1. VCU Death and Complications Conference

2. HPI
26 yo man with no PMH/PSH, presented to the ED with 10 hours of abdominal pain, which woke him from sleep that morning.
The pain was diffuse, severe, and worsening.
It was most severe in the periumbilical region. Associated with anorexia, nausea/vomiting, exacerbated by movement.
He denied fevers, dysuria, hematuria.
Last bowel movement was the previous day.

3. Physical exam T 36.8 C BP 141/101 HR 88 RR 16 Sp02 99%
ill appearing young man in moderate distress, lying still, holding onto bedrails
alert, oriented
NSR, CTAB
Abd mildly distended, exquisitely ttp in periumbilical region and lower quadrants R>L, +guarding, +peritoneal signs
DRE normal tone, no gross blood
CBC Hgb HCT WBC PLT 317

4. Operative Procedure Diagnostic laparoscopy
Meckel’s diverticulum 60cm from terminal ileum, torsed on a mesodiverticular band from its tip to adjacent mesentery
Open resection of 2cm small bowel containing the diverticulum
Pathology: Segment of ileum with ischemic changes, clinically strangulated Meckel's diverticulum. Contains fecalith, vegetable matter, green/brown mucosa.
PROCEDURE:
1. Diagnostic laparoscopy.
2. Exploratory laparotomy.
3. Meckel's diverticulectomy.
4. Bowel resection and primary anastomosis.
PREOPERATIVE DIAGNOSIS: Acute appendicitis.
POSTOPERATIVE DIAGNOSIS: Strangulated Meckel's diverticulum.
ESTIMATED BLOOD LOSS: 30 mL.
SPECIMEN REMOVED: Meckel's diverticulum.
INDICATIONS FOR PROCEDURE: This is a 26-year-old man who had 1 day of severe periumbilical pain, with nausea, vomiting, anorexia, WBC, and peritoneal signs on exam. The risks and benefits of diagnostic laparoscopy and possible appendectomy were explained to the patient. He desires to procede with surgery.
PROCEDURE IN DETAIL: After informed consent was obtained, the patient was brought into the operating room. He was placed supine on the operating table. Sequential compression devices were placed on both legs. General anesthesia was induced. The patient was intubated. A Foley catheter was placed in sterile conditions and appropriate preoperative antibiotics were given. The abdomen was prepped and draped in sterile fashion. A time-out was conducted after which a 2-cm incision was made inferior to the umbilicus in a horizontal orientation, and a Veress needle was introduced into the abdomen. It was connected to CO2 insufflation and the abdomen inflated appropriately. After this, a 10-mm trocar was placed and a camera was used to examine the intraabdominal cavity. On looking in the abdomen, we saw the cecum with a normal-appearing appendix, but a large loop of dark, dusky-appearing, strangulated bowel. At this point, the decision was made to open. We made a lower midline incision below the umbilicus and eviscerated the small intestine about 60 cm from the ileocecal valve, proximal to the ileocecal valve in the ileum. A approximately 15-cm Meckel's diverticulum was found, which had adhered at its tip to another piece of bowel and had become twisted around its base causing it to become strangulated. The adhesion was taken down and the diverticulum was then removed by resecting a small length of bowel approximately a centimeter on each side of the location of the Meckel's. The bowel was resected using a GIA stapler and then re-anastomosed using another GIA stapler load, placing the bowel side-by-side with antimesenteric sides lined up, completing a side-to-side anastomosis using a TA stapler to come across the tops of the bowel. After this was completed and the hemostasis was established, we then also took a 2-0 silk stitch and dunked the corners at each end of the staple line. The remainder of the bowel appeared healthy and there were no other concerning findings in the abdomen. We replaced the bowel and abdominal contents back into the abdomen and closed the fascia with a running looped PDS suture. We then closed the skin with staples and placed a sterile Coverlet dressing. At the conclusion of the case, the patient was awakened and extubated. Needle, towel and sponge counts were correct x2. The patient tolerated the procedure well. Dr. Duane was present and scrubbed for the entire procedure.

6. Meckel’s Diverticulum
Most common congenital anomaly of GI tract
True diverticulum, all layers of bowel wall
Found on antimesenteric border of distal ileum
Due to incomplete obliteration of vitelline duct during 5th week of fetal development
Arises from antimesenteric border of distal ileum
True diverticulum (contains all layers of bowel wall)
Most common congenital anomaly of GI tract
Formed by incomplete obliteration of ileal end of vitelline duct
Rule of 2s
Fibrous band (obliterated part of vitelline duct may connect apex of diverticulum to umbilicus)
Length of 2 inches (on average)
Located within 2 feet of ileocecal valve
Seen in ~ 2% of population
2 main complications in adults: Diverticulitis (20%) and intestinal obstruction (40%)
Symptomatic usually before age 2

7. Rule of 2’s 2% of the population Found within 2ft of ileocecal valve
average length 2in
usually symptomatic before age 2

8. Meckel’s Diverticulum
50% contain ectopic gastric mucosa
± pancreatic, duodenal, and colonic mucosa
90% of cases with bleeding contain gastric mucosa
Presents in adults with diverticulitis (20%) or intestinal obstruction (40%)
Most are short and wide mouthed; mean length 2.9cm, width1.9cm
Giant MD are >5cm

9. Meckel’s Diverticulitis
About 1/3 of pts with symptomatic Meckel's diverticulum have acute diverticulitis.
Intraluminal obstruction at the base of a Meckel's diverticulum can lead to distal inflammation, gangrene, and subsequent perforation.
Signs and symptoms of Meckel's diverticulitis are virtually indistinguishable from appendicitis, and exploration is both diagnostic and therapeutic.

