|Year : 2019 | Volume
| Issue : 6 | Page : 201-206
Demography of the remnant of omphalomesenteric duct
Dinesh Kumar Barolia, Aditya Pratap Singh, Ramesh Tanger, Arun Kumar Gupta, Vinita Chaturvedi, Neeraj Tuteja
Department of Pediatric Surgery, SMS Medical College, Jaipur, Rajasthan, India
|Date of Submission||26-Jan-2019|
|Date of Decision||18-Feb-2019|
|Date of Acceptance||27-May-2019|
|Date of Web Publication||05-Dec-2019|
Dinesh Kumar Barolia
Barolia Bhawan, Srimadhopur, Sikar, Rajasthan
Source of Support: None, Conflict of Interest: None
Introduction: Pediatric surgeons dealt with cases of omphalomesenteric duct remnants, which presented with various symptomatic patterns. Meckel's diverticulum was the most common remnant in this study, which presented with different signs and symptoms. The aim is to study the various remnants of omphalomesenteric duct with their presenting symptoms and to introduce a new variant of patent vitellointestinal duct (PVID) and describe how to treat these variants of omphalomesenteric duct.
Materials and Methods: This is a retrospective study conducted in 132 neonates and children (102 male and 30 female), who were operated at our institute and containing persistent omphalomesenteric duct and its derivatives. This study was conducted from January 2017 to June 2018 at our institute. This study analyzed the presenting sign and symptoms of various remnants of omphalomesenteric duct. The study analysis was based on the following parameters – age, sex, sign, symptom, investigation, operative finding, and postoperative complications.
Results: In this study, male-to-female ratio was 3.4:1. Meckel's band obstruction was the most common presentation (n = 48, 36.36%), while umbilical cyst (n = 1, 0.75%) and umbilical sinus were least commonly present (n = 1, 0.75%) in all remnants of omphalomesenteric duct. We found a new variant of PVID, which presented with an intact omphalomesenteric duct, but the umbilical end was obliterated. This variant had not been included or reported in literature.
Conclusion: Omphalomesenteric duct remnants are presenting with various sign and symptoms, like intestinal obstruction, umbilical discharge, umbilical swelling, pain abdomen etc. A new variant of PVID is named end- obliterated PVID reported here, may present with features of intestinal obstruction.
Keywords: Intestinal obstruction, Meckel's band, Meckel's diverticulum, mesodiverticular band, omphalomesenteric duct, patent vitellointestinal duct
|How to cite this article:|
Barolia DK, Singh AP, Tanger R, Gupta AK, Chaturvedi V, Tuteja N. Demography of the remnant of omphalomesenteric duct. Formos J Surg 2019;52:201-6
|How to cite this URL:|
Barolia DK, Singh AP, Tanger R, Gupta AK, Chaturvedi V, Tuteja N. Demography of the remnant of omphalomesenteric duct. Formos J Surg [serial online] 2019 [cited 2020 Jan 27];52:201-6. Available from: http://www.e-fjs.org/text.asp?2019/52/6/201/272314
| Introduction|| |
Omphalomesenteric duct is a connecting pathway between yolk sac and mid-gut during intrauterine life. This omphalomesenteric duct usually becomes obliterated and separated from the mid-gut between 5th and 9th weeks of gestation., Partial and complete failure of involution in the omphalomesenteric duct may lead to persistent vitelline duct, Meckel's diverticulum, omphalodiverticular band, mesodiverticular band, Meckel's cyst, umbilical sinus, and umbilical polyp. This is a retrospective study conducted in 132 neonates and children (102 male and 30 female) [Table 1], who were operated at our institute and containing persistent omphalomesenteric duct and its derivatives. Out of 132 cases, 18 cases were found incidentally in surgery for nonrelated causes. Omphalomesenteric duct and its derivatives present with various symptoms or without symptoms. Sometimes, Meckel's diverticulum was found incidentally in addition to appendicitis or omphalocele minor. Patent vitellointestinal duct (PVID) was also found with hernia of the umbilical cord, and everted PVID was also found with hernia of the umbilical cord [Figure 1]h.
|Figure 1: (a) Incidentally found Meckel's diverticulum in case of appendicitis. (b) Mesodiverticular band with gangrenous Meckel's diverticulum. (c) Omphalodiverticular band. (d) Resected Meckel's diverticulum with Meckel's band. (e) Umbilical polyp. (f) Patent vitellointestinal duct. (g) End obliterated patent vitellointestinal duct. (h) Patent vitellointestinal duct in hernia of umbilical cord|
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| Materials and Methods|| |
This study included all patients who were operated for symptomatic omphalomesenteric duct remnants or which were found incidentally during surgery for other reasons. This study was done at single institute. This study was conducted from January 2017 to June 2018. A detailed history, thorough clinical examination, and all needed investigations were performed in each case. Clinical history regarding umbilical discharge, vomiting, abdominal distension, and excessive cry history was taken at the time of admission. Vital signs, hydration status, abdominal distension, visible bowel loops, any fecal discharge over umbilicus, tenderness, guarding, rigidity, and free fluid in the peritoneum cavity were noted through clinical examination. Systemic examination of the cardiovascular system, respiratory system, and central nervous system was done.
| Results|| |
This is a study of various remnants of omphalomesenteric duct. The study was done in 132 cases in which 17 cases were neonates. The average age of Meckel's band obstruction was 5 years 6 months. The average age of Meckel's diverticulum presentation was 3 years 9 months.
