| Part ? Clinical characteristics and preoperative diagnosis of Meckel's diverticulumObjective:This study aimed to investigate the clinical manifestations,preoperative diagnosis,and surgical and pathological findings of Meckel's diverticulum,and to explore the reasonable preoperative evaluative modalities and diagnostic flowchart for patients of different ages and symptoms so as to improve the understanding and diagnosis of Meckel's diverticulum.Methods:The medical records of patients with clinically,surgically,and endoscopically confirmed Meckel's diverticulum,collected from the first affiliated hospital of Soochow University,Ruijin hospital affiliated to Shanghai Jiao Tong University School,and Suzhou hospital affiliated to Nanjing Medical University from January 2008 to January 2018,were reviewed to analyze the following information:age,gender,clinical presentation,laboratory examination,imaging modality,endoscopy,intraoperative findings,and pathologic findings.The data were analyzed using SPSS 18.0 for Windows.P<0.05 was considered statistically significant.Results:(1)Seventy-two patients with Meckel's diverticulum were enrolled in the study.The male-female ratio was 2:1 and the ratio of adults to children was 1.9:1.76.4%of patients with Meckel's diverticulum were aged 10 to 40 years.(2)Patients with gastrointestinal bleeding,which accounted for 70.8%(51/72),were more common in children,and patients with abdominal pain which accounted for 29.2%(21/72)were more common in adults(P<0.05).In patients aged more than 10 years,the frequency of Meckel's diverticulum with bleeding decreased,while the frequency of Meckel's diverticulum with abdominal pain increased,with age.(3)The course of disease was longer in patients with bleeding than in patients with abdominal pain,and the episodes in patients with bleeding were more(P<0.05).In the gastrointestinal bleeding group,patients with anemia accounted for 84.3%,with abdominal pain accounting for 25.5%,and 17.6%of the patients having predisposing factors.In the abdominal pain group,the pain located in the mid-lower abdomen and the periumbilical area in 85.7%of patients,and the pain was moderate or severe in 81%of patients.(4)The evaluative modalities of choice were related to patient's age and clinical symptoms.The use of technetum-99m pertechnetate scan was more common in pediatric patients than in adults,while the use of multi-slice spiral computed tomography(MSCT)was more common in adults than in pediatric patients(P<0.05).The use of double-balloon enteroscopy(DBE)was more common in patients with bleeding than in patients with abdominal pain.In addition,MSCT scanning protocols were different in different groups.Pediatric patients and patients with bleeding were more likely to use computed tomography angiography(CTA)or computed tomography enterography(CTE),adults were more likely to use unenhanced CT,and abdominal pain patients were more likely to use unenhanced CT or contrast-enhanced CT(P<0.05).(5)The diagnostic yield of CTE was higher than that of any other CT examinations(P<0.05).The diagnostic yield of CTE in patients with gastrointestinal bleeding was higher than that in patients with abdominal pain(P<0.05).In patients with undetected Meckel's diverticulum,the unenhanced CT scan had a high detection rate for complications of Meckel's diverticulum(P<0.05).(6)The diagnostic yield of the three most commonly used evaluative modalities was in the following order:DBE>CTE>capsule endoscopy(P<0.05).Conclusions:(1)In general hospitals,the number of adult patients with Meckel's diverticulum is about twice as that of pediatric patients,and patients aged 10-40 years are the most common.(2)Differences exist in the clinical characteristics and the preoperative examinations of choice between pediatric and adult patients.A reasonable diagnostic flowchart should be selected in patients of different ages and clinical presentations.(3)The high-to-low sequence of preoperative diagnostic yield is DBE,CTE,and CE.The diagnostic yield of CTE is higher than that of any other CT examinations,which should be selected preferentially.Part II Multi-slice spiral CT manifestations of Meckel's diverticulum and factors influencing the detectionObjective:This study aimed to investigate the multi-slice spiral computed tomography(MSCT)manifestations of Meckel's diverticulum with complications and the factors influencing the CT detection of Meckel's diverticulum.Methods:Eighty-one MSCT examinations of 64 patients with Meckel's diverticulum were retrospectively analyzed.The following features of Meckel's diverticulum were recorded:location,size,distention degree,dominant contents,tissues around the diverticulum,wall thickness,enhancement,soft tissue nodules,and independent artery of the diverticulum if present.The following factors that might influence the MSCT detection of Meckel's diverticulum were also recorded:examination technology,image quality,intraperitoneal fat,degree of intestinal distention,diagnosis of other examinations,and MSCT features of diverticulum.Results:(1)Of 64 patients,26(40.6%)had Meckel's diverticulum diagnosed in the MSCT original report and 56(87.5%)in the retrospective analysis.The detection rate in the retrospective analysis was higher than that in the original report(P<0.05).