Elective right hemicolectomy in a patient with diabetes, steroids and anaemia
A 64-year-old man is listed for an elective laparoscopic-assisted right hemicolectomy for a 4.5 cm caecal adenocarcinoma; staging CT shows no metastases. He has a BMI of 36 kg/m², type 2 diabetes with HbA1c 9.1%, and continues to smoke 25 cigarettes daily (45 pack-years). For two years he has taken prednisolone 10 mg daily for polymyalgia rheumatica. Bloods: haemoglobin 9.8 g/dL, mean cell volume 76 fL, albumin 31 g/L, creatinine 132 µmol/L (eGFR 52), and he has never had iron studies. He lives alone and works as a long-distance lorry driver. The tumour is not obstructing and he has no weight loss or bleeding. The next available operating list is in 10 days; the multidisciplinary team suggests proceeding then to avoid delay. He is ASA III.
1. Which modifiable risk factors would you address in the 10 days before surgery, and what targets would you set? Justify the priority you give each.
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Priority: reducing infective complications and supporting anastomotic healing. The window is short, so I would choose measures with rapid, high-impact effects and avoid steps that merely postpone cancer surgery.
- Smoking: offer same-day cessation support and nicotine replacement. Even 3–4 weeks of abstinence lowers surgical-site infection and pulmonary complications; 10 days is imperfect but still worthwhile. Do not delay surgery for a formal cessation programme.
- Hyperglycaemia: involve the diabetes team. HbA1c 9.1% cannot be corrected in 10 days, so focus on perioperative capillary glucose 6–10 mmol/L with a basal-bolus or insulin infusion regimen. Avoid a sliding-scale-only approach.
- Anaemia: check ferritin and transferrin saturation. If iron deficient, give intravenous iron now and target haemoglobin at least 10 g/dL. Transfuse only if symptomatic or below 8 g/dL, and recognise the caecal tumour as the likely cause.
- Steroids: continue prednisolone. Give perioperative hydrocortisone, for example 100 mg at induction then 50 mg every 8 hours for 24 hours, to prevent adrenal crisis. Do not stop steroids abruptly.
- Nutrition: dietitian review and oral supplements; albumin 31 g/L predicts poor wound healing.
- BMI and renal function: not modifiable in 10 days; plan antibiotic timing, wound protection and avoidance of nephrotoxins.
2. Explain the mechanisms by which his diabetes, smoking, chronic steroid use and anaemia increase the risk of anastomotic leak and surgical-site infection.
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These factors act at different phases of healing and are additive.
Diabetes and hyperglycaemia. Glucose above 10 mmol/L impairs neutrophil chemotaxis and phagocytosis, reduces complement function and depresses collagen synthesis by fibroblasts. Microangiopathy reduces tissue oxygen delivery. The result is impaired clearance of contamination, weaker collagen at the anastomosis and higher rates of both surgical-site infection and leak.
Smoking. Nicotine causes vasoconstriction and carbon monoxide reduces oxygen carriage, while cyanide and other compounds impair fibroblast proliferation and epithelialisation. Tissue oxygen tension in the wound falls for several weeks after the last cigarette, so both infection and dehiscence risks rise.
Chronic corticosteroids. Prednisolone suppresses the inflammatory phase, macrophage recruitment and collagen deposition, and inhibits wound contraction. This produces a mechanically weak anastomosis and masks early signs of infection.
Anaemia and hypoalbuminaemia. Low haemoglobin reduces oxygen delivery to healing tissue. Iron deficiency also impairs collagen maturation through reduced prolyl hydroxylase activity. Albumin 31 g/L reflects visceral protein depletion, so substrate for repair is limited.
Obesity adds technical difficulty, tension on the anastomosis and poor mesenteric vascularity, compounding all of the above.
3. He refuses any delay and asks why 10 days is not acceptable. How do you frame the decision, and what would change if he presented with obstruction?
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I would avoid presenting the delay as a fixed rule. I would explain that the MDT is not delaying for its own sake: 10 days is being used to reduce the probability of a leak or wound infection that could delay adjuvant chemotherapy far longer than 10 days. I would quote absolute rather than relative risk where possible, acknowledge uncertainty, and record a shared decision. If he still refuses, proceeding is reasonable provided steroids are covered, glucose is controlled and antibiotics are timed correctly; I would not coerce him.
The situation changes completely with obstruction. He would then need emergency surgery without time for optimisation. The priorities become resuscitation, nasogastric decompression, correction of potassium and renal function, and a damage-control operative strategy. I would consider a staged approach, such as a stoma rather than a primary anastomosis, especially with a unprepared bowel, steroid use and hyperglycaemia. Perioperative hydrocortisone and glucose control still apply, but the risk-benefit calculation shifts from elective optimisation to preventing perforation and sepsis.