liver transplantation is widening. In the early days of liver transplantation patients with alcoholic liver disease were usually excluded,' 2 but some centres are ...
BMJ
LONDON, SATURDAY 16 SEPTEMBER 1989
Transplantation for alcoholic liver disease Contraindicated by alcohol dependence or extrahepatic disease As the annual number of transplants increases and the one year survival rate improves the range of indications for liver transplantation is widening. In the early days of liver transplantation patients with alcoholic liver disease were usually excluded,' 2 but some centres are now offering such patients transplantation. Recent results from Pittsburgh, one of the foremost centres of liver transplantation,3 suggest that patients with alcoholic liver disease may have virtually as good an outcome as those with other chronic liver diseases: at a median of 14 5 months after transplantation 52 of 73 patients were alive, and only about one in 10 had returned to drinking. This compares with results of liver transplantation for all patients treated in Birmingham: at a median of 15 months 95 of 152 patients were alive, and all but four returned to a completely normal life (P McMaster, personal communication). Among the reasons for the reluctance to perform transplantation in people with alcoholic liver disease has been the concern that such patients are unlikely to stand the considerable psychological stresses associated with the operation, and they may not comply with attending follow up clinics and taking immunosuppressant drugs. A further fear has been that they will return to their previous drinking habits, creating difficulties in maintaining immunosuppression and developing damage to their graft and other organs as well as malnutrition. In a few patients these fears may be right.3 The reason for the low transplantation rate among patients with alcoholic liver disease does not seem to be a puritanical streak among transplant surgeons and physicians. Of far greater importance is that many of the patients also have cerebral disease, myopathy, neuropathy, pancreatic disease, cardiomyopathy, and malnutrition-all induced by alcohol. In most patients with alcoholic liver disease abstention from alcohol results in improved liver function and lengthened survival.4 But some patients develop progressive hepatic impairment despite abstaining," and those who present with haematemesis or advanced portal hypertension may be especially at risk.6' Other reasons why such patients might become candidates for transplantation include developing hepatocellular carcinoma, intractable ascites, or encephalopathy. Before transplantation is undertaken these patients and their families must be fully assessed not only by surgeons and physicians but also by those experienced in alcohol counselling; this support must be maintained postoperatively. BMJ VOLUME 299
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Prolonged abstinence is unlikely if first degree relatives of the patient are also abusing alcohol. Some centres now consider transplantation in patients with alcohol induced liver disease only if they have abstained from alcohol completely for six months. Great difficulties arise in those who present with alcoholic hepatitis9 because there is no time to assess whether the patient is alcohol dependent, and formal psychological assessment may not be possible because of increasing encephalopathy. Some of these patients might be considered for transplantation, but many have severe extrahepatic disease that precludes grafting. If the indications for transplantation were widened to include alcohol induced liver disease there would be considerable economic implications. It is difficult to assess the number of patients in Britain with alcoholic injury to the liver who are potential transplant recipients. Although as few as one third of cases of alcohol associated liver damage may be correctly reported in those under 60,10 in England and Wales the number of deaths attributed to alcohol induced liver injury is still about 1030 each year." Many of these patients may not be suitable because of alcohol dependence or extrahepatic disease,'2 but if even a fifth are suitable this means about 200 patients a year. In 1988 just over 250 liver transplants were performed in Britain at a cost for each operation of £20 000 to £25 000. If the indications for liver transplantation were widened to include alcohol associated liver injury then considerably more money would be required for expanding the existing transplant units and possibly for creating more. And additional efforts would be needed to ensure an adequate supply of donor organs. Currently it seems reasonable to consider for transplantation those patients with alcoholic hepatitis who have no serious disease of other organs, no history of alcohol dependence, and excellent family and social support. Transplantation may also be indicated in those with chronic disease who have abstained from alcohol once advised to do so, have no serious damage to other organs, and have a poor quality of life (because of the liver disease) and an estimated length of survival of less than one year. Because of the important implications for allocating resources careful evaluation is required to determine not only the indications and contraindications in this group of patients but also the long term results. JAMES M NEUBERGER Consultant Physician, Queen Elizabeth Hospital, Birmingham B15 2TH 693
I Startl I , Inwitsuki S, van 'Ih1id1 DH ct al. Evolution in liver traulsplaittatioi). IIcpaltolo* 1982;2:614-32. 2 Rolles K, VCilliatuis R, Neubcrgcr J, (Calinc RY. TI'he Cambridge and King's (Collcgc Hospital experience of licr transplanitation. Hepatulogtv 1984;4:50)-5 S. 3 Kunmar S, Basista M, Stauber RE, . al. Orthotopic liver tratisplantatioit for alcoholic liver disease. Ga(strt7enterolog,v 1989;96:A'916 4 lBruint '1iW, Kew MIC, Sclictier PJ, Shcrlock S. StuLdies in alcoholic liver discase in Britain. Gut
1974;15:52-8. 5 IPares A, Caballeria J, Brugiuera M, Torrcs M, Rodes J. Histological coursc ofl alcoholic hepatitis.
