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Meckel diverticulum: "too" much chatter?

Although an uncommon intraoperative finding, Meckel diverticulum garners substantial attention in the medical literature. A quick PubMed search for Meckel diverticulum yields nearly 3,000 entries since 1951 for the disease governed by the "rule of twos." We remember Meckel diverticulum for its association with the number two: 2% of the population is affected, men afflicted twice as often as women, frequently identified in persons under 2 years of age, and located 2 feet from the ileocecal valve. In addition, Meckel diverticulum routinely enters the differential diagnosis of patients that have intestinal obstruction, right lower quadrant inflammation, and acute gastrointestinal bleeding. This seems straightforward, right?

Not so. A closer look at the journal titles for the entries in PubMed explains why this seemingly small accessory organ attracts so much attention. Meckel diverticulum is also described in association with inguinal (Littre hernia) and Spigelian hernias, intussusception, inversion resulting in acute and chronic gastro-intestinal blood loss, carcinoid and other rare tumors, and nesidioblastosis to name a few unusual affiliations. Thus, the odd clinical presentations of Meckel diverticula are impetus enough for the abundant discussion in the literature.

In this issue of the Southern Medical Journal, a ten-year experience with Meckel diverticula in 47 adults is presented. (1) Two-thirds of the patients in this study were women, largely because asymptomatic diverticula were removed during the course of gynecologic surgery. Male patients were more likely to be symptomatic (50%) than were females (13%), and six patients had heterotopic, primarily gastric, mucosa. Two patients had Meckel diverticula associated with neoplasia. Three patients (6.4%) developed complications as a result of surgical removal, one wound infection and two suture-line leaks. The authors concluded that symptoms arising from a Meckel diverticulum are rare, the complication rate from surgical removal is low but meaningful, and that these intestinal diverticula should not be removed incidentally during the course of abdominal surgery.

How do these findings stack up with other medical literature? Interestingly, as the authors correctly point out, for all that is written about Meckel diverticulum, little information about the natural history of this entity exists. I, and others, (2) refer to the article by Cullen et al (3) as the best source of information about the management of Meckel diverticulum. In a population-based study, in which nearly 100% of patients received their care in two health care systems in Olmsted County, Minnesota, they found that the risk of complications was 87 per 100,000 person-years with a lifetime risk of 6.4%. Contrary to other studies, the risk did not diminish with age, but, true to form, men had a higher risk of complications than women. Patients that presented with a complication from a Meckel diverticulum and underwent surgery had mortality, morbidity, and long-term complication rates of 2%, 12%, and 7%, whereas patients that had an incidental diverticulectomy had corresponding rates of 1%, 2%, and 2%, respectively. Therefore, Cullen et al recommended removal of Meckel diverticula regardless of age.

Why do these two studies offer conflicting conclusions? First, the patient population in the current study is select, and many incidental diverticulectomies were performed in women undergoing pelvic operations. Several studies suggest that women have a lower likelihood of complications from Meckel diverticula, making even a modest surgical complication rate of just over 6% appear unjustified. In addition, because Meckel diverticula were removed rather than followed over the long-term, we are left wondering what happens to patients with a Meckel diverticulum left in situ? Nonetheless, this study demonstrates several important teaching points about Meckel diverticula. First, patients do develop symptoms of obstruction, inflammation, and bleeding and require surgical treatment. Also, a small percentage of patients have neoplasia associated with Meckel diverticulum.

Meckel diverticulum is uncommon in-and-of-itself, but it is associated with unusual complications and presents a life-time risk, and therefore, should be removed incidentally. The authors of the current article and the editors of SMJ should be congratulated for continuing to update the medical community on a topic that, because of its protean clinical presentation, cannot receive "too" much attention.

Accepted February 26, 2004.

Please see "Meckel Diverticulum: Ten-year Experience in Adults" on page 1038 of this issue.

References

1. Stone PA, Hofeldt MJ, Campbell JE, et al. Meckel Diverticulum: ten-year experience in adults. South Med J 2004;97:1038-1041.

2. Yahchouchy EK, Marano AF, Etienne J-CF, et al. Meckel's diverticulum. J Am Coll Surg 2001;192:658-662.

3. Cullen JJ, Kelly KA, Moir CR, et al. Ann Surg 1994;220:564-568.

Kevin E. Behrns, MD

From the Center for Pancreatic and Biliary Disorders, Division of Gastro-intestinal Surgery, Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC.

Reprint requests to Kevin E. Behrns, Associate Professor of Surgery, Co-Director, Center for Pancreatic and Biliary Disorders, Division of Gastrointestinal Surgery, Department of Surgery, CB# 7081 Medical Wing E, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-7081. E-mail: kevin_behrns@med.unc.edu
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Title Annotation:Editorial
Author:Behrns, Kevin E.
Publication:Southern Medical Journal
Geographic Code:1USA
Date:Nov 1, 2004
Words:818
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