Journal of Pediatric Surgery xxx (2017) xxx–xxx

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Journal of Pediatric Surgery

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Multifaceted behavior of Meckel's diverticulum in children

Qingjiang Chen, Zhigang Gao, Lifeng Zhang, Yuebin Zhang, Tao Pan, Duote Cai, Qixing Xiong,
Qiang Shu, Yunzhong Qian ⁎
Department of pediatric general surgery, Children's Hospital, Zhejiang University School of Medicine, No. 57 Zhugan Street, Xiacheng District, Hangzhou, P.R. China 310000

a r t i c l e i n f o a b s t r a c t

Article history: Purpose/background: Meckel's diverticulum (MD) is one of the most common congenital malformations of gas-
Received 16 April 2017 trointestinal tract in children. However, the nonspecific clinical manifestations of MD often cause a diagnostic
Received in revised form 20 November 2017 as well as therapeutic challenge to pediatric surgeon. This study aimed to review our experience in managing
Accepted 27 November 2017 this disease while evaluating the management strategies.
Available online xxxx
Methods: We retrospectively analyzed the clinical data of all patients diagnosed with MD admitted to our center
between January 2010 and December 2015. Factors documented including demographic criteria, clinical mani-
Key words:
Meckel's diverticulum
festations, preoperative examinations, surgical methods, histopathological characteristics, postoperative compli-
Children cations, and outcomes.
Diagnosis and treatment Results: The patients included 210 males and 76 females, aged from 1 day to 15 years. In fifty three patients, the
Gastrointestinal hemorrhage MD was an incidental finding at laparotomy or laparoscopy. The remaining 233 patients were symptomatic and
Laparoscopy presented with various clinical features. Ninety nine patients presented with episodes of bleeding per rectum or
melena. Fifty six patients demonstrated symptoms of diverticulitis or perforated MD. Forty patients were diag-
nosed as intestinal obstruction, and 35 patients with intussusception requiring surgical reduction. Two cases of
Littre hernia and one case of foreign body trapped in MD were also observed in this group. Six patients
misdiagnosed as appendicitis at another institution were reoperated in our department. Among the 99 patients
with bleeding per rectum, 78 underwent a Tc-99m scan that showed a positive tracer in 55 patients and negative
in 23. All patients underwent resection of the diverticulum, except for 2 cases of postponed resection. Histology
revealed ectopic gastric mucosa or ectopic pancreatic tissue in 154 patients; significant differences were ob-
served between the symptomatic group and the accidentally found group. One patient died of peritonitis and
sepsis postoperatively; one case of anastomotic leak and one case of adhesive intestinal obstruction were
reoperated.
Conclusion: Meckel's diverticulum has various clinical presentations and it is difficult to make a precise diagnosis
preoperatively. It is necessary to maintain a high suspicion of MD in the pediatric age group with symptoms of
abdominal pain, gastrointestinal hemorrhage or intestinal obstruction. Heterotopic tissue is the main cause of
complicated diverticulum, and it is safe and feasible to remove the incidentally found MD. Laparoscopy should
become the first choice of methods in diagnosis and treatment of MD.
Type of study: Treatment study.
Level of evidence: Level IV.
© 2017 Published by Elsevier Inc.

Meckel's diverticulum (MD) is one of the most common congenital
gastrointestinal malformations in children, occurring in 2% to 4% of the
population [1,2]. It develops as a result of incompletely obliterated vitel-
line duct or omphalomesenteric duct around the 5th to 7th weeks of
gestation [3]. A wide spectrum of anomalies may result depending on
the stage of arrest of this normal involution, including intestinal–
umbilical fistulas, MD, omphalomesenteric cyst, mesodiverticular
bands, umbilical sinus and umbilical polyp. MD is the most frequent en-
tity of these potential anomalies. Microscopic histopathology reveals
⁎ Corresponding author. Tel.: +86 571 88873641; fax: +86 571 87033296.
E-mail address: qianyunzhong@zju.edu.cn (Y. Qian).
the remnant of the omphalomesenteric duct contains heterotopic mu-
cosa in 45%–80% of surgical specimens, mainly gastric mucosa, and
sometimes pancreatic tissues or colonic mucosa [3–6]. The abnormal
mucosa lines the greater part of the proximal end of the pouch and
sometimes extends for a short distance into the nearby ileum. It is there-
fore vulnerable to bleeding, infection and obstruction.
The majorities of patients with MD are clinically silent and often
identified incidentally by abdominal exploration [3,7]. However, still
considerable MD accounts for diverse clinical processes, including pain-
less rectal bleeding, acute abdominal pain and small bowel obstruction,
occurs more commonly in children than adults [8]. Although rare, the
complications of MD can cause extremely serious consequences such

https://doi.org/10.1016/j.jpedsurg.2017.11.059
0022-3468/© 2017 Published by Elsevier Inc.

