Diverticulectomy is inadequate treatment for short Meckel's diverticulum with heterotopic mucosa

Abstract

Background: Meckel's diverticulum is a vestigial remnant of the vitellointestinal duct that may occasionally contain heterotopic gastric mucosa thought to arise from residual yolk sac cells. This may cause significant rectal bleeding, the source of which may be difficult to identify. The present paper addresses the question of whether the choice of resection technique should depend on the macroscopic appearance of the Meckel's diverticulum.

Methods: A retrospective analysis of patients with resected Meckel's diverticulum at Prince of Wales and Sydney Children's Hospitals between 1992 and May 2003 was performed. The external appearance was expressed as a height-to-diameter ratio (HDR) and the presence or absence of macroscopic thickening was recorded. The morphology was then correlated with the presence and site of the heterotopic gastric mucosa (HGM).

Results: Seventy-seven patients were identified with an age range between 1 day and 92 years. Fifty-seven (74%) of the patients were men. Presenting symptoms were gastrointestinal bleeding (11.7%), diverticulitis (15.6%), volvulus (2.6%), intussusception (10%) and umbilical fistula (7.8%). Fifty-seven per cent of the resected Meckel's diverticulae were found incidentally. Eight patients underwent a technetium pertechnate nuclear Meckel's scan. The Meckel's scan detected only two of seven patients with HGM on pathological examination. Twenty-nine (38%) patients underwent diverticulectomy and 48 (62%) small bowel resection. Ectopic mucosa was found in 25 (32.5%) patients. Of the Meckel's diverticula that were defined as long (HDR >or=2.0) and containing HGM, five of five (100%) had the ectopic mucosa in the diverticular tip and body only. Of those that were short (HDR <2.0) there was a wide distribution of HGM sites with 12 (60%) involving the whole diverticulum including the base and eight (40%) involving the tip and body only. The presence or absence of macroscopic thickening was described in 18 resected Meckel's diverticula. Thirteen (72%) were described as thickened in the operation report and six of these 13 (46%) were found to have HGM. One of the seven (14%) Meckel's diverticulae with HGM was thought to be of normal appearance and was therefore undetected.

Conclusion: Simple transverse resection is not recommended for the short Meckel's diverticulum. A HDR of 2.0 is recommended as the cut-off when deciding on the most appropriate operation. The external appearance of the Meckel's diverticulum does not predict the presence of HGM and is therefore an unreliable indicator to aid resection decisions when presented with an incidental Meckel's diverticulum.