The impact of surgical delay on resectability of colorectal cancer: An international prospective cohort study

AIM: The SARS-CoV-2 pandemic has provided a unique opportunity to explore the impact of surgical delays on cancer resectability. This study aimed to compare resectability for colorectal cancer patients undergoing delayed versus non-delayed surgery. METHODS: This was an international prospective cohort study of consecutive colorectal cancer patients with a decision for curative surgery (January-April 2020). Surgical delay was defined as an operation taking place more than 4 weeks after treatment decision, in a patient who did not receive neoadjuvant therapy. A subgroup analysis explored the effects of delay in elective patients only. The impact of longer delays was explored in a sensitivity analysis. The primary outcome was complete resection, defined as curative resection with an R0 margin. RESULTS: Overall, 5453 patients from 304 hospitals in 47 countries were included, of whom 6.6% (358/5453) did not receive their planned operation. Of the 4304 operated patients without neoadjuvant therapy, 40.5% (1744/4304) were delayed beyond 4 weeks. Delayed patients were more likely to be older, men, more comorbid, have higher body mass index and have rectal cancer and early stage disease. Delayed patients had higher unadjusted rates of complete resection (93.7% vs. 91.9%, P = 0.032) and lower rates of emergency surgery (4.5% vs. 22.5%, P < 0.001). After adjustment, delay was not associated with a lower rate of complete resection (OR 1.18, 95% CI 0.90-1.55, P = 0.224), which was consistent in elective patients only (OR 0.94, 95% CI 0.69-1.27, P = 0.672). Longer delays were not associated with poorer outcomes. CONCLUSION: One in 15 colorectal cancer patients did not receive their planned operation during the first wave of COVID-19. Surgical delay did not appear to compromise resectability, raising the hypothesis that any reduction in long-term survival attributable to delays is likely to be due to micro-metastatic disease

Toe ulcers and early diagnosis of osteomyelitis in diabetic patients

Category: Diabetes Introduction/Purpose: Neuropathy and Peripheral arterial disease are the main causes of diabetic foot ulcers. Toes are the most frequent location. Osteomyelitis diagnosis of foot ulcers is still controversial, mainly in ulcers without bone exposure. Although MRI has 90% sensitivity and 85% specificity for osteomyelitis diagnosis, it is not usually used for early detection of bone changes, due to lack of availability and high cost. Bone biopsy puncture is considered the gold standard methodology together with microbiological and histological examinations, but it is not always available in all practices. The purpose of this study was to describe the diagnosis in forefoot ulcers found in diabetic patients using MRI and bone biopsy puncture. Methods: This is a retrospective study, a case series. Clinical records of patients with injuries limited to toes between January 2013 and December 2015 were analyzed. The inclusion criteria were: patients with Diabetes Mellitus (DM) diagnosis and with a grade 1 or 2 digital ulcer according to Wagner’s classification for at least 3 weeks, with visible bone edema in the magnetic resonance (MRI) and those with a bone biopsy performed, and with a minimum follow–up of a year. Patients with diabetic foot ulcers were evaluated by an interdisciplinary team. Laboratory standards were evaluated preoperative and during antibiotic therapy. The surgical bone biopsy was performed by a foot and ankle surgeon with experience in Diabetic foot pathologies. Microbiological and histological study was analyzed. We also recorded the demographic data and identified the patients who had received previous empiric antibiotic therapy. Statistical analysis was performed. Results: Thirty patients out of 93 patients fulfilled inclusion criteria between January 2013 and December 2015. Eleven patients had grade 1 ulcers and 19 grade 2. Twenty-two patients (73.3%) got bone biopsies with positive cultures and 14 (63,3%) had a positive pathological anatomy. Eight patients got negative cultures and pathology. Six patients that did not received empiric antibiotic therapy and 19 patients out of 24 who had received empiric antibiotics had positive cultures. Mean healing time for patients who did not had antibiotics was 4 weeks (3-12) and for the group who received empiric antibiotics was 6 weeks (4-10/) Only 4 patients out of 19 patients with Wagner II ulcers had the toe amputated. Conclusion: A precise diagnosis of the germ was obtained in 73.3% of the patients and a specific antibiotic treatment was completed. Although empiric antibiotic therapy 19 out of 24 patients had positive bone cultures and healing time was longer. Amputation index was 13%, all of them were grade 2 ulcers. There were no major amputations. We consider that in these kind of ulcers that had more than 3 weeks without healing and had no radiographic changes, MRI can show bone edema. Surgical bone biopsy should be done to begin specific antibiotic therapy and improve healing time