Please cite this article as: Chen Q, et al, Multifaceted behavior of Meckel's diverticulum in children, J Pediatr Surg (2017), https://doi.org/10.1016/
j.jpedsurg.2017.11.059
2 Q. Chen et al. / Journal of Pediatric Surgery xxx (2017) xxx–xxx

as mechanical obstruction, intestinal perforation and shock [9]. Thus Table 2

prompt diagnosis and proper treatment are critical in warranting a bet- Associated disease of MD during abdominal exploration.

ter outcome of MD. Unfortunately, MD has varied clinical manifesta- Associated disease b 1 year 1–3 years 3–15 years
tions for different individuals, such as recurrent vague abdominal pain, (n = 33) (n = 6) (n = 14)
abdominal distention, painless lower gastrointestinal bleeding, nausea Alimentary tract duplication 1 1
and vomiting. These nonspecific presentations are usually confused Annular pancreas 3
with those of appendicitis, inflammatory bowel disease and other clini- Anorectal malformation 3 1
Appendicitis 1 11
cal scenarios. Traditional diagnostic methods, such as conventional ab-
Choledochocyst 1 2
dominal radiography, abdominal ultrasonography, computed Colitis gravis 1
tomography (CT) or scintigraphy with Tc-99m pertechnetate often pro- Colonic perforation 1
duce false-negative or false-positive result [3,5,10]. It is difficult to pro- Foreign body ingestion 1
spectively diagnose a Meckel's diverticulum, and it presents quite a Gastric perforation 1
Hirschsprung's disease 4 1
diagnostic as well as a therapeutic challenge to the pediatrician and pe-
Inguinal hernia 1
diatric surgeon. Intestinal atresia 6
In order to provide more useful information to pediatricians for early Malrotation 2
diagnosis and treatment, this study investigated the clinical characteris- Meconium peritonitis 1
Mesenteric cyst 1 2
tics of MD with different manifestations in the pediatric population and
Mesenteric hiatal hernia 1
shared our experience in managing this condition during recent six years. Necrotizing enterocolitis 1
Omphalocele 5
1. Methods

