Challenges and Strategies in Colorectal Surgery among Patients with Morbid Obesity

Abstract

This chapter explores the interplay between morbid obesity and the challenges encountered in colorectal surgery. Understanding the unique considerations in preoperative and intraoperative management along with weight optimization tools such as bariatric surgery emerges as potential mitigators, demonstrating benefits in reducing colorectal cancer risk and improving perioperative outcomes. Furthermore, the pervasive stigma associated with morbid obesity further complicates patient care, emphasizing the need for empathetic and nuanced approaches. Recommendations for minimizing stigma involve recognizing obesity as a medical diagnosis, fostering respectful communication, and actively dispelling misconceptions. Colorectal surgeons are pivotal in navigating these complexities, ensuring comprehensive and tailored care for patients with morbid obesity.

By 2030, approximately 50% of all adults in the United States will have obesity, defined as a body mass index (BMI) of ≥30 (BMI is the weight in kilograms divided by the square of height in meters). Also, nearly one in four adults will have severe obesity, defined as BMI ≥35. ¹ There are several recognized associations between obesity and serious conditions such as heart disease, stroke, type 2 diabetes, and various cancers, including colorectal cancer. The strong correlation between obesity and colon cancer risk, particularly in males, as well as the demonstrated dose–response relationship of weight gain and colorectal cancer risk, reinforces the importance of addressing challenges specific to patients with obesity and enhancing provider clinical and interpersonal skills when caring for patients with obesity. ^{2 3} In the realm of colorectal surgery, treating patients with morbid obesity introduces unique considerations. These patients face an elevated risk of complications, including wound infections, ostomy pouching problems, anastomotic leaks, and medical complications. ⁴

This chapter focuses on specific preoperative and intraoperative considerations for this population and will be crucial for informed consent discussions for both benign and malignant pathologies. We will discuss preoperative weight management strategies, including a multidisciplinary approach involving nutritionists, physical therapy, and the potential role of bariatric surgery. Additionally, the chapter addresses the stigma often encountered by patients with obesity in clinical settings, emphasizing the need for implementing strategies that ensure patients not only receive dignified and respectful treatment but also have access to appropriate care tailored to their specific needs. Given the prevalence of obesity in the patient population, equipping surgeons with tangible tools to navigate these challenges is critical to optimizing patient care.

Clinical Challenges among Patients with Morbid Obesity

Delayed Age-Appropriate Colorectal Cancer Screening

Previous research has highlighted a concerning fact that physicians spend less time in clinics to educate patients with obesity about their health in comparison to patients without obesity. ⁵ This discrepancy in attention has important implications, as studies indicate that patients perceiving weight bias in health care are more likely to avoid seeking future medical care, which undoubtedly contributes to worse health outcomes. ^{5 6 7} Additionally, obesity has been associated with decreased rates of age-appropriate colorectal cancer screening, especially among severely obese men, resulting in diagnostic and treatment delays. ⁸ Possible underlying mechanisms identified include weight-based stigma, physicians' failure to recommend appropriate screening, and patient barriers such as cost and access. The early onset of strain in the patient–physician relationship, exacerbated by these dynamics, can foster low trust and hinder effective communication—a critical aspect, especially when broaching discussions about potentially life-altering colorectal procedures or emphasizing the importance of proper cancer screening.

The Difficult Ostomy

Creating an ostomy is a fundamental aspect of colorectal surgery, demanding meticulous attention to both technical and nontechnical aspects to provide the patient with a durable stoma. Reported complications associated with stomas vary widely, ranging from 21 to 70%, with the highest incidence occurring within 5 years of stoma formation. ^{9 10 11} Patients with obesity experience elevated rates of stoma-related complications, including parastomal hernias, stoma retraction or prolapse, and mucocutaneous separation. ¹² These complications can exacerbate issues such as skin irritation, excoriation, and pouching problems, all of which present challenges that require consistent care. As such, preoperative and intraoperative considerations are important in optimizing outcomes.

Preoperatively, the nature of the ostomy—whether temporary or permanent, elective or emergent—is considered. Elective cases give time for thorough discussions with the patient about the rationale for the stoma, ideally involving meetings with an ostomy specialist to lessen some of the anxiety that comes along with managing an ostomy. A critical preoperative consideration for patients with obesity involves assessing the abdominal region for a pannus and skin folds to identify the most suitable and durable stoma site. The goal is to select a site that facilitates optimal pouching, minimizes stoma retraction risk, and allows for independent patient care ( Fig. 1 ). Adequate site selection involves evaluating multiple positions, above and below the umbilicus, while the patient is both seated upright, supine, and standing. This allows options in the event of special intraoperative findings that make a certain position difficult to construct.

