their poor general condition and because it would be difficult to discriminate between necrotic and normal tissue during the sur-gery. Besides, the risk of uncontrolled hem-orrhage during or immediately after the surgery would be very high. Open necrosectomy results in signifi-cant deterioration of organ dysfunction scores after the procedure [2]. M IPN is less aggressive compared to open surgery but it is a much more aggressive method com-pared to percutaneous catheter drainage (PCD) using 8- or 10-Fr catheters under ultrasound or CT control (general anes-thesia, progressive dilatation of the drain tract to 30 Fr allowing insertion of a trocar, using grasping forceps for removal of ne-crotic tissue) [1, 3]. P CD seems technically feasible in the vast majority of patients with necrotizing pancreatitis [4, 5] . B-esides, with this method a few catheters can be simultaneously introduced into liquid areas of necroses (into different pancreatic and peripancreatic regions) without gen-eral anesthesia and with fewer traumas, performing vigorous irrigation with simi-lar or better effects than by MIPN. On the basis of our long-term experi-ence [4, 6] , we believe that necrosecto-my (including MIPN) as a primary treat-ment may represent overtreatment of IPN. Therefore, we consider that sole conserva-tive treatment with proper intravenous hy-dration and administration of proper an-tibiotics should be performed at the begin-ning of the disease. PCD with vigorous D e a rE d itor, We read with great interest the article by Ahmad et al. [1] published in issue 1 of Pancreatology 2 011, volume 11. The article describes a case series outlining the expe-rience and results of retroperitoneal mini-mally invasive pancreatic necrosectomy (MIPN) and demonstrates that MIPN can be performed with acceptable morbidity and mortality and with good end results. The authors note that multiple MIPNs may be needed to eradicate the necrosis satisfactorily [1] . However, we wish to highlight certain issues regarding the statement that multiple MIPNs represent the optimal treatment for infected pancre-atic necroses (IPN). In the beginning of acute necrotizing pancreatitis, pancreatic and peripancreatic necroses are solid and the discrimination between necrotic tissue and normal tissue is very difficult. However, during the course of IPN, after the transition from solid ne-crotic tissue to more liquid contents takes place, there is a chance of a higher success rate in evacuating the necrotic tissue from the cavities, regardless of the method that is used. The presence of infection and vigor-ous irrigation can accelerate the process of transition from solid necrotic tissue to more liquid content. In those conditions, patients with necrotizing pancreatitis are not good candidates for surgery because of

To the Editor: We read with great interest the article by Harwood et al published in issue 10 of J Clin Gastroenterol 2010. Authors retrospectively analyzed the results of 107 blind percutaneous liver biopsies (PLB) and compared their results in obese and nonobese children. They concluded that blind PLB could be safely carried out in obese children with no increase in complication rate compared with nonobese children. Similarly, there was no difference in number of passes, biopsy size, portal triads per biopsy, or biopsy success in obese children. However, there are several important points that need to be addressed. From our point of view, after a long experience in performing ultrasound (US) guidance PLB, we believe that direct US control of the needle pathway during the procedure represents the guarantee that hepatic fragment obtained by PLB is adequate for histologic analysis and additionally reduces complication rates. Several studies showed that complications appeared more often in “blind” than in “US-guided” biopsies. In this study, authors have presented similar statements in discussion section. In a prospective study, Riley reported that US examination before the PLB forced a change of the site of biopsy in 15.1% of the cases because of interposition of lung, gallbladder, large central vessel, ascites, colonic loop, and slim liver edge. Our main concern is based on the question whether blind biopsy (especially in children) would be ethical nowadays, with extensive use of US. Above all, many physicians consider US “the stethoscope of 21st century”. The opinion that the blind method of PLB (without visual inspection of the needle pathway) has the same chances for successful outcome is simply not realistic (especially regarding safety of the intervention and its complication rate). Therefore, we believe that blind biopsy is to a certain degree acceptable for clinicians (gastroenterologists/hepatologists) in the countries where only radiologists are allowed to perform US examination. In the countries where clinicians do perform US examination, we cannot recommend blind biopsy as US-guided method is likely to reduce the risk of complications and improves the quality of specimens obtained, as recommended by the American Association for the Study of Liver Diseases guidelines.

Endothelin 1 (ET-1) is vasoactive peptide that acts via ET-A receptors coupling inducing vascular smooth muscle cell proliferation and contraction. ET-1 is involved in the development and maintenance of hypertension. Aim of this study was to determine the contribution of Ras farnesyl transferase, mitogen activated protein kinase (MAP kinase) and cytochrome P¬450 (CYP450) metabolites to ET-1 induced hypertension. ET-1 (5 pmol/kg per minute) was chronically infused into to the jugular vein by use of mini-osmotic pump for 9 days in male Sprague-Dawley rats. Mean arterial blood pressure (MABP) in ET-1-treated rats was 154±2 mm Hg (hypertensive rats) compared with 98±3 mm Hg in control (normotensive) rats. Infusion of Ras farnesyl transferase inhibitor FPTIII (138 ng/min), MAP kinase inhibitor PD-98059 (694 ng/min) and CYP450 inhibitor 17-ODYA (189 ng/min) significantly attenuated MABP to 115±2.5 mm Hg, 109±3 mm Hg and 118±1.5 mm Hg, respectively. These results suggest that CYP-450 metabolites and Ras/MAP kinase pathway contribute to the development of ET-1 induced hypertension. Further investigation has to be done to confirm whether activation of RAS/MAP kinase pathway by arachidonic acid metabolites plays an important role in the development of ET-1 induced hypertension.

