Find best premium and Free Joomla templates at GetJoomlaTemplatesFree.com

Laparoscopic treatment of Meckel's diverticulum in 24 children

JC. Gouli, G. Andrianandraina, D. Forgues, MP. Guibal, N. Kalfa, E. Sabatier-Laval, H. Allal, R. B. Galifer.
Department of Visceral Pediatric Surgery and Pediatric Urology
Lapeyronie Hospital
Montpellier, France

 

 

Correspondence

Dr Gouli Jean-Christian
Department of Visceral Pediatric Surgery and Pediatric Urology
Hôpital Lapeyronie
371 avenue du Doyen Gaston Giraud
34295 Montpellier Cedex 5, France
E-mail: This email address is being protected from spambots. You need JavaScript enabled to view it.
Tel: +33 (0)625 48 23 89

 

Abstract

Background: Laparoscopic assistance is indicated in the management of pediatric abdominal surgical diseases. We report our experience treating Meckel’s diverticulum (MD) in the Department of Visceral Pediatric Surgery of the Montpellier University Hospital.

Patient and method: The records of 24 children hospitalized over a period of 10 years (1997-2007) for lower gastrointestinal bleeding and/or abdominal pain syndrome were reviewed retrospectively. The mean age of the 16 boys and 8 girls was 7.2 years. In 13 cases, MD was diagnosed incidentally during laparoscopy for acute surgical abdomen. All 24 patients underwent laparoscopic-assisted extracorporeal diverticulectomy and intestinal resection. The following preoperative examinations were conducted: ultrasound (n = 24), upper/lower gastrointestinal endoscopy (n = 6). The diagnosis of MD was suspected by ultrasound in 11 cases. In all cases, diverticulectomy with end-to-end anastomosis was performed. All postoperative complications were documented.

Results: The 13 cases of fortuitous discovery presented as acute surgical abdomen. In these cases, the MD was complicated by peritonitis (n = 10; 40%), bowel obstruction (n = 2; 10%) or pseudo-appendicitis syndrome (4%). In 11 other cases, the MD was symptomatic. Six patients presenting massive rectal bleeding with hemoglobin levels below 7g/dl underwent gastroscopy and colonoscopy, without showing the cause of bleeding. Abdominal ultrasound revealed the MD in 11 of the 24 children who had this exam (i.e., 45%). Laparoscopic-assisted extracorporeal resection was performed in all patients: 15 cases (62.5%) by umbilical incision and nine (37.5%) by transverse incision in the right iliac fossa. In our series, resection of the MD plus the involved bowel was performed, with end-to-end anastomosis. Heterotopic gastric mucosa was found in 16 cases (67%). The average length of hospitalization was 7 days. We noted acute pancreatitis as a complication in one patient.

Conclusion: Extracorporeal diverticulectomy with resection of involved bowel is the procedure of choice because it ensures the radical excision of ectopic gastric mucosa. When assisted by laparoscopy, it is safer and less invasive than conventional surgery. Laparoscopy has many advantages, including reduced postoperative pain and more esthetic result.

Key words: Meckel’s diverticulum, extracorporeal diverticulectomy, laparoscopy, child

 

 

Introduction

Meckel’s diverticulum (MD), named after Johann Friedrich Meckel (1781-1833), is a common congenital abnormality of the small intestine found in approximately 4% of the general population [1, 5]. It indicates the incomplete obliteration of the vitelline duct in the fifth month of gestation. It may be totally asymptomatic and symptoms range from non-specific painful phenomena to acute complications, the most typical in children being intestinal obstruction due to intussusception or a mesodiverticular band and rectal bleeding. However when it is discovered, the treatment remains radical diverticulectomy, with resection of the involved bowel to ensure complete removal of ectopic gastric mucosa [13].

The preoperative diagnosis of MD is difficult; both diagnosis and treatment have greatly benefited from laparoscopic surgery, which has several advantages over open surgery in children. The purpose of this study is to report our experience of laparoscopic management of MD in the child.

