Endoscopic submucosal dissection in gastric lesions: the 100 cases experience from a tertiary reference center in West.

OBJECTIVE: Endoscopic submucosal dissection (ESD) is an endoscopic treatment method widely used in premalignant and malignant lesions in countries of the Far East. This method, which is difficult technically and has a high complication risk rate, has rarely been performed in the West, because of the fewer number of upper gastrointestinal lesions. In the present study, we aimed to present our results of gastric ESD procedures in respect to the learning curve. METHODS: A total of 100 ESD procedures, which were performed in the stomach between April 2012 and September 2014, were recorded prospectively before and after the procedure. Patient data were analyzed retrospectively. ESD procedures were numbered chronologically; the first 30 patients constituted group 1, whereas the rest were classified as the group 2. ESD results were compared between the groups. RESULTS: In a total of 95 patients, 100 gastric ESDs were performed. The overall en-bloc and complete resection rates were 93% and 92%, respectively. In respect of the learning curve, there were significant differences in the sizes of lesions and tissues obtained, procedure duration and dissection rate, snare use and knife preferences between groups (p = 0.002, p < 0.001, p = 0.003, p < 0.001, p = 0.009, and p < 0.001, respectively). No significant difference was detected in the en-bloc and complete resection rates and complications between the groups. CONCLUSION: According to guideline recommendations and masters for ESD, if ESD training is initiated and continued, successful ESD may be performed in localized lesions in the stomach.

Evaluation of the relationship between serum ghrelin, C-reactive protein and interleukin-6 levels, and disease activity in inflammatory bowel diseases.

BACKGROUND/AIMS: Ghrelin is a 28 aminoasid peptide hormone, have generally focused upon this peptide's role upon growth and energy metabolism. Recently, studies investigating ghrelin's effect upon inflammation and immune response have gained importance. We aimed to compare the effectiveness of ghrelin levels, Creactive protein and interleukin-6 levels in establishing disease activity. METHODOLOGY: 52 cases with ulcerative colitis and 33 with Crohn's disease, total 85 patients, were included in this study. The serum ghrelin levels of the patients in remission and of those with active disease were compared. RESULTS: The mean serum ghrelin level in active patients (1243 ± 648 pg/ml), was found to be higher than those in remission (466 ± 214 pg/ml) (p<0.001). In establishing the disease activity, CRP is a the most effective marker compared to the other two inflammatory markers. AUC values were established as; CRP: 0.947 (95% CI,0.903-0.992),ghrelin:0.934(95% CI, 0.884-0.984) and interleukin-6: 0.756 (95% CI, 0.648- 0.864). DISCUSSION: Serum ghrelin level can be used with CRP as an important marker in establishing the mucosal damage in inflammatory bowel diseases.

Effects of mucosal TNF-alpha levels on treatment response in Crohn's disease patients receiving anti-TNF treatment.

BACKGROUND/AIMS: We aimed to find out if mucosal TNF-α (m-TNF-α) levels have predictive impact on anti-TNF treatment response in Crohn's disease (CD). METHODOLOGY: TNF-alpha values were determined with immunohistochemical staining of intestinal biopsies taken from 35 subjects on anti-TNF treatment for CD and 25 controls. Correlation between m-TNF-α levels and anti-TNF treatment were evaluated. RESULTS: m-TNF-α levels were determined higher in CD group (28.0±8.9 vs 5.8±2.1; P<0.001). m-TNF-α levels were lower in CD patients who were hospitalized (23.0±8.7 vs. 30.3±8.1; P=0.024). Although not to a statistically significant level, favorable parameters such as clinical remission (28.5±8.0 vs. 26.4±11.8, p=0.419) and mucosal healing (29.9±8.2 vs. 23.9±9.2, p=0.097) were increased in patients with high m-TNF-α levels whereas unfavorable parameters such as relapse (26.0±9.4 vs. 29.7±8.2, P=0.107), surgery requirement (22.8±11.1 vs. 29.1±8.1, P=0.147), steroid requirement (25.9±9.0 vs. 28.6±8.9, P=0.595), and anti-TNF intensification (22.3±3.8 vs. 28.5±9.0, P=0.183) were increased in patients with low m-TNF-α levels. CONCLUSIONS: High mucosal TNF-α levels before treatment have favorable effects on anti-TNF treatment response in CD. Presence of high m-TNF-α levels at the diagnosis may be encouraging in early initiation of anti-TNF treatment.

