Surgically inverting an incidentally detected Meckel's diverticulum - Wrong method.

INTRODUCTION: Intusussception leading to intestinal obstruction is a known complication of Meckel's diverticulum. Inverting of Meckel's acts as a lead point for intussusception. Causes of inversion are many but surgical inversion leading to intusussception is extremely rare. PRESENTATION OF CASE: We hereby report a case of a 14 year adolescent boy operated previously for open appendicetomy presenting to us with intestinal obstruction who on exploration was found to have an surgically inverted Meckel's diverticulum acting as a lead point for ileo-colic intusussception. DISCUSSION: To the best of our knowledge, surgically inverting any Meckel's diverticulum is never a treatment option even when the diverticulum is incidentally detected. Diverticulectomy or segmental resection is the procedure of choice for Meckel's diverticulum.
CONCLUSION: Meckel's divereticulum should never be inverted surgically. Not only it is a wrong method but also increases the risk of complications.

Introduction

Meckel's diverticulum accounts for 90% of all omphalo-mesenteric (vitelline) duct anomalies and is the most common congenital abnormality of the gastrointestinal tract. It is reported to occur in 1–3% of the general population and autopsy series. However, the lifetime risk of developing complications in patients with Meckel's diverticulum is believed to be less than 5%. These complications included intestinal obstruction, intussusception, inflammation, perforation and bleeding.

Infrequently, Meckel's diverticulum can invert and invaginate into the ileal lumen and can be the leading point of the intussusception (Figs. 1 and 2).

The incidence of intussusception attributed to an inversion of Meckel's diverticulum accounts for 4% of all cases presenting with intestinal obstruction due to intussusception.

It occurs when the Meckel's diverticulum sags into the bowel lumen and then serves as a lead point to allow telescoping of the small intestine, first into the distal ileum and then in to the large intestine, causing ileo-ileal and ileo-colic type of intussusceptions.

We hereby report a case where surgical inversion was done as a treatment for Meckel's diverticulum which lead to intussusception and intestinal obstruction.

Case report

A 14-year-old boy presented with colicky abdominal pain and distention of abdomen with bilious vomiting. He had undergone open appendicectomy through McBurney's incision 5 days back at a peripheral rural setup.

On presentation he had tachycardia and fever. Abdomen was distended and tenderness was present all over. Bowel movements were hyper peristaltic and per rectal ballooning was present.

Erect abdominal X-ray showed dilated small bowel loops with multiple air fluid levels. Ultrasonography of abdomen showed multiple fluid filled dilated small bowel loops suggestive of small bowel obstruction. His hematological investigations were within normal limits.

Naso-gastric decompression was done and he was started on IV fluids, anti-spasmodics and antibiotics. He was explored in view of presence of persistent signs of small bowel obstruction.

Midline laparotomy incision was taken and ileo-colic intussusceptions were identified as the cause of small bowel obstruction. Intussusceptions could be reduced and surgically inverted Meckel's diverticulum (done probably at the time of open appendicectomy) was identified as the lead point for intussusception. At about 50 cm from IC junction non-absorbable silk sutures were identified which were invaginating 2 cm × 1 cm of Meckel's diverticulum into the ileal lumen. As rest of the bowel was viable and healthy, segmental resection of Meckel's diverticulum with ileo-ileal anastomosis was done. Patient recovered well in the post-operative period. Histopoathology confirmed the diagnosis of Meckel's diverticulum.

Discussion

In children less than 3 years, lead points for 90–95% of the intussusceptions are idiopathic. Where as Meckel's diverticulum is the most common cause of non-idiopathic intussusception, especially in older children. There are various mechanisms by which it can cause intestinal obstruction like (a) Volvulus of small intestine around a fibrous band extending from Meckel′s diverticulum to umbilicus. (b) Intussusception – in which Meckel's diverticulum sags into the bowel lumen and then serves as a lead point to allow telescoping of the small intestine into first the distal ileum and then in to the large intestine causing ileo-ileal and ileocolic type of intussusception. (c) Littre′s hernia – incarceration of the diverticulum in hernia, (inguinal or femoral) causing intestinal obstruction. (d) Entrapment of small bowel beneath the blood supply of the diverticulum, also known as a meso-diverticular band. (e) Stricture secondary to chronic diverticulitis. (f) Meckel′s diverticulum lithiasis. (g) Band extending between the diverticulum and the base of the mesentery, forming a loop in which a part of ileum may get stuck causing obstruction.

Symptoms caused by Meckel's diverticulum are abdominal pain, malena and vomiting.

More often patients present with features of small bowel obstruction. Radiological investigations help diagnose the case and Ultrasonography shows classical appearance of ‘target’ or ‘doughnut sign’. CECT abdomen is the most sensitive imaging modality with reported accuracy of 58–100% and it characteristically shows the inverted diverticulum as a central core of fat attenuation surrounded by a collar of multiple concentric rings of soft-tissue attenuation.

Treatment of Meckel's diverticulum depends on the location of diverticulum and the progression and the severity of the disease. Simple diverticulectomy or segmental resection is preferred since the malignancy rate is low (17%). Diverticulectomy is predicted as a simple, minimal and cost effective technique which can resolve the disease.

Resection with anastomosis is clearly indicated in cases of inflammation and ischemia of ileum and is also recommended in oedematous, inflamed or perforated base of Meckel's diverticulum. Laparoscopy represents an alternative method of treatment with techniques varied from segmental resection of Meckel's diverticulum to reduction of intussusception, diverticulectomy and intracorporeal anastomosis.

In asymptomatic or incidentally detected Meckel's diverticulum, it is advocated that prophylactic resection of the diverticulum be done when it has an umbilical connection, mesodiverticular band or is heterogeneous on palpation and there is no contraindication for diverticulectomy. Literature does not support surgically inverting a Meckel's diverticulum as a treatment modality.

Conclusion

Thus we conclude, there is no role for surgical inversion of diverticulum even in patients with incidentally detected Meckel's diverticulum.

Conflict of interest

None.

Funding

Nil.

Ethical approval

Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Surgically inverting Meckel's diverticulum is not a treatment option.

Instead of curing it predisposes to further complications.