Background and Objectives: Currently, there is no consensus about immunosuppressive therapy following kidney transplantation. Acute rejection rates and allograft survival rates are the clinical outcomes traditionally used to compare the efficacy of various immunosuppressive regimens. Therefore, we conducted this study to evaluate whether patient survival rates improved in the era of modern immunosuppressive treatment during living-related kidney transplantation. Design and Setting: Retrospective cohort study in a university-based tertiary internal medicine teaching hospital performed between 1999 and 2009 and patients followed up to 7 years. Patients and Methods: Survival rates were assessed in 38 patients receiving basiliximab and mycophenolate mofetil (regimen A) and 32 patients receiving antithymocyte globulin and azathioprine (regimen B). The rest of the regimen (cyclosporine A and steroids) remained the same. A secondary end point was acute rejection episode. Results: Seven-year survival rates were 100% and 72% (P=.001) and 7-year acute rejection-free survival rates were 82% and 53% (P=.03), in groups A and B, respectively. Conclusion: Long-term survival after living-related kidney transplantation has improved in the era of modern immunosuppressive treatment.

We read with great interest the article by Vege et al published in issue 34 of World J Gastroenterol 2010. The article evaluates the ability of contrast-enhanced computerized tomography (CECT) to characterize the nature of peripancreatic collections found at surgery. The results of their study indicate that most of the peripancreatic collections seen on CECT in patients with severe acute pancreatitis who require operative intervention contain necrotic tissue and CECT has a limited role in differentiating various types of collections. However, there are some points that need to be addressed, including data about the stage of acute pancreatitis in which CECT was done and the time span between CECT examination and surgery.

GOAL The aim of the study is to evaluate efficacy of single-session 20% NaCl solution sclerotherapy in the treatment of symptomatic nonparasitic benign liver cysts. METHODS 20 patients were chosen (7 man and 13 woman, mean age 52.9 with mean duration of disease before treatment 9.4 months) for a prospective trial. Patients were treated with ultrasound-guided percutaneous aspiration and injection of 20% NaCl solution. Patient demographics, clinical characteristics, treatment outcome and complications were analyzed during the trial. The procedure was considered successful if the cyst disappears. The cyst was considered to have disappeared if it could no longer be visualized on ultrasonography. Other important measures to document the efficacy of treatment included the length of the hospital stay and complications related to the procedure. RESULTS The average volume reduction was 96.3% (range, 74.9-100%). During the 24-month follow up period, 8 cysts (40.0%) disappeared completely. The hospital stay was one day for all patients. CONCLUSION Percutaneous treatment and sclerotherapy with hypertonic NaCl (20%) is safe and effective for hepatic non-parasitic cysts.

The primary treatment goals in patients with gastroesophageal reflux disease (GERD) are relief of symptoms, prevention of symptom relapse, healing of erosive esophagitis and prevention of complications. The severity of GERD is directly correlated with the degree and duration of oesophageal acid exposure and is highly pH dependent. Healing of reflux esophagitis is directly correlated with the intragastric pH > 3.5. In patients with GERD, treatment is directed at acid suppression through the use of lifestyle modifications (e.g., elevating the head of the bed, modifying the size and composition of meals) and pharmacologic agents (a histamine H2-receptor antagonist [H2RA] or a proton pump inhibitor [PPI]). The relief of symptoms and the long-term control of the disease are the primary aims of therapy for the majority of patients. The efficacy of antisecretory drugs in healing GERD depends on the strength and duration of acid suppression within a 24 h period, and the duration of the treatment. PPIs are more effective for acid-related symptoms and higher endoscopic healing rates in comparison with H2-RAs. Most PPIs (except pantoprazole) inhibit the bioactivation of clopidogrel to its active metabolite as they are associated with the loss of the beneficial effects of clopidogrel as well as an increased risk of reinfarction. Some clinicians reported their experiences that the generic has sometimes shown less effective than the corresponding branded PPIs. We conducted the overview of the effectiveness of PPIs in the treatment of patients with both categories of GERD; nonerosive reflux disease (NERD) and erosive reflux disease (ERD). We also report about interactions between PPIs and other drugs and differences between generic and branded PPIs.

azra Latic1, Ljubica fuštar-Preradovic2, Mirela Delibegovic3, Milan Bitunjac4, ferid Latic5, enver Zerem6 Department of radiology, General hospital slavonski Brod, slavonski Brod, croatia1 Department of forensic medicine, Pathology and cytology, General hospital slavonski Brod, slavonski Brod, croatia2 Department of radiology, university clinical centre tuzla, tuzla, Bosnia and herzegovina3 Department of neurology, General hospital slavonski Brod, slavonski Brod, croatia4 Department of surgery, General hospital slavonski Brod, slavonski Brod, croatia5 Department of science and research, university clinical centre tuzla, tuzla, Bosnia and herzegovina6