Patient and method

Twenty-four children were hospitalized for MD in the Department of Visceral Surgery and Pediatric Urology, University Hospital of Montpellier, France, over a period of 10 years ( from January 1997 to December 2007). Their records were reviewed retrospectively. The children were hospitalized for gastrointestinal bleeding and/or acute abdominal pain syndrome.

All underwent clinical examination, routine laboratory tests (blood count, C-reactive protein, coagulation tests, etc.) and systematic abdominal ultrasound by an experienced pediatric radiologist, even in emergency situations. Patients with massive rectal bleeding (hemoglobin below 7g/dl) underwent additional gastroscopy and colonoscopy. All children were admitted to the hospital mostly on emergency basis, depending on the symptoms severity and the presence of acute surgical abdomen and were operated on with an identical protocol: diagnostic laparoscopy to explore or confirm a suspected MD followed by extracorporeal resection of the MD and the involved bowel by externalization through the umbilical trocar or a small incision in the right iliac fossa.

The operative technique was the following: a 5- or 7-mm optical device was introduced into the abdominal cavity through an arciform incision using the “open laparoscopy” technique; the pneumoperitoneal pressure ranged from 8 to 12 mm Hg, depending on the size of the child. Two 3- or 5-mm working ports were inserted in the right iliac fossa and the left flank. The search for an MD requires meticulous exploration along the entire length of the small intestine, and repeated examination may be necessary. Once an MD was located, it was externalized through an incision above the umbilicus or sometimes through the trocar aperture in the right iliac fossa, slightly enlarged via a Mc Burney-type mini-laparotomy.

In the event of intussusception, volvulus or intestinal obstruction due to a mesodiverticular band, specific treatment preceded the diverticulectomy. Once the MD and the bowel were externalized, they were resected in one piece with immediate restoration of intestinal continuity by an end-to-end anastomosis. The anastomosed intestine was then replaced into the abdomen and the peritoneal cavity was washed to complete the procedure. All the children received preoperative and postoperative antibiotics. In cases of peritonitis, three antibiotics were used in combination (beta-lactams, aminoglycosides and metronidazole) for 7 to 10 days and single perioperative antibiotic was used in other cases. Antacids combined with analgesics were administered to patients for 5 days postoperatively. The average length of hospitalization was 7 days (range: 5 to 10 days). Patients were seen in follow-up at 1 month, 6 months and 1 year after surgery.

Results

This series included 16 boys and 8 girls with a mean age of 7.2 years (range: 6 months to 13 years). The clinical and paraclinical data, with histological findings are summarized in Table 1. Eleven patients (46%) presented with rectal bleeding, and the six who presented with massive bleeding and a hemoglobin level below 7 g/dl also underwent gastroscopy and colonoscopy, which ruled out an etiology in the supra- or inframesocolic compartment. Clinical findings of peritonitis and acute intestinal obstruction were observed in ten (42%) and two (8%) children, respectively. In almost half of the cases (45%), preoperative abdominal ultrasound detected the MD.

In one case, clinical examination and ultrasound was suggestive of acute appendicitis, which was found to be an MD during surgery. A case of ileal duplication located 3 cm from the MD was diagnosed by ultrasound. All patients underwent exploratory laparoscopy, which revealed or confirmed the MD. Extracorporeal diverticulectomy was performed in 15 cases through a supraumbilical incision (62.5%) and in 9 through the widened trocar aperture in the right iliac fossa. In all cases, both the MD and the involved bowel were resected and an end-to-end anastomosis was performed. The patient with ileal duplication had both anomalies resected in one piece. Moreover, a mesodiverticular band was resected in two cases (8%) and extensive peritoneal washing was carried out in cases of associated peritonitis.

