Management of Incidentally Found Meckel’s Diverticulum A New Approach: Resection Based on a Risk Score

The management of incidentally found Meckel’s diverticulum (MD) remains unclear. The risk for future complications of a non-resected MD must be weighed against the risk of complications for a resected MD in order to justify a prophylactic resection. Morbidity-rates after resection of incidentally found MD are much lower than those after resection of symptomatic MD. Several risk factors which increase the risk for future complications of an asymptomatic MD have been described in the literature.

We suggest that an asymptomatic MD should be removed in cases where there is a higher risk of it becoming symptomatic in the future, on condition that the resection can be done with presumed low morbidity. Based on the literature data we propose a scoring system in order to base the decision for surgery on more objective grounds and weighted criteria. This Risk Score is based on 4 risk factors: male sex, patients younger than 45 years, diverticula longer than 2 cm and the presence of a fibrous band. We suggest resection of an asymptomatic MD with a Risk Score of > 6 points. A transverse diverticulectomy is preferable in most cases. In short, broad based MD, or in the case of a palpable mass at the base, a wedge-shaped excision is the best alternative.     

Management of incidentally found Meckel's diverticulum a new approach: resection based on a Risk Score

Abstract. The management of incidentally found Meckel's diverticulum (MD) remains unclear. The risk for future complications of a non-resected MD must be weighed against the risk of complications for a resected MD in order to justify a prophylactic resection. Morbidity-rates after resection of incidentally found MD are much lower than those after resection of symptomatic MD. Several risk factors which increase the risk for future complications of an asymptomatic MD have been described in the literature. We suggest that an asymptomatic MD should be removed in cases where there is a higher risk of it becoming symptomatic in the future, on condition that the resection can be done with presumed low morbidity. Based on the literature data we propose a scoring system in order to base the decision for surgery on more objective grounds and weighted criteria. This Risk Score is based on 4 risk factors: male sex, patients younger than 45 years, diverticula longer than 2 cm and the presence of a fibrous band. We suggest resection of an asymptomatic MD with a Risk Score of > or = 6 points. A transverse diverticulectomy is preferable in most cases. In short, broad based MD, or in the case of a palpable mass at the base, a wedge-shaped excision is the best alternative.     

Nation-wide Brain Tumor Registry-based Study of Intracranial Meningioma in Japan: Analysis of Surgery-related Risks

Although surgical resection is the most preferred treatment for intracranial meningiomas, a detailed analysis of the surgery-related risks based on large population data has not been conducted to date. In this study, we analyzed the nation-wide brain tumor registry to assess the surgical risk factors for intracranial meningiomas to provide information for an optimal treatment strategy. Data of 4081 meningioma patients who underwent initial resection between 2001 and 2008 were extracted from the Brain Tumor Registry of Japan (BTRJ) database and reviewed for postoperative mortality, aggravation of Karnofsky Performance Score (KPS), and complications. The total in-hospital mortality rate was 0.59%. Male sex and tumor size ≥30 mm were independent risk factors for mortality. Among 4081 cases, 4.4% of patients had KPS that were lowered by 20 or more points at the time of discharge after surgery. Age ≥65 years, higher WHO grading, tumor location at the skull base, tumor size ≥30 mm, and non-gross total resections were associated with lowering of KPS scores by 20 or more points. The overall incidence of surgical complications was 19.3%. The rate of occurrence of new postoperative seizure in patients with supratentorial meningioma was 10.9%. All complications except for vascular complications occurred with significantly lower frequencies in asymptomatic patients than in symptomatic patients. Our results provide useful information regarding the surgical risks when surgical intervention is being considered for intracranial meningiomas. Surgery is an important option for asymptomatic meningiomas as the mortality rate and complication rate in the current study were sufficiently low.     

