Performance of biliary stents in malignant biliary strictures.

INTRODUCTION: Endoscopic stenting is a commonly applied method of treatment in patients with malignant biliary strictures. It involves the use of self­expandable metal stents (SEMSs) or plastic stents (PSs). OBJECTIVES: The aim of the study was to compare the effectiveness of SEMSs and PSs in the endoscopic drainage of malignant strictures of the biliary tree and its sequels for future optimalization of this treatment method. PATIENTS AND METHODS: Data on 618 consecutive patients with malignant biliary stricture, in whom 1271endoscopic retrograde cholangiopancreatography procedures with biliary stenting have been performed in the years 2012-2017 with at least 3­year follow­up,  were retrospectively derived from a hospital database. RESULTS: The main indications for stenting were pancreatic cancer (37%) and cholangiocarcinoma (34%). The use of SEMSs resulted in a greater decline of serum bilirubin as compared with PSs (37% vs 32% of baseline concentration; P = 0.01). Consequently, hospital stay was shorter by more than 2 days (mean [SD], 9.5 [5.6] vs 11.8 [7.9] days; P <0.001). The median (interquartile range) patency time of SEMSs was more than 2 times longer than for PSs (118 [56-232] days vs 46 [18-97] days; P <0.001), and procedure­related complications were less frequent (19.3% vs 12.9%, respectively in the SEMS and PS group; P = 0.001). SEMSs proved also to be more cost­effective; the hospital profit was 1375 USD for a single hospitalization with SEMS insertion. CONCLUSIONS: In patients with malignant strictures of the biliary tree SEMSs outperform PSs. SEMSs should be used as a treatment of choice for biliary drainage in that group of patients.

The prospective validation of a scoring system to assess mucosal cleanliness during EGD.

BACKGROUND AND AIMS: Cleanliness of the mucosa of the upper GI (UGI) tract is critical for performing a high-quality EGD. The aim of this study was to validate a recently developed UGI cleanliness scale (the Polprep: Effective Assessment of Cleanliness in Esophagogastroduodenoscopy [PEACE] system) in the detection of clinically significant lesions (CSLs) in the UGI tract. METHODS: Patients who underwent a complete diagnostic EGD were prospectively enrolled from August 2021 to October 2022. The UGI tract (esophagus, stomach, and duodenum) cleanliness was scored from 0 to 3 for each segment. The primary outcomes were the detection of CSLs and PEACE scores. RESULTS: Of 995 patients enrolled from 5 centers, adequate cleanliness (AQ; all scores ≥2) was found in 929 patients. In multivariate regression analysis, AQ was associated with the number of diagnosed CSLs (odds ratio [OR], 1.78; 95% confidence interval [CI], 1.06-3.01; P = .03). Other factors related to CSL detection were duration of EGD (OR, 1.29, 95% CI, 1.23-1.35, P < .001), male sex (OR, 1.33, 95% CI, 1.04-1.71; P = .025), and EGD indication (dyspepsia, alarm symptoms, gastritis surveillance, other indications vs GERD) (OR, 0.43 [95% CI, 0.31-0.6, P < .001], OR, 0.44 [95% CI, 0.28-0.67, P < .001], OR, 0.44 [95% CI, 0.25-0.76; P = .004], and OR, 0.44 [95% CI, 0.31-0.62; P < .001], respectively). Twenty-seven patients were diagnosed with UGI neoplasia, all in patients with adequate cleanliness of the UGI tract. CONCLUSIONS: Adequate cleanliness of the UGI tract as assessed with the PEACE system was associated with a significantly higher detection rate of CSLs during EGD. The relationship of this scale with UGI neoplasia detection warrants further investigation.

Guidelines for the management of ulcerative colitis. Recommendations of the Polish Society of Gastroenterology and the Polish National Consultant in Gastroenterology.