Hepcidin as a predictor of disease severity in acute pancreatitis: a single center prospective study.

BACKGROUND/AIMS: Predicting the severity of acute pancreatitis is limited to clinical, laboratory and radiological risk factors. Hepcidin levels increase in acute inflammation. We aimed to assess the relationship between hepcidin and C-reactive protein (CRP), white blood cells (WBC) and multi-detector computerized tomography (MDCT) in predicting the severity of pancreatitis. METHODOLOGY: We undertook a prospective review of 59 consecutive patients with acute pancreatitis admitted to our clinic. Biochemical values were measured from blood samples taken within 2 hours of admission and from between 2 and 72 hours related to the time of symptom onset. RESULTS: In predicting severe acute pancreatitis, hepcidin was superior to CRP and WBC (Area Under the Curve (AUC)=0.79, p=0.003; AUC=0.69, p=NS; AUC=0.53, p=NS, respectively). CONCLUSIONS: In this study, hepcidin was found to be superior to CRP in predicting the severity of pancreatitis.

The use of radial endosonography findings in the prediction of cholangiocarcinoma in cases with distal bile duct obstructions.

BACKGROUND/AIMS: We retrospectively collected the data of radial endosonographic (EUS) imaging findings of the patients with the distal bile duct obstructions due to different benign and malignant conditions. We aimed to assess and analyze the EUS findings in the distal bile duct obstruction which can predict or detect the existence of cholangiocarcinoma originating from the distal bile duct wall. METHODOLOGY: We gathered the data of 192 cases with distal biliary stricture due to various causes which all were diagnosed. RESULTS: With EUS, The sensitivity and specificity for diagnosis of cholangiocarcinoma in lesions were respectively as following: Firstly, small hypoechoic mass which interrupts to see lumen and choledoch wall with total occlusion at distal choledoch: 75.8%, 88.1%. Secondly, hypoechoic and irregular thickening than surrounding regions at distal choledoch wall: 68.1%, 87.3%. Thirdly, appearance of lumen prompt termination at distal choledoch: 57.1%, 87.6%. Lastly, appearance where lumen narrows short segment: 13.6 %, 59.3 %. CONCLUSIONS: EUS findings including hypoechoic mass appearance completely occluding the lumen or heterogeneously increased irregular wall-thickness in the distal bile duct were found to be highly predictive and sensitive for detecting malignancy originating from the distal bile duct.

Comparison of multidetector CT and endoscopic ultrasonography in malignant pancreatic mass lesions.

BACKGROUND/AIMS: Endoscopic ultrasonography (EUS) has been shown to be superior to conventional CT in detecting and staging pancreatic cancer. We conducted a prospective trial to compare EUS and MDCT, in discriminating benign/malignant, in determining local and vascular invasion of a suspected pancreatic cancer and deciding its resectability. METHODOLOGY: The study was performed at the Gastroenterology Department of Izmir Ataturk Training and Research Hospital, from June 2009 to June 2010, all patients with suspected pancreatic and periampullary tumors referred to our department were enrolled. A total of 56 patients were evaluated at the beginning. Five patients having distal CBD tumor (n=2), gallbladder tumor (n=1) and papillary tumor (n=2) were excluded from the study. Analysis was done for the remaining 51 patients. RESULTS: For the diagnosis of resectability/unresectability, EUS alone demonstrated a definite role in 4 (9%) of the 43 patients in confirming surgical and pathologic results and MDCT alone demonstrated a definite role in 6 (14%) of the 43 patients in confirming their results. An accurate diagnostic decision regarding resectability/unresectability was accomplished in 27 (63%) patients with EUS and MDCT. CONCLUSIONS: While MDCT is clinically quite effective, in terms of a correct resectability/unresectability decision, EUS should also be used.