10. Treatment Symptomatic Meckel's diverticula requires open exploration.
Resection
antimesenteric wedge excision
segmental bowel resection with primary closure or anastomosis.
Laparoscopic dx and mgt also described.
Minimal morbidity/mortality unless intestinal necrosis occurred

11. Axial Torsion Rare complication of Meckel’s diverticulum
24 of 1605 cases in one review
Predisposing factors
Persistent mesodiverticular band
Narrow base
Excessive length
Neoplasm or inflammation of the diverticulum
Axial Torsian as a Rare and Unusual Complication of Meckel’s Diverticulum. Journal of Medical Case Reports 2011, 5:118
Meckel’s diverticulum: report of two unusual cases. N Engl Journal of Med, 1947, 237:

12. Axial Torsion
Twisting of diverticulum at its base can lead to peritonitis, necrosis, perforation
Presentation
Abdominal pain, often RLQ, range from acute to indolent course
Mistaken for appendicitis
Imaging often not as helpful
Axial Torsian as a Rare and Unusual Complication of Meckel’s Diverticulum. Journal of Medical Case Reports 2011, 5:118
Meckel’s diverticulum: report of two unusual cases. N Engl Journal of Med, 1947, 237:
Pediatric Radiology
Volume 31, Number 12 (2001), , DOI: /s
Published in partnership with
ESPR, SPR, AOSPR and SLARP
Axial torsion of Meckel's diverticulum presenting as a pelvic mass
J La State Med Soc Jan-Feb;161(1):19-22; quiz 23, 54.
Torsion and gangrene of a Meckel's diverticulum.
Caillouët IS, Jaffe BM.
Source
Department of Surgery, Tulane University School of Medicine, New Orleans, Louisiana, USA.
Abstract
A 19-year-old woman presented to the emergency department with intermittent and progressively worsening abdominal pain, nausea, and vomiting. A computed tomographic scan revealed findings consistent with distal small bowel obstruction of unknown etiology. In the operating room, a torsed and gangrenous Meckel's diverticulum with extension of ischemia to adjacent small bowel was discovered and immediately resected. Pathology confirmed the diagnosis of gangrenous Meckel's diverticulum. Torsion and gangrene of a Meckel's diverticulum is a rare complication and often presents with vague and poorly localized signs and symptoms. The preoperative diagnosis is often difficult and presumed to be appendicitis or small bowel obstruction of unclear etiology. Complications of Meckel's diverticulum should be considered in patients with lower abdominal pain and acute abdomen.

13. Learning points
Keep Meckel’s diverticulum in the differential for abdominal pain/acute abdomen.
Look for it if your acute appendicitis is not an appendicitis.
Once identified, resect.
Wedge it out or small bowel resection and anastomosis
J Med Case Rep Mar 28;5:118.
Axial torsion as a rare and unusual complication of a Meckel's diverticulum: a case report and review of the literature.
Seth A, Seth J.
Source
Brighton and Sussex Medical School, University of Sussex, Falmer, Brighton BN1 9PX, UK.
Abstract
INTRODUCTION:
In 1809, Johann Friedrich Meckel described the embryology of a small bowel diverticulum, which now bears his name. Meckel's diverticulum is the most common congenital abnormality of the gastrointestinal tract, with a prevalence ranging from 1% to 4% of the population. The majority are clinically silent and are incidentally identified at surgery or at autopsy. The lifetime risk of complications is estimated at 4%, with most of these complications occurring in adults. It is these cases that can cause problems for the clinician, as the diagnosis can be elusive and the consequences extremely serious.
CASE PRESENTATION:
We present the case of a 68-year-old Caucasian man with axial torsion of a Meckel's diverticulum around its base, a rare complication. He presented with acute, severe abdominal pain, and a clinical diagnosis of perforated acute appendicitis was made. Laparotomy revealed a torted Meckel's diverticulum with distal necrosis and perforation, which was resected. His recovery was uncomplicated, and he was discharged to home six days post-operatively.
CONCLUSION:
Torsion is an extremely rare complication of Meckel's diverticulum. Its presentation can be elusive, and it can mimic a number of different, more common intra-abdominal pathologies. Imaging appears to be an unreliable diagnostic tool, and the diagnosis is usually made intra-operatively. Factors pre-disposing these patients to axial torsion of Meckel's diverticulum include the presence of mesodiverticular bands, a narrow base, excessive length, and associated neoplastic growth or inflammation of the diverticulum. The importance of searching for a diseased Meckel's diverticulum at laparotomy in appropriate circumstances is highlighted. Once identified, prompt surgical excision generally leads to an uncomplicated recovery.