Surgery in the patient with liver disease.

Surgery is performed in patients with liver disease more frequently now than in the past, in part because of the long-term survival of patients with cirrhosis. Recent work has focused on estimating perioperative risk in patients with liver disease. Hemodynamic instability in the perioperative period can worsen liver function in patients with liver disease. Operative risk correlates with the severity of the underlying liver disease and the nature of the surgical procedure. Thorough preoperative evaluation is necessary prior to elective surgery. Surgery is contraindicated in patients with certain conditions, such as acute hepatitis, acute liver failure, and alcoholic hepatitis. Estimation of perioperative mortality is inexact because of the retrospective nature of and biased patient selection in available clinical studies. The Child-Pugh classification (Child-Turcotte-Pugh score) and particulary the Model for End-Stage Liver Disease (MELD) score provide reasonable estimations of perioperative mortality but do not replace the need for careful preoperative preparation and postoperative monitoring, as early detection of complications is essential for improving outcomes. Medical therapy for specific manifestations of hepatic disease, including ascites, encephalopathy, and renal dysfunction, should be optimized preoperatively or, if necessary, administered in the postoperative period.