A retrospective study of pediatric patients with a diagnosis of MD
admitted to The Children's Hospital Zhejiang University School of Med-
icine between January 2010 and December 2015 was conducted. We re-
corded the data of demographic characteristics, clinical manifestations,
associated anomalies, details of preoperative examination, surgical pro-
cedure performed, intraoperative and histological findings, short- and
midterm complications, and final outcomes. The follow-up period
ranged from 6 months to 5 years. Informed consent was obtained
from each patient according to the research proposals approved by
the local ethics committee of Zhejiang University.
All data were processed using descriptive statistical procedures for
calculating means, standard deviations, frequencies, and percentages.
Statistical analysis was completed using the Statistical Program for So-
cial Sciences (SPSS, version 19.0, Chicago, IL) to perform analysis of var-
iance (ANOVA) or the chi-square tests; P b 0.05 was considered to be
statistically significant.
2. Results
Between January 2010 and December 2015, a total of 286 children
(210 boys and 76 girls) were diagnosed with Meckel's diverticulum in
our department. The patients' age range from 1 day to 15 years (median
2.75 years), with 75 cases less than 1 year, 71 cases aged between 1 and
3 years, and 140 cases aged 3 to 15 years (Table 1).
Among the entire cohort, 53 cases (18.53%) of MD were an inciden-
tal finding during abdominal exploration (Table 2), mainly occurring in
the first year of life (62.26%). The remaining 233 patients were symp-
tomatic and presented with various clinical features (Table 3). Ninety
nine patients presented with episodes of bleeding per rectum or
melena, without abdominal pain in most cases, and their hemoglobin
level was dramatically decreased (means, 77.16 ± 15.96 g/L vs
127.13 ± 27.71 g/L) and was significantly different from other groups
(F = 264.27, P b 0.001). Fifty six patients with abdominal pain and
Table 1
Various clinical presentations distributed in different age groups..
b1 year 1–3 years
(75 cases) (71 cases)
Incidental finding 33 6 14
Gastrointestinal bleeding 12 29
Diverticulitis/perforation 4 13
Intestinal obstruction 10 12
Intussusception 13 11
Littre hernia 2 0
Foreign body incarceration 1 0
fever, with/without nausea and vomiting, were suspected to have ap-
pendicitis or peritonitis preoperatively, while were identified to have
diverticulitis or perforated MD at laparoscopy or laparotomy. Forty pa-
tients presented with bilious vomiting, stomach ache and abdominal
distension, and abdominal radiography showed signs of intestinal ob-
struction. During operation, Meckel's band (by direct compression, in-
duction of volvulus or internal hernia) or diverticulitis associated with
intestinal adhesive was found to be the cause of the obstruction. Intus-
susception were revealed by ultrasound in 35 patients who required
open reduction, and MD was confirmed as the lead point during opera-
tion, with 71.43% (25/35) cases of small-bowel intussusception with or
without colonic involvement and that relapsed at a mean of 1.57 ± 0.33
times. Two cases of Littre hernia and one case of foreign body incarcer-
ated in MD were also observed. Six patients who still had symptoms of
peritonitis, intestinal obstruction or hematochezia after procedure of
appendectomy at another institution were confirmed with MD in our
department. Complicated MD was found in 43 patients, including 11
cases of volvulus and intestinal necrosis, 17 cases of diverticulum perfo-
ration and peritonitis, and 15 cases of severe anemia (hemoglobin
b 60 g/L), accounting for 18.45% (43/233) of the symptomatic patients.
Various imaging studies, including Meckel's scan, gastroscopy, colo-
noscopy, abdominal radiography, ultrasonography or CT, and some-
times capsule endoscopy or intestinal magnetic resonance
hydrography were performed to assist the diagnosis, depending on
the clinical presentations of the patients. Among 99 cases of intestinal
bleeding, 78 cases underwent a Tc-99m scan and 55 cases showed a
positive result (Fig. 1A). No significant differences of hemoglobin level
were observed between Meckel's scan positive patients and negative
patients (F = 1.138, P = 0.363). Three cases of Meckel's diverticulum
were identified under capsule endoscope. Other results reported includ-
ed intestinal obstruction in 48 cases, intussusception in 36 cases, appen-
dicitis in 16 cases, thickening of intestinal wall and ascites accumulation
in 12 cases, pneumoperitoneum in 6 cases, strip echogenic structure of
right low quadrant in 6 cases, inguinal hernia incarceration in 2 cases
and foreign body ingestion in 1 case. The preoperative diagnostic rate
of MD was only 24.89% (58/233).
All patients with MD underwent diverticulectomy or partial ileal re-
N3 years
section under laparoscopy or laparotomy, besides one case of necrotiz-
(140 cases)
ing enterocolitis and one case of colon perforation owing to
colonoscopy. Enterostomy was performed in the two patients and the
58
39 diverticulum was left in situ during initial operation, and a postponed
18 diverticulectomy was performed during enterostomy closure. Surgical
11 approaches were selected according to the clinical presentations. For
0 all cases of bleeding MD and a portion of diverticulitis cases or inciden-
0
tally found cases, a total of 135 cases of laparoscopic-assisted

Please cite this article as: Chen Q, et al, Multifaceted behavior of Meckel's diverticulum in children, J Pediatr Surg (2017), https://doi.org/10.1016/
j.jpedsurg.2017.11.059
 Q. Chen et al. / Journal of Pediatric Surgery xxx (2017) xxx–xxx 3

Table 3
Clinical characteristics in symptomatic groups.