Fig. 1.

Steps for optimal ostomy creation in patients with obesity. (Adapted from the Wound, Ostomy, and Continence Nurses Society [WOCN]).

Moreover, preoperative strategies may involve allowing time for weight loss, optimizing the feasibility of the operation. For instance, performing ileal J pouches can be challenging for patients with obesity, prompting considerations such as initially performing a total colectomy and end ileostomy, followed by subsequent procedures after weight loss. ¹³ Intraoperatively, considerations extend to the thickness of the abdominal wall and pannus, ensuring safe passage of bowel length through the stoma opening. Adequate bowel mobilization is crucial to alleviate tension, requiring careful attention to the chosen surgical approach, whether sigmoid colostomy or others, and employing tools like the Alexis wound protector. ¹³ Regardless of the surgical context, whether elective or emergent, colorectal surgeons must factor in the potential for future operations, contemplating aspects such as reestablishing bowel continuity or resiting to ensure comprehensive patient care.

Surgical Approach: Minimally Invasive versus Open Surgery

Operating on patients with obesity presents challenges for both minimally invasive and open approaches. Overall benefits of minimally invasive surgery include faster postoperative recovery, less post-operative pain, and fewer wound infections. ¹⁴ However, some studies demonstrate that severe obesity is associated with worse intraoperative and postoperative outcomes, including longer operative times, higher rates of infection, wound dehiscence, and higher chance of mortality when compared with patients without obesity. ^{15 16} One study specifically showed that worse outcomes may be mitigated by utilizing a robotic approach. The investigators found that a minimally invasive approach (laparoscopic or robotic) had better outcomes when compared with open surgery and, specifically, that the robotic approach was associated with better outcomes that remained when stratified by BMI. ¹⁷ Once BMI was above 40, outcomes worsened, which may be highlighting the technical challenges that comes with operating on patients with obesity. Regardless, this study adds to others that show that minimally invasive colorectal surgery is safe, feasible, and cost-effective for patients with obesity. ^{18 19}

For example, the ROLARR randomized clinical trial found no difference in conversion to laparotomy rates between laparoscopic and robotic approaches for rectal cancer resection; however, there was a higher statistically significant rate of conversion in patients with obesity as compared with patients who are underweight or normal weight. ²⁰ In this study, there was no statistically significant difference in circumferential resection margin positivity, a marker for appropriate oncologic resection, for all patients. Further research is imperative to comprehensively evaluate specific oncologic outcomes in patients with obesity undergoing colorectal procedures.

While ensuring optimal patient positioning is essential for safety considerations in all surgical cases, it becomes even more crucial for patients with obesity. Utilizing an appropriate operative table with an adequate weight limit is needed. Adequate securing of the patient to the operative table is needed for safe Trendelenburg positioning. Additionally, recognizing the physiological differences in patients with obesity, particularly their tolerance to pneumoperitoneum and associated side effects, is essential. Proper padding of pressure points should be ensured to prevent peripheral nerve injuries. Deliberate decision-making on laparoscopic incision sites and hand-assisted ports is important to avoid difficulty in reaching intended anatomy. Limited field of view and motion restrictions with laparoscopic or robotic instruments in patients with obesity emphasize the heightened importance of these considerations that could differentiate between a good or poor outcome.

The Role of Bariatric Surgery in Colorectal Surgery

Colorectal Disease-Specific Benefits of Bariatric Surgery

Bariatric surgery is a safe and effective treatment for obesity and obesity-related diseases. ²¹ Among patients with obesity, bariatric surgery results in weight loss, longer life expectancy, resolution of comorbidities such as diabetes and hypertension, reduced risk of myocardial infarction and stroke, and reduced risk of cancer. ²² Moreover, bariatric surgery is safe, with a 30-day mortality rate of 0.08%. ²³

Bariatric surgery also has benefits specific to patients with colorectal disease. In particular, recent data suggest that bariatric surgery may reduce the risk of colorectal cancer. In a recent meta-analysis of over 1 million patients with over 7-year follow-up, patients with obesity who underwent bariatric surgery had a 36% reduction in their risk of developing colorectal cancer compared with patients who did not undergo bariatric surgery. ²⁴ Other systematic reviews and meta-analyses have demonstrated similar colorectal cancer risk reduction after bariatric surgery. ²⁵ A large national cohort study found that individuals with obesity who underwent bariatric surgery share the same risk of colorectal cancer as the general population, whereas individuals with obesity who did not undergo bariatric surgery had a 34% higher risk of colorectal cancer compared with the general population. ²⁶ Although the data among patients with inflammatory bowel disease (IBD) are not as robust given its much lower prevalence, retrospective studies suggest that bariatric surgery among patients with obesity and Crohn's disease or ulcerative colitis may be associated with fewer IBD-related complications. ²⁷