One patient presented acute clinical and biological pancreatitis (amylase: 115 mol/l and lipase: 212 mol/l) on the fourth postoperative day, with a normal findings on abdominal ultrasound. This complication was resolved on the seventh day after cessation of antacids (Azantac®). Histological analysis of the resected specimens confirmed heterotopic gastric mucosa in 16 cases (67%), 11 of which were revealed by rectal bleeding and five by peritonitis. Ileal mucosa was found in seven surgical specimens (29%) and heterotopic gastric mucosa and pancreatic tissue were associated in one case (4%). At an average follow-up of 6 months, no complications or late sequelae were noted.

Table 1: Pre- and postoperative characteristics of patients presenting MD

Parameters

Number of patients (n = 24)

Percentages (%)

Symptoms

Rectal bleeding

Pseudo-appendicitis

Peritonitis

Intestinal obstruction

11

1

10

2

46

4

42

8

Abdominal ultrasound

MD* seen

MD not seen

11

13

46

54

Associated bowel lesions

and externalization of MD

Intestinal duplication

Laparoscopy + Mc Burney

Laparoscopy + supraumbilical

1

9

15

4

37,5

62,5

Complications

Without

Postoperative pancreatitis

23

1

96

4

Histology

Gastric heterotopia

Ileal mucosa

Gastric heteropia + pancreatic tissue

16

7

1

67

29

4

*MD= Meckel’s diverticulum 

Discussion

MD is the most common congenital abnormality of the small intestine, with a reported incidence of between 1 and 4% of the general population [3, 9, 13]. In our department, we see an average of 2.4 cases per year. The preoperative diagnosis of MD is difficult because the clinical symptoms are heterogeneous and non-specific. Although full consensus is lacking, lower gastrointestinal bleeding is generally assumed to be the most evocative sign [7, 9] and it was the major diagnostic sign (46%) in our series.

Moreover, investigations and clinical evaluation were not particularly informative, except perhaps the ultrasound. Technetium 99m (99mTc) scintigraphy originally seemed promising for diagnosing MD because it is a sensitive tool for detecting intestinal tract bleeding, but its specificity is low (bleeding may be detected but the origin may not be the MD) and it gives unacceptable high false-positive results [11]. Gastrointestinal endoscopy (gastroscopy and colonoscopy) cannot diagnose MD, but it is essential for identifying the origin of bleeding in the absence of obvious gastroduodenal or colonic causes. Conventional imaging cannot currently provide a reliable diagnosis of this pathology. Ultrasound performed by an experienced pediatric radiologist should be the gold standard, but in our study this method was able to confirm the diagnosis of MD in only half the cases (45%). Baldisserotto et al. [3] noted the utility of ultrasound in the diagnosis of MD, but concluded it was not sufficiently reliable because of the high number of false negatives and false positives. According to Veyrac [16], severe isolated rectal bleeding in the child should raise the suspicion of MD and ultrasound examination is indicated.

This technique has a sensitivity of 85%, a specificity of 95% and an accuracy of 90% in the diagnosis of MD in cases of rectal bleeding in children [16]. In this context, laparoscopy appears to be an excellent means of diagnostic confirmation and treatment. Laparoscopic treatment of MD was originally described by Attwood et al. [2] as a true diverticulectomy, with a staple applied transversely at the base of the MD. The consensus today is that resection along with the adjacent bowel is needed to avoid leaving behind ectopic mucosal tissue [8, 9, 12, 13, 15]. In our study, externalization of the MD and the adjacent bowel through the supraumbilical incision was preferred (15 cases) to that of the trocar orifice of the right iliac fossa (9 cases) because it gave a more esthetic result and did not require muscle splitting. The histological analysis of the surgical specimens showed heterotopic gastric mucosa in 67% of the cases.

This rate seems to be halfway between the extreme levels found in the literature: 44-45% for Artigas et al. [1] and Shalaby et al. [13] and 85.7% and 100% for Prasard Sai et al. [12] and Chiengkrwate et al. [4], respectively. As noted by other authors [6, 14], histology showed normal ileal mucosa in seven cases and pancreatic tissue in one case. The postoperative acute pancreatitis we observed may have been a side effect of ranitidin (Azantac), which is routinely administered to reduce postoperative stress [10]. In contrast to some authors who performed either conventional surgery [9] or laparoscopic surgery [12], we observed no intestinal adhesions at an average follow-up of 6 months.