Symptomatic patient Gastrointestinal bleeding Diverticulitis/perforation Intestinal obstruction Intussusception Others

(n = 233) (n = 99) (n = 56) (n = 40) (n = 35) (n = 3)

Demographic
characteristic
Age (mean ± SD, y) 4.79 ± 3.77 5.23 ± 3.92 5.81 ± 4.01 4.15 ± 3.92 3.13 ± 3.77 -
Sex (male/female) 179/54 76/23 45/11 26/14 29/6 3/0
Clinical features n (%)
Blood per 116 (54.08) 99 (100) 2 (3.57) 0 15 (42.86) 0
rectum/melena
Abdominal pain 129 (55.36) 19 (19.19) 49 (87.50) 27 (67.5) 32 (91.43) 2
Nausea/vomiting 104 (44.64) 4 (4.04) 40 (71.43) 36 (90.00) 22 (62.86) 2
Abdominal 54 (23.18) 8 (8.08) 11 (19.64) 25 (62.50) 10 (28.57) 0
distention
fever 59 (25.32) 7 (7.07) 33 (58.93) 13 (32.50) 6 (16.67) 0
Positive Meckel scan - 55/78 (70.51) - - - -
n (%)
Ectopic tissue n (%) 144 (61.80) 94 (94.95) 24 (42.86) 9 (22.50) 16 (45.71) 1 (33.33)
P value⁎ 0.000 0.000 0.007 0.667 0.007
⁎ Positive distribution of ectopic mucosa as compared with accidentally found group.

extracorporeal diverticulectomy were carried out through single inci-
sion transumbilical laparoscopic surgery or three-port technology rou-
tinely (Fig. 1 B, C, D). The remained 151 cases of MD were removed by
laparotomy. Two hundred and forty cases of MD exerted segmental
ileal resection and anastomosis, and simple diverticulectomy or wedge
excision of the adjacent ileum was performed in the remaining 46
cases. The diverticulums were found to be located 10 cm to 150 cm
from ileocecal valve (means, 41.11 ± 18.09 cm).
Postoperative histopathology revealed heterotopic gastric mucosa
and/or ectopic pancreatic tissue in 154 cases, including 132 cases of gas-
tric mucosa, 16 cases of coexistent gastric mucosa and pancreatic tissue,
5 cases of pancreatic tissue and 1 case of kidney tissue (Fig. 2). The pos-
itive rate of ectopic mucosa distribution was 61.80% (144/233) in the
symptomatic group, and significant differences were observed as com-
pared with the accidentally found group (X 2=32.027, P b 0.001)
(Table 3). But no difference was observed between the intestinal
obstruction group and the accidentally found group. The positive rate
of ectopic epithelium in the b 1 year age group (25/75) was signifi-
cantly lower than that of the N1 year group (129/211), (X 2=17.21,
P b 0.001).
All patients survived, except one case of MD associated with volvu-
lus and intestinal necrosis who died of peritonitis and sepsis postopera-
tively. The surviving patients were followed up for 6 months to 5 years.
Near- and midterm complications were identified in 7 patients. One
case of anastomotic leak was reoperated on the fourth day
postoperation; one case of adhesive intestinal obstruction was

Fig. 1. Meckel's scan of ectopic mucosa and transumbilical laparoscopic diverticulectomy. A: Tc-99m scan demonstrated a dense isotopic accumulation in the lower abdomen which was
suspected with heterotopic gastric mucosa residue. B, C, and D: Two ports were placed around the edge of umbilicus, and the diverticulum was found under laparoscope and exteriorized
through the slightly extended umbilical incision. The umbilical wound was hidden in the navel with nearly viewless scar after the accomplishment of the procedure.

Please cite this article as: Chen Q, et al, Multifaceted behavior of Meckel's diverticulum in children, J Pediatr Surg (2017), https://doi.org/10.1016/
j.jpedsurg.2017.11.059
4 Q. Chen et al. / Journal of Pediatric Surgery xxx (2017) xxx–xxx

Fig. 2. Postoperative histopathology revealed heterotopic gastric mucosa and/or ectopic pancreatic tissue in the diverticulum. A: Gastric heterotopia intercalated into the glandular mucosa
of intestine; glands lined by parietal cells and chief cells typical of gastric-type mucosa. B: Small bowel mucosa comprising villi and Paneth cells in the crypts typical of small intestinal type
mucosa; ectopic pancreatic tissue located under laminae propria. C: Coexistence of heterotopic gastric mucosa and pancreatic tissue in a Meckel's diverticulum. Gastric mucosa was
intercalated into the mucosal layer, while pancreatic tissue was located under laminae propria, and pancreatic duct were found locally. ★ laminae propria; ▲ Paneth cells; ▽ ectopic
gastric mucosa; ↓ heterotopic pancreatic tissue.