Influence of erythropoietin therapy on serum prohepcidin levels in dialysis patients.

BACKGROUND: Anemia is a common finding in dialysis patients. Recent evidence has accrued that hepcidin, an iron regulatory peptide, may play a crucial role in the pathophysiology of this condition. This study investigated the effect of erythropoietin (EPO) therapy on serum levels of prohepcidin, the pro-hormone of hepcidin, in patients with end-stage renal disease (ESRD) undergoing chronic dialysis treatment. MATERIAL/METHODS: A total of 40 ESRD patients with renal anemia receiving either hemodialysis or peritoneal dialysis were included in this study. The patients were randomly allocated to EPO (subcutaneous 2000 microg three times weekly) plus parenteral iron (n=23) or parental iron only (n=17). Serum prohepcidin levels were measured before and at the end of the study. RESULTS: The two groups were comparable in their demographic and laboratory characteristics. No significant differences were found in hemoglobin, hematocrit, iron store indices, or serum levels of prohepcidin at study entry. Significant increases in both hemoglobin and hematocrit as well as a decrease in serum prohepcidin level were evident in the EPO group at the end of the 6-month follow-up in comparison with their values at study entry compared with the control group (P<0.01). CONCLUSIONS: It is concluded that EPO therapy, besides enhancing erythropoiesis, modulates serum prohepcidin levels in dialysis patients.

Helicobacter pylori: a role in schizophrenia?

Schizophrenia is a devastating psychiatric disorder that affects approximately one percent of the world's adult population. Despite substantial investigative efforts over the last decades, the exact mechanisms and pathogenesis of this condition are not yet fully understood. Published data support certain infectious agents as potential risk factors for schizophrenia. Since its discovery, Helicobacter pylori has been implicated in a variety of extra-digestive diseases, but its potential role in the pathogenesis of psychiatric disorders has thus far been neglected. It is hypothesized here that infection with H. pylori occurring in early childhood may induce persisting systemic biochemical aberrations, including dopaminergic dysfunction, decreased levels of essential polyunsaturated fatty acids, subtle inflammation, and homocysteine alterations, that may play a crucial role in the development of schizophrenia in genetically predisposed individuals. Evidence in favor of this hypothesis is provided and possible therapeutic implications are discussed.

Endoscopic ultrasound-guided tissue sampling: How can we improve the results?

Endoscopic ultrasound (EUS) enables a gastroenterologist to sample the masses of the middle and inferior mediastinum, which are adjacent to the esophagus; cystic or solid lesions of the pancreas, which are adjacent to the stomach and duodenum; and perirectal lesions. Needles used for EUS sampling include aspiration (19, 20, and 22 Gauge) or core biopsy needles (ProCore and Trucut) (19, 20, and 22 Gauge). The type and size of EUS needles do not alter the diagnostic results. Rapid on-site cytopathological evaluation will increase the diagnostic efficacy to 100% without prolonging the procedure time. Diagnostic efficacy of EUS-guided fine-needle aspiration or core biopsy depends on the experience of an endoscopist and a cytopathologist. In the presence of an experienced endoscopist and cytopathologist, the size of the needle does not have any significant impact on the diagnostic success.

Resistin: New serum marker for predicting severity of acute pancreatitis.

