Background: The metabolic syndrome is a distinct obesity-related syndrome characterized by truncal obesity, insulin resistance, dyslipidemia, hypertension and decreased glucose tolerance (or Type 2 diabetes), of which the prevalence has been increasing obviously in recent years. The metabolic syndrome affects multiple interacting organ systems, and greatly increases the perioperative risks of anesthesia and surgical procedures. Purpose: The objective of this review was to offer reference for the perioperative risk assessment and the anesthetic management of patients with the metabolic syndrome, by summarizing current opinions and actualities available. Content: Elaborating the concept, pathogenesis and epidemiology of the metabolic syndrome, and discussing the perioperative risk assessment and management from different aspects, such as the physiopathologic changes in the respiratory, circulatory, and digestive systems. Trend: Our review may help to provide information for the development of anesthetic management strategies and clinical algorithms.