reoperated two months after initial procedure; two cases of wound in-
fection and three cases of intestinal obstruction recovered after conser-
vative treatment.
3. Discussion
Preoperative diagnosis of symptomatic Meckel's diverticulum is dif-
ficult, particularly for the patients presenting with symptoms other than
bleeding [11]. Quite varied clinical presentations and relative uncertain-
ty of diagnostic examination are the main causes of low preoperative
detection rate.
Symptomatic MD varies considerably in clinical scenarios, including
intussusception, volvulus, internal hernia, adhesion, Littre hernia, gas-
trointestinal bleeding, diverticulitis, and perforation [5,12].
Misdiagnosed or miss diagnosed preoperatively were often encoun-
tered. According to our data, 134 cases of MD demonstrated symptoms
of infection, obstruction or induction of intussusception, accounting for
57.51% (134/233) of the symptomatic MD patients; none of these pa-
tients was diagnosed with MD initially. Delayed diagnosis may cause ex-
tremely serious complications, such as intestinal gangrene and
perforation, peritonitis and sepsis, and may even result in life-
threatening consequences. In this group, a total of 43 cases of volvulus
and intestinal necrosis, diverticulum perforation and peritonitis or se-
vere anemia were recorded, and unfortunately, one patient died of peri-
tonitis and septic shock postoperatively. We proposed that patients
under the following circumstances should be highly suspected to have
MD and laparoscopy or laparotomy is recommended: (1) patients
with repeated lower gastrointestinal bleeding, especially with massive
bleeding or associated with iron deficiency anemia and abdominal
pain, but with negative result of gastroscopy and colonoscopy;
(2) chronic abdominal pain with unknown reason or acute stomach
ache with fixed tenderness and elevated white blood cell counts, with
signs of peritonitis or GI perforation; (3) idiopathic acute ileus that
fails conservative treatment or partial chronic intestinal obstruction as-
sociated with chronic abdominal ache, especially with fixed bowel loops
on abdominal radiography; (4) repeated attack of intussusception, es-
pecially in older children or chronic intussusception. Six patients with
MD were confirmed in our department because of the persistent symp-
toms of stomach ache or melena after appendectomy, which were
misdiagnosed as appendicitis at other institutions. Here we reiterate
the importance of intestinal exploration when the severity of appendi-
citis doesn't agree with preoperative evaluation.
Diagnosis of MD is difficult by the traditional diagnostic methods.
The use of technetium-99m (Tc-99m) pertechnetate scintigraphy to de-
tect ectopic gastric mucosa has been a well-established technique to
diagnose MD for more than three decades, with the reported sensitivity
varying from 60% to 90%, and the specificity varying from 90% to 98%
[13]. It was reported that certain substances, such as pentagastrin,
histamine-2 blockers and glucagons, would increase the diagnostic
yield of the Meckel's scan [6,10]. However, various factors still exist
that might interfere with the signal of Tc-99m, and cause a false nega-
tive or false positive result [10,14]. In this study, the positive rate of
the Tc-99m scan was 70.51% in bleeding patients, but no provocative
test was performed routinely. At the same period, 10 cases of intestinal
hemorrhage with positive Meckel's scan, were proved to have intestinal
duplication in 5 cases, intestinal polyps in 2 cases and negative explora-
tion in 3 cases under laparoscopy. The relative low accuracy of Tc-99m
scanning made it not sufficient to exclusively diagnose or exclude an
MD. RBC scan or visceral angiography is a supplementary tool to detect
the bleeding site of active hemorrhage patient with Tc-99m negative
scan, but is rarely performed to ascertain the diagnosis of MD in children
[5,6,12]. Wireless capsule endoscopy is a novel, noninvasive diagnostic
technique that may aid in the diagnosis of a bleeding MD [15]. But the
shortcomings of capsule endoscopy were also evident, such as the lim-
itation of patient's age range, potential risks of delayed passage and ob-
struction requiring surgical removal, and need to deliver by endoscopy
sometimes, which restricted the widespread application in the pediatric
population [16]. Other conventional diagnostic methods including plain
abdominal radiographs, abdominal ultrasound, computed tomography
or MRI seldom produce positive results with diagnostic significance
[4,5,12]. But they remain indispensable in differential diagnosis of MD
and assessing the indication for surgical intervention; especially ultraso-
nography still remains the first choice of examination in diagnosing MD
associated with intussusception or diverticulitis.
Heterotopic tissue, consisting mostly of gastric mucosa but less com-
monly of pancreatic, jejunal, or colonic tissue, is the cause of most com-
plications of MD. Symptomatic MD has a 10-fold increased incidence for
heterotopic tissue, but it is estimated that only 50% to 60% of patients
with ectopic tissue become symptomatic. The incidence of ectopic gas-
tric tissue in symptomatic MD is reported to be 45%–80% in previous pe-
diatric series [3,4]. In this group, the incidence of ectopic mucosa in
symptomatic MD patients was 61.80%, which was significantly higher
than that in the incidentally found patients, especially in patients with
hemorrhage, diverticulitis and intussusception. The gastric acid or pan-
creatic juice secreted by gastric mucosa or pancreatic tissue inside di-
verticulum, may damage the diverticulum itself and neighboring
intestine, leading to ulceration, bleeding or inflammation. Aside from
functioning as a lead point, the MD can alter the rhythm of peristalsis
of vicinity bowel, thus inducing the onset of intussusception. While in
obstruction group, except for inflammatory adhesion, the main causes

