'It's just a mucocele': a case report of a massive appendiceal mucocele presenting as a left upper quadrant mass

Tumours of the appendix are very rare tumours that can and often present with a mucocele. This is a case report highlighting the associated pathology of appendix tumours and the management of a large mucocele. Specifically, how a right hemicolectomy is very rarely needed in these cases regardless of size and local anatomical relationships and some important considerations for the practicing surgeon in the non-tertiary centre that encounters a case like this.

Cost effectiveness of using Faecal Immunochemical Testing (FIT) as an initial diagnostic investigation for patients with lower gastrointestinal symptoms suggestive of malignancy

Background

There has been an increase in the numbers of patients presenting to primary care with suspected colorectal malignancy and subsequently an increase in demand for endoscopy. This study aims to forecast the cost of faecal immunochemical testing (FIT) compared to conventional diagnostic tests as a primary investigation for patients with symptoms suggestive of colorectal malignancy.

Methods

Retrospectively, 1950 patients with symptoms suggestive of colorectal malignancy who were referred through primary care and underwent investigations through standard endoscopic evaluation were included. These patients were used to forecast the cost of faecal immunochemical testing creating theoretical data for sensitivity and specificity. Outcome measures included: the number of investigations under current protocol; cost of current investigations; number of predicted false negatives and false positives and positive/negative predictive values using current sensitivity data for FIT; the cost forecast of using FIT as the primary investigation for colorectal malignancy.

Results

Median age was 65 (IQR 47–82) with 43.7% male and 56.3% female. A total of 1950 investigations were carried out with a diagnostic yield of 26 cancers (18 colon, 8 rectal), 138 polyps and 29 high risk adenomas (HGD ±  > 10 mm). In total, £713,948 was spent on the investigations. The commonest investigation was colonoscopy totalling £533,169. The total cost per cancer diagnosis was £27,459. Sensitivity (92.1% CI 86.9–95.3) and specificity (85.8% CI 78.3–90.1) for FIT in colorectal cancer was taken from NICE and was costed via the manufacturer(s). The projected total cost of FIT for the same population using a ≥ 4 μg haemoglobin cut off was £415,680 (£15,554 per cancer). The total cost of high-risk polyps using ≥ 4 μg cut off was £404,427 (sensitivity 71.2% CI 60.5–87.2, specificity 79.8%CI 76.1–83.7) or £13,945 per polyp.

Conclusions

FIT is a cheaper and effective alternative test with the potential to replace current expensive methods. The forecast is based on the limited data available for sensitivity/specificity in the current literature. FIT has now been commenced for symptomatic patients in the UK and therefore sensitivity may change in the future.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-021-01435-7.

Suture rectopexy versus ventral mesh rectopexy for complete full-thickness rectal prolapse and intussusception: systematic review and meta-analysis

Background

This systematic review and meta-analysis aimed to compare recurrence rates of rectal prolapse following ventral mesh rectopexy (VMR) and suture rectopexy (SR).

Methods

MEDLINE, Embase, and the Cochrane Library were searched for studies reporting on the recurrence rates of complete rectal prolapse (CRP) or intussusception (IS) after SR and VMR. Results were pooled and procedures compared; a subgroup analysis was performed comparing patients with CRP and IS who underwent VMR using biological versus synthetic meshes. A meta-analysis of studies comparing SR and VMR was undertaken. The Methodological Items for Non-Randomized Studies score, the Newcastle–Ottawa Scale, and the Cochrane Collaboration tool were used to assess the quality of studies.

Results

Twenty-two studies with 976 patients were included in the SR group and 31 studies with 1605 patients in the VMR group; among these studies, five were eligible for meta-analysis. Overall, in patients with CRP, the recurrence rate was 8.6 per cent after SR and 3.7 per cent after VMR (P < 0.001). However, in patients with IS treated using VMR, the recurrence rate was 9.7 per cent. Recurrence rates after VMR did not differ with use of biological or synthetic mesh in patients treated for CRP (4.1 versus 3.6 per cent; P = 0.789) and or IS (11.4 versus 11.0 per cent; P = 0.902). Results from the meta-analysis showed high heterogeneity, and the difference in recurrence rates between SR and VMR groups was not statistically significant (P = 0.76).

Conclusion

Although the systematic review showed a higher recurrence rate after SR than VMR for treatment of CRP, this result was not confirmed by meta-analysis. Therefore, robust RCTs comparing SR and biological VMR are required.

Assessing the effectiveness of retrograde autologous priming of the cardiopulmonary bypass machine in isolated coronary artery bypass grafts

INTRODUCTION

Currently, around 35-80% of patients undergoing cardiac surgery in the UK receive a blood transfusion. Retrograde autologous priming (RAP) of the cardiopulmonary bypass circuit has been suggested as a possible strategy to reduce blood transfusion during cardiac surgery.

METHODS

Data from 101 consecutive patients undergoing isolated coronary artery bypass grafts (where RAP was used) were collected prospectively and compared with 92 historic patients prior to RAP use in our centre.

RESULTS

Baseline characteristics (ie age, preoperative haemoglobin [Hb] etc) were not significantly different between the RAP and non-RAP groups. The mean pump priming volume of 1,013ml in the RAP group was significantly lower (p<0.001) than that of 2,450ml in the non-RAP group. The mean Hb level at initiation of bypass of 9.1g/dl in patients having RAP was significantly higher (p<0.001) than that of 7.7g/dl in those who did not have RAP. There was no significant difference between the RAP and non-RAP groups in transfusion of red cells, platelets and fresh frozen plasma, 30-day mortality, re-exploration rate and predischarge Hb level. The median durations of cardiac intensive care unit stay and in-hospital stay of 1 day (inter-quartile range [IQR]: 1-2 days) and 5 days (IQR: 4-6 days) in the RAP group were significantly shorter than those of the non-RAP group (2 days [IQR: 1-3 days] and 6 days [IQR: 5-9 days]).

CONCLUSIONS

In the population group studied, RAP did not influence blood transfusion rates but was associated with a reduction in duration of hospital stay.