Christos Zavos | Aristotele University of Thessaloniki (original) (raw)

Papers by Christos Zavos

Treatment of inflammatory bowel disease has significantly improved since the introduction of biol... more Treatment of inflammatory bowel disease has significantly improved since the introduction of biological agents, such as infliximab, adalimumab, certolizumab pegol, and golimumab. The Food and Drug Administration has classified these factors in category B, which means that they do not demonstrate a fetal risk. However, during pregnancy fetuses are exposed to high anti-tumor necrosis factor (TNF) levels that are measurable in their plasma after birth. Since antibodies can transfer through the placenta at the end of the second and during the third trimesters, it is important to know the safety profile of these drugs, particularly for the fetus, and whether maintaining relapse of the disease compensates for the potential risks of fetal exposure. The limited data available for the anti-TNF drugs to date have not demonstrated any significant adverse outcomes in the pregnant women who continued their therapy from conception to the first trimester of gestation. However, data suggest that anti-TNFs should be discontinued during the third trimester, as they may affect the immunological system of the newborn baby. Each decision should be individualized, based on the distinct characteristics of the patient and her disease. Considering all the above, there is a need for more clinical studies regarding the effect of anti-TNF therapeutic agents on pregnancy outcomes. Core tip: Modern inflammatory bowel disease treatment includes biological therapy, such as anti-tumor necrosis factor (TNF) agents. There are concerns over the use of anti-TNF agents during pregnancy, although the data available to date are limited. No significant increases in the adverse outcomes of pregnancy have been reported in women who continued their treatment from conception to the first trimester of pregnancy.

Gastrointestinal Endoscopy, 2006

Therapeutic ERCP has an established role in the treatment of pancreatobiliary diseases, but littl... more Therapeutic ERCP has an established role in the treatment of pancreatobiliary diseases, but little information is available on the outcomes of this procedure in patients 90 years of age and older. To evaluate the efficacy and the safety of therapeutic ERCP in an extremely elderly cohort. Retrospective study. Two Greek cohorts of patients > or =90 and 70 to 89 years of age who underwent therapeutic ERCPs. Sixty-three patients aged 90 years and older (group A) and 350 patients 70 to 89 years of age (group B). A retrospective review of therapeutic ERCPs was performed between 1994 and 2000 on both groups, identified by using a database linked to the endoscopy reporting system in our department. Efficacy and safety of therapeutic ERCPs. Concomitant diseases, complications, and outcome were also evaluated. Group A patients had a higher incidence of concomitant diseases than group B patients (100% vs 72.8%, respectively). The rate of post-ERCP early complications was low in both groups: 6.3% in group A and 8.4% in group B. The frequency of ERCP-related mortality was 1.6% (1 patient) in group A and 0.6% (2 patients) in group B. Group A required endoscopic sessions for stone clearance and mechanical lithotripsy more frequently than group B (20.6% vs 11.4% and 17.5% vs 10.3%, respectively). No patient in either group experienced subjective deterioration in mental status, and the 3 patients who died required ventilatory support before death. Late complications occurred in 2.3% of patients in group B. Therapeutic ERCP is safe and effective for the treatment of pancreatobiliary diseases in extremely elderly patients, and advanced age per se should not impinge on decisions relating to its use.

Gastrointestinal Endoscopy, 2006

Therapeutic ERCP has an established role in the treatment of pancreatobiliary diseases, but littl... more Therapeutic ERCP has an established role in the treatment of pancreatobiliary diseases, but little information is available on the outcomes of this procedure in patients 90 years of age and older. To evaluate the efficacy and the safety of therapeutic ERCP in an extremely elderly cohort. Retrospective study. Two Greek cohorts of patients > or =90 and 70 to 89 years of age who underwent therapeutic ERCPs. Sixty-three patients aged 90 years and older (group A) and 350 patients 70 to 89 years of age (group B). A retrospective review of therapeutic ERCPs was performed between 1994 and 2000 on both groups, identified by using a database linked to the endoscopy reporting system in our department. Efficacy and safety of therapeutic ERCPs. Concomitant diseases, complications, and outcome were also evaluated. Group A patients had a higher incidence of concomitant diseases than group B patients (100% vs 72.8%, respectively). The rate of post-ERCP early complications was low in both groups: 6.3% in group A and 8.4% in group B. The frequency of ERCP-related mortality was 1.6% (1 patient) in group A and 0.6% (2 patients) in group B. Group A required endoscopic sessions for stone clearance and mechanical lithotripsy more frequently than group B (20.6% vs 11.4% and 17.5% vs 10.3%, respectively). No patient in either group experienced subjective deterioration in mental status, and the 3 patients who died required ventilatory support before death. Late complications occurred in 2.3% of patients in group B. Therapeutic ERCP is safe and effective for the treatment of pancreatobiliary diseases in extremely elderly patients, and advanced age per se should not impinge on decisions relating to its use.