Please cite this article as: Chen Q, et al, Multifaceted behavior of Meckel's diverticulum in children, J Pediatr Surg (2017), https://doi.org/10.1016/
j.jpedsurg.2017.11.059
 Q. Chen et al. / Journal of Pediatric Surgery xxx (2017) xxx–xxx
of obstruction are attributed to volvulus and internal hernia around
Meckel's band, the incidence rate of ectopic mucosa is comparable to
that in the incidentally found group in our series. Neoplasias arising
from the diverticulum were also reported, commonly seen in adults
[17]. Ectopic mucosa in the diverticulum plays a pivotal role during
this ontogenesis. The location of heterotopic mucosa in the diverticulum
also influenced the choice of surgical treatment [18]. The ectopic muco-
sae are located at the distal area of MD in most cases; a simple
diverticulectomy is recommended. In cases of broad-based diverticu-
lum, ectopic tissues are found at the base of diverticulum, and even ex-
tended to the neighboring ileum. Simple diverticulectomy is insufficient
and carries the risk of leaving heterotopic tissue. Wedge-shaped exci-
sion or segmental bowel resection is considered the preferred choice
of treatment.
It is still controversial whether an incidentally found MD during lap-
arotomy should be removed. Soltero and Bill mentioned a 4.2% lifetime
complication risk of MD versus 9% morbidity after incidental resection,
and did not favor incidental diverticulectomy [19]. Park et al. suggested
a selective removal of incidental asymptomatic MD in males, patients
younger than 50 years, diverticulum greater than 2 cm and presence
of histological abnormal tissue [6]. However, most authors do not
agree with these strategies; they support the work of prophylactic
diverticulectomy [14,20,21]. We performed a routine diverticulectomy
during our clinical practice with the following consideration: (1) Het-
erotopic tissues also exist in the incidentally found diverticulum. (2) It
is difficult to predict who will become symptomatic, especially in chil-
dren. The possibility of a life-long potential for complications is highly
likely. Moreover, the risk of postoperative morbidity after resection of
complicated diverticulum is estimated to be up to 33% [14]. (3) There
was hypothesis that ectopic tissue might develop later in life [22], in-
creasing the risk of complicated MD, which was confirmed in this
study. (4) Neoplasias (carcinoid tumors, gastrointestinal stromal tu-
mors, leiomyosarcomas, adenocarcinomas) arising from the diverticu-
lum were reported, which may bring catastrophic consequences [14].
(5) With the improvement of suture material and suture skill, the com-
plications of intestinal resection are extremely low, obviously lower
than the complications of diverticulum itself. The fifty three cases of in-
cidentally found diverticulum were removed initially or delayed with-
out exception, no postoperative complications occurred, and 10 cases
of ectopic tissue were reported with histological examination. We advo-
cate that the incidentally found diverticulum should be removed pro-
vided the patient's condition permits it.
In the past decade, laparoscopic surgery for children has undergone
tremendous development. It has been used widely in the treatment of
gastrointestinal diseases. Currently, laparoscopy is a well-established
initial step for establishing the diagnosis and subsequent management
of MD in children [21,23]. It is especially valuable for patients with ob-
scure intestinal bleeding or chronic stomach ache, highly skeptical of
MD, but with negative results of Meckel's scan and other workups.