Intestinal obstruction and ischemia by necrotic annular Meckel’s diverticulum: Case report and review of the literature

Introduction and importanceMeckel’s diverticulum (MD) is a vestigial remnant of the omphalomesenteric duct, representing the most common congenital malformation of the gastrointestinal tract. Diagnosis of MD is a challenge because of its rarity and frequent asymptomaticity. Radiological exams generally aren’t useful for its diagnosis. Intestinal obstruction represents the most common complication of MD in adults. Surgery is the appropriate treatment of complicated MD.Case presentationA 70-year-old Caucasian male was admitted to the Emergency Department with a two-day history of abdominal pain associated with inability to pass gas or stool, nausea and vomiting. Physical examination revealed abdominal distention and abdominal pain without Blumberg’s sign. Abdominal contrast-enhanced computed tomography (CECT) showed small bowel obstruction caused by suspected MD. Laboratory tests reported high serum levels of glycemia, LDH, C-reactive protein and leukocytosis. After diagnosis of intestinal obstruction, the patient underwent exploratory laparotomy: a segmental resection of ischemic distal ileum bearing a necrotic MD was performed. The postoperative course of patient was uneventful.Clinical discussionMD is found in 2%–4% of the population in large autopsy and surgical series. MD is mostly asymptomatic and incidentally discovered if not complicated; a debate exist about management of asymptomatic MD. Surgery represents the definitive treatment of complicated MD.ConclusionMD is a true diverticulum rarely discovered in adults. Diagnosis of MD is difficult even with the help of radiological exams. Although surgical resection represents the correct treatment of symptomatic MD, nowadays there is no consensus on the optimal treatment of asymptomatic and incidentally discovered MD.     

Urachal anomalies: ultrasonography and management

Background: Fifty-six children with anomalies of the urachus remnant identified by ultrasound scan have been encountered in the authors’ hospital over the last 4 years.Methods Twenty of these 56 cases were symptomatic urachal remnants, whereas the urachus remnants were seen incidentally by ultrasound scanning in the other 36 patients. Symptomatic cases were treated with antibiotics or observation. Then, symptomatic cases were divided into 2 groups. One group, surgical group, was treated with surgical resection of the urachal remnant. The other group, observation group, was followed up without its surgical resection. Forty-four patients, 11 cases of symptomatic urachal remnant and 33 asymptomatic cases, were followed up, excluding patients who had surgical treatment and who were lost to follow-up.Results Thirty patients underwent periodical ultrasonographic examination during follow-up. In 9 cases, including 2 symptomatic cases, urachal remnants have disappeared during the follow-up period spontaneously. No symptom had developed during follow-up from asymptomatic cases.Conclusions The patients with asymptomatic urachal remnants do not require follow-up, and urachal remnants, especially those under 1 year of age, do not require surgical resection unless the patient has multiple episodes.     

Surgical management of Meckel's diverticulum in adults--retrospective analyses of 62 cases

Meckel's diverticulum (MD) is the most common congenital anomaly of the small intestine. We searched and analyzed the records of 62 cases with MD admitted in University Emergency Hospital Bucharest between 2001-2009. Sex ratio was M:F 3:1, with 74% male and 26% female. 51.6% (n = 32) of this where symptomatic and 48.4% (n = 30) asymptomatic, discovered during laparotomy for other reasons. The analysis highlights an increased frequency of symptomatic diverticulum at early ages, with a medium age of about 39.2 years comparing to asymptomatic group with a medium age of about 54.2 years. The diverticulum complication generated: occlusion--43.7% (n = 15), inflammation--37.5% (n = 12), bleeding, two cases of diverticulum tumor, an intussusception case and a perforation case with unknown object. 25% of the diverticulectomies were followed by postsurgery complications, the parietal suppuration being the most frequent (50%). Three patients died independent of the diverticulum or its resection, all three having an asymptomatic diverticulum. The difficult diagnosis and the seriousness of diverticulum complications force us to take into consideration DM in all cases of severe or chronic abdominal pain. The diverticulum has to be surgically removed to all patients under 50 years, especially men.     

Results of surgical treatment for pulmonary aspergilloma.

OBJECTIVES: The purpose of this retrospective study is to analyze the results of the surgical treatment for pulmonary aspergilloma and to confirm that aggressive surgical resection can provide effective outcome for these patients. PATIENTS AND METHOD: From 1987 to 2000, 110 patients underwent thoracotomy for treatment of pulmonary aspergilloma in two hospitals. The most common indication for operation was hemoptysis (82%). Underlying diseases were tuberculosis (89%), bronchiectasis (5%), carcinoma (3%), lung tumor (1%) and none (2%). The procedures were lobectomy (74%), segmentectomy (12%), wedge resection (9%), pneumonectomy (4%) and cavernoplasty in two patients. Twenty-nine patients (26%) had severe underlying intrathoracic pathologies. RESULTS: Postoperative complications occurred in 23.6% of the patients including: empyema (n=13), bleeding (n=6), respiratory insufficiency (n=2), wound infection (n=4) and bronchopleural fistula (n=1). There was one hospital death due to panperitonitis after gastric ulcer perforation. CONCLUSIONS: We recommend early surgical resection of symptomatic aspergilloma and even asymptomatic cases with reasonable complication.     

