Journal of Postgraduate Medicine Medknow Publications and Staff Society of Seth GS Medical College and KEM Hospital, Mumbai, India ISSN: 0022-3859 EISSN: 0972-2823 Vol. 56, Num. 1, 2010, pp. 40-41

Journal of Postgraduate Medicine, Vol. 56, No. 1, January-March, 2010, pp. 40-41

Case Snippet

What Johann Friedrich Meckel did not think of when he named the diverticulum!

Karangelis D^1,2 , Tagarakis GI ² , Drakos A¹ , Giaglaras A¹

¹ Department of General Surgery, General Hospital of Larissa, Thessaly,
² Department of Cardiovascular and Thoracic Surgery, University of Thessaly, Larissa, Greece

Correspondence Address: Dr. Dimos Karangelis, Department of General Surgery, General Hospital of Larissa, Thessaly; and Department of Cardiovascular and Thoracic Surgery, University of Thessaly, Larissa, Greece, dimoskaragel@yahoo.gr

Code Number: jp10015

PMID: 20393253

DOI: 10.4103/0022-3859.62424

Meckel′s diverticulum is the most prevalent congenital abnormality of the small intestine. ^[1] It results from the failure of the vitelline duct to obliterate during the fifth week of fetal life. It may remain completely asymptomatic, or mimic disorders like Crohn′s disease, appendicitis and peptic ulcer. It contains all layers of the intestinal wall and, in approximately half the cases, tissue from other sites. This ectopic, or heterotopic tissue is potentially associated with complications such as ulcer, bleeding and perforation. ^[2] Although Meckel′s diverticulum occurs in about 2% of the population, reports from autopsy and retrospective studies range from 0.14 to 4.5%. Although the diagnosis is primarily reported in the adolescent population, it should also be considered in adults. Herein, we present a case of an 83-year-old male with obstructive ileus from a left colon cancer who underwent an urgent laparotomy. The intraoperative findings convinced us that the most preferable method of treatment was to perform a palliative "meckelostomy".

An 83-year-old male presented to our department with a three-day history of abdominal pain, vomiting and constipation without signs of acute abdomen. The patient had a thoracoabdominal aortic aneurysm repair two years ago. Initial management of the patient involved IV fluid resuscitation, nasogastric tube insertion, blood tests and chest/abdominal X-rays. Although there were no significant findings from the rest of the tests, the abdominal film revealed evidence of subacute ileus. The computed tomography scan of the abdomen with oral contrast revealed a mass on the left colon with signs of infiltration of the transverse colon. We performed a diagnostic laparotomy and managed the patient accordingly. Laparotomy showed a large mass arising from the left colon 5 cm from the splenic flexure which infiltrated the transverse colon and the greater omentum. Metastatic foci were found on the previous midline incision, the peritoneum, the small intestine, the mesocolon, the mesentery. At that point, what constituted the most preferable method of treatment was a decompressional cecostomy or ileostomy. While exploring the small intestine, we discovered a Meckel′s diverticulum measuring approximately 10 cm in length with colon cancer metastasis on it [Figure - 1]. Meckel′s half diverticulectomy and removal of the metastasis was done, while the proximal end of the diverticulum was exteriorized and sutured to the skin. Thus, an approximately 4 cm in diameter stoma was created. The stoma started to work from the first postoperative day, the patient had an uneventful recovery and was discharged from the hospital on the sixth postoperative day. At follow-up six months postoperatively, the stoma was working flawlessly. The patient died 11 months after the operation due to the metastatic disease.

This report highlights the possibility of using an incidentally discovered large Meckel′s diverticulum as an enterostomy site when a palliative decompressive ileostomy or caecostomy is considered. What are the advantages brought by this novel technique? To our opinion, these are connected with the anatomical characteristics of Meckel′s diverticulum. It is easy to find, short, with a broad base and can be handled conveniently even by a surgeon who lacks outstanding experience. To our knowledge this is the first time that the method and the term "meckelostomy" has been used and we believe that it could be introduced in the medical literature.

References

1.	Das PC, Rao PL, Radhakrishna K. Meckel's diverticulum in children. J Postgrad Med 1992;38:19-20.  Back to cited text no. 1  [PUBMED]
2.	Madhyastha S, Prabhu VL, Saralaya V, Prakash. Meckel's diverticulum. A case report. Int J Morphol 2007;25:519-22.  Back to cited text no. 2

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