VASA, 2008

Congenital afibrinogenemia is a rare genetic disorder characterized by the complete absence of fu... more Congenital afibrinogenemia is a rare genetic disorder characterized by the complete absence of functional fibrinogen. We report a 22-year-old female who developed nephrogenic arterial hypertension and intestinal ischemia due to congenital afibrinogenemia-associated angiopathy of large abdominal arteries. We describe, for the first time, the capsule findings and discuss the pathophysiology of this unusual condition.

Surgical Laparoscopy, Endoscopy & Percutaneous Techniques, 2010

Endoscopic sphincterotomy (ES) is the cornerstone of therapeutic ERCP and bleeding is one of its ... more Endoscopic sphincterotomy (ES) is the cornerstone of therapeutic ERCP and bleeding is one of its most frequent and serious complications. Monopolar coagulation has been used effectively for many causes of gastrointestinal hemorrhages. We investigated the efficacy and safety of endoscopically delivered monopolar coagulation through a polypectomy snare in patients with ES-induced bleeding not responding to injection treatment. The study included 672 consecutive patients who underwent ES between June 2007 and January 2009. Bleeding patterns (trickle, oozing, spurting) were recorded. Patients with bleeding not responding to spray irrigation or injection of 0.9% NaCl+epinephrine 1: 10,000 solution were treated with monopolar coagulation. Complications related to the technique were assessed. ES-induced bleeding occurred in 59 patients (8.78%). Visible bleeding patterns immediately after ES were: 32 trickle, 21 oozing, and 4 spurting. Delayed bleeding was observed in 2 patients. In 11 patients with intraprocedural bleeding (7 oozing and 4 spurting) not responding to spray irrigation and injection treatment with epinephrine solution, bleeding was successfully treated with monopolar coagulation. There were no procedure-related complications in this series. Monopolar coagulation is an effective and safe treatment modality and is recommended as an alternative method to other therapeutic modalities for post-ES bleeding not responding to injection treatment.

Surgical Endoscopy, 2007

Background: Colonoscopy remains an uncomfortable examination and many patients prefer to be sedat... more Background: Colonoscopy remains an uncomfortable examination and many patients prefer to be sedated. The aim of this study was to evaluate the efficacy and safety of intravenous administration of fentanyl in titrated doses compared with intravenous administration of the well-known midazolam in titrated doses. Methods: One hundred twenty-six patients scheduled for ambulatory colonoscopy were randomly assigned to receive either 25 mcg fentanyl (Fentanyl group, n = 66, 35 females, mean age = 61.5 years) and titrated up to 50 mcg or 2 mg midazolam (Midazolam group, n = 60, 33 females, mean age = 63.2 years) and titrated up to 5 mg. Patients graded discomfort on a scale from 0 to 4 and pain on a scale from 0 to 10. Success of the procedure, time to cecum, complications, and recovery time for each patient were independently recorded. Results: Mean discomfort scores were 0.4 in the Fentanyl group and 1.0 in the Midazolam group (p = 0.002). Similarly, mean scores for pain and anus to cecum time were lower in the Fentanyl group than in the Midazolam group [2.59 vs. 4.43 (p = 0.002) and 8.7 vs. 12.9 min (p = 0.012), respectively]. No adverse events were reported in the Fentanyl group, while in the Midazolam group a decrease in oxygen saturation was noted in 23/ 60 (35%) patients. Mean recovery time was 5.6 min in the Fentanyl group and 16 min in the Midazolam group (p = 0.014). Mean dosage was36 mcg for fentanyl and 4.6 mg for midazolam. Conclusion: Administration of fentanyl in low incremental doses is sufficient to achieve a satisfactory level of comfort during colonoscopy.

Journal of Clinical Gastroenterology, 2008

Endoscopic stent insertion is the optimum method of palliation for malignant biliary obstruction.... more Endoscopic stent insertion is the optimum method of palliation for malignant biliary obstruction. Various types of self-expanding metal stents have been introduced in the market. Whether one type of stents is superior to the others in terms of stent patency remains undefined. This randomized trial compared 2 uncovered metal stents with similar technical characteristics, but significant cost difference, in the palliation of inoperable malignant biliary strictures. Ninety-two patients with inoperable biliary obstruction were randomized to receive either a 10-mm diameter Hanaro or Luminex uncovered metal stent. The duration of stent patency, the overall patient survival, the mechanism of stent occlusion, and the adverse events were analyzed. Eighty-nine patients were included in the analysis; 44 received Hanaro stents and 45 Luminex stents. The overall median patency rates between the 2 stents did not differ (328 d for the Hanaro vs. 289 d for the Luminex stent; P=0.815). Similarly, no difference was found between the overall median survival rates by the 2 stents (347 d for the Hanaro vs. 307 d for the Luminex stent; P=0.654). Two major procedure-related complications occurred, perforation (Hanaro stent) and proximal stent migration (Luminex stent). Stent occlusion requiring reintervention occurred in 25 patients (11 with the Hanaro vs. 14 with the Luminex stent; P=0.521). The 2 uncovered metal stents are comparable in terms of placement, occlusion rates, overall stent patency, and patient survival; Hanaro stent insertion, however, seems to be a cost-saving strategy at least in Greece.