Symptomatic vitelline duct anomalies in children

A wide variety of anomalies may occur as a result of the vitelline duct (VD) failing to obliterate completely. Most reports on symptomatic VD focus on Meckel's diverticulum, while other anomalies are given little attention. A retrospective review was conducted at our institution. According to the records 18 symptomatic children with VD anomalies were seen over 22 years, including 10 boys and 8 girls aged 11 days -14 years (median 7.5 months). Twelve patients aged below 10 years (median 28 days) had patent vitelline ducts (PVDs), 3 children aged 13 months, 13 years and 14 years respectively had Meckel's diverticulum (MD), presenting as inflammation, tapeworm incarceration and volvulus respectively. Two patients, both 8 years old, had umbilical sinus, and a 3-year-old had a vitelline cyst. Only 1 patient with PVD had an associated anomaly (intestinal malrotation). The diagnosis of PVD was obvious clinically, but in 1 patient the fistula was demonstrated by fistulogram. The diagnosis of MD was intraoperative in all 3 patients. Treatment was by various types of resection for PVD and MD and excision for umbilical sinuses and cysts. One patient with PVD developed postoperative intestinal obstruction from adhesions, requiring re-laparotomy and adhesiolysis. Two patients with PVD died from sepsis and anaesthetic-related complications, respectively. Although MD is the most commonly VD anomaly, PVD is the most common symptomatic presentation in our environment.     

Surgical management of intestinal obstruction after treatment for cancer. Case reports.

Eighty-five consecutive patients operated on for malignant intestinal obstruction after earlier treatment of cancer were studied retrospectively. The overall postoperative mortality was 22% (19/85) and morbidity 42% (36/85). Intra-abdominal sepsis (N = 5) and intestinal fistula (N = 3) were the most common complications, and seven deaths were attributed primarily to the underlying malignant disease. Emergency procedures (p less than 0.003) and age greater than 70 years (p less than 0.025) were significantly associated with fatal outcome. Just over half of the patients were relieved of their symptoms. The median survival was 8 months for the 25 patients who underwent resection and 2 months for the 60 patients for whom no resection was made. The cumulative 5-year survival was significantly better for patients who underwent resection than for those who did not (p less than 0.01) and in patients with regional cancers compared with those with distant growths (p less than 0.001). We conclude that operative treatment for malignant intestinal obstruction is indicated if widespread carcinomatosis and extensive tumour growth are excluded and that this surgery should be done urgently while there is still time to resuscitate the patient.     

Multifaceted behavior of Meckel's diverticulum in children

Purpose/background

Meckel's diverticulum (MD) is one of the most common congenital malformations of gastrointestinal tract in children. However, the nonspecific clinical manifestations of MD often cause a diagnostic as well as therapeutic challenge to pediatric surgeon. This study aimed to review our experience in managing this disease while evaluating the management strategies.

Complications and management of Meckel's diverticulum--a review.

OBJECTIVE: To review the anatomy, symptomatology, diagnosis, complications and management of symptomatic and asymptomatic Meckel's diverticula. DESIGN: Retrospective study. SETTING: Teaching hospital, The Netherlands. SUBJECTS: 27 consecutive patients who underwent resection of a Meckel's diverticulum during the 16 year period 1 January 1981-31 August 1997. MAIN OUTCOME MEASURES: The symptomatology and histopathological findings. RESULTS: 15 patients had symptoms and 12 did not. Haemorrhage and inflammation were the most common presenting symptoms. All histopathological signs of inflammation were found in those with symptomatic diverticula. Resected asymptomatic Meckel's diverticula were abnormal in only two occasions: one contained an adenocarcinoma and one a faecolith. CONCLUSION: All symptomatic Meckel's diverticula should be resected. The surgical treatment of asymptomatic Meckel's diverticula is still controversial.     