j Heputol 1986;2:33-42.
6 Stitcrakis J, Rcsnick RH, lber FL. Ettcct oit alciohol abstinence on survival in cirrhotiic portal hvpertension. Laneti 1973;ii:65-7. 7 Mlartini GA, lcschke R. Alcohotl abstitciicc in alcoholic liver diseasc. lita Sled Sicand [Suppl] 1973;703: 185-94. 8 (iluud C, Ienrtksci SH, N'cisci Gi, atid the Copenhagein Study (irituor Liver Diseasc. 1'rognostic itidications in alcoholic cirrhotics. Hepatiiloiv 1988;8:222-7. 9 Maddrev W C, Biotinott 1K, Bedine NIS, \'Weber FL, Mezcy E, White RI. Corticosteroid therapy ot alcoholic hepatitis. Gsutroenterology 1978;75:193-9. 10 Maxwell JD, Knapman P. Etlects of coroner's rules oni death certification for alcoholic liver disease. BrMedl7 1985;297:708. 1 1 Office of Population CensuseCs and Surveys. .lliirtalltt stattitti s. London: HMSO, 1986. 12 Bismuth H, G(igcnheim J, Ciardullo M\S. Itidication for hcpatic transplantation in alcoholic liter cirrhosis. I'ranisplatit Prot 1986;4ssuppl 3 j:83-5.
Endoscopic sinus surgery remains a limited specialised procedure in Britain. The lack of disease classification and long term follow up has meant that there have been no controlled studies, but clinical reports of several thousand procedures from Europe and the United States show results when performed by an experienced endonasal surgeon similar to the older approaches.'3 The main benefits of the technique comes from the accurate diagnosis of early disease, particularly when there is a localised cause for widespread sinus inflammatory changes. In these circumstances endoscopic surgery can be effective without the morbidity associated with traditional approaches. CHARLES A EAST Senior Registrar, Ferens Institute of Otolaryngology, University College and Middlesex School of Medicine, London WIP 5FD I Mcsscrklinger WV. Uher Drainage der menschlichen nasennebenhohlen under normalen und pathologischen Bendingungen II Mitteilung: Die Stirnhohle und ihr Ausfurhrungssystem.
Functional endoscopic surgery to the sinuses
MIionatsschrifi Ohrenheikune 1967;101:313-26.
2
D Zinreich SJ, Rosenbaum A, Johns M. Funictional endoscopic sinus suirgerv: theory Kcincv15W, illd diagnosis. Arch Otolarsngol Head and Neck Surgery 1985;111:576-82.
3 Stammherger H, Wolf G. Headaches and sinus disease: the endoscopic approach. Ann Otol Rhinol
Lanrvgol 1988;97(suppl 134):3-23. 4 Stammberger H. Endoscopic cndonasal surgery: concepts in treatment of recurring rhinosinusitis.
Otolarengology 1986;94:143-56.