This paper is an update of the diagnostic and therapeutic recommendations of the National Consultant for Gastroenterology and the Polish Society of Gastroenterology from 2013. It contains 49 recommendations for the diagnosis and treatment, both pharmacological and surgical, of ulcerative colitis in adults. The guidelines were developed by a group of experts appointed by the Polish Society of Gastroenterology and the National Consultant in the field of Gastroenterology. The methodology related to the GRADE methodology was used to assess the quality of available evidence and the strength of therapeutic recommendations. The degree of expert support for the proposed statements was assessed on a 6-point Likert scale. Voting results, together with comments, are included with each statement.

Liver phenotypes in PCOS: Analysis of exogenous and inherited risk factors for liver injury in two European cohorts.

BACKGROUND & AIMS: Fatty liver disease (FLD) is common in women with polycystic ovary syndrome (PCOS). Here, we use non-invasive tests to quantify liver injury in women with PCOS and analyse whether FLD-associated genetic variants contribute to liver phenotypes in PCOS. METHODS: Prospectively, we recruited women with PCOS and controls at two university centres in Germany and Poland. Alcohol abuse was regarded as an exclusion criterion. Genotyping of variants associated with FLD was performed using TaqMan assays. Liver stiffness measurements (LSM), controlled attenuation parameters (CAP) and non-invasive HSI, FLI, FIB-4 scores were determined to assess hepatic steatosis and fibrosis. RESULTS: A total of 42 German (age range 18-53 years) and 143 Polish (age range 18-40 years) women with PCOS, as well as 245 German and 289 Polish controls were recruited. In contrast to Polish patients, Germans were older, presented with more severe metabolic profiles and had significantly higher LSM (median 5.9 kPa vs. 3.8 kPa). In the German cohort, carriers of the PNPLA3 p.I148M risk variant had an increased LSM (p = .01). In the Polish cohort, the minor MTARC1 allele was linked with significantly lower serum aminotransferases activities, whereas the HSD17B13 polymorphism was associated with lower concentrations of 17-OH progesterone, total testosterone, and androstenedione (all p < .05). CONCLUSIONS: FLD is common in women with PCOS. Its extent is modulated by both genetic and metabolic risk factors. Genotyping of variants associated with FLD might help to stratify the risk of liver disease progression in women suffering from PCOS.

Potential benefits of one­time gastroscopy in search for precancerous conditions.

INTRODUCTION: Precancerous conditions for esophageal (EA) and gastric adenocarcinoma (GA) are Barrett's esophagus (BE) and atrophic gastritis (AG), respectively. Their surveillance is crucial for the detection of early lesions. OBJECTIVES: The study aimed to assess whether one­timeesophagogastroduodenoscopy (EGD) in search for precancerous conditions would be effective in the population with low­to­moderate esophageal and gastric cancer risk. PATIENTS AND METHODS: A total of 5984 individuals who underwent diagnostic EGD in 3 endoscopic centers, from March 2018 to October 2019, were analyzed to assess the age of occurrence of precancerous conditions and cancers. Age distribution of the patients with malignant gastric and esophageal tumors registered in the national cancer registry from 2014 to 2017 was analyzed. RESULTS: In comparison with individuals below 40 years old, the risk of EA and GA diagnosis increased at the age of 60 to 64 years (odds ratio [OR], 12.1; 95% CI, 1.5-98.6), gastric and esophageal dysplasia at the age of 55 to 59 years (OR, 3.6; 95% CI, 1.3-9.7), and BE and AG at the age of 40 to 44 years (OR, 1.6; 95% CI, 1.04-2.4). The number of procedures per 1 cancer that could be potentially avoided was 236, 235, 290, 360, 394, and 344 for the age groups of 40-44 years, 45-49 years, 50-54 years, 55-59 years, 60-64 years, and 65-69 years, respectively. The assessed potential benefit­to­harm ratio was 47, 38, 31, 28, and 32 for the age groups of 40-49 years, 50-54 years, 55-59 years, 60-64 years, and 65-69 years, respectively. CONCLUSIONS: One­time EGD in search for precancerous conditions could be potentially applicable in individuals between 40 and 69 years of age.

Impact of tumor size and location on endoscopic ultrasound-guided sampling of pancreatic neuroendocrine tumors: A recursive partitioning analysis.