Evans Osteotomy with Locked Plate with Wedge Block for Stage IIB Flat Foot

Category: Hindfoot Introduction/Purpose: Elongation of the lateral column is indicated only in patients who have a flexible deformity Stage 2B of flat foot. The Evans osteotomy is performed 1.5 or 2 cm from the cuboideal calcaneal joint, and in many publications is maintained by different kind of devices. Our hypothesis is that Evans osteotomy, with blocked plates with a wedge block, without the use of bone graft, maintain the correction obtained at one year after surgery. The primary objective was to evaluate the radiological results at the postoperative year of the osteotomy Secondary objectives were to evaluate the persistence of the correction obtained between the 3 months and the year of the postoperative period and to evaluate the functional outcomes with AOFAS score. Methods: We studied a total of 12 patients, 14 feet. with stage 2 B flat foot, in all cases surgery was performed by the same specialist between March of 2011 and March of 2014 in the Service of foot and ankle of our institution. Inclusion criteria were: patients with type 2B flat foot, submitted to external column elongation, with plates blocked with a 6 to 10 mm wedge block, without the use of bone grafting, minimum follow-up of 1 year. Exclusion criteria: revision of previous surgery, another type of material used for elongation of the external column, neurological sequelae. The study was performed retrospectively through clinical records database, data collection and measurements were performed by 2 second-year Foot and ankle fellow trained in the same institution. Statistical analysis was performed with the T-student test. Results: A total of 12 patients / 14 feet were evaluated during the study period, with a diagnosis of flatfoot type 2B. The average age was 57 years (32-65 years), 11 (78.5%) were female. No statistically significant difference was observed in any of the radiographic variables measured, at 3 months and at 12 months postoperatively. The preoperative AOFAS score, was 54 points. At the first year was 93 points. Consolidation was achieved at 3 months in all cases. The complications found were 2 superficial infections and 1 wound dehiscence. As a late complication, there was only 1 case of cuboidal calcaneal osteoarthritis that did not require surgical resolution. Conclusion: Evans osteotomy for elongation of the external column provides a reproducible and reliable method to restore the normal functional stability of the midfoot and hindfoot. According to the results obtained in our work, we can conclude that the blocked plates with a wedge lock manage to preserve the corrections obtained with the Evans osteotomy in patients with type IIB flat foot. There is no need of autograft with the consequent risk of comorbidities produced by a second approach to the grafting as well as the complications that could happen with the use of allografts

Percutaneous surgery for overlapping fifth toe

Category: Lesser Toes Introduction/Purpose: Overlapping fifth toe is an unusual disease in which the fifth toe is adducted, rotated, and hyperextended. This pathology is often asymptomatic, however pain may occur with footwear. Although there are many surgical techniques available, there is yet no gold standard. While old techniques were aggressive and cosmetically inappropriate, newest techniques involve large surgical incisions and risk of neurovascular damage. Percutaneous surgery is a novel approach which avoids the disadvantages that old and new techniques present. It was originally described by De Prado but no case series have been reported in adults up to date. The aim of this study is to describe a percutaneous corrective technique of the overlapping fifth toe and to evaluate its functional results and patient satisfaction. Methods: We performed a retrospective review of 12 feet in 10 adult patients who were surgically treated between 2008 and 2016. The percutaneous surgical technique consisted in a dorsal capsulotomy and extensor tenotomy followed by an osteotomy of the proximal phalanx (as described by De Prado). We added to his procedure the use of a K-wire to stabilize the osteotomies. In 6 of these feet a percutaneous oblique osteotomy of the fifth metatarsal was also performed. This osteotomy was stabilized using the same K-wire, which was removed 1 month after surgery. All patients were clinically rated prior to surgery and at the final follow-up visit using the AOFAS Score for lesser toes. In addition, patients were asked to provide a subjective qualification of the results (pain/cosmetic) as “excellent”, “good”, “regular” and “poor” and to state if they would recommend the surgical procedure to one of their peers. Results: The average follow up was 48 months (104 - 9). Osteotomy consolidation was completely achieved in all patients. There were no infections or wound complications. Mean preoperative AOFAS score was 38 (20-55) and postoperative score was 84 (62-95). Patient subjective qualification after surgery was: excellent for 7 feet, good for 3 and regular and poor for the remaining 2 feet. Nine of the ten patients stated that they would recommend the procedure. Conclusion: Percutaneous treatment of the overlapping fifth toe is a reproducible surgical technique with good functional results, low postoperative complications and good cosmetic acceptance by the patients