Çocuklarda Meckel Divertikülünün Farklı Klinik Semptomları ve Cerrahi Tedavisi

Giriş: Meckel divertikülü gastrointestisnal sistemin en sık görülen konjenital anomalisidir ve genellikle başka bir ameliyat sırasında insidental olarak, başka bir hastalığı araştırırken radyolojik olarak tesadüfen veya otopsi sırasında saptanır. Meckel divertikülü gastrointestinal kanama, volvulus, divertikülit, intusepsiyon, volvulus, Littre hernisi, umblikustan gaita deşarjı semptomatik hale gelir. Bu çalışmada farklı klinik semptomlarla başvuran Meckel divertikülü nedeniyle ameliyat edilen çocuk hastaları inceledik. Yöntemler: Temmuz 2002-temmuz 2021 tarihleri arasında çocuk cerrahisi kliniğinde meckel divertikülü nedeniyle opere edilen pediatrik hastaların dosyaları retrospektif olarak incelendi. İnsidental divertikülektomi yapılan hastalar çalışma dışında tutuldu. Bulgular: Çalışmaya dahil olan 47 hastanın 34 erkek, 13 kız ve ortalama yaşı 4,8 (1 günlük, 16 yaş) idi. Hastaların %49’u 2 yaşından küçüktü. Hastalarda görülen en sık semptom karın ağrısı (%63,8) idi. En sık ameliyat endikasyonu intestinal obstrüksiyondu (%53,2). İntestinal obstrüksiyon gelişen hastaların %64ünde neden intususepsiyondu. Gastrointestinal (GİS) kanama şikayeti %12,8 hastada saptadık. Cerrahi olarak en sık segmenter barsak rezeksiyonu (%46,8) yapıldı. Patolojik incelemede 27 (%57,4) piyeste ektopik dokuya rastlandı. Ameliyat sonrası 9 hastada komplikasyon gelişirken 4 hasta konservatif olarak 5 hasta da cerrahi olarak tedavi edildi. Sonuç: Klasik vişne çürüğü gaita olan rektal kanamalar dışında meckel divertikülünün preoperatif tanısı zordur. Semptomatik meckel divertiküllerinde divertikülün neden olduğu komplikasyona göre basit divertikülektomi, wedge rezeksiyon veya segmenter barsak rezeksiyonu planlanmalıdır.

Different clinical symptoms and surgical treatment of Meckel's diverticulum in children

Objective: Meckel's diverticulum is the most common congenital anomaly of the gastrointestinal tract and is usually identified incidentally during surgery for other reasons, upon radiological workup while investigating another disease or during autopsy. Among certain major symptoms of Meckel's diverticulum include gastrointestinal bleeding, volvulus, diverticulitis, intussusception, Littre's hernia or stool discharge from the umbilicus. In this study, we examined pediatric patients who were operated on for Meckel's diverticulum presenting with different clinical symptoms. Methods: The files of pediatric patients who were operated for Meckel's diverticulum in the pediatric surgery clinic between July 2002 and July 2017 were retrospectively reviewed. Patients who underwent incidental diverticulectomy were excluded from the study. Results: The 47 patients included in the study were 34 boys, 13 girls, and their mean age was 4.8 (1 day, 16 years). 49% of the patients were younger than 2 years old. The most common symptom observed in the patients was abdominal pain (63.8%). The most common indication for surgery was intestinal obstruction (53.2%). Intussusception was the cause in 64% of the patients in whom intestinal obstruction was the initial diagnosis. We detected gastrointestinal (GI) bleeding complaint in 12.8% of the patients. Segmentary bowel resection (46.8%) was the most common surgical procedure. In the pathological examination, ectopic tissue was found in 27 (57.4%) pathological specimens. While postoperative complications developed in 9 patients, 4 patients were treated conservatively and 5 patients were treated surgically. Conclusion: Establishing a preoperative diagnosis of Meckel's diverticulum may be difficult non other than rectal bleeding with currant jelly stool. In symptomatic Meckel's diverticulum, simple diverticulectomy, wedge resection or segmental bowel resection should be planned according to the complication caused by the diverticulum.

