How to manage a patient with chronic liver disease undergoing colorectal surgery?

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.