Meckel's diverticulectomy: a multi-centre 19-year retrospective study

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Abstract

Background

Methods

Results

Conclusion

Discussion

Meckel's diverticulectomy has been demonstrated to be a safe method in the management of symptomatic MD in both adult and paediatric cohorts.^8, 9 In this cohort, the approach to MD resection was almost equally split between diverticulectomy and small bowel resection (56% vs. 44% respectively), based on surgeon preference, with the majority of Meckel's diverticulectomy performed with stapled resection (86%), utilizing a linear gastrointestinal stapler applied to the diverticulum at its base (Fig. 1), Diverticulectomy in asymptomatic and symptomatic groups demonstrated similar outcomes and safety, even in perforation despite significant differences in MD size. Previously, two case series have demonstrated that short and broad-based diverticula have ectopic tissue present throughout the whole diverticula, with segmental small bowel resection therefore traditionally preferred surgical technique^10, 11 to ensure clearance of all ectopic tissue. However, the results of this study demonstrate greater complication rates in open bowel resection compared to stapled diverticulectomy. In addition to fewer complication rates, our results support the safety of stapled diverticulectomy in the management of both symptomatic and perforated MD, as perforation is most likely at the tip, as observed in our cohort.

The reported incidence of perforation associated with symptomatic MD varies between 0.5% and 12% within the literature,^1, 12 compared to 15% in our study of an adult population. Perforation is commonly secondary to diverticulitis or ulceration and more rarely, trauma from a foreign body. In addition to pathology, acid secreted by ectopic mucosa (most commonly gastric), may pool in single area and cause erosion and bleeding downstream from the point of acid secretion. However, these ectopic tissue nests, present in 29% of our cohort (10%–60% in the literature), are commonly asymptomatic and.^5, 13, 14 Thus, the management of asymptomatic MD would suggest resection due to potential malignant transformation of ectopic heterotopia which are estimated to account for 0.5%–3.2% of complications.^12, 15-17 Comparable to previous reports on incidence, 5% of our cohort were associated with malignancy.¹⁸ Of note, there were no cases of malignancy arising from ectopic mucosa within the ileum within our study cohort. Isolated resection of the MD with stapled diverticulectomy therefore represents a safe oncological approach to resection of MD. While a wedge resection (Fig. 2) may provide the benefit of mucosal visualization to ensure complete excision of ectopic tissue, a laparoscopically stapled diverticulum can be sent for frozen section analysis intraoperatively¹⁹ to assess the base for ectopic or malignant tissue. If the resected diverticulum has only ileal mucosa at the base, simple stapled diverticulectomy should suffice^5, 13, 14 thereby also favourably avoiding the morbidity of open operation and small bowel resection.

Size of MD, in particular the heterogeneously described “long MD”, has been a focus of interest in the management of MD as a risk factor for ectopic tissue distribution with a predominance for tip ectopic tissue described in the literature where length: width ratio is greater than 1.6 or 2.0.^10, 11 This tip predominance was not evident in our cohort at either cut-off ratio, however MD ratio >2 correlated with presence of ectopic tissue but length and width independently did not. Symptomatic patients had a greater incidence of ectopic tissue which supports literature recommendations that all symptomatic patients undergo resection. Furthermore, we propose that intra-operative assessment of a MD size ratio >2, and not MD length assessed in isolation, as a relative indication for resection.

There is ongoing debate surrounding the benefits of prophylactic resection for MD when found incidentally in adults. Numerous studies advocate for the resection of MD found intraoperatively based on the risk of future complications or malignant transformation, while others advocate for a conservative approach given the morbidity associated with resection.^20, 21 MD has been associated with a 4%–9% lifetime risk of complications^13, 20 and a 70-fold risk of malignant transformation compared to any other site in the ileum.¹⁹ In light of this evidence and given the overall low complication rate, this study supports laparoscopic stapled resection of MD found intraoperatively.

Limitations

As this is a retrospective analysis of records, this study was subject to recall bias. Data that was collected was limited to the recorded information at the time of surgery. In turn this resulted in incomplete data as evident in the microscopic perforation sites. Retrospective analysis restricts ability to reliability identify factors contributing to each surgeon's resection choice, thereby limiting our conclusions somewhat. Insufficient number of cases with perforation limited appropriate risk factor analysis of variables outside length: width ratio including age, type of ectopic tissue, presence of malignancy or symptomatic presentation. In addition, by the nature of how the database was queried, cases in which MD was found incidentally at time of operation but not operated on were not included.

Confounding factors of patients undergoing bowel resection including presenting pathology, operative indication and higher perforation rates, must be acknowledged, as the evidence suggests that small bowel resection is associated with increased postoperative morbidity, particularly in regard to wound infection and mechanical obstruction.3

Conclusion

Our study demonstrated Meckel's diverticulectomy is safe compared to small bowel resection with fewer complications and complete resection of ectopic tissue. Despite higher perforation rates in MD with greater length: width ratio, no malignancy or ectopic risk was identified, supporting diverticulectomy as a safe operative approach for complete resection not requiring subsequent re-operation. Confounders of surgeon's resection preference exist, and future prospective studies including long term postoperative outcomes are needed to fully understand the risks and benefits of the surgical approach of MD.