Laparoscopic colorectal surgery in the cirrhotic patients: Safe and feasible

Alberto F Chapa-Lobo, MD¹, Raul Ramos-Lopez, MD², Luis Salgado-Cruz, MD¹, Marco A Juarez-Parra, MD³, Hector F Sanchez-Maldonado, MD³Ulises Caballero-de la Pena, MD³, Ernesto Miranda-Cervantes, MD³. ¹Servicio de Cirugia General Tec Salud. Tecnologico de Monterrey. Campus Monterrey, ²Digestive Disease Center. University of Texas Health Science Center. San Antonio Texas, ³Hospital Christus Muguerza Alta Especialidad / UDEM

Introduction: Major abdominal surgery in cirrhotic patients is associated with high rates of morbidity (33-77%) and mortality (17-41%). Complications like hemorrhage, sepsis, and metabolic imbalance are common. A 2.59 fold risk for 30-day mortality has been reported in patients undergoing colorectal surgery. Post-operative mortality is increased along Child’s classification.

Advances in laparoscopic surgery have expanded the benefits of MIS to colorectal surgery. Once considered an absolute contraindication, promising outcomes in carefully selected patients have been reported. We present 3 consecutive cirrhotic patients with associated colorectal disease successfully treated by laparoscopy.

Case reports: A 75 y.o. male with known alcoholic cirrhosis. He was admitted for fecaluria and pneumaturia for the last 4 weeks. An abdominal CT scan revealed a cirrhotic liver with dilated portal and mesenteric vessels with splenomegaly and porto-systemic collaterals. Thickening of the sigmoid colon wall and air in the bladder was also noticed. Classified as Child’s A-MELD 11 and underwent a laparoscopic sigmoidectomy with colovesical fistula excision.                                             

An 85 y.o. male with known history alcoholic cirrhosis. He had a 10 m. history of anemic syndrome and weight loss. A tumor was found in the ascending colon on a CT-scan. This same study also revealed splenomegaly and dilated splanchnic vessels.  Classified as Child’s A-MELD 10 and underwent a laparoscopic right hemicolectomy.

A 73 y.o. male with history of fecal incontinence due to peripheral neuropathy. He had a 6 m. history of hematoquezia and weight loss. Rectal exam revealed the presence of a polypoid mass 1.5 cm from the anal verge, biopsy reported adenocarcinoma. Staging CT scan demonstrated a cirrhotic liver. Classified as Child’s A-MELD 7. After neo-adjuvant therapy, he underwent a LAR with taTME and end colostomy.

All patients were operated electively. The preoperative conditioning included: hyposodic regime, fluid restriction, enteral supplements, K vitamin and FFP. Laparoscopic technique was carried out as routine fashion. Drains placed and removed early to prevent infection. Mean operative time was 160 minutes with minimum blood loss. All patients developed mild ascites with adequate response to diuretics and albumin. Diet was started once peristalsis was present; the median hospital stay 5 days. No complications are reported.

Discussion: Management of colorectal disease in cirrhotic patients is not straightforward and data comes from small series. Several reports have demonstrated the feasibility of laparoscopic surgery in cirrhotic patients with similar results to open procedures. After correct metabolic optimization, MIS seems to be safe in compensated patients.