Forty-eight (43 males and 5 females) cases were presented with Meckel's band obstruction in this study. The total cases of Meckel's diverticulum in this study were 31 (20 males and 11 females). Cases of PVID in this study were 17 (13 males and 4 females) and 34 (25 males and 9 females) cases were presented with umbilical polyp. One female umbilical sinus and one male umbilical cyst case were included in this study.
| Discussion|| |
Omphalomesenteric duct is also known as vitellointestinal duct or vitelline duct or omphaloenteric duct. In early fetal life, mid-gut communicates with yolk sac through omphalomesenteric duct. This duct gradually reduces in size and becomes obliterated., Aberration in normal obliteration of omphalomesenteric duct leads to various remnant formation.
It is the fibrous remnant of omphalomesenteric duct. Meckel's band can be classified into two variants. (a) Mesodiverticular band: It is the remnant of vitelline artery. It connects the tip of Meckel's diverticulum to retroperitoneum [Figure 1]b. Its incidence is 5% in the patients of Meckel's diverticulum. Mesodiverticular band causes intestinal obstruction by direct compression of bowel or internal hernia formation through snare-like opening formed by mesodiverticular band., (b) Omphalodiverticular band: This fibrous band connects the Meckel's diverticulum to umbilicus [Figure 1]c. Presenting symptoms of Meckel's band obstruction were bilious vomiting and gradual abdominal distension. There was coffee-colored nasogastric suction content in case of obstruction, leading to gangrenous gut.
There were 48 cases of Meckel's band obstruction in our study. Of 48 cases, 39 cases showed mesodiverticular band obstruction and nine cases showed omphalomesenteric band obstruction [Table 2]. Treatment options of Meckels band obstruction are exploratory laparotomy and band release, band release with resection of meckels diverticulum [Figure 1]d and ileoileal anastomosis.
It is the most common remnant of omphalomesenteric duct. Wilhelm Fabricius Hildanus was a German surgeon, who described first about the diverticulum in 1598. It was named after Johann Friedrich Meckel, who reported its anatomy and embryology in 1809. It is a true diverticulum because it has all three embryonic layers; ectoderm, mesoderm and endoderm., It is the most common congenital anomaly of the small bowel. It is asymptomatic most commonly. It present in 2% of population, 2 feet proximal to ileocecal junction, 2 inches in length, 2 times more common in boys. If it becomes symptomatic, it presented before 2 years of age and contains 2 types (gastric and pancreatic) of heterotypic mucosa. The average age of symptomatic Meckel's diverticulum in our study was 5 years 6 months.
Meckel's diverticulum can present with gastrointestinal bleeding, intestinal obstruction, perforation, and volvulus. In this study, eight cases of Meckel's diverticulum found incidentally in surgery for other reason [Figure 1]a (5 cases of appendicitis, 2 cases of omphalocele minor, and 1 case of umbilical hernia) [Table 3]. Twenty-one cases of Meckel's diverticulum commonly present with intestinal obstruction in this study. The most frequent complications of Meckel's diverticulum are hemorrhage and diverticulitis. Intestinal obstruction is the second most common complication of Meckel's diverticulum., Our study showed that intestinal obstruction is the most common complication of Meckel's diverticulum in pediatric age group.
Patent vitellointestinal duct
PVID is a complete patency of omphalomesenteric duct. PVID is the persistent omphalomesenteric duct which connects the mid-gut to the umbilicus. It is the rarest remnant of omphalomesenteric duct. Our study showed that the least common remnant of omphalomesenteric duct is umbilical cyst and umbilical sinus. PVID commonly presents with umbilical feculent discharge as presented in 11 cases of this study [Figure 1]f. Sometimes, ileum prolapsed through PVID. In our study, we found a case of prolapsed PVID itself in case of hernia of umbilical cord [Table 4]. This is a rare association. We found a case of PVID which presented with intestinal obstruction. On exploration, there was patent urachus along with PVID. PVID associated with patent urachus presenting with intestinal obstruction is an extremely rare case. PVID was treated by complete excision of tract and either wedge resection or end-to-end ileoileal anastomosis.