OBJECTIVE: To assess the effectiveness of resistin in predicting the severity of acute pancreatitis. METHODS: Patients with acute pancreatitis who presented at the Gastroenterology Clinic, Erzurum Education and Research Hospital, Turkey were enrolled in this prospective study. White blood cell (WBC), C-reactive protein (CRP) and resistin levels were measured on admission and at 24 h, day 3 and day 7 following admission, along with other blood parameters. Patients were divided into two groups: mild acute pancreatitis and moderate/severe acute pancreatitis. RESULTS: Of 59 patients with acute pancreatitis (mild, n = 37; moderate/severe, n = 22), significant between-group differences were found in terms of resistin and CRP levels. Receiver operating curve analysis showed that resistin levels were better for predicting severe cases of acute pancreatitis than CRP or WBC levels on day 3 (area under the curve [AUC], 0.88 versus 0.81 and 0.63, respectively). Resistin levels on day 3 were better than CRP levels for predicting necrosis development (AUC, 0.70 versus 0.69, respectively). CONCLUSIONS: Resistin may represent a new, effective indicator to predict the severity of acute pancreatitis and presence of necrosis in patients with acute pancreatitis.

Radial EUS Examination Can be Helpful in Predicting the Severity of Acute Biliary Pancreatitis.

We investigated the utility of noncontrast enhanced endosonography (EUS) in predicting the severity of acute pancreatitis (AP) during the first 72 to 96 h of admission.In total, 187 patients with acute biliary pancreatitis were included. The patients were classified into 2 groups as having severe and mild AP according to the Modified Glasgow scoring and computerized tomography severity index (SI). The 158 cases with mild and 29 cases with severe AP had a similar age and sex distribution.Although none of the cases with mild AP developed morbidity and death, of the cases with severe AP, 16 developed serious morbidities and 5 died. On EUS examination, we looked for parenchymal findings, peripancreatic inflammatory signs, free or loculated fluid collections, and abnormalities of the common bile duct and the pancreatic channel. Statistical analysis indicated a significant relationship between the severity of AP with diffuse parenchymal edema, periparenchymal plastering, and/or diffuse retroperitoneal free fluid accumulation, and peri-pancreatic edema. We also defined an EUSSI and found that the EUSSI had sensitivity of 89.7%, specificity of 84.2%, positive predictivity value (PPV) of 88.9%, negative predictivity value (NPV) of 91.2%, and an accuracy of 87.9% in the differentiation of mild and severe AP. We found that the EUSSI had an accuracy of 72.4%, sensitivity of 75.4%, specificity of 65.1%, PPV of 69.3%, and NPV of 73.1% for determining mortality.Our data suggest that EUS allowed us to accurately predict the severity and mortality in nearly 90% of cases with AP.

An Evaluation of the Correlation between Hepcidin Serum Levels and Disease Activity in Inflammatory Bowel Disease.

Aim. While there are many well-defined serological markers for inflammatory bowel disease (IBD), there is limited evidence that they positively affect clinical outcomes. This study aimed to evaluate the correlation between hepcidin serum levels and disease activity in IBD. Materials and Methods. Eighty-five consecutive IBD patients were enrolled in the study. Hepcidin serum levels were assessed using an enzyme-linked immunosorbent assay (ELISA) and were compared with disease activity as well as the interleukin-6 (IL-6) and C-reactive protein (CRP) levels. Results. The mean hepcidin serum levels in Crohn's disease (CD) patients in remission and in the active phase were 3837 ± 1436 and 3752 ± 1274 pg/mL, respectively (P = 0.613). The mean hepcidin serum levels in ulcerative colitis (UC) patients in remission and in the active phase were 4285 ± 8623 and 3727 ± 1176 pg/mL, respectively (P = 0.241). Correlation analysis between inflammatory markers and hepcidin serum levels indicated that there was no correlation between hepcidin levels and IL-6 (P = 0.582) or CRP (P = 0.783). Conclusion. As an acute-phase protein, hepcidin seems to have a lower efficacy than other parameters in the detection of activation in IBD.

