Malignant polyp for hemicolectomy

86-year-old man for consideration of laparoscopic right hemicolectomy


  • Malignant Caecal Polyp = Not fully excised at colonoscopy
  • No evidence of metastatic spread
  • COPD – Last exacerbation 2018, required hospital admission
  • Type II MI in context of LRTI
  • AF – anticoagulated
  • Moderate MR 
  • Mild OSA


  • Exertional dyspnoea at clinic, spirometry showed severe obstruction with good bronchodilator response.
  • Chest pain, new symptom. Occurring weekly. No cardiology follow-up since 2018
  • Clinical Frailty scale 5
  • Advanced age
  • Perioperative risk assessment – NSQIP scoring above average for all variables including a 47% risk of functional decline and approx. 20 % risk of serious complications, discharge into care, and delirium. SORT score gives a 7% risk of death for an elective procedure


Surgical options

  • Is there scope for repeat colonoscopy/further attempt at excision or a luminal-based procedure.
  • Disease prognosis –uncertain regarding expected progression of cancer.
  • If there is an increased likelihood of bowel obstruction, may expedite decision for surgery.

Increased Perioperative risk

  • Risks discussed with patient and his son at the clinic. They both expressed that the perioperative risks were too great for them to proceed. Patient currently has a reasonable quality of life and would not be accepting of functional decline.
  • Life expectancy calculated to be < 5 years. Discussion regarding online prediction tools for life expectancy and their use in complex perioperative decision-making.


  • Prehabilitation and pulmonary rehab would be excellent opportunities to optimize respiratory function
  • Non-invasive stress testing and an echocardiogram should be performed preoperatively.
  •  If attending prehab, we should initiate concurrent cardiac investigations. 


  • Formal PFT’s and respiratory review organized
  • Discussion with surgical team – prognosis and surgical options
  • Liaise with GP regarding prehabilitation via Kaden centre or pulmonary rehab
  • Non-invasive cardiac stress testing and echocardiogram
  • Re-review in clinic with results of above 

UPDATE – surgical discussion. Histology revealed likelihood of very slow tumour progression. Surgeon in agreement with patient that no further management required at this stage. GP to organise prehab/pulmonary rehab and cardiac testing.