Services for liver disease in the United Kingdom
BMJ 2005; 331 doi: https://doi.org/10.1136/bmj.331.7521.858 (Published 13 October 2005) Cite this as: BMJ 2005;331:858All rapid responses
Rapid responses are electronic comments to the editor. They enable our users to debate issues raised in articles published on bmj.com. A rapid response is first posted online. If you need the URL (web address) of an individual response, simply click on the response headline and copy the URL from the browser window. A proportion of responses will, after editing, be published online and in the print journal as letters, which are indexed in PubMed. Rapid responses are not indexed in PubMed and they are not journal articles. The BMJ reserves the right to remove responses which are being wilfully misrepresented as published articles or when it is brought to our attention that a response spreads misinformation.
From March 2022, the word limit for rapid responses will be 600 words not including references and author details. We will no longer post responses that exceed this limit.
The word limit for letters selected from posted responses remains 300 words.
Professor Willliam’s timely editorial brings attention to the need
for increased provision of services for hepatology, both medical and
surgical, resulting from the increasing prevalence of liver disease and
the recent development of effective treatments including liver resection,
transplantation and antiviral agents. He highlights the special funding
available to the six liver transplant centres in the UK and suggests that
increasing their number would provide for the shortfall in liver services
across the country.
While the provision of additional liver transplant centres may be
desirable to make transplantation more widely available this alone will
not fulfil the overall need for hepato-pancreato-biliary (HPB) services.
The numbers of liver resections for colorectal metastases are increasing
exponentially annually with five year survival figures >35% in most
series. This is due to neo-adjuvant chemotherapy improving resectability,
the use of staged liver resections, the use of pre-operative portal vein
embolisation to grow segments to be preserved and most of all due to
better education of colorectal surgeons and oncologists as to what is
possible in the hands of hepatic surgeons. Even if the number of
transplant centres were doubled we estimate from our experience with a
population of 2.5 million that each unit would have to provide at least
200 HPB resections a year in addition to the increasing number of
transplants as split liver and live donor transplants evolve.
To cope with the volume of work we believe that alongside the
expansion in transplant centres there should be increased support for
regional HPB centres to provide for the majority of patients that do not
require transplant technology.
Yours sincerely
Nariman Karanjia MS FRCS(Gen)
Consultant HPB Surgeon
Robin Lightwood MCh FRCS
Consultant HPB Surgeon and Lead Clinician HPB Unit for Surrey and Sussex
Competing interests:
None declared
Competing interests: No competing interests
Provision of hepatology services in the United Kingdom
Sir,
Roger Williams’ excellent editorial made several valid points
regarding the provision of hepatology services in the United Kingdom.
In particular, I note the view that specialist liver services are
presently concentrated in too few institutions. The UK’s seven liver
transplant centres clearly perform outstanding work, but they also command
the lion’s share of hepatology funding and training opportunities, despite
some 30-65% of their hepatology referrals being for non-transplant
services [1].
To offer a comparison, the state of California has twelve UNOS-
approved liver transplant centres, serving a much smaller total population
of around 26 million adults. There is a wide geographical distribution,
weighted toward the major conurbations, and transplantation centres are
linked with all the approved gastroenterology fellowship training programs
in the state.
As Williams recognises, large areas of the UK are under-represented
by the current transplant centre-based services. Published evidence
suggests that post-transplant outcomes are not significantly different at
medium-sized centres when compared to high-volume units [2] and so a
modest increase in the number of centres need not be too dilutional.
Perhaps we should encourage a more equitable allocation of services for
our patients, in cities closer to where they live.
Such redistribution would also enable more gastroenterology trainees
to work in specialized liver units, ideally within their own regional
rotation. The recent creation of dedicated hepatology training slots is of
course very welcome, but these are still likely to benefit only a
minority. Anecdotally, I found arranging a move to the USA to be less
complicated than negotiating a transfer between two adjacent SpR training
regions in the UK.
As highlighted in Williams’ editorial, the authors of the draft
National Plan for Liver Services have called for prioritizing care through
some 10-15 hepatology centres (including the existing 7 transplant units),
considerably less than the number of hospitals currently providing liver
services [3]. The report has clearly stimulated an important debate on how
best to manage the increasing burden of liver diseases.
References
[1] Williams R. Provision of specialist liver services in England.
July 2004. www.bsg.org.uk/pdf_word_docs/hepservices.doc
[2] Axelrod DA, Guidinger MK, McCullough KP, Leichtman AB, Punch JD,
Merion RM. Association of center volume with outcome after liver and
kidney transplantation.
Am J Transplant. 2004 Jun;4(6):920-7
[3] Moore K, Thursz M, Mirza DF. National plan for liver
services—specialised services for hepatology, hepatobiliary and pancreatic
surgery. 2003. Report prepared for the British Association for the Study
of the Liver.
www.basl.org.uk/National%20Plan%20for%20Liver%20Services%20UK%20Final-
May04.pdf
Competing interests:
None declared
Competing interests: No competing interests