Assessing the Effect of Leptin on Liver Damage in Case of Hepatic Injury Associated with Paracetamol Poisoning.

Background Aim. In case of high-dose acetaminophen intake, the active metabolite can not bind to the glutathione, thereby inducing cellular necrosis through binding to the cytosol proteins. This trial was performed to histologically and biochemically investigate whether leptin was protective against liver damage induced by paracetamol at toxic doses. Material and Method. In our trial, 30 female rats, divided into 5 groups, were used. IP leptin administration was performed after an hour in the group of rats, in which paracetamol poisoning was induced. The groups were as follows: Group 1: the control group, Group 2: 20 µg/kg leptin, Group 3: 2 g/kg paracetamol, Group 4: 2 g/kg paracetamol + 10 µg/kg leptin, and Group 5: 2 g/kg paracetamol + 20 µg/kg leptin. Results. The most significant increase was observed in the PARA 2 g/kg group, while the best improvement among the treatment groups occurred in the PARA 2 g/kg + LEP 10 µg/kg group (p < 0.05). While the most significant glutathione (GSH) reduction was observed in the PARA 2 g/kg group, the best improvement was in the PARA 2 g/kg + LEP 10 µg/kg group (p < 0.05). Conclusion. Liver damage occurring upon paracetamol poisoning manifests with hepatocyte breakdown occurring as a result of inflammation and oxidative stress. Leptin can prevent this damage thanks to its antioxidant and anti-inflammatory efficacy.

What is the most accurate method for the treatment of diminutive colonic polyps?: Standard versus jumbo forceps polypectomy.

Different methods such as standard, hot, and jumbo forceps are used in endoscopic treatment of diminutive colon polyps. In the current study, it was aimed to compare efficacy and safety of standard and jumbo forceps polypectomy methods in treatment of diminutive colon polyps of ≤5 mm. Polyps with ≤5 mm which were excised during colonoscopy by using standard or jumbo forceps were evaluated. Standard and jumbo forceps polypectomy methods were randomly performed in 212 consecutive patients with diminutive colorectal polyp. One-bite polypectomy and complete resection rates were also determined among polypectomy methods. Results of 161 standard forceps polypectomy and 102 jumbo forceps polypectomy were retrospectively evaluated. Both one-bite polypectomy and complete resection rates were significantly higher in the jumbo forceps polypectomy group than the standard forceps polypectomy group (P < 0.001). In the subgroup analysis performed according to polyp sizes, complete resection rate among polyps with 3-mm diameter was determined as 100%. However, numbers of bites in 4-mm and 5-mm polyps were higher in the standard forceps polypectomy group, and complete resection rate was lower than in the jumbo forceps polypectomy group (P < 0.001). Both endoscopic treatment methods may be employed in treatment of diminutive colon polyps with ≤5 mm. However, jumbo forceps polypectomy is a more effective treatment method in 4- to 5-mm polyps with high one-bite polypectomy and complete resection rate.

The effect of intravenous iron treatment on quality of life in inflammatory bowel disease patients with nonanemic iron deficiency.

Background. Iron deficiency is the prevalent complication of inflammatory bowel disease (IBD). Herein, we investigated the effect of intravenous iron treatment on quality of life (QoL) in nonanemic and iron deficient IBD patients. Methods. Eighty-five IBD patients were recruited for this study. The patients were intravenously administered 500 mg iron sucrose in the first week of the study. Hematologic parameters and QoL were evaluated before to iron treatment and during the 12th week of treatment. The Inflammatory Bowel Disease Questionnaire (IBDQ) and the Short Form-36 (SF-36) Health Survey were used to assess QoL. Results. Prior to intravenous iron administration, the IBDQ, SF-36 Physical Component Summary (PCS) and Mental Component Summary (MCS) scores were 152.3 ± 30.6, 46.7 ± 7.3, and 45.7 ± 9.8, respectively. In the 12th week of iron administration, those scores were 162.3 ± 25.5 (P < 0.001), 49.3 ± 6.4 (P < 0.001), and 47.6 ± 8.9 (P = 0.024), respectively, which were all significantly different from the scores prior to iron administration. The mean changes in the IBDQ scores for ulcerative colitis and Crohn's disease were 8.7% and 3.0% (P = 0.029), were 6.4% and 4.7% (P = 0.562) for the SF-36 PCS, and were 4.6% and 3.2% (P = 0.482) for the SF-36 MCS, respectively. Conclusion. Intravenous iron treatment may improve QoL in nonanemic, but iron deficient, IBD patients.