BACKGROUND: Current guidelines provide weak recommendations to treat small (<2 cm) non-functional pancreatic neuroendocrine tumors with low Ki-67 proliferation index either by resection or clinical follow-up. However, there is a lack of consensus regarding the minimal size of pNET, which allows EUS-guided biopsy with high enough diagnostic accuracy for stratification. METHODS: We conducted a retrospective, bicentric analysis of patients who had undergone EUS-guided pNET sampling in two tertiary care Endoscopy Units in Germany and Poland. Using a recursive partitioning of the tree-aided model, we aimed to stratify the probability of successful EUS-guided biopsy of pNET lesions according to their size and location. RESULTS: In our pNET cohort, successful histological confirmation of a pNET diagnosis was achieved in 59/69 (85.5%) cases at the initial EUS-guided biopsy. In 41 patients with a pNET size less than 18.5 mm, the EUS-guided first biopsy was successful in 90.2%. In 16 of these patients with smaller lesions, EUS-guided sampling was 100% in very small (less than 11 mm) and extremely small lesions (less than 8 mm). The biopsy success rate was 100% in tail lesions in the size range between ≥5.95 and <8.1 mm but only 33.3% independent of the investigator in pancreatic head or body, with an error rate of 11.2% CONCLUSION: Using a recursive partitioning of the tree-aided stratification model, we demonstrate for the first time that in balancing risks and benefits, very small pNETs (<1 cm) in the tail of the pancreas should be sampled under EUS-guidance.

The relation of esophagogastroduodenoscopy time and novel upper gastrointestinal quality measures.

OBJECTIVES: Various measures of esophagogastroduodenoscopy (EGD) quality have been proposed so far and the examination time was one of the first. The aim of the study was to compare the procedure time with novel novel quality measures - composite detection rate (CDR) and endoscopist biopsy rate (EBR). METHODS: It was prospective observational study. A total of 880 diagnostic EGDs conducted from 01.2019 to 07.2019 have been enrolled in the study. RESULTS: Median EGD time was 4.2 min. Procedures of longer duration were marked with higher CDR (26.3% vs. 11.8%; P < 0.0001), higher EBR (44.9% vs. 12.3%; P < 0.0001), and better upper gastrointestinal neoplasm (UGN) detection (1.8% vs. 0%; P = 0.004) in comparison with procedures of shorter duration. The procedures were divided into 4 groups based on the time quartiles (group 1 <3.3 min; group 2 3.3-4.2 min; group 3 4.2-5.3 min; group 4 >5.3 min). The odds ratios of groups 2, 3, and 4 for biopsy rate were 2.42 (95% CI, 1.33-4.55), 4.33 (95% CI, 2.46-7.94), and 5.51 (95% CI, 3.18-10.03), respectively, in comparison with group 1. The odds ratios of groups 2, 3, and 4 for CDR were 3.18 (95% CI, 2.03-4.97), 5.46 (95% CI, 3.51-8.50), and 23.44 (95% CI, 14.3-38.4), respectively, in comparison with group 1. CONCLUSIONS: The procedure time is related to novel metrics - CDR and EBR. It is also related to UGN. Based on our findings it could be concluded that EGD should not last less than 4.2 min.

The role of endoscopic and demographic features in the diagnosis of gastric precancerous conditions.