Inflammatory Bowel Diseases, 2014

Osteopenia and osteoporosis are common manifestations in inflammatory bowel diseases (IBD) but th... more Osteopenia and osteoporosis are common manifestations in inflammatory bowel diseases (IBD) but the pathogenetic mechanism of bone loss in IBD is only partially understood. There is evidence that fat mass is an important determinant of the bone mineral density and adipose-derived factors seem to play an important role for the association between fat mass and bone mass. The association between adiposity and low bone density is rather poorly studied in IBD, but emerging data on adipokines in IBD in relation to osteoporosis provide a novel pathophysiological concept that may shed light on the etiology of bone loss in IBD. It could be suggested that adipokines interfere in bone metabolism by altering the sensitive balance between osteoblasts and osteoclasts although further studies in this setting are needed. (Inflamm Bowel Dis 2014;0:1-11) Ghrelin is a new amino acid polypeptide mainly secreted by the neuroendocrine cells of the fundus of the stomach and in smaller amounts from the hypothalamus cells. It is believed to Inflamm Bowel Dis Volume 0, Number 0, Month 2014 Adiposity and Bones and in IBD www.ibdjournal.org | 7

ImmunoGastroenterology, 2012

ImmunoGastroenterology, 2012

European Journal of Gastroenterology & Hepatology, 2014

Surgical Laparoscopy, Endoscopy & Percutaneous Techniques, 2012

Normal saline (NS) plus epinephrine (E) is the traditionally used solution as submucosal fluid cu... more Normal saline (NS) plus epinephrine (E) is the traditionally used solution as submucosal fluid cushion for a safe and effective endoscopic mucosal resection (EMR) of sessile colorectal polyps. It was hypothesized that hydroxyethyl starch (HES), an inexpensive and easily available solution might be an ideal solution for prolonged elevation of submucosal cushion for an easy and safe EMR of giant colorectal lateral spreading tumors (LSTs). During a 6-year period, patients suffering from colorectal LSTs with a diameter of ≥ 30 mm were randomized to undergo EMR by using either HES+E (group A) or NS+E (group B) for submucosal fluid cushion. All patients who had undergone a colonoscopy set the diagnosis of LSTs. The LSTs were examined with standard white light and narrow-band imaging to accurately delinate their margins before resection. The initial volume of injected solution, the additional amount to maintain the submucosal cushion, the duration of submucosal elevation and post-EMR-related complications were recorded. After EMR, patients had a standard follow-up at 3, 6, and 12 months and further if it was necessary using total colonoscopy. Forty-nine patients suffering from giant LSTs were included in the study. No difference between the 2 groups was observed in patients' characteristics, size of LSTs, and the initial volume of injected solution. However, the additional amount of solution to maintain submucosal elevation was lower in group A (median, 4 mL; range, 2 to 25) than in group B (median, 6 mL; range, 3 to 8; P=0.001). Moreover, submucosal elevation had a statistically longer duration in group A (median, 18.5 min; range, 14.5 to 28.4) than in group B (median, 20.15 min, range, 9.6 to 13.4; P<0.001), and there was a statistical difference on total procedure time in favor of group A [group A, 20.15 min (12 to 32.5) vs. group B, 22.8 min (18 to 34.5)]. One case of macroperforation, 2 cases of postpolypectomy syndrome, and 1 case of EMR-related bleeding were observed in the HES+E group, whereas 6 cases of EMR-related bleeding were observed in the NS+E group. During a median follow-up of 32 and 34 months, for HES+E and NS+E groups, respectively, 5 and 7 recurrences were observed, which were all treated endoscopically. HES+E injection produces a more prolonged submucosal elevation and lowers total procedure time than NS+E; however, the safety of EMR is not influenced.