结直肠肿瘤并急性肠梗阻的外科治疗

目的探讨结直肠癌并急性肠梗阻围手术期的处理方法。方法回顾性分析2006年6月至2011年6月收治的97例结直肠肿瘤致急性肠梗阻患者的临床资料。结果 97例均经手术治疗。右半结肠癌伴梗阻32例,其中30例行右半结肠一期切除,无吻合口漏发生,另2例癌肿不能切除行捷径手术;一期左半结肠切除肠吻合术15例,术后发生吻合口漏1例;Hartmann手术13例,术后恢复顺利,造口排便通畅,3～6个月后均进行了顺利关瘘手术;直肠癌Dixon手术27例,低位直肠癌行Miles术10例;行单纯肠造口6例。死亡1例。术后最常见的并发症为切口感染与肺部感染。结论对于结直肠癌并急性发肠梗阻,应根据患者的具体情况决定手术时机及手术方式,左半结肠癌合并肠梗阻可考虑一期切除吻合,但要注意吻合口漏。做好围手术期的处理是减少并发症、降低病死率的关键。     

放射性小肠炎并肠梗阻的外科治疗(附21例临床分析)

报告21例放射性小肠炎并肠梗阻的外科治疗结果。全部病例采用粘连肠段切除吻合术,其中2例行回肠端端吻合,术后并发吻合口瘘,保守治愈。19例行回肠与升结肠端侧吻合术,18例恢复良好,1例术后早期死于多器官功能衰竭。组织学检查符合放射性小肠炎病理特征。同时还重点讨论了放射性肠炎并肠梗阻的手术时机及方法,以及直肠癌放疗的选择、剂量和并发症的预防等有关问题。     

原发性腹膜后神经鞘瘤的外科治疗

目的 探讨原发性腹膜后神经鞘瘤的诊治与预后.方法 回顾性分析1995年1月至2009年12月北京大学第一医院诊治的47例原发性腹膜后良、恶性神经鞘瘤患者的临床资料.结果 良性神经鞘瘤36例,中位年龄41岁,体检发现25例,有症状者11例;恶性神经鞘瘤11例,中位年龄38岁,体检发现5例,有症状者6例.术前CT和MRI诊断阳性率分别为36.2%(17/47)和58.3%(7/12).免疫组化染色良性组S-100阳性率100%;恶性组S-100阳性者率81.8%(9/11).47例患者均行手术治疗,良性组手术切除率100%,恶性组手术切除率90.9%(10/11),两组均无围手术期死亡患者,术后并发症5例(10.6%).良、恶性神经鞘瘤术后5年生存率分别为100%与45.5%.良性组术后复发2例;恶性组术后复发4例,远处转移3例.结论 腹膜后神经鞘瘤确诊依靠病理及免疫组化检查,手术完整切除是治疗主要方法.良性神经鞘瘤预后良好,恶性神经鞘瘤易转移和复发.

Abstract：

Objective To explore the clinical diagnosis and surgical treatment of primary retroperitoneal neurilemoma (schwannoma). Methods Clinical data of 47 patients of primary retroperitoneal schwannoma admitted and surgically treated from January 1995 to December 2009 were retrospectivelly reviewed. Results As diagnosed by pathology there were 36 cases of Benign schwannoma,with a median age at onset of 41 years, among those 11 patients were symptomatic, and 25 were asymptomatic. There were 11 malignant 11 cases, the median age was 38 years, among those 6 patients were symptomatic, and 5 were asymptomatic. The positive diagnostic rate of preoperative CT and MRI were 36. 2％ ( 17/47 ) and 58. 3％ ( 7/12 ) respectively. Immunohistochemically positive rates of S-100 were 100％ and 81.8％ (9/11) in benign and malignant group respectively. All cases underwent surgical treatment. Surgical resection rates for benign and malignant groups were 100％ and 90. 9％ (10/11)respectively. There was no perioperative death, Overall 5-year survival rates were 100％ and 45.5％ for benign and malignant tumors groups respectively. In benign group 2 cases recurred, in malignant group 4 cases recurred, and 3 had distant metastasis. Conclusions Primary retroperitoneal schwannomas are less common. It is difficult to make an accurate preoperative diagnosis. Surgery is the most effective therapy.Prognosis is good for benign and poor for malignant retroperitoneal neurilemomas.     

