Because of the multiple functions of the liver-synthesis of most serum proteins, metabolism of nutrients and drugs, excretion and detoxification of endogenous toxins and exogenous agents, and filtering of portal venous blood-assessing the risk of surgery in patients with liver disease is a challenging endeavor. Any or all of the functions of the liver may be impaired in patients with liver disease. 1,2 As a result, the pharmacokinetic parameters of anesthetics, muscle relaxants, analgesics, and sedatives can be affected by changes in binding to plasma proteins, detoxification, and excretion; bleeding risk can be increased because of coagulopathy; and susceptibility to infection can be increased because of altered functioning of hepatic reticuloendothelial cells and other changes in the immune system as well as portal hypertension. Perhaps most importantly, a diseased liver is particularly susceptible to the hemodynamic changes that accompany surgery. On the other hand, operative risk is probably not increased in the vast majority of patients with liver disease, including most of those with chronic hepatitis C, in whom liver function is preserved.
Mild elevations of serum aminotransferase, alkaline phosphatase, or bilirubin levels are frequent after surgical procedures, whether performed under general, spinal, or epidural anesthesia. 3,4 In patients without preexisting liver disease, these perturbations are usually transient, of no clinical significance, and often unnoticed. Clinically important hepatic dysfunction is more likely to occur in patients with preexisting liver disease. This review will consider the factors that contribute to perioperative hepatic dysfunction and prediction of operative risk in patients with liver disease undergoing surgery other than liver transplantation.