Available online 17 October 2023, 100986

Author links open overlay panel, Abstract

The indications for colorectal surgery in cirrhotic patients have recently been broadened, mostly due to a better understanding and multidisciplinary management of cirrhosis. However, anesthesia and colorectal surgery may both exacerbate deteriorations in liver function in a patient with chronic liver disease such that careful preoperative patient selection remains mandatory. Four scores (i.e., Child-Turcotte-Pugh, the Model for End-Stage Liver Disease, Mayo Risk Score, and (VOCAL)-Penn cirrhosis surgical risk score) are currently available to assess the severity of cirrhosis, determine the risk of decompensation, and to estimate postoperative mortality. For colorectal resection to be safely performed electively in patients with compensated liver disease, optimization of the patient is mandatory in the preoperative setting. Preoperative transjugular intrahepatic portosystemic shunt (TIPS) is a promising strategy in patients with portal hypertension, but it requires further evaluation. Similarly, further studies are needed to validate both the feasibility and safety of the laparoscopic approach to colorectal surgery in cirrhotic patients. In summary, preoperative identification and optimization combined with meticulous postoperative care are essential for optimum outcomes in patients with chronic liver disease undergoing colorectal surgery.

Section snippetsINTRODUCTION

The overall incidence of chronic liver disease (CLD) and cirrhosis, whatever its origin (alcohol misuse, infection with hepatitis viruses, and nonalcoholic liver disease), is rising in most European and Western populations 1. Their natural history is fraught with life-threatening complications (i.e., variceal bleeding, ascites, hepatorenal syndrome, hepatic encephalopathy) 2. However, a better knowledge of the pathophysiology and multidisciplinary management has dramatically increased their

Why should the cirrhotic patient be screened preoperatively?

Cirrhosis leads to many hepatic consequences (hepatocellular insufficiency, portal hypertension, lower glucogenesis, ascites, and hepatic encephalopathy) but also systemic: hematological (thrombocytopenia, thrombopathy, coagulopathy); metabolic (hepatorenal syndrome, insulin resistance, adrenal insufficiency); immunological (exaggerated inflammatory response, altered innate and adaptive immunity, decreased complement synthesis, bacterial translocation); cardiovascular (vasodilatation,

CONCLUSIONS

The high postoperative morbidity and mortality after colorectal surgery in cirrhotic patients warrant a multidisciplinary pre-operative assessment. A rigorous assessment of co-morbidities and risk stratification is essential to select only patients with compensated liver function. Several scores (CPT, MELD, and preferentially the VOCAL-Penn cirrhosis surgical risk tool) are available to predict the risk of liver decompensation, infectious complications, and ultimately mortality. In the case of

Declaration of Competing Interest

None to declare.

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