Conclusion

Our study has shown that laparoscopy can confirm the diagnosis of MD and permits radical extracorporeal treatment (surgery and intestinal segmental resection), as well as other necessary gestures or procedures (mesodiverticular band resection and peritoneal washing), with the same level of safety, lower morbidity and greater cosmetic result than conventional surgery.

 

 

 

REFERENCES 

  1. Artigas V, Calabuig R, Badia F, Puis X, Allende L, Jouer J. Meckel’s diverticulum: value of ectopic tissue. Am J Surg 1986; 151: 631-634
  2. Attwood SE, McGrath J, Hill AD, Stephens RB. Laparoscopic approach to Meckel’s diverticulectomy. Br J Surg 1992; 79: 211
  3. Baldisserotto M, Maffazzoni DR, Dora MD. Sonographic finding of Meckel’s diverticulitis in children. AJR 2003; 180: 425-428
  4. Chiengkrwate P, Patracpimyokul S, Sangkhathat S, Chowchuvech V. Circumumbilicus incision for bleeding Meckel’s diveticulectomy. J Med Assoc Thai 2007; 90: 931-935
  5. Gluecklich B. Johann Friedruch Meckel, the younger (1781-1833). Am J Surg 1976; 132: 384-6
  6. Huang CS, Lin LH. Laparoscopic Meckel’s diverticulectomy in infants: report of three cases. J Pediatr Surg 1993; 28: 1486-1489
  7. Lüdtke FE, Mende V, Kohler H, Lepsien G. Incidence of frequency on complications and management of Meckel’s diverticulum. Surg Gynecol Obstet 1989; 6: 537-42
  8. Mukaï M, Takawatsu H, Noguchi H, Fukushige T, Tahara H, Kaji T. Does the external appearence of a Meckel’s diverticulum assist in choice of the laparoscopic procedure? Pediatr Surg Int 2002; 18: 231- 233
  9. Onen A, Cigdem MK, Oztürk H, Otçu S, Dokucu AI. When to resect and when not to resect an asymptomatic Meckel’s diverticulum: an ongoing challenge. Pediatr Surg Int 2003; 19: 57-61
  10. Reynolds KS, Song MH, Heizer WD, Burns CB, Sica DA, Brouwer KLR. Effect of pancreatico-biliary secretions and GI transit time on the absorption and pharmacokinetic profile of ranitidine in humans. Pharmaceutical Research, 1998; 8: 1281-85
  11. Rossi P, Gourtsoyiannis N, Bezzi M et al. Meckel’s diverticulum: Imaging diagnosis. AJR 1996; 166: 567-573
  12. Sai Prasard TR, Chui CH, Singorewalla FR, Caroline Ong CP, Loow Y, Yap TL, Jacpbsen AS. Meckel’s diverticular complications in children: is laparoscopy the order of the day? Pediatr Surg Int 2007; 23: 241-247
  13. Shalaby RY, Soliam SM, Fawy M, Samaha A. Laparoscopic management of Meckel’s diverticulum in children. J Pediatr Surg 2005; 40: 562-567
  14. Teitelbaum DH, Poley TZ Jr, Obeid F. Laparoscopic diagnosis and excision of Meckel’s diverticulum. J Pediatr Surg 1994; 29: 495-497
  15. Varcoe RL, Wong SW, Taylor CF, Neustead GL. Diverticulectomy is inadequate treatment for short Meckel’s diverticulum with heterotopic mucosa. Anz J Surg 2004; 74: 869-872
  16. Veyrac C. Abnormalities of the omphalomesenteric duct. In: Baert AL, Knauth M, Sartor K, eds., Gastrointestinal tract ultrasound in fetuses and children. Berlin: Heidelberg-Springer 2008: 481-509