INTRODUCTION: The diagnosis of atrophic gastritis (AG) and intestinal metaplasia (IM) is a crucial screening and surveillance strategy for gastric adenocarcinoma. OBJECTIVES: The main objective was to assess the performance of endoscopic diagnosis of gastric precancerous conditions in a real­life scenario. PATIENTS AND METHODS: A total of 2099 gastroscopies with biopsy to evaluate gastritis performed in 3 endoscopic centers from March 2018 to October 2019 were retrospectively analyzed. Endoscopic data regarding gastritis, atrophy, and intestinal metaplasia were compared with histopathological reports. RESULTS: The endoscopic diagnosis sensitivity was 69.5% for AG and 19.4% for IM. The specificity of endoscopic detection of AG was 69.5% and of IM, 97.9%. The endoscopic detection of gastritis was a risk factor for AG and IM diagnosis (odds ratio [OR], 5.1; 95% CI, 1.9-14.1 and OR, 14.5; 95% CI, 5.9-35.8, respectively) and the patient's age was a risk factor for AG, IM, dysplasia, and advanced stage of AG (ASAG) diagnosis (OR, 1.05; 95% CI, 1.04-1.06; OR, 1.035; 95% CI, 1.03-1.04; OR, 1.04; 95% CI, 1.02-1.06; and OR, 1.05; 95% CI, 1.02-1.09, respectively). The age threshold of 45 or 40 years with endoscopically diagnosed gastritis for obtaining biopsy would result in 96.3% and 95% ASAG or dysplasia diagnosis sensitivity, and in the reduction of the number of biopsies by 20.2% and 20.5%, respectively. CONCLUSIONS: The application of the age threshold with or without an endoscopic diagnosis of gastritis could reduce the number of mapping biopsies to detect advanced stages of atrophic gastritis or dysplasia with high sensitivity.

Performance of plastic stents used for benign and malignant biliary strictures: experience of a single high­volume endoscopy unit.

INTRODUCTION: Endoscopic plastic biliary stenting has been used for more than 30 years as a temporary or definitive treatment of benign and malignant neoplasms. These stents are commonly available, inexpensive, and easy to implant. OBJECTIVES: We aimed to evaluate the duration of plastic stent patency, to assess complications associated with stent use, and to determine the optimal timing of stent replacement depending on the indication for biliary stenting. PATIENTS AND METHODS: This was a retrospective cohort study with a 5­year follow­up including patients who underwent plastic biliary stent implantation between 2012 and 2013 in a tertiary referral gastroenterological center. The performance of stents was assessed on the basis of medical records, direct contact with patients or their family members, and information derived from the national death registry. RESULTS: We assessed 830 biliary stenting procedures performed in 346 patients. The indications for biliary stenting included choledocholithiasis in 120 patients (34.7%), benign stricture in 70 patients (20.2%), and malignant stricture in 156 patients (45.1%). The mean duration of stent patency for these conditions was 110, 106, and 55 days, respectively (P <0.001). Stents implanted for malignant perihilar strictures had a shorter duration of patency than those used for distal strictures (40 days vs 76 days, P = 0.002). CONCLUSIONS: The patency of plastic stents depends on the underlying disease. In patients with benign biliary disease, stent replacement is recommended after about 3.5 months. In patients with cancer, the timing of stent replacement should be guided by survival prognosis and location of stricture.

Scoring system assessing mucosal visibility of upper gastrointestinal tract: The POLPREP scale.

BACKGROUND AND AIM: The proper visibility of mucosa during esophagogastroduodenoscopy (EGD) is crucial for the detection of early upper gastrointestinal tract lesions. In contrast to colonoscopy, no validated scoring system for the assessment of upper gastrointestinal mucosal cleanliness has been developed so far. The aim of the study was to create and validate standardized grading system (POLPREP) to assess the mucosal cleanliness during EGD. METHODS: To assess the visibility of mucosa during EGD, 4-point scale was developed (0-3). Twelve operators assessed 18 images of esophagus, stomach, and duodenum twice (in 2 weeks interval). In validation round, the images and endoscopy reports of 443 EGDs performed in six centers were assessed. RESULTS: The inter-observer accordance of POLPREP was 0.8 (intra-class correlation coefficient; 0.79 consultants, 0.85 trainees). The intra-observer repeatability was 0.64 (Fleiss kappa value; 0.64 consultants, 0.64 trainees). The lesions detection rate was significantly higher in clean (scores 2 and 3; 19.7%) than in "unclean" segments (score 1; 7.7%, P = 0.049). Score 3 was associated with over three-fold higher lesion detection than score 1 (odds ratio 3.2, 95% confidence interval 1.1-9; P = 0.03). CONCLUSIONS: The proposed POLPREP scale allows for unified assessment of upper gastrointestinal tract mucosal cleanliness. The higher cleanliness scores are related with greater upper gastrointestinal pathologies detection.

