A retrospective study was conducted in the Department of Paediatric Surgery after approval from the Institutional Ethical Committee (No. Dean/2015-16/EC/362). The study was conducted from January 2012 to December 2019 using the case records of the patients. The study included all the children of age less than 12 years who were managed for complications of MD or those in which MD was found incidentally during laparoscopy or laparotomy for some other abdominal condition. The patients were divided into two groups: Symptomatic Group and Incidental Group based on above criteria. The case records of all the patients were reviewed for demographic profile of the children, indication of surgery, surgical procedures performed, postoperative complications and follow-up. The children in which the case records were missing for above details were excluded from the study. In present study, incidentally diagnosed group and asymptomatic group was same.

Ethical approval: All procedures performed in studies involving human participants were in accordance with the Ethical standards of the Institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Statistical analysis was performed using the IBM Statistical Package for the Social Sciences (SPSS) 19.0 Statistics for Windows software (IBM Corp., Armonk, NY). Data were expressed as Mean±SD (Standard Deviation). Data were tested for normality by using Kolmogorov-Smirnov test. Chi-square test was used to test the association between the variables. The p-value <0.05 was considered to be statistically significant.

Total 132 patients were included in the study, out of which 56.06% (74) were symptomatic and 43.9% (58) were asymptomatic. The mean age of symptomatic patients was 3.1±.1.1 years and the asymptomatic group was 6.5±2.4 years. It was significantly less in the symptomatic group (p≤0.001). The gender ratio of the two groups was similar with a slight male preponderance in both the groups [Table/Fig-1].

Histopathological records were available for 35 patients of the symptomatic group and 42 patients of the asymptomatic group. Only ectopic gastric mucosa was found in present study. The incidence of ectopic mucosa was significantly higher in symptomatic group compared to the asymptomatic group [Table/Fig-1].

In 9 (15.5%) of asymptomatic patients (n=58) a diverticulectomy was performed [Table/Fig-2]. All these cases were diagnosed during laparoscopy and were associated with Meckel’s band. None of these patients had any complication in postoperative period. In rest 49 cases, only the primary procedure was performed either by laparoscopy or laparotomy and no intervention was done for MD. Out of 49 asymptomatic patients of MD without intervention for MD, 6 (12.2%) patients presented with complications like haemorrhage or diverticulitis at follow-up. The median duration of this presentation was 3 years (range 2-6 years). On subgroup analysis of the patients with age less than 4 years, size of MD <2 cm and male gender had significantly higher chances of presenting later with complications [Table/Fig-3].

The most common presentation in the symptomatic group (n=74) was acute intestinal obstruction [Table/Fig-4] followed by obstruction, haemorrhage, recurrent pain and perforation peritonitis [Table/Fig-2]. All the patients with symptomatic MD were managed by laparotomy. Diverticulectomy was performed in 8 (10.8%) patients, Wedge resection 10 (13.5%) cases. Resection of the ileal segment with ileo-ileal anastomosis was performed in 44 (59.4%) patients. About 12 (16.2%) patients were managed by a diversion in the form of ileostomy due to underlying gangrene and haemodynamic instability and diverticulectomy. Out of these, 3 (4.05%) patients developed a postoperative anastomotic leak in the resection group and all underwent relaparotomy. An ileostomy was used in two and resection and anastomosis in the other patient. About 16 (21.6%) patients with laparotomy presented with an adhesive obstruction within a median follow-up of 4.5 years (range 2-6 years). Out of this 11 (68.7%) had resection and anastomosis and in 5 (31.2%) cases had segmental resection of MD.

[Table/Fig-4]:

Meckel’s Diverticulum (MD) presenting with band obstruction. Black arrow indicating the MD.

The MD is the most common congenital anomaly of the small bowel. Its prevalence varies from 5-25% and the incidence of symptoms in patients with a MD can range from 4-34% [7,8]. The male-female distribution of asymptomatic cases is same but it is around four-time more common in males than females in among the symptomatic cases [9]. In present study, the male cases dominated both in the symptomatic and asymptomatic group. The proportion of symptomatic cases decreases with the highest risk of complication in infants and children. Overall, around 50% of symptomatic cases occur in children in less than 2 years of age [8,10].

In children, the higher rate of morbidity and mortality is reported in symptomatic cases compared to asymptomatic [11,12]. In a systematic review of 244 retrospective studies, Zani A et al., found that the resection of incidentally discovered MD had a significantly higher postoperative complication rate in comparison to those in which it was left in-situ. The present study concluded that incidentally diagnosed cases of MD should be left as this reduces the risk of postoperative complications and does not alters the rate of late complications [3]. But in retrospective review of 76 patients with Zulfikaroglu B et al., found that the resection of incidentally discovered MD was not associated with increased operative morbidity and mortality [4]. Similarly, other studies have highlighted different criteria, that in presence of like male sex, younger than 45 years, diverticula longer than 2 cm and the presence of a fibrous band, should be resected [13].

The most common presentation in present study for symptomatic cases was obstruction compared to bleeding in series from some western countries [9,12]. We hypothesise that acute cases of bleeding may be misdiagnosed in our setup or these children die even before reaching hospital as most of the patients were from poor social background.

All symptomatic complicated MD require surgical resection but the procedure of choice is controversial. The procedure range from simple diverticulectomy in cases with no ectopic mucosa, wedge resection in cases with heterogeneous consistency on palpation to resection and anastomosis [14-16]. In the present study, resection was performed in maximum cases as most of the cases presented with long standing obstruction. The condition of bowel near the diverticula was unhealthy in most of these cases.

The incidence of complication varies with the prevalence of ectopic mucosa in the MD. The gastric mucosa is associated with highest rate of complication. The gastric mucosa may be responsible for ulceration and a higher incidence of bleeding. The incidence of the gastric mucosa is estimated at about 16% in asymptomatic and 50-80% in symptomatic MD [17,18]. In present study also, the ectopic mucosa was higher in symptomatic cases compared to asymptomatic cases.

There has been long standing debate on management of asymptomatic MD. Most studies favour excision of asymptomatic Meckel’s in younger children. With the advent of laparoscopy this indication is expanding. As the most common complication in follow-up in most series is adhesive obstruction and with more and more laparoscopic procedures, this number is decreasing [18,19]. Further, six of the cases in which Meckel’s was left in-situ, presented with complications later. The complications of adhesive obstruction were slightly more in resection group but there was no statistical difference for the excision or wedge resection group. Ileostomy was performed in cases with widespread intra-abdominal infection or marked oedema of the intestinal wall.

The retrospective nature of the study was the main limitation.

The rate of late complications in asymptomatic incidentally diagnosed MD was higher in males with age less than four years and diverticulum of size more than 2 cm. Laparoscopic diverticulectomy should be performed in these cases.