Novel technique for treating intussuscepted intestinal Meckel’s diverticulum: enteroscopic intestinal diverticulum dissection (EIDD)

Meckel’s diverticulum is a well-described anomaly of the small intestine caused by the incomplete closure of the omphalomesenteric or vitelline duct. It generally does not cause any symptoms [1]. Treatment is usually performed for complications, the most serious being gastrointestinal bleeding. Traditional treatments including diverticulum exclusion, varus suture, simple resection of the diverticulum, and partial resection of the small intestine, are traumatic [2] [3]. Enteroscopic surgery is a recently developed treatment modality. Herein, we report on a novel technique, called enteroscopic intestinal diverticulum dissection (EIDD) ([Fig. 1]), for treatment of intussuscepted intestinal Meckel’s diverticulum.

Fig. 1 Illustration of the enteroscopic intestinal diverticulum dissection (EIDD) technique. The procedure is performed with the patient under general anesthesia with endotracheal intubation. Prophylactic intravenous antibiotics are introduced 30 minutes before the procedure. A transparent cap is attached to the tip of the gastroscope and carbon dioxide is used routinely during the procedure. The EIDD procedure includes 5 steps. a, b Step 1 – The diverticulum is located. The structure is examined carefully, including the head, body, and base of the intussuscepted diverticulum, especially the surface mucosa, umbilicus-like depression, and the structure inside the diverticulum, and whether there is heterotopic mucosa or intestinal wall structure. c Step 2 – An endoloop is positioned at the base of the stalk to block the blood vessels in the root while preventing perforation. d, e Step 3 – Snare diverticulectomy. The resection is performed using a combination of endocut and forced coagulation current (mainly forced coagulation); electrocoagulation is applied initially as forced coagulation and then in endocut mode, so that the current can conduct and coagulate the distal vessels. f Step 4 – Several metallic clips are placed above the endoloop to prevent post-resection bleeding. Step 5 – Tumor extraction. By using a snare, the diverticulum is retrieved from the intestine.

A 30-year-old woman complained of tenderness in the lower abdomen. Contrast-enhanced computed tomography showed a long intussuscepted diverticulum. Double-balloon enteroscopy at our hospital located a 10-cm pedunculated mass protruding into the intestinal cavity, with an umbilicate depression at the center of the head of the mass. Two metallic clips were placed at the base of the diverticulum for future location. Two weeks later, symptoms remained and the patient opted for endoscopic treatment. The EIDD technique, which is applied in large pedunculated polyps, was performed and complete resection of the diverticulum was achieved, thus avoiding surgery ([Fig. 2], [Video 1]). The postoperative course was uneventful. The patient was discharged 3 days after enteroscopic surgery. Her symptoms resolved completely during follow-up.

Fig. 2 Enteroscopic intestinal diverticulum dissection for the treatment of occult gastrointestinal bleeding caused by intussuscepted Meckel’s diverticulum in a 30-year-old female patient. a Computed tomography showed a sheath-like structure. b, c Visualization of an inverted Meckel’s diverticulum 100 cm from the ileocecal valve. d Location site. e The endoloop around the stalk. f Snare diverticulectomy. g Diverticulum inversion. h Hemoclips at the stalk. i Finger-like specimen: 7 × 2 × 2 cm in size.

Video 1 Enteroscopic intestinal diverticulum dissection for the treatment of intussuscepted Meckel’s diverticulum in a 30-year-old female patient, with successful therapeutic double-balloon enteroscopy and an operative time of 40 minutes. The morphology showed a finger-like mass, 7 × 2 × 2 cm in size. Histologic examination showed that the diverticulum was composed of heterotopic pancreatic tissue.

When considering EIDD, we should ensure that the diagnosis is clear preoperatively to exclude intestinal duplication, polyp, submucosal tumor, or intestinal wall varus. Standardization of the procedure should be established by constant accumulation and review of experience, including choice of instruments, method of resection, suture techniques, and so on. In this way, enteroscopic treatment can maintain intestinal integrity and lead to rapid healing, free of postoperative adverse events, especially anastomotic complications. Further clinical studies with a larger number of patients are necessary to confirm this hypothesis.

Endoscopy_UCTN_Code_TTT_1AP_2AD

Competing interests

The authors declare that they have no conflict of interest.

Acknowledgement

This study was supported by grants from the National Natural Science Foundation of China (81902394), Shanghai Dawnlight program (20CG07), and Excellent Young Scholar Foundation of Zhongshan Hospital (2021ZSYQ08).

• References

• 1 Park JJ, Wolff BG, Tollefson MK. et al. Meckel diverticulum: the Mayo Clinic experience with 1476 patients (1950–2002). Ann Surg 2005; 241: 529-533
• 2 Takagaki K, Osawa S, Ito T. et al. Inverted Meckel’s diverticulum preoperatively diagnosed using double-balloon enteroscopy. World J Gastroenterol 2016; 22: 4416-4420
• 3 Uchiyama S, Sannomiya I, Hidaka H. et al. Meckel diverticulum diagnosed by double-balloon enteroscopy and treated laparoscopically: case report and review of the literature. Surg Laparosc Endosc Percutan Tech 2010; 20: 278-280

Publication History

Article published online:
21 December 2021