Gut microbiota, liver disease, and perioperative anesthesia: interactions, risks, and therapeutic opportunities

Liver disease is increasingly common worldwide and poses significant challenges during anesthesia and surgery. Growing evidence demonstrates that the gut microbiome plays an essential role in hepatic inflammation, metabolic imbalance, immune dysfunction, and the progression of conditions such as metabolic associated steatotic liver disease, alcohol related liver injury, and cirrhosis. This review summarizes the concept of the gut-liver-anesthesia axis, which describes how disturbances in the intestinal microbiome shape perioperative risk. Importantly, this framework conceptualizes the gut-liver-anesthesia axis as a unified perioperative risk model, integrating microbial dysbiosis, hepatic vulnerability, and anesthetic exposure into a single pathophysiological continuum. Patients with advanced liver disease frequently exhibit reduced microbial diversity, impaired intestinal barrier function, disordered bile acid signaling, and heightened systemic inflammation. These alterations increase susceptibility to infection, kidney injury, hemodynamic instability, and neurocognitive complications including hepatic encephalopathy and postoperative delirium. Anesthetic agents can further disrupt the gut ecosystem by weakening mucosal integrity and facilitating bacterial translocation, while the microbiome itself influences drug metabolism and clearance, leading to unpredictable anesthetic responses. Understanding this bidirectional interaction highlights opportunities for microbiome focused perioperative strategies. Approaches such as probiotic based preparation, opioid sparing anesthesia, regional techniques, early enteral feeding, and targeted microbial restoration may improve postoperative outcomes in patients with liver disease.