Annals of the Royal College of Surgeons of England
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Ann R Coll Surg Engl · Jan 2007
ReviewThe role of liver transplantation in the management of paediatric liver tumours.
In recent years, considerable progress has been made in the treatment of children with hepatoblastoma largely due to effective pre-operative chemotherapy. Total hepatectomy and liver transplantation has emerged as an effective treatment for the small proportion of children with unresectable hepatoblastoma limited to the liver. A 5-year survival of 70% can be achieved in such cases. ⋯ An exception is those children in whom the hepatocellular carcinoma is detected during surveillance of chronic liver disease - they typically have smaller tumours and frequently have a good prognosis after liver transplantation. The role of liver transplantation in children with other primary hepatic malignancies remains uncertain because experience is very limited. Liver transplantation is rarely needed in the management of children with benign liver tumours but, if other treatments have failed, it can be a life-saving intervention.
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Acute renal failure can occur following major surgery. Predisposing factors include massive haemorrhage, sepsis, diabetes, hypertension, cardiac disease, peripheral vascular disease, chronic renal impairment and age. Understanding epidemiology, aetiology and pathophysiology can aid effective diagnosis and management. ⋯ Acute renal failure is a marker of disease severity, carrying a poor prognosis if associated with deteriorating respiratory and cardiovascular function. Acute renal failure in the critically ill surgical patient exerts a massive impact on the evolution of complications and prognosis. Management relates to treating life-threatening problems, maintaining effective ventilation and circulation, removal (or reduction) of nephrotoxins and, where appropriate, establishing either renal replacement therapy or palliative care.
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Critical illness is an emergency because the inflammatory response has redundant multiple pathways; once triggered, it is difficult to control or suppress. Infection is a potent precursor of critical illness and increasing organ dysfunction has a synergistic, rather than purely additive, adverse effect on mortality. The longer the inflammatory process continues unabated, the more advanced and unrecoverable the pathophysiological processes become resulting in a high mortality. ⋯ Formalising measurement of physiological (in)stability on the general ward using Early Warning Scores improves recognition of unstable and potentially critically ill patients. Prompt intervention will either reverse further physiological decline or facilitate timely referral to the critical care service for further, more invasive, organ support.