Evaluation of factors associated with response to hepatitis B vaccination in patients with inflammatory bowel disease.

It is recommended to investigate the serology of hepatitis B virus (HBV) and vaccinate seronegative patients at the time of diagnosis in inflammatory bowel diseases (IBD). This study aimed to investigate the efficacy of HBV vaccine and factors affecting the response.In this retrospective, observational study, HBV-seronegative IBD patients were administered 3 doses (at months 0, 1, and 6) recombinant 20  µg HbsAg. Patients' demographics, IBD attributes, and treatment methods were investigated as the factors with potential impacts on vaccination outcomes.One hundred twenty-five patients with IBD were evaluated. The number of patients with Anti-HBs >10  IU/L was 71 (56.8%), and the number of patients with anti-HBs >100  IU/L was 50 (40%). Age, disease activity, Crohn disease subtype, and immunosuppressive treatment (IST) were found to have significant effects on immune response (P = 0.011, P < 0.001, P = 0.003, and P < 0.001, respectively). With multivariate analysis, age < 45 years (OR 3.1, 95% CI 1.2-8.3, P = 0.020), vaccination during remission (OR 5.6, 95% CI 2.3-14, P < 0.001), and non-IST (OR 11.1, 95% CI 2.9-43.2, P = 0.001) had favorable effects on the occurrence of adequate vaccine response.The likelihood of achieving adequate immune response with standard HBV vaccination protocol in IBD is low. Selecting vaccination protocols with more potent immunogenicity is a better approach to achieve effective vaccine response in patients with multiple unfavorable factors.

Can red cell distribution width be a marker of disease activity in ulcerative colitis?

AIM: The current study aimed to investigate the association between disease activity and red cell distribution width (RDW) levels in ulcerative colitis and to determine whether RDW can be used as a marker of disease activity in non-anemic ulcerative colitis. METHODS: The RDW levels of 310 ulcerative colitis patients who underwent colonoscopy were analyzed retrospectively. The patients were divided into two groups (active disease and remission) according to the endoscopic activity index. In addition, the accuracy of RDW in determining disease activity in non-anemic patients was assessed. The efficacy of RDW in determining disease activity was compared to that of white blood cell count, platelet count, C-reactive protein, and erythrocyte sedimentation rate. RESULTS: Two hundred and six (66.5%) patients had active disease, and 104 (33.5%) were in remission. The mean RDW levels in patients with active ulcerative colitis and in those in remission were 16.8±2.9 and 15.5±1.4, respectively (P<0.001). Ninety-six (46.6%) patients in the active disease group and 89 (85.6%) in the remission group were non-anemic, and their respective RDW levels were 15.4±1.2 and 15.3±1.1 (P=0.267). The sensitivity and specificity of RDW in determining inflammation were 41% and 91%, respectively (AUC 0.65, P<0.001). CONCLUSIONS: This study demonstrated that RDW can be used as a marker for disease activity in ulcerative colitis, but it did not have the same efficacy in the non-anemic group.

Serum Syndecan-1 Levels and Its Relationship to Disease Activity in Patients with Crohn's Disease.

