Perforated Meckel's diverticulum containing a carcinoid tumor successfully treated by the laparoscopic approach: Case report.

Mekel's diverticulum is a gastrointestinal malformation. Occurs in one of every 40 patients. It is usually asymptomatic whereas complications can be developed in 2% to 4%. The report is based on a 41-year old male, who attended to emergency, complaining of right lower quadrant abdominal pain. Blood tests showed high level of inflammatory markers. With acute appendicitis as presumptive diagnosis, laparoscopy was performed. The intraoperative findings were: a perforated Mekel's diverticulum with normal cecal appendix. Mechanical diverticular resection was made. The patient was successfully recovered from surgery. Histopathology examination showed: Meckel's diverticulum perforated with acute inflammation and neuroendocrine tumor (G1) pT1. Mekel's diverticulum is rarely affected by inflammatory complications and just few cases are associated with tumors. However, has ever been described before, coexisting both situations, being our patient the first reported with this exceptional clinical presentation, and treated successfully by laparoscopic approach.

The acute peritonitis is shown as a complication of Meckel's diverticulum (MD). Perforation is observed at the upper portion.

The images are based on a 41-year-old male, who consulted to the emergency room with a history of abdominal pain, localised at the right lower quadrant. On physical examination, he had a normal vital signs lecture, with rebound tenderness at her lower right abdominal quadrant, especially in McBurney's point. Blood tests revealed C-reactive protein (CRP) of 154 with a high white blood cell count.

With acute appendicitis as presumptive diagnosis, laparoscopic surgery was performed with a periumbilical trocar of 10 mm width and a second one of 5 mm width. The first trocar was at the left flank and the other one at the suprapubic region. As intraoperative findings, we had an extensive purulent peritonitis, with normal cecal appendix features and a perforated MD with inflammatory signs at its base [Figure 1].

Figure 1

Intraoperative finding of Meckel's diverticulum

The intervention started with aspiration of the pus of the entire peritoneal cavity, and profuse washes after that. The MD dissection was performed, in addition, mechanical resection was done with a 60 mm Endo GIA Articulating Medium/Thick (AMT). The patient was successfully recovered from the surgery, and was discharged 5 days later, and he did not refer to abdominal pain or other symptoms until this day. Histopathological examination showed: MD with acute transmural inflammation and perforation, coexisting with neuroendocrine tumor (G1), measuring 1.1 mm, affecting until submucous tissue (pT1), positive results of chromogranin and synaptophysin, Ki-67 <1% with no neoplasic findings at the margin [Figure 2].

Figure 2

Histopathology examination. Left side: Positive results of chromogranin suggesting neuroendocrine tumor. Right side: Histopathology examination of Meckel's diverticulum showing acute transmural inflammation, coexisting with neuroendocrine tumor (G1), which affects until submucosal tissue, without mitosis and with no neoplasic findings at the margin

MD is the most common congenital disease of the gastrointestinal tract. The clinical presentation may be asymptomatic, being accidentally found while other abdominal pathologies are treated by surgery.[1] Less frequently, it is accompanied for non-specific symptoms or complications as: Mechanical, caused by bowel intussusception, bleeding, generally associated with the presence of ectopic gastric mucosa and the last one, the inflammatory complication that appears with perforation and is most of the time indistinguishable from acute appendicitis.[2]

In some cases, MD can additionally accommodate several types of tumors such as: Carcinoid tumors, adenocarcinomas, gastrointestinal stromal tumors (GIST) and lymphomas. Therefore, as in the presented case, the coexisting inflammatory complications, such as perforation and acute peritonitis, with a carcinoid tumor in an adult patient, is an exceptional clinical presentation, our patient being the first to be reported with both these situations. After laparoscopic diagnosis and treatment, the histological result obtained, confirmed the diagnosis above, besides clinical improvement and good postoperative evolution.[3]

As for any rare case, we consider it a new data, to bear in mind when making a differential diagnosis in adult patients, who present a compatible clinical scenario.

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Conflicts of Interest

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