Role of fenestration and resection for symptomatic solitary liver cysts

BACKGROUND: Symptomatic liver cysts can be managed surgically by fenestration or by hepatic resection. The present study was designed to investigate the current role of each surgical technique in the management of this benign condition. METHODS: Forty consecutive patients with symptomatic liver cyst (non-parasitic and non-malignant) surgically treated by fenestration or resection were identified from a prospectively collected database. An analysis of primary outcome measures including operative parameters, morbidity and mortality rates, length of postoperative stay and recurrence rates in months was carried out. RESULTS: The laparoscopic fenestration group had the best perioperative outcome. At median follow up of 20 months, there were no recurrences in the resection group but recurrence occurred in 6/27 (22%) in the fenestration group. Four of these recurrences were asymptomatic and were managed conservatively while two symptomatic recurrences required a resection. CONCLUSION: Laparoscopic fenestration is the best treatment for symptomatic liver cysts as the primary operation. It is associated with the lowest blood loss, lowest morbidity and shortest hospital stay. Liver resection is best reserved for recurrent symptomatic cysts and cystic lesions suspicious of tumours where it can be safely performed and associated with a zero recurrence rate.     

Giant Meckel’s diverticulum: An exceptional cause of intestinal obstruction

Meckel's diverticulum(MD) results from incomplete involution of the proximal portion of the vitelline(also known as the omphalomesenteric) duct during weeks 5-7 of foetal development. Although MD is the most commonly diagnosed congenital gastrointestinal anom-aly, it is estimated to affect only 2% of the population worldwide. Most cases are asymptomatic, and diagno-sis is often made following investigation of unexplained gastrointestinal bleeding, perforation, inflammation or obstruction that prompt clinic presentation. While MD range in size from 1-10 cm, cases of giant MD(≥ 5 cm) are relatively rare and associated with more severe forms of the complications, especially for obstruction. Herein, we report a case of giant MD with secondary small bowel obstruction in an adult male that was suc-cessfully managed by surgical resection and anasto-mosis created with endoscopic stapler device(80 mm, endo-GIA stapler). Patient was discharged on post-operative day 6 without any complications. Histopatho-logic examination indicated Meckel's diverticulitis with-out gastric or pancreatic metaplasia.     

Surgery for stage IV gastric cancer

BACKGROUND: Surgical treatment for stage IV gastric cancer is controversial. METHODS: We analyzed the surgical experience with advanced gastric carcinoma in a tertiary referral center in Mexico City from 1995 through 2000. We analyzed surgical morbidity, mortality, and factors associated with prognosis. Survival was analyzed with the Kaplan-Meier method, and the curves were compared with the log-rank test. Significance was assigned at P <0.05. RESULTS: Seventy-six cases were identified. Mean patient age was 56 +/- 14.5 years. Thirty-nine patients (51.3%) were women. Patients were grouped according to surgical procedure: group 1 underwent resection (40 patients), group 2 underwent bypass procedures (10 patients), and group 3 underwent either celiotomy and biopsy alone or jejunostomy placement (26 patients). Twenty patients (26%) developed operative complications, but most were minor. There was no difference in morbidity between surgical groups and no difference according to patient's age. Operative mortality was 2.6%. Good palliation of symptoms was significantly more common in group 1 patients (82%) than in group 2 patients (60%) (P = 0.0001). Median survival was 8 months (95% confidence interval 4 to 12) for the entire cohort and 13, 5, and 3 months for groups 1, 2, and 3, respectively (P = 0.00001 for group 1 vs groups 2 and 3). CONCLUSIONS: Surgical resection for stage IV gastric cancer can be done with low operative mortality and acceptable morbidity rates, and it provides patients with good symptomatic relief. Advanced patient age is not a contraindication for surgical treatment.     