Umbilical polyp is a rare malformation. It arises from umbilical end remnant of the omphalomesenteric duct [Figure 1]e. Umbilical stump shed off between 5 and 15 days of life. After this, raw surface become covered by normal skin. Sometimes, raw area bleeds easily and forms the polyp-like structure. Distal persistent part of omphalomesenteric duct toward umbilicus present as discharging umbilicus, through polyp-like lesion. Histopathology of the umbilical polyp derived from omphalomesenteric duct showed intestinal mucosa, villi, and intestinal glands., There are 34 cases of umbilical polyp in our study. In case of umbilical polyp, complete evaluation was required to rule out PVID, umbilical sinus, and patent urachus. Because umbilical polyp may be the only finding in clinical examination of PVID, umbilical sinus, and patent urachus. Final diagnosis may confirm after ultrasonography of abdomen., Umbilical polyp was treated by surgical excision and electrocauterization.
It is the umbilical side patent partially obliterated toward intestine, omphalomesenteric duct remnant, lined by intestinal epithelium. It is a rare remnant. We found only one case of umbilical sinus in our study. It present with mucopurulent discharge from umbilicus. There is no evidence of feculent discharge through umbilical sinus. It needs exploratory laparotomy and excision of whole tract of umbilical sinus along with fibrous band connecting to small bowel if present.
Umbilical cyst or omphalomesenteric cyst
It is the cystic presentation of omphalomesenteric duct after obliteration at enteric and umbilical end. Nix and Young classified it as a remnant of omphalomesenteric duct. Excision of cyst and fibrous band is the treatment of choice.
End-obliterated patent vitellointestinal duct
It is a new variant of PVID found in this study. It was just like PVID, but there was no patency at umbilicus [Figure 1]g. The enteric end was patent and distal end of that was obliterated at umbilicus [Figure 2]. End-obliterated PVID was connecting the small bowel to the umbilicus. It was lined by intestinal mucosa. We found two cases of this type with intestinal obstruction. It may be due to arrested obliteration of omphalomesenteric duct in early stage. It is treated by wedge resection or end-to-end ileoileal anastomosis after excision.
|Figure 2: Pictorial presentation of various omphalodiverticular remnants|
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Intestinal obstruction is the most serious complication due to the remnants of omphalomesenteric duct. Reported different mechanism of intestinal obstruction due to omphalomesenteric remnants are (a) bowel entrapped by mesodiverticular band, (b) axial rotation and volvulus of gut over mesodiverticular band and Meckel's band, (c) intussusceptions lead by Meckel's diverticulum, (d) adhesion formation by inflamed and gangrenous Meckel's diverticulum.,
In this study, of 132 cases, 74 cases presented with intestinal obstruction. Intestinal obstruction in our study was found to be due to Meckel's diverticulum with mesodiverticular band (29 cases), Meckel's diverticulum with mesodiverticular band with gangrene gut (8 cases), Meckel's diverticulum with mesodiverticular band with volvulus with gangrene gut (2 cases) [Table 5], Meckel's diverticulum with omphalodiverticular band with volvulus (1 case), Meckel's diverticulum with omphalodiverticular band with appendicitis (2 cases), Meckel's diverticulum with omphalodiverticular band obstruction (6 cases) [Table 6], inflamed Meckel's diverticulum (6 cases), perforated Meckel's diverticulum (3 cases), gangrenous Meckel's diverticulum (4 cases), Meckel's diverticulum in intussusceptions (7 cases), Meckel's diverticulum with appendicitis (3 cases), Meckel's diverticulum with ileal atresia (1 case) [Table 7], and end-obliterated PVID (2 cases) [Table 8].
|Table 5: Intestinal obstruction in cases of mesodiverticular band, (n=39)|
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|Table 6: Intestinal obstruction in cases of omphalodiverticular band, (n=9)|
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|Table 7: Intestinal obstruction in cases of Meckel's diverticulum, (n=24)|
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|Table 8: Intestinal obstruction in cases of new variant of patent vitellointestinal duct, (n=2)|
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| Conclusion|| |
This retrospective study of 132 neonates and children (102 male and 30 female) have finding with Omphalomesenteric duct remnants, operated at our single institute. Study showed that most common remnant is meckels diverticulum and commonly present with intestinal obstruction.
Umbilical sinus and umbilical cyst are least common remnant of omphalomesenteric duct. We are reporting here a new variant of PVID named end-obliterated PVID [Figure 1]g. It is characterized by patent omphalomesenteric duct with obliterated umbilical end. Pictorial presentation of end-obliterated PVID is shown in [Figure 2].
Declaration of patient consent
The authors certify that they have obtained all appropriate guardians' consent forms. In the form the guardians have given their consent for the images and other clinical information to be reported in the journal. The guardians understand that the names and initials will not be published and due efforts will be made to conceal their children's identity, but anonymity cannot be guaranteed.
We acknowledge Dr. Neelam Dogra, Senior Professor, Department of Anaesthesia, SMS Medical College Jaipur, Rajasthan, India.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]