SAGES colorectal and metabolic bariatric surgery committee joint task force call to action for synchronized severe obesity and colorectal cancer management

Background: Severe obesity (body mass index ≥ 40 kg/m² or ≥ 35 kg/m² with obesity-related comorbidities) is increasingly prevalent and independently associated with elevated perioperative morbidity and inferior oncologic outcomes in patients with colorectal cancer (CRC). Despite these risks, intentional preoperative weight optimization is not routinely incorporated into CRC management, owing to concerns regarding treatment delay, absence of guideline endorsement, and limited supporting evidence. Methods: A literature review was conducted using PubMed and Embase to evaluate the impact of severe obesity on morbidity, mortality, and oncologic outcomes in CRC. Peer-reviewed English-language studies involving adult human subjects were included, while conference abstracts, non-English publications, and studies unrelated to obesity and CRC were excluded. In the absence of published reports describing synchronized weight loss and CRC management in patients with severe obesity, three novel retrospective case examples were included to demonstrate feasibility during neoadjuvant treatment, with institutional review board approval obtained for all cases. Results: Severe obesity complicates CRC staging due to limitations in cross-sectional imaging and anatomic delineation. Furthermore, severe and particularly visceral obesity is associated with increased rates of anastomotic leak, surgical site infection, and conversion to open surgery. Current CRC guidelines do not incorporate structured weight-loss strategies into standard treatment algorithms. Metabolic bariatric procedures, such as sleeve gastrectomy, achieve rapid and clinically meaningful weight reduction, often resulting in improved operative exposure and technical conditions for subsequent resection. Pharmacologic therapies, while more broadly accessible and less invasive, typically yield more modest reductions in visceral adiposity. Task force members report early experience across three distinct cases of locally advanced CRC in patients with severe obesity, demonstrating successful preoperative visceral fat reduction through multidisciplinary coordination incorporating metabolic bariatric surgery or pharmacologic therapy during neoadjuvant windows, followed by definitive oncologic resection. Conclusions: Severe obesity adversely influences CRC staging, operative complexity, and perioperative outcomes. Intentional metabolic optimization—through bariatric surgery or pharmacologic therapy—may represent a viable adjunct within multidisciplinary, patient-centered CRC care pathways. However, the absence of prospective short- and long-term outcome data underscores the need for systematic investigation to define optimal timing, safety parameters, and oncologic efficacy of weight-loss interventions in this high-risk population.