Composite detection rate as an upper gastrointestinal endoscopy quality measure correlating with detection of neoplasia.

BACKGROUND: Esophagogastroduodenoscopy (EGD) is commonly used diagnostic method with no widely accepted quality measure. We assessed quality indicator-composite detection rate (CDR)-consisting of detection of at least one of the following: cervical inlet patch, gastric polyp and post-ulcer duodenal bulb deformation. The aim of the study was to validate CDR according to detection rate of upper gastrointestinal neoplasms (UGN). METHODS: It was a multicenter, prospective, observational study conducted from January 2019 to October 2019. The endoscopic reports from 2896 symptomatic patients who underwent diagnostic EGD were analyzed. The EGDs were performed in three endoscopy units located in tertiary university hospital, private outpatient clinic and local hospital. RESULTS: 64 UGNs were detected. The mean CDR was 21.9%. The CDR correlated with UGN detection rate (R = 0.49, p = 0.045). Based on CDR quartiles, operators were divided into group 1 with CDR < 10%, group 2 with CDR 10-17%, group 3 with CDR 17.1-26%, and group 4 with CDR > 26%. Detection rate of UGN was significantly higher in the group 4 in comparison to group 1 (OR 4.4; 95% CI 2.2 - 9.0). In the multivariate regression model, patient age, male gender and operator's CDR > 26% were independent risk factors of UGN detection (OR 1.03; 95% CI 1.01 - 1.05, OR 2; 95% CI 1.2 - 3.5, and OR 5.7 95% CI 1.5 - 22.3, respectively). CONCLUSIONS: The CDR is associated with the detection of upper gastrointestinal neoplasms. This parameter may be a useful quality measure of EGD to be applied in general setting.

Influence of narrow-band imaging (NBI) and enhanced operator's attention during esophagus inspection on cervical inlet patches detection.

PURPOSE: Heterotopic gastric mucosa in the upper esophagus (cervical inlet patches - CIP) may be easily missed during esophagogastroduodenoscopy (EGD) due to low awareness of this usually, but not invariably, benign lesion. Narrow-band imaging (NBI) emphasizes contrast between normal esophageal mucosa and CIP. The purpose of this study was to investigate how NBI use and enhanced attention of operator during inspection of upper esophagus impacts cervical inlet patch detection rate (CIPDR). MATERIALS AND METHODS: This is a prospective, randomized study in which we enrolled 1000 patients, qualified for diagnostic EGD. The trial was divided into two parts; the first, when 6 operators performed EGD with standard attention (SA), and the second, when the same operators were asked to step up with attention at CIP (enhanced attention - EA). In both parts of the study, patients were randomized to NBI and white light endoscopy (WLE) in 1:1 ratio. The study is registered in ClinicalTrials.gov (No. NCT03015571). RESULTS: Differences in CIPDR between WLE and NBI in SA and EA were not statistically different (5.6% vs 7.6%; p â€‹= â€‹0.3, and 7.6% vs 11.6%; p â€‹= â€‹0.1, respectively). In multivariate regression analysis, the only factors improving CIPDR were NBI with EA (NBIEA, OR 3.31; 95%CI 1.57-6.98; p â€‹= â€‹0.003) and sedation (OR 1.97; 95%CI 1.27-3.05; p â€‹= â€‹0.002). CONCLUSIONS: The use of NBI combined with EA significantly improves CIPDR.

Detection of hepatocellular carcinoma by tissue resonance interaction method (TRIM).

