in pediatric patients 1
  • CT enterography - may help detect the diverticulum but less specific than nuclear medicine scans 1
  • Diagnostic laparotomy - most sensitive test when other investigations are inconclusive 1

Treatment Algorithm

1. Symptomatic Meckel's Diverticulum

For patients presenting with complications (bleeding, obstruction, diverticulitis, perforation):

• Surgical intervention is mandatory 2

• Surgical options:

  • Diverticulectomy - for diverticula with narrow base and no inflammation at the base
  • Segmental bowel resection - for diverticula with wide base, inflammation extending to the base, or perforation

• Specific approaches based on complications:

  • For bleeding: Resection of the diverticulum containing ectopic gastric or pancreatic tissue 3
  • For obstruction: Band lysis if caused by adhesive band, followed by diverticulectomy 4
  • For diverticulitis/perforation: Segmental resection with primary anastomosis 2

2. Incidentally Found Meckel's Diverticulum

For asymptomatic diverticula discovered during surgery for other conditions:

• Age-based approach:

  • Patients <50 years old: Consider prophylactic resection as 70% of patients under 50 years develop symptoms 5
  • Patients >50 years old: Resection less beneficial as only 10% develop symptoms 5

• Risk factors favoring prophylactic resection:

  • Diverticulum length >2 cm
  • Narrow base
  • Presence of heterotopic tissue (if known)
  • Male gender (slightly higher risk)

Technical Considerations

• Preferred surgical technique: Simple resection by stapler at the base of diverticulum is often the correct choice for uncomplicated cases 3
• Laparoscopic approach: Feasible and safe for both diverticulectomy and segmental resection
• Open surgery: May be necessary in complicated cases with peritonitis or severe obstruction

Postoperative Management

• Antibiotic therapy for 4 days in immunocompetent and non-critically ill patients if source control is adequate 2
• Extended antibiotic therapy up to 7 days based on clinical conditions in immunocompromised or critically ill patients 2
• Monitor for recurrent bleeding or signs of anastomotic leak

Special Considerations

• Heterotopic tissue: Present more commonly in symptomatic patients (33%) compared to asymptomatic patients (0%) 5
• Mortality risk: Meckel's diverticulum can present as a life-threatening condition requiring emergency surgery, especially when complicated by obstruction, perforation, or severe bleeding 4
• Previous missed diagnosis: Some patients with symptomatic Meckel's diverticulum may have had the diverticulum identified but left untouched during previous surgeries 6

Common Pitfalls

1. Delayed diagnosis due to nonspecific symptoms mimicking appendicitis or other acute abdominal conditions
2. Incomplete resection of heterotopic tissue, which may lead to recurrent bleeding
3. Failure to consider Meckel's diverticulum in young patients with unexplained lower gastrointestinal bleeding
4. Leaving asymptomatic diverticula in patients under 50 years of age who have higher risk of developing complications

The surgical approach should be determined based on the patient's clinical condition, the characteristics of the diverticulum, and the presence of complications, with the goal of minimizing morbidity and mortality.