Background. Syndecan-1 (SDC-1), a member of the family of heparan sulfate proteoglycans, plays an important role in the resolution of inflammation. This study aimed to investigate the relationship between SDC-1 and disease activity in Crohn's disease (CD). Methods. Serum samples of 54 patients with CD and 30 healthy controls were obtained. First, SDC-1 levels of the CD patients were compared to the control group. Subsequently, SDC-1 levels were analyzed in patients with CD in active and remission periods. Finally, SDC-1 efficacy in predicting disease activity was evaluated by performing correlation analysis between SDC-1 and C-reactive protein (CRP) and Crohn's disease activity index (CDAI). Results. SDC-1 level was higher in the CD group (61.9 ± 42.6 ng/mL) compared with the control group (34.1 ± 8.0 ng/mL) (p = 0.03). SDC-1 levels were higher in active CD patients (97.1 ± 40.3 ng/mL) compared with those in remission (33.7 ± 13.5 ng/mL) (p < 0.001). A significant positive correlation was found between SDC-1 and CRP (r = 0.687, p < 0.001) and between SDC-1 and CDAI (r = 0.747, p < 0.001). Conclusion. Serum levels of SDC-1 are higher in CD compared to the normal population and can be an effective marker of disease severity.

Relation of asymmetric dimethylarginine levels to macrovascular disease and inflammation markers in type 2 diabetic patients.

AIM. We aimed to determine the relation of asymmetric dimethyl arginine (ADMA) levels to atherosclerotic vascular disease and inflammation markers in type 2 diabetes. METHODS. We recruited 50 type 2 diabetic patients with atherosclerosis, 50 type 2 diabetic patients without atherosclerosis, and 31 healthy control patients into our study. We obtained fasting serum and plasma samples and measured HbA1c, fasting blood glucose, C-peptide, creatinine, total cholesterol, triglycerides, HDL cholesterol, LDL cholesterol, hsCRP, fibrinogen, erythrocyte sedimentation rate, total homocysteine, and ADMA levels. In addition, all of the patients were evaluated for carotid artery intima media thickness by ultrasound. We evaluated ADMA levels in healthy controls, diabetic patients with macrovascular complications, and diabetic patients without macrovascular complications and evaluated the relationship between ADMA levels and total homocysteine, inflammation markers, and macrovascular disease. RESULTS. Mean ADMA values in non-MVD and control groups were significantly lower than in MVD group (0.39 ± 0.16, 0.32 ± 0.13, 0.52 ± 0.23, P < 0.05, resp.). These three variables (carotid intima-media thickness, inflammatory markers, and ADMA levels) were significantly higher in diabetes group than control (P < 0.05). CONCLUSION. There is a relationship between ADMA and macrovascular disease in type 2 diabetes, but further studies are needed to understand whether increased ADMA levels are a cause of macrovascular disease or a result of macrovascular disease.

The effect of biliary stenting on difficult common bile duct stones.

INTRODUCTION: If common bile duct (CBD) stones (choledocholithiasis) are left untreated, they may cause increases in morbidity and mortality due to several conditions. AIM: In this study, using transient biliary stenting following the failure of an initial endoscopic retrograde cholangiopancreatography (ERCP) session, we aimed to show the effects of making the CBD stones smaller and easier to remove in the following session. MATERIAL AND METHODS: In 156 of 1300 (12%) patients with CBD stones, who underwent balloon screening and/or basket lithotripsy following ERCP and CBD cannulation, it was not possible to remove the stones in the first session. Of these 156 patients, 64 (4.9%) were further followed and tested following transient biliary stenting. RESULTS: In the last ERCP following biliary stenting, the maximum stone sizes and stone indices were decreased in 54 (83%) patients and stone fragmentation was observed in 46 (72%) patients. Complete and incomplete removal was obtained in 40 (62.5%) and 24 (37.5%) patients, respectively. CONCLUSIONS: Biliary stenting, fragmentation and the reduction in the size of difficult common bile duct stones caused by the first session of ERCP may increase the chance of success in the next session of ERCP.