A minimally invasive treatmentfor sinusitis Endoscopy is now being used for both diagnosis and surgical treatment of disorders of the nose and paranasal sinuses. Endoscopic examination has improved our understanding of the pathological basis of chronic and recurrent sinusitis. Direct observations of mucociliary clearance patterns have shown that there are clear cut pathways in the sinuses, with secretions always trying to leave through the natural ostia.' The maxillary and frontal sinuses both drain into the nose through narrow channels in the ethmoids, an area subject to frequent anatomical variations and known as the "ostiomeatal complex."' In health these narrow clefts convey mucus into the nose with no difficulties. But if the mucosa become inflamed the pathways in the ethmoids will become obstructed and impede normal sinonasal drainage, possibly acting as a focus for recurrent or persistent inflammation, producing the clinical picture of "maxillary" or "frontal" sinusitis.3 This condition can now be treated by endoscopic functional surgery, which relies on the ability ofdiseased sinus mucosa to recover when the source of inflammation has been removed. Clinical reports suggest that this potential reversibility may have been underestimated.46 The concept that the ethmoid sinuses might influence inflammatory disease in adjacent sinuses is not new,7 but our ability to visualise directly areas of mucosa and accurately image the deeper recesses of the sinuses has allowed direct confirmation of the association.8 This evidence gave a logical basis for a direct surgical approach to the ethmoids as an alternative to and possibly a replacement for the traditional radical procedures such as the Caldwell-Luc operation-at least until disease in the ostiomeatal complex area has been assessed and treated.9 10 Outpatient diagnosis in adults and children is made using 4 mm and 2 7 mm telescopes in the nose." 12 Surgery is performed under either local or general anaesthesia and differs from other types of ethmoidectomy in that the procedure is carried out entirely under direct vision and an external incision is avoided. The technique is demanding and requires a detailed knowledge of ethmoid anatomy. Careful endoscopic follow up is required, but there is less of a need for x ray examinations as the sinuses can be inspected directly if symptoms of disease recur. 694
5 Albegger KW. Abnormal "hair-like" filaments in chronic maxillary sinusitis. A scanning electron microscopic inv estigation. Ann Otolarvngol Head and Neck Surgery 1978;220:239-49. 6 Wigand ME. rransnasal ethmoidectomv under endoscopical control. Rhinology 198 1;19:7-15. 7 Proctor DF. I he nose, paranasal sinuses and pharvnx. In: Walters W, ed. Lewis-Walters practice of surgers.Vo. 4. Hagerstown, Maryland: Prior, 1966:1-37. 8 Zinreich SJ, Kennedy 1)XW, Rosenbaum AE, Gavler BW, Kumar AJ, Stammberger H. Paranasal sinuses: CT imaging requirements for endoscopic surgery. Radiology 1987;163:769-75. 9 Stammbergcr H, Zinreich SJ, Kopp W, Kennedy DW, Johns ME, Rosenbaum AE. Surgical treatment of chronic recturrent sinusitis-the Caldwell-Luc versus a functional endoscopic technique. HNO 1987;35:93-105. 10 Kennedy DW. Functional endoscopic sinus surgery technique. Arch Otolaryngol Head and Neck
Surgerv 1985;111:643-49. 11 Messerklinger W. Endoscopy oJ the nose. Baltimore: Urban and Schwarzenburg, 1978. 12 Stammberger H. Nasal and -paranasal sinus endoscopy, a diagnostic and surgical approach to recurrent sinusitis. Endoscopy 1986;18:213-18. 13 Kentnedv DW, Zinreich SJ, Shaalan H, Kuhn F, Naclerio R, Loch E. Endoscopic middle meatal antrostomv: theory, technique and patency. Laryngoscope 1987;97 (suppl 43):1-9.
Adult consequences of early parental loss Quality of care matters more than the loss itself Many studies show an increased risk of adult affective disorder after loss in early childhood. The studies support theories that link depression with the quality of the child's psychological response to the death or other loss of a person who is important to them. ' 2 But the degree of risk varies from study to study, and much effort has been made to explain these variations and to decide whether it is the loss itself that constitutes the risk. It may not be. The childhood experiences that precede depression or anxiety in adulthood3 have been identified mainly for women,4 but associations have also been found for men. 6 Loss results not only from the death of a parent7 but also from separation caused, for example, by marital breakdown, hospitalisation, and wartime evacuation.6 The term "early" has been used in the studies to cover the whole of childhood up to the age of 17. Studies have nearly always been retrospective, with possibly inaccurate data about early separations and the domestic circumstances at the time being recalled by the subjects. Adult subjects have been drawn from a wide age range (18 to over 50) of people from outpatient clinics and the general population and have shown varying degrees of BMJ
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