腹腔镜下微波消融治疗肝血管瘤的临床研究

目的：研究腹腔镜下微波消融治疗有临床症状的、直径<10 cm肝血管瘤的临床疗效。 方法：收集2011年1月—2014年1月在华中科技大学附属同济医院住院治疗的145例肝血管瘤患者资料，其中腹腔镜下微波消融58例（腔镜消融组），手术切除87例（手术切除组）。分析两组手术及随访结果，评估治疗效果。 结果：两组术前一般资料具有可比性。腔镜消融组在手术时间、术中出血量、输血例数、术后并发症、术后住院时间等方面有明显优势（均P<0.05），症状消失情况与手术切除组相当。随访所有患者，病灶均无复发。 结论：对有症状、直径<10 cm的肝血管瘤采用腹腔镜下微波消融可以获得肯定效果，且具有安全、微创、并发症少等优点。     

Acute abdominal complications in bone marrow transplant recipients

Bone marrow transplant is currently the treatment of choice for a number of haematological neoplasms. High doses of antiblastic drugs, immunosuppressive agents and acute graft versus host disease before and after bone marrow transplant cause toxic damage to the liver and to the gastrointestinal tract. Related acute abdominal complications often need emergency surgical treatment with a 30-60% mortality rate. In these patients the surgical strategy is complex and hard to schematise. Ninety-one patients undergoing bone marrow transplantation showed acute abdominal symptoms requiring thorough surgical monitoring: 51 had ileocolitis, 17 pancreatitis, 9 cholangitis, 6 cholecystitis, 6 appendicitis, and 2 gastric perforation. Nine patients needed an emergency operation (2 gastroduodenal resections, 1 ileal resection, 2 right hemicolectomies, 2 total colectomies, 1 cholecystectomy and one appendectomy. The operative mortality was 22.2%. Positive blood cultures were quite frequent (63.7%). Moderate granulocytopenia was observed (neutrophils: 500 x mm3) in about 40% of cases, and severe granuloctopenia in only one patient (neutrophils: 100 x mm3) with ileotyphlitis. Moderate thrombocytopenia (PLTS < 50,000 x mm3) was observed in 43.9% of cases while in three cases (all submitted to surgical treatment) the platelet count was < 5,000 x mm3. The recent increase in bone marrow transplants has led to a progressive rise in the number of patients with acute abdominal complications. When deciding the surgical strategy in treating acute abdominal complications the surgeon must consider that surgical intervention is indicated only after unsuccessful medical treatment and that the intestinal segment involved must always be removed as far as possible; severe neutropenia, thrombocytopenia (< 10,000 x mm3) and positive blood cultures, especially for CMV, are unfavourable prognostic factors.     

Diagnosis,management, and outcomes of 115 patients with hepatic hemangioma

BACKGROUND: Hepatic hemangiomas are congenital vascular malformations and are the most common benign hepatic tumors. Because the use of cross-sectional imaging has increased, benign hepatic tumors, especially hemangiomas, are encountered more frequently, so clinicians should be familiar with the most appropriate diagnostic tests, management, and outcomes of patients with hepatic hemangioma. STUDY DESIGN: All patients with a primary diagnosis of hepatic hemangioma referred for surgical evaluation at our institution between January 1992 and December 2000 were identified from a prospective database. Demographics, presentation, tumor characteristics, diagnostic studies, surgical procedures, and outcomes were analyzed. RESULTS; Of 115 patients in the study, nearly half were asymptomatic. In symptomatic patients, abdominal pain or discomfort was the most common presenting symptom. At our institution, the diagnosis of hemangioma was established by ultrasonographic studies in 57% of patients tested, by CT scan in 73%, and by MRI in 84%. In patients with large tumors considered for resection, direct angiography or, more recently, CT angiography, confirmed the diagnosis in 27 of 29 patients (93%). Enucleation was performed in 31 (60%) of the 52 patients who underwent surgical resection; 63 patients were observed. Postoperative complications occurred in 13 patients (25%), and there were no perioperative deaths. Of the patients with symptoms before resection, 96% had resolution of symptoms after operation. CONCLUSIONS: Hepatic hemangioma can be diagnosed in most patients using noninvasive studies, particularly MRI. Hepatic hemangiomas can be removed safely if patients become symptomatic or when malignancy cannot be excluded. CT angiography can be a valuable preoperative study in patients with large tumors, and enucleation is the procedure of choice. In asymptomatic or minimally symptomatic patients, hepatic hemangiomas usually have a benign course and can be observed.