For patients with obesity who undergo surgery for colorectal cancer, there may be perioperative benefits to bariatric surgery as well. At least one study has found that bariatric surgery is associated with decreased risk of postoperative complications and reduced health care costs and utilization. ²⁸ McKechnie et al used the National Inpatient Sample to propensity score match 376 patients with obesity who had previously undergone bariatric surgery with 1,197 patients with obesity who had not undergone bariatric surgery. After matching, patients with a history of prior bariatric surgery had a 6.5% reduction in in-hospital postoperative morbidity, a $5,256 reduction in hospitalization cost, shorter length of stay, and were more likely to be discharged home. ²⁹ These findings mirror those in other procedures where patients who have previously undergone bariatric surgery have a lower risk of adverse postoperative outcomes compared with patients with obesity who have not undergone bariatric surgery.

Because of its perioperative risk reduction, bariatric surgery has become part of the preoperative optimization pathway for patients who are planning to undergo several different surgical procedures. For example, for especially high-risk patients with obesity, bariatric surgery prior to abdominal wall hernia repair and solid organ transplantation has been described as ways to optimize patients for their operation and improve their outcomes. ^{30 31} Unfortunately, utilizing bariatric surgery as part of patient optimization prior to colorectal cancer surgery is unrealistic, given the time-sensitive and often urgent nature of cancer diagnosis and treatment. Preoperative optimization involving bariatric surgery has the potential to delay definitive surgery by over a year, which would not be ideal for colorectal cancer surgery, and would also preclude the use of neoadjuvant treatment when needed. However, bariatric surgery prior to elective colorectal surgery may be considered in some cases.

Benefits of Preoperative Optimization

While bariatric surgery prior to colorectal cancer resection may not be feasible, the benefits nevertheless highlight the importance of preoperative optimization in high-risk patients with obesity planning to undergo surgical resection for colorectal cancer. Preoperative optimization, in general, has been shown to be especially important in this population since these patients often have several modifiable risk factors at the time of surgery. Optimization pathways that seek to improve diabetes control encourage smoking cessation, physical activity, and healthy diet can improve postoperative outcomes and reduce hospital spending. ^{32 33} Two other weight-specific strategies have shown promise in this population. For example, glucagon-like peptide-1 receptor agonists such as Semaglutide and liraglutide are now being used as part of preoperative optimization in patients with severe obesity and diabetes. ³⁴ Alternatively, preoperative very low-calorie diets have been shown to significantly reduce weight prior to bariatric surgery in patients with severe obesity; however, it is still unclear to what extent this reduces perioperative risk. ³⁵

Where bariatric surgery may be most relevant for this population is for patients who have an ostomy following surgical resection. For patients with a permanent ostomy, obesity significantly increases the risk of parastomal hernia and its subsequent complications (e.g., incarceration, strangulation, pain, and functional limitations). ³⁶ Therefore, following surgical resection for colorectal cancer, bariatric surgery may play a role in reducing the lifelong risk of parastomal hernia and its complications in patients with obesity. For patients with a temporary ostomy who will become eligible for reversal, obesity is associated with both short-term complications as well as long-term hernia recurrence following parastomal hernia repair and ostomy reversal. ^{37 38} Again, insofar as patients can undergo ostomy takedown electively, it may be reasonable to consider referral for bariatric surgery preemptively to reduce the risk of postoperative complications and hernia recurrence.

The Pervasive Stigma of Morbid Obesity and How to Challenge It

What Stigma Do Patients with Morbid Obesity Face?

The escalating rates of obesity in the United States have given rise to fatphobia and fat shaming and weight bias and stigma against individuals diagnosed with morbid obesity. Patients carry a substantial cognitive burden, particularly in clinical settings, where the absence of a safe space hinders open communication about critical aspects of their health. Patients may be reluctant to share the truth about several aspects of their health, such as diet, concerns for eating disorders such as binge eating disorders or bulimia, and frequency of exercise or physical activity. This is largely secondary to a fear of judgment or learned reactionary behavior as a coping mechanism to prior bad experiences. Surgeons play a crucial role in establishing a trustworthy relationship, especially given their responsibility for patients while under anesthesia. Addressing the years of shame and guilt, especially in the context of a new cancer diagnosis, requires a nuanced approach that prioritizes timing and context, focusing on the patient's journey moving forward rather than inundating them with detailed statistics.

