Surgery in the Patient with Liver Disease Jacqueline G. O’Leary, MD, MPH a , Patrick S.Yachimski, MD, MPH b,c,d , Lawrence S. Friedman, MD e,f ,g,h, * Administration of anesthesia reduces blood flow to the liver during all surgical proce- dures. In patients with normal liver function, the reduction in blood flow can result in asymptomatic elevation in the results of serum liver biochemical tests postoperatively; in patients with compromised liver function preoperatively, hepatic decompensation can occur intra- and postoperatively, leading to morbidity and mortality. Because liver disease is common and patients with liver disease are frequently asymptomatic, the preoperative assessment of all patients undergoing surgery must include a careful history and physical examination to uncover risk factors for and evidence of liver dysfunction. If liver disease is present, elective surgery should be deferred until the patient has been evaluated or recovered. Operative risk correlates with the severity of the underlying liver disease and the nature of the surgical procedure. In patients with cirrhosis, the Child class and Model for End-Stage liver Disease (MELD) score should be calculated to assist in preoperative risk assessment. When patients with decompensated liver disease must undergo surgery, their clinical condition should be optimized perioperatively to improve the chances of a favorable outcome. EFFECTS OF ANESTHESIA AND SURGERY ON THE LIVER Changes in Liver Biochemical Test Levels Most surgical procedures, whether performed under general or conduction (spinal or epidural) anesthesia, are followed by minor elevations in the results of serum liver a Division of Hepatology, Department of Internal Medicine, Baylor University Medical Center, 4th Floor Roberts, 3500 Gaston Avenue, Dallas, TX 75246, USA b Department of Medicine, Harvard Medical School, Boston, MA 02115, USA c Gastrointestinal Unit, Massachusetts General Hospital, Blake 4, 55 Fruit Street, Boston, MA 02114, USA d Division of Gastroenterology, Brigham and Women’s Hospital, Boston, MA 02115, USA e Department of Medicine, Harvard Medical School, Boston, MA 02115, USA f Department of Medicine, Tufts University School of Medicine, Boston, MA 02110, USA g Department of Medicine, Newton-Wellesley Hospital, 2014 Washington Street, Newton, MA 02462, USA h Department of Medicine, Massachusetts General Hospital, Boston, MA 02114, USA * Corresponding author. E-mail address: lfriedman@partners.org (L.S. Friedman). KEYWORDS  Cirrhosis  Surgery  MELD score  Child class  Liver disease Clin Liver Dis 13 (2009) 211–231 doi:10.1016/j.cld.2009.02.002 liver.theclinics.com 1089-3261/09/$ – see front matter ª 2009 Elsevier Inc. All rights reserved.