What is the recommended management of Meckel diverticulum in symptomatic versus incidentally discovered cases, considering patient age, comorbidities, and severity of complications?

Management of Meckel Diverticulum

Symptomatic Meckel Diverticulum

All symptomatic Meckel diverticula require surgical resection, with the specific procedure determined by the clinical presentation and anatomical features. 1, 2

Surgical Approach Based on Presentation

For simple diverticulitis:

• Long diverticula (height-to-diameter ratio >2): Perform diverticulectomy, as ectopic tissue is typically located at the body and tip 2
• Short diverticula: Perform wedge resection, as ectopic tissue has wide distribution including the base 2

For complicated presentations requiring more extensive resection:

• Complicated diverticulitis with perforated base: Wedge or segmental resection 2
• Complicated intestinal obstruction: Wedge or segmental resection 2
• Gastrointestinal bleeding: Wedge or segmental resection are preferred, as ectopic gastric mucosa causing bleeding requires removal with adequate margins 2
• Tumor or malignancy: Segmental resection with adequate margins 3, 2

Clinical Presentations Requiring Immediate Diagnosis

Painless rectal bleeding in young patients is the classic presentation, particularly in children and young adults, and warrants a Meckel scan (99mTc pertechnetate scintigraphy) as the diagnostic test of choice with 89% sensitivity and 98% specificity 4

Obstruction occurs in 42.9% of symptomatic cases, often from volvulus around a fibrous band connecting the diverticulum to the umbilicus or entrapment beneath a mesodiverticular band 4, 5

Diverticulitis presents in 41.4% of symptomatic cases and requires CT scan with contrast for diagnosis 4, 5

Incidentally Discovered Meckel Diverticulum

Prophylactic resection of incidentally discovered Meckel diverticulum should be performed when the patient has a Risk Score ≥6 points based on four weighted risk factors. 6

Risk Score Calculation for Incidental Diverticula

Assign points for each risk factor present:

• Male sex: 2 points 6
• Age <45-50 years: 2 points 6, 2
• Diverticulum length >2 cm: 2 points 6, 2
• Presence of fibrous band or umbilical connection: 2 points 6, 5

Total the points and apply this algorithm:

• Risk Score ≥6: Resect the diverticulum 6
• Risk Score <6: Leave undisturbed 6

Additional Indications for Prophylactic Resection

Resect incidentally discovered diverticula when:

• Heterogeneous on palpation (suggests ectopic tissue or pathology) 5
• Palpable mass at the base (suggests tumor or complicated anatomy) 6, 1
• Mesodiverticular band present (high risk for future obstruction) 5
• Diverticulum easily fits in stapling device without technical difficulty 1

When to Leave Incidental Diverticula Alone

Do not resect incidentally discovered diverticula when:

• Broad-based or very short diverticula that cannot be stapled without difficulty, as these are unlikely to become symptomatic 1
• Risk Score <6 and no concerning features on palpation 6
• Patient has significant contraindications to diverticulectomy 5

Surgical Technique Selection

For incidentally discovered diverticula meeting resection criteria:

• Transverse diverticulectomy is preferable in most cases using stapling devices for ease and low complication rates 6, 1
• Wedge-shaped excision for short, broad-based diverticula or when palpable mass at base 6

For symptomatic diverticula:

• Segmental ileal resection for all symptomatic and pathologic diverticula to ensure complete removal of ectopic tissue and prevent recurrence 1

Evidence Supporting Prophylactic Resection

Morbidity after prophylactic resection of incidental diverticula is significantly lower than after resection of symptomatic diverticula: Major postoperative complications occurred in 0% of incidental cases versus 6.6% in symptomatic cases, with no mortality in either group 3

The lifetime risk of complications decreases with age: Symptomatic patients are significantly younger (mean 41.7 years) compared to incidental cases (mean 54.7 years), and the male-to-female ratio is much higher in symptomatic cases (14:1 vs 2.6:1) 3

Malignancy risk justifies resection in high-risk cases: Neuroendocrine tumors were found in 4.5% of resected diverticula, all in the symptomatic group 3

Common Pitfalls to Avoid

Do not routinely resect all incidentally discovered diverticula without risk stratification, as this exposes low-risk patients to unnecessary surgical morbidity 6, 1

Do not perform simple diverticulectomy for bleeding diverticula without ensuring adequate margins, as ectopic gastric mucosa may extend to the base requiring wedge or segmental resection 2

Do not rely on intraoperative palpation alone to determine presence of ectopic tissue, as it cannot be accurately predicted by macroscopic appearance 2

Do not attempt to resect broad-based or very short diverticula that require difficult stapling, as these are unlikely to become symptomatic and resection carries higher technical risk 1