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Vitelline artery remnant causingintestinal obstruction in an adultAikaterini T. Michopoulou, MD, FRCSEd,a Stylianos S. Germanos, MD,b

Anestis P. Ninos, MD, FRCSEd,a and Stephanos K. Pierrakakis, MD,a Athens, Greece

From the Department of General Surgery, Thriassio General Hospitala and Patission General Hospital,b

Athens, Greece

Figure. Band (arrow) extending from the tip of theMeckel’s diverticulum (:) to the mesoileum near theappendix (*). Obstructed loops of ileum are reducedand are slightly dusky in appearance but viable.

A 35-YEAR-OLD MAN presented to our hospital with a12-hour history of severe central abdominal pain ofacute onset, nausea, and vomiting. He had no his-tory of any abdominal surgery in the past but com-plained of rare episodes of self-limiting epigastricand periumbilical pain for years.

Physical examination revealed a diffusely tenderabdomen with generalized rebound tenderness. Thewhite cell count was elevated at 12. 2 3 109/L, andC-reactive protein was 40 mg/L. An abdominal x-raywith the patient standing upright revealed dilatedloops of small bowel with multiple air-fluid levels.

At emergency laparotomy, the patient was foundto have small bowel obstruction, caused by trap-ping of ileal bowel loops by a band tethering aMeckel’s diverticulum to the ileal mesentery(Figure). The intestine proximal to the obstructedloops was distended and that distal to the band wascollapsed. After reduction, the trapped ileum wasproven to be nonischemic and was functional.The Meckel’s diverticulum measured 7 cm inlength and 4 cm in diameter, and a mass was palpa-ble at the apex. A diverticulectomy was performedwith a linear stapler, and the cord structure was li-gated and divided near the mesoileum. On patho-logic examination, the presence of heterotopicgastric, colonic and pancreatic tissue was noted atthe tip of the Meckel’s diverticulum. The patientmade an uneventful postoperative recovery.

DISCUSSION

Persistent omphalomesenteric or vitelline arteryis among the rarer conditions that are encountered

d for publication June 14, 2012.

requests: Aikaterini T. Michopoulou, MD, FRCSEd,ent of General Surgery, Thriassio General Hospital,s Genimata, Magoula, Athens 19018, Greece. E-mail:michopoulou@hotmail.com.

2013;154:1137-8.

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x.doi.org/10.1016/j.surg.2012.06.034

by surgeonsduring operation.1 Its presence is oneofthe infrequent causes of intestinal obstruction asso-ciated with a high rate of mortality.1,2

Aitken,2 in a study of 88 children with vitellineremnants, reported 50% mortality in those pre-senting with intestinal obstruction. In 12 of the18 children in this group, a cord extended fromthe Meckel’s diverticulum to the mesentery, asalso noted in our case. Most of these patientswere in the 4–5 years’ age group, when childrenare uncooperative, making an earlier diagnosis dif-ficult and delaying admission to a hospital.

It has been reported that in 59% of cases withpersistent omphalomesenteric artery, a Meckel’sdiverticulum also was present, an association ex-plained by the origin and changes noted in thesestructures, in the embryo.1

The embryonic midgut is connected ventrally tothe yolk sac via the vitelline duct. Normally regress-ing between thefifth and seventhweeks of gestation,the persistence of a portion of the vitelline duct onthe antimesenteric side of the intestine results inone of several anomalous structures either alone or

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in combination. Meckel’s diverticulum is probablythe most common, but others include vitellinesinuses, cysts, fibrous cords from the intestine tothe umbilicus, and omphaloenteric fistulas. Theright and left vitelline arteries originate from theprimitive dorsal aorta and travel with the omphalo-enteric duct. The left involutes whereas the rightbecomes the superior mesenteric artery.3

Vitelline artery remnants can persist as fibrousbands that may contain a patent vessel, covered byperitoneum. Usually one end of the persistentartery is attached to the anterior abdominal walland the other is attached to the ileal mesentery.Less often, it connects a Meckel’s diverticulum tothe ileal mesentery. In a few cases, the cord isattached at only one end.1

Rutherford and Akers4 observed that, althoughthe right vitelline artery remnant may persist as anaccentuation of the superior mesenteric, the leftvitelline artery may, likewise, also persist arisingfrom the aorta. They course along the side of themesentery and insert into Meckel’s diverticulumor the posterior wall of the umbilicus.

Vitelline artery remnants are therefore associ-ated with intestinal obstruction that can result

either from volvulus around a band or entrapmentof the intestine in a snare-like opening createdbetween the apex of the diverticulum and themesentery, leading to incarceration and infarction.

Torn vitelline remnants have also been impli-cated in cases of haemoperitoneum.5 Persistentvitelline artery is a rare cause of acute intestinalobstruction and usually presents a diagnostic chal-lenge. Early recognition and prompt surgical man-agement is essential because of the high rate ofmortality associated with this rare condition.

REFERENCES

1. Manning VR, McLaughlin EF. Persistent omphalomesenteric(vitelline) artery causing intestinal obstruction and gangreneof Meckel’s diverticulum. Ann Surg 1947;126:358-65.

2. Aitken J. Remnants of the vitello-intestinal duct: a clinicalanalysis of 88 cases. Arch Dis Child 1953;28:1-7.

3. Dassinger MS. Meckel’s diverticulum. In: Mattei P, editor.Fundamentals of pediatric surgery. 2nd ed. New York:Springer; 2011. p. 409-13.

4. Rutherford RB, Akers DR. Meckel’s diverticulum: a review of148 pediatric patients, with special reference to the patternof bleeding and to mesodiverticular vascular bands. Surgery1966;59:618-26.

5. Vellacott KD. Haemoperitoneum due to Meckel’s diverticu-lum. J R Coll Surg Edinb 1981;26:89-90.