Stigma largely stems from preconceived negative attitudes or emotions toward patients with obesity. There are abundant data showing that stereotypes include being lazy, having lack of will power or self-discipline, being overindulgent, unintelligent, and/or unsuccessful, and also translates over to a stereotype of being noncompliant with care recommendations. ³⁹ This then in turn facilitates implicit bias which can be sensed either overtly with the language used during a clinic setting or indirectly by body language. Furthermore, the combination of weight bias and racial discrimination may have multifold negative effects on black and Hispanic patients with obesity. According to the Centers for Disease Control and Prevention, obesity rates vary across race and ethnicity, for example, 49.9% of non-Hispanic black adults and 45.6% of Hispanic adults are considered obese, whereas 41.4% of non-Hispanic white adults meet criteria. ^{40 41} The effects of racism and racial discrimination are known to be a detriment to patients' health, and the added effects of perpetuated negative weight-based stereotypes can be damaging. ⁴² Health care providers are either unconscious perpetrators of obesity and stigma or are reluctant to admit it for fear of being labeled as discriminatory. Acknowledging the potential for bias is a crucial step forward to building a trusting relationship, especially for minoritized patients, signaling to them that their unique challenges are recognized and factored into their treatment plan.

In the previous section, we discussed the role of bariatric surgery in colorectal surgery, and it's worth noting that patients undergoing any of these types of surgery face heightened weight stigma. This stigma, fueled by perceptions of laziness or shortcuts to weight loss, leads many to conceal their surgical status. This concealment may contribute to the strikingly low percentage of only 0.1 to 2% of currently eligible patients receiving surgery. ⁴³ Recognizing and addressing this nuanced aspect of weight stigma is essential for comprehensive patient care and promoting the consideration of beneficial interventions.

Consensus to End the Stigma of Obesity

The Joint International Consensus Statement for Ending Stigma of Obesity was put together by world-renowned obesity clinicians and researchers who came together to publish a statement in Nature about the stigma patients face. They state “although raising awareness of the negative consequences of weight stigma is important, awareness alone is not sufficient to eliminate the issue. Challenging and changing widespread deep-rooted beliefs, longstanding preconceptions, and prevailing mindsets requires a new public narrative of obesity that is coherent with modern scientific knowledge.” ⁴⁴ They go on to highlight the psychological effects of weight stigma such as depression, anxiety, low self-esteem, substance use, and social isolation, which is independent of the psychological and physical risks of obesity itself. Paradoxically, encountering weight stigma results in elevated avoidance of exercise, reduced engagement in physical activity, and heightened consumption of unhealthy diets and sedentary behaviors. This leaves patients in a vulnerable position during interactions with health care providers, as such encounters can act as psychological triggers, potentially causing patients to regress in their care rather than making progress.

What Can Colorectal Surgeons Do to Minimize the Effects of Stigma for their Patients?

Given the escalating prevalence of obesity and colorectal cancer in the United States, it is imperative that colorectal surgeons possess the necessary tools to effectively treat patients with obesity. First, recognizing obesity as a distinct medical diagnosis, separate from the individual, is crucial. Similar to how we refer to patients with other medical conditions like heart disease or cancer, describing a patient as having a “past medical history of obesity” rather than labeling them as “obese” emphasizes the medical nature of the condition rather than defining the individual. ⁴⁴ Second, in the clinical setting, careful consideration must be given to how we discuss patients' bodies and avoid disparaging statements. Surgeons, uniquely positioned where body habitus directly impacts care, must comment on a patient's physical appearance in a respectful and clinically relevant manner. ⁴⁵ Third, actively dispelling misconceptions about obesity is essential. It is crucial to counter the notion that obesity is solely a lifestyle choice; instead, surgeons should acknowledge its multifactorial nature, citing potential causes such as genetic and epigenetic factors, sleep deprivation, psychological stress, endocrine problems, medication side effects, and intergenerational effects. ^{46 47 48}

Conclusion

The increasing prevalence of obesity in the United States underscores the critical need for colorectal surgeons to adeptly address the unique challenges faced by patients with morbid obesity. The intricate relationship between obesity and colorectal cancer risk, coupled with the elevated complications in surgical interventions, emphasizes the importance of comprehensive preoperative and intraoperative considerations for this population. The significance of preoperative optimization, considering weight-specific strategies and emphasizing the importance of timely interventions to minimize complications, can go a long way for patient outcomes. Moreover, the pervasive stigma associated with morbid obesity poses significant hurdles in patient communication and care, necessitating a nuanced and empathetic approach from all health care providers.

Overall, a comprehensive and patient-centered approach is essential for colorectal surgeons caring for patients with morbid obesity. By addressing clinical challenges, optimizing preoperative strategies, and confronting weight stigma head-on, health care providers can contribute to improving outcomes and fostering a supportive environment for patients with obesity undergoing colorectal surgery.