INTRODUCTION: Diagnosis of hepatocellular carcinoma (HCC) is considerably delayed, being frequently done in the non-curative stage of disease. The reason for delayed diagnosis is indolent course in early stages and/or unspecific symptoms indistinguishable from underlying cirrhosis. Hitherto methods used for screening of HCC have important limitations. TRIMprob is a non-invasive method, which showed utility in detection of cancers located in prostate, breast, or urinary bladder. AIM: To determine the diagnostic accuracy of TRIMprob in detecting HCC in cirrhotic liver. MATERIAL AND METHODS: Forty-five patients were prospectively enrolled according to final clinical diagnosis into a group of cirrhosis and HCC or a group of cirrhosis without HCC. A control group consisted of 33 healthy subjects. Hepatocellular carcinoma was diagnosed by computed tomography (CT) or magnetic resonance (MR) and guided biopsy. The TRIMprob examination was performed in each patient. Three wave frequencies were used: 465, 930, and 1395 MHz. RESULTS: In patients with HCC the intensity of return signal using wave a frequency of 465 MHz was significantly reduced in patients with HCC in comparison to healthy subjects (p < 0.0005), but not to cirrhotic patients without HCC. Moreover, cirrhosis was associated with significantly decreased TRIMprob signal in comparison to healthy liver (p < 0.002). In ROC analysis an optimal cut-off value for detection of HCC was 106 units, which yielded 80% sensitivity. CONCLUSIONS: TRIMprob identifies HCC with good sensitivity; however, the accuracy of this method to identify HCC in screening circumstances may be hindered by attenuation of the resonance interaction signal by cirrhosis itself.

Serum interleukin­17 levels predict inflammatory activity in patients with autoimmune hepatitis.

INTRODUCTION    The etiology of autoimmune hepatitis (AIH) is unclear, with molecular mimicry between host and viral/drug antigens being the most plausible mechanism initiating the immune cascade that induces hepatocyte injury. Finding a serologic parameter that closely relates to the liver histology would be beneficial for monitoring AIH activity and optimizing treatment. OBJECTIVES    We studied serum interleukin (IL)-17 levels and IL­17 activators (IL­6 and transforming growth factor ß1 [TGF-ß1]) in treatment-naive and immunosuppressed patients with AIH. We also analyzed the relationships between these cytokines and histological inflammation scores. PATIENTS AND METHODS    A total of 44 patients with confirmed AIH were enrolled to the study (22 treatment-naive patients and 22 patients in clinical remission after at least 3 years of immunosuppression). Liver biopsies were performed, and the histological grading of inflammatory activity was performed by a single pathologist. The control group comprised 30 healthy age- and sex­matched subjects. Serum IL­17, IL­6, and TGF­ß1 levels were measured by a quantitative sandwich enzyme immunoassay. RESULTS    Serum IL­17, IL­6, and TGF­ß1 levels were higher in treatment-naive patients compared with controls (23.2 pg/ml vs 15.3 pg/ml, P = 0.0001; 5.20 pg/ml vs 1.42 pg/ml, P = 0.0001; and 40.5 ng/ml vs 30.1 ng/ml, P = 0.04; respectively). In treatment-naive patients, serum IL­17 negatively correlated with hepatic inflammation (r = -0.63, P = 0.01). A reduced serum IL­17 concentration correlated with an increased TGF­ß1 concentration in patients in clinical remission (r = -0.51, P = 0.03). CONCLUSIONS    Serum IL­17 levels may be a useful parameter for assessing disease activity in patients with AIH.

Mucosal miR-3677 is over-expressed in cirrhotic patients with gastric antral vascular ectasia (GAVE).

INTRODUCTION: Gastric antral vascular ectasia (GAVE) is a rare vasculopathy that associates several diseases, most commonly liver cirrhosis. It usually presents as an occult gastrointestinal bleeding leading to profound iron deficiency anemia. We hypothesized that GAVE is local mucosal pathology dependent on genetic mechanisms, and the purpose of the study was to characterize miRNAs expression in gastric tissue of patients with cirrhosis and GAVE. MATERIALS AND METHODS: Thirteen patients with GAVE and cirrhosis and 35 healthy subjects were recruited. Microarray analysis and comparative microRNA study was done by quantitative polymerase chain reaction (qPCR). The microarray scores were grouped with use of the hierarchical clusterization analysis and miRNA target prediction was done with TargetScan 6.2 algorithm and Gene Ontology analysis (DIANA-miRPath). RESULTS: Concentration of miR-3677 in GAVE-affected mucosa was higher by 72% in comparison with GAVE-free mucosa of patients with cirrhosis (33.7 vs. 35.6 PCR cycles; p < .001) and by 45% in comparison with normal mucosa (33.7 vs. 34.9 PCR cycles; p < .05). According to Gene Ontology analysis miR-3677 was related to angiopoietin-like protein 4 (ANGPTL4) gene. CONCLUSION: GAVE in liver cirrhosis is associated with increased expression of miR-3667 that may be linked with ANGPTL4 gene.