Rivas and Poulsen recommended that laparoscopy should replace
Meckel's Scan to be the first choice of modality [24,25], which has
been reported to be a useful and accurate tool in the diagnosis of MD
and the different intraabdominal pathologies, and offers the possibility
of laparoscopic resection of the lesion. Various methods of laparoscopic
Meckel's diverticulectomy have been described, such as Laparoscopic
intestinal resection with intracorporeal suturing or by using Endo Linear
cutter stapler, laparoscopic-assisted extracorporeal resection and
anastomosis [21]. Laparoscopic intracorporeal diverticulectomy carries
the risk of leaving heterotopic mucosal tissue and potential intraperito-
neal spillage; there is a need to create an extra port to place the expen-
sive endoscopic stapler. Whereas in performing transumbilical
laparoscopic-assisted diverticulectomy, the diverticulum is delivered
via a slightly extended umbilical wound and performance of
diverticulectomy extracorporeally with hand-sewn anastomosis, thus
avoid abdominal contamination and ectopic mucosa omission. It is con-
sidered to be safe and effective in the management of MD and is
Please cite this article as: Chen Q, et al, Multifaceted behavior of Meckel's diverticulum in children, J Pediatr Surg (2017), https://doi.org/10.1016/
j.jpedsurg.2017.11.059
5
recommended to be the treatment of choice in pediatric patients by
most surgeons [26]. In this group, including 99 cases of intestinal hem-
orrhage, a total of 135 cases of diverticulum were removed via this pro-
cedure, no umbilical wound infection was observed, and excellent
cosmetic result was obtained with the almost invisible scar hidden in
the navel. However, laparoscopy has its intrinsic shortcomings as well.
It may leave out the lesions at site of mucosa surface without the
sense of palpation and cannot explore the extraperitoneal organs be-
yond its reach. Therefore, we should pay more attention to comprehen-
sive analysis of the clinical data and adopt strictly indication for
exploration to avoid unnecessary damage to patients before the proce-
dure of laparoscopy.
In conclusion, Meckel's diverticulum remained a challenge for the
pediatrician and pediatric surgeon, as it is still difficult to be diagnosed
preoperatively. Integrative application of multiple approaches, such as
Meckel's isotopic scan, capsule endoscopy and laparoscopy can help us
to achieve a more accurate diagnosis, while significantly decreasing
misdiagnosis or delayed diagnosis. The key point of diverticulectomy
is to remove the ectopic mucosa completely owing to the fact that het-
erotopic tissue is the cause of most complications, and any operative
methods selected should follow this principle. It is safe and feasible to
remove the incidentally discovered MD as long as the patient's condi-
tion allows it. Different surgical procedures may be chosen according
to the anatomical morphology and pathological changes of the MD,
and laparoscopy should become the first choice of methods in diagnosis
and treatment of MD.
References
[1] Papparella A, Nino F, Noviello C, et al. Laparoscopic approach to Meckel's diverticu-
lum. World J Gastroenterol 2014;20:8173–8.
[2] Ruscher KA, Fisher JN, Hughes CD, et al. National trends in the surgical management
of Meckel's diverticulum. J Pediatr Surg 2011;46:893–6.
[3] Menezes M, Tareen F, Saeed A, et al. Symptomatic Meckel's diverticulum in children:
a 16-year review. Pediatr Surg Int 2008;24:575–7.
[4] Chan KW, Lee KH, Mou JW, et al. Laparoscopic management of complicated Meckel's
