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

Management of Meckel's Diverticulum

All symptomatic Meckel's diverticula should be surgically removed with resection of a segment of ileum, while incidentally discovered diverticula in adults should generally be left alone unless they are easily amenable to stapled resection. 1

Symptomatic Meckel's Diverticulum: Surgical Resection Mandatory

When a Meckel's diverticulum causes symptoms, surgical removal is the definitive treatment. 1 The key presentations requiring intervention include:

Clinical Presentations Requiring Surgery

Gastrointestinal Bleeding:

• Most common in children and young adults (typically <40 years old), presenting as painless rectal bleeding or melena 2, 3
• Caused by ectopic gastric mucosa within the diverticulum that secretes acid, ulcerating adjacent ileal mucosa 4
• Technetium-99m pertechnetate scintigraphy (Meckel scan) is the diagnostic test of choice, with 89% sensitivity and 98% specificity in symptomatic patients 5, 2
• In one pediatric series, 78 of 99 bleeding patients underwent Tc-99m scanning, with 55 showing positive uptake 4

Intestinal Obstruction:

• Can occur via volvulus around a fibrous band connecting the diverticulum to the umbilicus, entrapment beneath a mesodiverticular band, or intussusception 2, 6
• More common in adults and accounts for 35.1% of complicated cases 3

Diverticulitis:

• Presents similarly to appendicitis with right lower quadrant pain 4, 7
• More common in adults over 40 years old (35.1% of complicated cases) 3
• Six patients in one series were misdiagnosed as appendicitis at other institutions 4

Surgical Approach

Laparoscopy is the preferred initial approach for both diagnosis and treatment, used successfully in 62% of pediatric cases and allowing for diagnostic exploration when preoperative imaging is inconclusive. 7 Conversion to open surgery occurred in only 8 of 36 laparoscopic cases in one series. 7

Resection technique:

• Segmental ileal resection including the diverticulum is preferred over simple diverticulectomy (performed in 89% vs 11% of cases) 3, 1
• This approach removes the entire pathologic segment and any adjacent ectopic mucosa 1
• Stapling devices facilitate safe resection with low complication rates 1

Incidentally Discovered Meckel's Diverticulum: Selective Management

The management of asymptomatic Meckel's diverticula found during surgery for other indications is more nuanced and depends on patient age and technical factors.

In Children: Remove When Found

Incidental removal is recommended in the pediatric population because:

• Heterotopic tissue (gastric or pancreatic mucosa) is present in a significant proportion and is the main cause of future complications 4
• The lifetime risk of complications is higher in younger patients 6
• One series found ectopic tissue in 154 of 286 patients, with significant differences between symptomatic and incidentally found groups 4

In Adults: Generally Leave Alone

Incidental removal in adults is NOT recommended, particularly in women, because:

• Adults rarely become symptomatic (only 25.5% of removed diverticula in one series were symptomatic) 8
• Female patients are significantly less likely to be symptomatic than males (13% vs 50%, P<0.05) 8
• Complications from removal (anastomotic leaks, wound infections) occurred in 8.5% of cases and can be life-threatening 8
• The morbidity of prophylactic removal outweighs the low risk of future complications 8

Exception: If the diverticulum easily fits in a stapling device without difficulty, removal is reasonable given the low complication rate of stapled resection. 1 However, broad-based or short diverticula that cannot be easily stapled should be left undisturbed as they are unlikely to become symptomatic. 1

Diagnostic Challenges and Pitfalls

Preoperative diagnosis is difficult: Only 40% of adult patients had a correct preoperative diagnosis, requiring exploratory laparoscopy in 60% to determine the cause of acute abdomen. 3 In pediatric patients with acute abdomen, an average of 2.3 diagnostic investigations were performed, with Meckel's recognized preoperatively in only 5 of 40 cases. 7

Key diagnostic considerations:

• Maintain high suspicion in young patients with painless rectal bleeding, unexplained anemia, or intestinal obstruction 5, 4
• Meckel scan is most useful in bleeding patients but requires active hemorrhage or ectopic gastric mucosa to be positive 5
• CT enterography can identify Meckel's diverticulum when bleeding is not active and helps exclude other etiologies 5, 2
• Negative upper endoscopy and colonoscopy in a bleeding patient should prompt consideration of Meckel's diverticulum 5

Postoperative Outcomes

Complications are uncommon but can be serious:

• Mortality is rare (one death from cardiac failure in a 92-year-old patient) 3
• Anastomotic leaks requiring reoperation occurred in 2 of 47 adult patients (4.3%) 8
• Wound infections and adhesive obstruction are reported complications 4, 8
• Overall morbidity ranges from 3.4% to 8.5% in reported series 7, 8