(2)The most common location of Meckel's diverticulum was the right lower abdomen(62.5%),followed by midline lower abdomen(19.6%).The location of diverticulum in MSCT was related to the distance between diverticulum and ileocecal valve(P<0.05).(3)Of 56 detected diverticula,25(44.6%)were located at the antimesenteric border of distal ileum.The diverticula with thickening wall,soft tissue nodule,and independent artery accounted for 67.9%,16.9%,and 35.7%,respectively.(4)For 97.6%of the Meckel's diverticula with bleeding,signs of intestinal hemorrhage could not be detected in MSCT.In five patients with acute diverticulitis,the wall of diverticulum thickened and enhanced with mesenteric inflammatory changes.Intraperitoneal free gas was detected in one diverticulum with perforation.In six of eight patients,intestinal obstruction was caused by intestinal adhesion with or without an internal hernia.Of four inverted diverticula,two manifested as an intraluminal mass with obvious enhancement on MSCT,and the other two resulted in intussusception with a lesion of fat attenuation detected in the intussusception.(5)Nine factors were related to MSCT detection of Meckel's diverticulum,including thin-layer image,multiplanar reformation,maximum intensity projection,intravenous contrast material,degree of intestinal distention,intestinal homogeneity,intraperitoneal fat,tissues around the diverticulum,and enhancement of the diverticulum.(6)By multivariate double logistic regression analysis,the factors contributing to MSCT detection of Meckel's diverticulum were abundant intraperitoneal fat and obvious enhancement of diverticulum.The maximum Yoden index of multivariate regression model was 0.541.The corresponding sensitivity,specificity,accuracy,positive predictive value and negative predictive value were 80.8%,73.3%,78.6%,66.9%,85.1%,respectively.The area under the receiver operating characteristic curve was 0.831.Conclusions:(1)In a retrospective analysis,MSCT could detect Meckel's diverticulum in up to 87.5%of patients.MSCT could display the characteristics of Meckel's diverticulum and its complications well.(2)Many factors influenced the MSCT detection.Adequate intestinal preparation and MSCT reconstruction techniques are of great value in detection.Part ?:Classification of CT enterography of Meckel's diverticulum and its clinical significanceObjective:This study aimed to establish a classification system of Meckel's diverticulum on computed tomography enterography(CTE)and explore the clinical significance of the classification.Methods:Data of 42 patients with surgically and pathologically confirmed Meckel's diverticulum who underwent a CTE examination were retrospectively analyzed.According to the length-width ratio of the diverticulum,the wall thickness,and the presence of soft tissue nodules,the CTE appearance of Meckel 's diverticulum was classified into three types.Type ?:The diverticular wall was thin,smooth without soft tissue nodule.Type ?:The diverticular wall was thickened,irregular without soft tissue nodule.Type ?:One or multiple soft tissues existed in the diverticulum with or without thickened wall.Furthermore,each type was subclassified into two subtypes.Subtype a:The outline of diverticulum was tubular or appendix-like shape with a ratio of length to basal width? 3:1;Subtype b:The outline of diverticulum was cystic or pouch-like shape with a ratio of length to basal width<3:1.The complications and pathological findings in different types were analyzed.Results:(1)The length and basal width of Meckel's diverticulum in 42 patients were 5.2±2.3cm(2-16 cm)and 1.9±1.0cm(0.9-6 cm)respectively,and the length-width ratio was 3.0±1.3(1-7).(2)The Meckel's diverticulum in different CTE types was classified as follows:9 patients(21.4%)with type ?(3 with type ? a and 6 with type ? b),22(52.3%)with type ?(13 with type ?a and 9 with type ?b),and 11(26.2%)with type ?(6 with type?a and 5 with type ?b).No statistically significant difference was found in the number of two subtypes in each type(P>0.05).(3)Compared with the diverticulum in types ? and type ?,the diverticulum in type ? had less enhancement(P<0.05).(4)Type ?diverticulum was more likely to have an independent artery than type ? diverticulum and was more prone to have chronic inflammation than types ? and type ? diverticulum(P<0.05).(5)Type ? diverticulum was more prone to have ectopic tissue than type ? and type ? diverticulum.Conclusions:(1)Classification of CTE can reflect the imaging characteristics of Meckel's diverticulum and help radiologists to standardize the description of Meckel's diverticulum.(2)CTE classification can help improve the preoperative detection of ectopic tissue in the diverticulum and the proper selection of surgical procedures. |
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