PDF

___

1. Korkmaz Ö, Yılmaz HG, Keleş C. Erişkinlerde Görülen Meckel Divertikül Komplikasyonları. Dicle Tıp Dergisi. 2008; 35: 91-5.
2. Meckel JF. About the diverticulum of the intestine. Arch Physiol (Halle) 1809; 9: 421-53.
3. Hansen CC, Søreide K. Systematic review of epidemiology, presentation, and management of Meckel's diverticulum in the 21st century. Medicine (Baltimore). 2018; 97: e12154.
4. Poley JR, Thielen TE, Pence JC. Bleeding Meckel's diverticulum in a 4-month-old infant: Treatment with laparoscopic diverticulectomy. A case report and review of the literature. ClinExpGastroenterol. 2009; 2: 37-40.
5. Gezer HÖ, Temiz A, İnce E, Ezer SS, Hasbay B, Hiçsönmez A. Meckel diverticulum in children: Evaluation of macroscopic appearance for guidance in subsequent surgery. J Pediatr Surg. 2016; 51: 1177-80.
6. Huang CC, Lai MW, Hwang FM, et al. Diverse presentations in pediatric Meckel's diverticulum: a review of 100 cases. PediatrNeonatol. 2014; 55: 369-75.
7. Jha SK, Ghimire S, Koirala DP. Torsed gangrenous Meckel's diverticulum causing gangrenous ileal segment: A rare case report of small bowel obstruction in children. Ann Med Surg (Lond). 2021; 69: 102723.
8. Levy AD, Hobbs CM. From the archives of the AFIP. Meckel diverticulum: radiologic features with pathologic Correlation. Radiographics. 2004; 24: 565-87.
9. Pathak A, Agarwal N, Singh P, Dhaneria M. Prolapse of inverted ileal loops through a patent vitellointestinal duct. BMJ Case Rep. 2015; 2015: bcr2015211563.
10. Elsayes KM, Menias CO, Harvin HJ, Francis IR. Imaging manifestations of Meckel's diverticulum. AJR Am J Roentgenol. 2007; 189: 81-8.
11. Fink AM, Alexopoulou E, Carty H. Bleeding Meckel's diverticulum in infancy: unusual scintigraphic and ultrasound appearances. PediatrRadiol. 1995; 25: 155-6.
12. Prall RT, Bannon MP, Bharucha AE. Meckel's diverticulum causing intestinal obstruction. Am J Gastroenterol. 2001; 96: 3426-7.
13. Rho JH, Kim JS, Kim SY, et al. Clinical Features of Symptomatic Meckel's Diverticulum in Children: Comparison of Scintigraphic and Non-scintigraphic Diagnosis. PediatrGastroenterolHepatolNutr. 2013; 16: 41-8.
14. Mackey WC, Dineen P. A fifty year experience with Meckel's diverticulum. SurgGynecol Obstet. 1983; 156: 56-64.
15. Moore GP, Burkle FM Jr. Isolated axial volvulus of a Meckel's diverticulum. Am J Emerg Med. 1988; 6: 137-42.
16. 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.
17. Urrutia Soto H, Donoso Carrasco C, Carvajal Flores O. Symptomatic Meckel's Diverticulum in pediatrics. Divertículo de Meckel sintomáticoenpediatría. Andes Pediatr. 2021; 92: 104-9.
18. Stănescu GL, Pleşea IE, Diaconu R, et al. Meckel's diverticulum in children, clinical and pathological aspects. Rom J MorpholEmbryol. 2014; 55(3 Suppl): 1167-70.
19. Francis A, Kantarovich D, Khoshnam N, Alazraki AL, Patel B, Shehata BM. Pediatric Meckel's Diverticulum: Report of 208 Cases and Review of the Literature. Fetal PediatrPathol. 2016; 35: 199-206.
20. Leys C. Meckel Diverticulum en: Holcomb and Ashcraft’s Pediatric Surgery 7a edition. Editorial Elsevier. 2020; 40: 641-6.
21. Poley JR, Thielen TE, Pence JC. Bleeding Meckel's diverticulum in a 4-month-old infant: Treatment with laparoscopic diverticulectomy. A case report and review of the literature. ClinExpGastroenterol. 2009; 2: 37-40.
22. Choi SY, Hong SS, Park HJ, Lee HK, Shin HC, Choi GC. The many faces of Meckel's diverticulum and its complications. J Med Imaging RadiatOncol. 2017; 61: 225-31.
23. Blevrakis E, Partalis N, Seremeti C, Sakellaris G. Meckel's diverticulum in paediatric practice on Crete (Greece): a 10-year review. Afr J Paediatr Surg. 2011; 8: 279-82.
24. Kamii Y, Zaki AM, Honna T, Tsuchida Y. Spontaneous regression of patient omphalomesenteric duct: from a fistula to Meckel's diverticulum. J Pediatr Surg. 1992; 27: 115-6.