Vaspin mRNA levels in the liver of morbidly obese women with nonalcoholic fatty liver disease.

The aim of this study was to evaluate hepatic vaspin mRNA in morbidly obese women with nonalcoholic fatty liver disease (NAFLD) and to look for its relationships with metabolic and histopathological features. The study included 56 severely obese women who underwent intraoperative wedge liver biopsy during bariatric surgery. Hepatic vaspin mRNA was assessed by quantitative real-time PCR. Vaspin mRNA found in all included patients was markedly higher in patients with body mass index (BMI) ≥ 40 kg/m2 (4.59 ±3.09 vs. 0.44 ±0.33; p = 0.05). An evident but statistically insignificant difference in vaspin mRNA levels was observed between patients with and without hepatocyte ballooning (4.77 ±4.23 vs. 0.45 ±0.29, respectively), with and without steatosis (4.80 ±4.20 vs. 0.41 ±0.29, respectively), without and with fibrosis (0.25 ±0.80 vs. 6.23 ±7.2, respectively), and those without and with lobular inflammation (0.27 ±1.0 vs. 5.55 ±10.1, respectively). There was marked difference in vaspin mRNA between patients with simple steatosis/borderline nonalcoholic steatohepatitis (NASH) compared to those with definite NASH (0.24 ±0.96 vs. 10.5 ±10.4). Adiposity is an undoubted confounding factor influencing vaspin levels. Hepatic vaspin mRNA seems to be markedly elevated in morbidly obese patients with more advanced NAFLD and when hallmarks of NASH were observed. Pointing to non-linear mRNA levels within the NAFLD spectrum and an evident increase in patients with fibrosis and definite NASH, the detrimental action of vaspin cannot be excluded.

Comparison of patency and cost-effectiveness of self-expandable metal and plastic stents used for malignant biliary strictures: a Polish single-center study.

INTRODUCTION: Most patients with malignant biliary obstruction are suited only for palliation by endoscopic drainage with plastic stents (PS) or self-expandable metal stents (SEMS). OBJECTIVE: To compare the clinical outcome and costs of biliary stenting with SEMS and PS in patients with malignant biliary strictures. PATIENTS AND METHODS: A total of 114 patients with malignant jaundice who underwent 376 endoscopic retrograde biliary drainage (ERBD) were studied. RESULTS: ERBD with the placement of PS was performed in 80 patients, with one-step SEMS in 20 patients and two-step SEMS in 14 patients. Significantly fewer ERBD interventions were performed in patients with one-step SEMS than PS or the two-step SEMS technique (2.0±1.12 vs. 3.1±1.7 or 5.7±2.1, respectively, P<0.0001). The median hospitalization duration per procedure was similar for the three groups of patients. The patients' survival time was the longest in the two-step SEMS group in comparison with the one-step SEMS and PS groups (596±270 vs. 276±141 or 208±219 days, P<0.001). Overall median time to recurrent biliary obstruction was 89.3±159 days for PS and 120.6±101 days for SEMS (P=0.01). The total cost of hospitalization with ERBD was higher for two-step SEMS than for one-step SEMS or PS (1448±312, 1152±135 and 977±156&OV0556;, P<0.0001). However, the estimated annual cost of medical care for one-step SEMS was higher than that for the two-step SEMS or PS groups (4618, 4079, and 3995&OV0556;, respectively). CONCLUSION: Biliary decompression by SEMS is associated with longer patency and reduced number of auxiliary procedures; however, repeated PS insertions still remain the most cost-effective strategy.