diverticulum in children: a 10-year review. Surg Endosc 2008;22:1509–12.
[5] Levy AD, Hobbs CM. Meckel diverticulum: radiologic features with pathologic corre-
lation. Radiographics 2004;24:565–87.
[6] Tseng YY, Yang YJ. Clinical and diagnostic relevance of Meckel's diverticulum in chil-
dren. Eur J Pediatr 2009;168:1519–23.
[7] Park JJ, Wolff BG, Tollefson MK, et al. Meckel diverticulum: the Mayo Clinic experi-
ence with 1476 patients (1950-2002). Ann Surg 2005;241:529–33.
[8] Prasad TR, Chui CH, Jacobsen AS. Laparoscopic-assisted resection of Meckel's diver-
ticulum in children. JSLS 2006;10:310–6.
[9] Jelenc F, Strlic M, Gvardijancic D. Meckel's diverticulum perforation with
intraabdominal hemorrhage. J Pediatr Surg 2002;37:E18.
[10] Rho JH, Kim JS, Kim SY, et al. Clinical features of symptomatic Meckel's diverticulum
in children: comparison of scintigraphic and non-scintigraphic diagnosis. Pediatr
Gastroenterol Hepatol Nutr 2013;16:41–8.
[11] Huang CC, Lai MW, Hwang FM, et al. Diverse presentations in pediatric Meckel's di-
verticulum: a review of 100 cases. Pediatr Neonatol 2014;55:369–75.
[12] Kotecha M, Bellah R, Pena AH, et al. Multimodality imaging manifestations of the
Meckel diverticulum in children. Pediatr Radiol 2012;42:95–103.
[13] Mariani G, Pauwels EK, AlSharif A, et al. Radionuclide evaluation of the lower gastro-
intestinal tract. J Nucl Med 2008;49:776–87.
[14] Sagar J, Kumar V, Shah DK. Meckel's diverticulum: a systematic review. J R Soc Med
2006;99:501–5.
[15] Sahn B, Bitton S. Lower gastrointestinal bleeding in children. Gastrointest Endosc
Clin N Am 2016;26:75–98.
[16] Cohen SA, Oliva S. Capsule endoscopy in pediatrics: a growing experience. Tech
Gastrointest Endosc 2015;17:31–6.
[17] Lorusso R, Forte A, Urbano V, et al. Small bowel stromal tumors in a “meckelian” lo-
cation. About a clinical observation. Ann Ital Chir 2003;74:707–11.
[18] Mukai M, Takamatsu H, Noguchi H, et al. Does the external appearance of a Meckel’s
diverticulum assist the choice of the laparoscopic procedure? Pediatr Surg Int 2002;
18:231–3.
[19] Soltero MJ, Bill AH. The natural history of Meckel's diverticulum and its relation to
incidental removal. A study of 202 cases of diseased Meckel's diverticulum found
in King County, Washington, over a fifteen year period. Am J Surg 1976;132:168–73.
[20] Gezer HÖ, Temiz A, İnce E, et al. Meckel diverticulum in children: evaluation of mac-
roscopic appearance for guidance in subsequent surgery. J Pediatr Surg 2016;51:
1177–80.
[21] Shalaby RY, Soliman SM, Fawy M, et al. Laparoscopic management of Meckel's diver-
ticulum in children. J Pediatr Surg 2005;40:562–7.
[22] Burjonrappa S, Khaing P. Meckel's diverticulum and ectopic epithelium: evaluation
of a complex relationship. J Indian Assoc Pediatr Surg 2014;19(2):85–9.
6 Q. Chen et al. / Journal of Pediatric Surgery xxx (2017) xxx–xxx

[23] Alemayehu H, Stringel G, Lo IJ, et al. Laparoscopy and complicated meckel divertic- [25] Poulsen KA, Quist N. Sodium pertechnetate scintigraphy in detection of Meckel's di-
ulum in children. JSLS 2014;18(3):1–5. verticulum is it usable? Eur J Pediatr Surg 2000;10:228–31.
[24] Rivas H, Cacchione RN, Allen JW. Laparoscopic management of Meckel's diverticu- [26] Cobellis G, Torino G, Noviello C, et al. Versatility of one-trocar surgery in children. J
lum in adults. Surg Endosc 2003;17:620–2. Laparoendosc Adv Surg Tech A 2011;21:549–54.

Please cite this article as: Chen Q, et al, Multifaceted behavior of Meckel's diverticulum in children, J Pediatr Surg (2017), https://doi.org/10.1016/
j.jpedsurg.2017.11.059