Approach

The approach to treatment depends on whether Meckel diverticulum is an incidental finding, or presents with symptoms.

Asymptomatic

Asymptomatic Meckel diverticulum discovered incidentally on imaging typically requires no treatment.[7]

The appropriate treatment for asymptomatic Meckel diverticulum discovered intraoperatively remains controversial, with no evidence-based guidelines. When prophylactic excision of an asymptomatic Meckel diverticulum is indicated, simple excision of the diverticulum is usually sufficient.[3][7][13][14]​​[24][26]

In general, in a child or young adult, if Meckel diverticulum is found during a nonacute operation, it should be removed, particularly if it is narrow-necked, provided the patient's general condition and the nature of the primary operation are appropriate.[22] Other features that further suggest the need for a prophylactic excision include:[4][14][18]​​​[43][44]

  • long diverticulum (>2 cm)

  • ectopic tissue or palpable abnormalities

  • male sex.

Given infrequency of the finding of an incidental Meckel diverticulum, developing general management guidelines is difficult. While it may be reasonable to resect the diverticulum in young and otherwise healthy patients undergoing an elective surgery, some have suggested that in patients ages >50 years, an incidental Meckel diverticulum without ectopic tissue should generally be left alone.[4] However, Meckel diverticulum may be a "hot spot" for ileal malignancy, with the risk of malignancy increasing with age.[20] Based on this observation, some have suggested that all incidental Meckel diverticula should be resected, irrespective of age. Further studies are needed to validate this approach, considering that the incidence of Meckel diverticulum-associated ileal malignancy remains very low at 1.44 per 10 million population. Although publications increasingly favor resection, the intraoperative decision should be individualized based on the patient's condition and primary reason for surgery.[45]

Symptomatic

When the diagnosis of symptomatic Meckel diverticulum has been established, surgical resection of the diverticulum should be performed.[46]

Several reports have shown that laparoscopy is a safe and efficient way of diagnosing and resecting Meckel diverticulum.[47][48][49][50] Data from the National Surgical Quality Improvement Program-Pediatric (NSQIP-Ped) database for children undergoing surgical intervention for Meckel diverticulum between 2011 and 2014 (148 cases) showed that nearly half of all resections for Meckel diverticulum were approached laparoscopically. Outcomes were similar to those with an open laparotomy approach.[51]

Bleeding

  • Definitive treatment is excision of the diverticulum along with segmental resection of the opposing region of the ileum, which often contains bleeding ulceration secondary to secretions from ectopic gastric tissue in the Meckel diverticulum.[3][13][14][18]​​​[24][26]

  • If hemoglobin and hematocrit are significantly decreased, blood transfusion may be required.

Obstruction

  • Definitive treatment is excision of the diverticulum and lysis of any adhesive bands.[3][13][14][18]​​[24][26]

Inflammation and perforation

  • Progression of diverticulitis may lead to perforation and peritonitis.

  • Patients have clinical symptoms and signs similar to those of acute appendicitis. Preoperative CT scans can help to differentiate between appendicitis and diverticulitis. However, if there is diagnostic uncertainty or the patient undergoes an urgent abdominal exploration, examine the appendix initially.

  • In the presence of acute appendicitis, do not carry out an intraoperative search for Meckel diverticulum.[22]

  • If during an operation for abdominal pain a normal appendix is found, inspect the terminal ileum for the presence of an inflamed Meckel diverticulum; if a Meckel diverticulum is found, remove both the Meckel diverticulum and the normal appendix.[22] The surgery depends on the extent of pathology. Simple excision of the diverticulum is appropriate if only the tip of the Meckel diverticulum is inflamed.[3][13][14]​​[24][26] If the pathology is very extensive, a small bowel segmental resection may be required. Simple excision of the diverticulum is usually sufficient if the base alone is inflamed. A normal appendix should generally be removed in this circumstance. 

  • Perioperative adjunctive antibiotic therapy is usually given. Check local protocols and seek advice from microbiology colleagues.

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