Table 10.
Recommendations for obese patients with colorectal cancer.
| Challenge | Recommendations for Obese Patients | |
|---|---|---|
| Diagnostic work up | Difficult endoscopy Obtaining endoscopic biopsies CT/MRI standard table weight and aperture limits |
For obese patients undergoing endoscopy, we recommend: (1) Dedicated endoscopy lists, with anaesthetic support and option for GA. (2) A bariatric-size endoscopy table and adequate staffing levels to manoeuvre the patient. (3) The presence of interventional gastroenterologist. For obese patients, where histological confirmation is not possible, we recommend: (1) Consider CT-PET as an alternative. For obese patients undergoing CT or MRI scan, we recommend: (1) Consider the scanner’s standard table weight and aperture limits. (2) Organise access to centres with bariatric-standard scanners. (3) Consider ERUS as an alternative in obese patients with rectal cancer. |
| Anaesthesia | High-risk airway Associated comorbidities Undiagnosed comorbidities |
For obese patients undergoing anaesthetic pre-assessment, we recommend: (1) Assessment by an anaesthetist with experience in bariatric anaesthesia and management of difficult airways. (2) Investigation and assessment of known and undiagnosed comorbidies, e.g., diabetes mellitus, cardiovascular disease, VTE, and obstructive sleep apnoea. (3) Appropriate optimisation of comorbidities, e.g., referral to Cardiology for cardiac optimisation. (4) Assess the need for critical care unit admission postoperatively. |
| Minimally invasive surgery | Hepatic steatosis Stoma complications Theatre setup Surgical challenges |
For obese patients undergoing resectional surgery, we recommend: (1) Preoperative liver shrinkage diet. (2) Preoperative consultation with the stoma nurse specialist if planning to defunction. (3) Preoperative assessment and optimisation by the dietician and physiotherapy team. (4) A bariatric-size theatre table, stirrups and Flowtrons. (5) A hover mattress, (6) Bariatric-size laparoscopic equipment, e.g., bariatric-length ports and long instruments. (7) Consider optical entry. (8) Intracorporeal anastomosis. (9) If available, consider robotic surgery to access the narrow pelvis. |
| Postoperative recovery | High risk of postoperative complications |
For obese patients in the postoperative period, we recommend: (1) Early mobilization and physiotherapy input. (2) Incentive spirometry +/− chest physiotherapy. (3) Weight-adjusted doses of VTE prophylaxis, antibiotics, and analgesia. |
| Adjuvant treatment | Risk of undertreatment |
For obese patients, undergoing adjuvant treatment, we recommend: (1) Chemotherapy dosing as per actual body weight, as per the ASCO guidelines. |
| Postoperative surveillance | Need for increased surveillance |
For obese patients, irrespective of staging, and in addition to the surveillance pathways in the current guidelines, we recommend: (1) Increased frequency of surveillance with CT chest-abdomen-pelvis every 6 months for 5 years. |
| Metastatic disease | Technical and anaesthetic challenges |
For obese patients with metastatic disease, we recommend: (1) Obesity should not be a contraindication to cytoreductive surgery and/or HIPEC in otherwise appropriate patients. (2) Palliative endoscopic stenting should be considered in obstructing tumours, where feasible. (3) Resection of lung and/or liver metastases should be planned as a two-stage procedure to reduce prolonged anaesthetic and surgical times. (4) Liver ablative techniques may be considered at the time of open abdominal surgery. |