How is early Barrett's cancer currently diagnosed and treated in Western Europe? Results of a survey at 52 university hospitals in eight Western European countries.

BACKGROUND AND STUDY AIMS: Endoscopic treatment is increasingly being accepted for early Barrett's cancer (EBC), as it is associated with few complications, excellent long-term results, and almost no mortality. This study investigated current standards and treatment strategies for EBC in eight countries in Western Europe. METHODS: A standardized questionnaire with questions on the endoscopic diagnosis, staging, and treatment of EBC was developed and sent to 107 university gastroenterology departments. The data were analyzed anonymously. RESULTS: The response rate was 49 % (52/107). For work-up of early Barrett's neoplasia, 67 % of hospitals use high-resolution endoscopes, with routine four-quadrant and targeted biopsies of visible lesions in 94 % of the cases. Narrow-band imaging and chromoendoscopy are used in 67 % of the cases, and other advanced imaging and staining techniques in 65 %. Before treatment, 63 % of the respondents recommended conventional endosonography, 6 % miniprobe endosonography, and 19 % both. Endoscopic resection is carried out at 98 % of the hospitals. Argon plasma coagulation is used for ablation in 52 % of the cases and radiofrequency ablation in 27 %. An 80-year-old patient with localized mucosal EBC would be treated endoscopically in all of the hospitals. Endoscopic therapy was recommended for 50-year-old patients with mucosal EBC by 87 % of the hospitals; esophageal resection was recommended for multifocal EBC by 15 % in 80-year-old patients, by 63 % in 50-year-old patients and by 44 % in patients with incipient submucosal infiltration. CONCLUSIONS: About two-thirds of the university hospitals use high-resolution endoscopy and advanced imaging. Endoscopic therapy is the accepted standard for treating localized mucosal Barrett's cancer in Western Europe; esophageal resection is recommended by the majority (63 %) for a young patient with multifocal EBC.

Poor outcome in progressive sclerosing cholangitis after septic shock.

BACKGROUND AND STUDY AIMS: Progressive sclerosing cholangitis after septic shock is an increasingly diagnosed disease entity. We evaluated the outcome after long-term follow-up of 29 patients treated in our institution between 1995 and 2007. PATIENTS AND METHODS: Patients with cholestatic liver disease without evidence of pre-existing hepatobiliary disease and who previously required long-term treatment in an intensive care unit for septic shock due to following reasons were included in the study: severe trauma (n = 10; five with burn injury and five following accident), cardiac operation (n = 9), bacterial infection (n = 5), sigmoidectomy (n = 2), operation of aortic aneurysm (n = 3). RESULTS: In all patients, endoscopic retrograde cholangiopancreatography showed multiple stenoses, pre-stenotic dilatations, and in part rarefication of intrahepatic small bile ducts. The bile ducts were partially filled by black-pigmented or necrotic material. In 18 of 29 patients, liver biopsies were performed and showed fibrosing cholangitis. The endoscopic therapy comprised removal of occluding material, dilation of stenoses, and intermittent stenting if necessary. All endoscopic procedures were done under antibiotic prophylaxis. During follow-up, 19 of the 29 patients died. Three patients received orthotopic liver transplantation. Four patients have been registered for transplantation, and the remaining three patients show signs of severe cholestasis. The actuarial estimate (Kaplan-Meier) indicated a survival free of liver transplantation of 55 % after 1 year, and only 14 % after 6 years. The median survival was 1.1 years. CONCLUSIONS: Progressive sclerosing cholangitis after septic shock is a recently described disease characterized by extremely short survival free of liver transplantation. This disease should be considered in patients who develop cholestasis following treatment of septic shock in an intensive care unit.