Journal of Neuroimmunology, 2013

Liver International, 2014

Cancer, 2014

To the authors&am... more To the authors' knowledge, little work has been done concerning adolescent precursors for gastroesophageal cancer. In the current study, the association of adolescent overweight as well as socioeconomic status (SES) with the incidence of esophageal adenocarcinoma (EAC), gastroesophageal junction adenocarcinoma (GEJAC), and noncardia gastric cancer (NCGC) was evaluated. Body mass index (BMI) was measured in 1 million Israeli adolescent males who underwent a general health examination at a mean age of 17.3 ± 0.5 years from 1967 to 2005. Overweight was defined as a BMI ≥ 85th percentile of the standard US distribution in adolescence. Incident cancer was identified by linkage with the Israeli National Cancer Registry. A total of 182 incident cancer cases were documented (52 combined EAC and GEJAC cases and 130 NCGC cases). Adolescent overweight at baseline (BMI ≥ 85th percentile) was associated with an increased risk in the combined group of cases of EAC and GEJAC (multivariable hazards ratio [HR], 2.1; 95% confidence interval [95% CI], 1.1-4.3 [P = .032]). Low SES (the lowest category vs the highest) as well as low number of years of education (≤ 9 years) were associated with an increased risk of intestinal-type NCGC (multivariable HR, 2.2; 95% CI, 1.0-4.8 [P = .041] and multivariable HR, 1.9; 95% CI, 1.1-3.19 [P = .020], respectively). The adjusted risk of NCGC was higher in immigrants born in Asian countries and the former Soviet Union. Overweight during adolescence was found to be substantially associated with the subsequent development of EAC and GEJAC. In addition, although potential confounding by Helicobacter pylori infection status or lifestyle factors was not fully accounted for in the analyses, lower SES as well as immigration from higher-risk countries are important determinants of NCGC.

Liver International, 2010

Surgical Laparoscopy, Endoscopy & Percutaneous Techniques, 2009

Management of giant pedunculated polyps can be a challenge for therapeutic endoscopists, mainly b... more Management of giant pedunculated polyps can be a challenge for therapeutic endoscopists, mainly because such polyps are not found in commonplace and experience from their management is limited. We describe a novel use of endoclips that induces significant polyp volume reduction, thereby facilitating the endoscopic removal of giant pedunculated polyps.

Clinical & Experimental Ophthalmology, 2008

European Journal of Gastroenterology & Hepatology, 2015

Melanoma Research, 2005

Although malignant melanoma has a great propensity (38-50%) for cardiac involvement, as indicated... more Although malignant melanoma has a great propensity (38-50%) for cardiac involvement, as indicated by autopsy findings, cardiac metastases are rarely identified ante-mortem. The aim of this study was to record abnormal electrocardiographic and echocardiographic findings in patients with malignant melanoma. One hundred and eighty-five consecutive patients (male/female, 99/86; mean age, 59.6 years) with histologically proven malignant melanoma (American Joint Committee on Cancer stages II-IV), and with no known history of heart disease, were evaluated prospectively over a period of 11 years. The cardiologic findings considered were an unexpected delayed conduction of an electrical stimulus, recorded by high-resolution signal-averaged electrocardiogram (presence of ventricular late potentials), prolongation of the PR, QRS and QTc segments in a surface electrocardiogram, and abnormal Q waves. Echocardiographic findings comprised pericardial implantation/effusion or presence of intracavitary/intramyocardial metastases. Forty-one abnormal findings were recorded, pertaining to 38 of the 185 patients (19.5%). In particular, PR interval prolongation was found in eight patients (4.3%) and QTc interval prolongation in 11 (6%). Abnormal Q waves were recorded in five patients (2.7%). The filtered QRS interval was prolonged in seven patients (3.8%). Finally, echocardiographic examination showed discrete pericardial implantations and small to moderate pericardial effusion in six patients (3.2%) and intracavitary/intramyocardial metastases in four (2.1%). The median survival of these patients was 33 months (95% confidence interval, 19.9-46.1 months). It can be concluded that abnormal electrocardiographic and echocardiographic findings are recorded at the time of diagnosis of the disease in a significant percentage of patients with malignant melanoma.

Treatment of inflammatory bowel disease has significantly improved since the introduction of biol... more Treatment of inflammatory bowel disease has significantly improved since the introduction of biological agents, such as infliximab, adalimumab, certolizumab pegol, and golimumab. The Food and Drug Administration has classified these factors in category B, which means that they do not demonstrate a fetal risk. However, during pregnancy fetuses are exposed to high anti-tumor necrosis factor (TNF) levels that are measurable in their plasma after birth. Since antibodies can transfer through the placenta at the end of the second and during the third trimesters, it is important to know the safety profile of these drugs, particularly for the fetus, and whether maintaining relapse of the disease compensates for the potential risks of fetal exposure. The limited data available for the anti-TNF drugs to date have not demonstrated any significant adverse outcomes in the pregnant women who continued their therapy from conception to the first trimester of gestation. However, data suggest that anti-TNFs should be discontinued during the third trimester, as they may affect the immunological system of the newborn baby. Each decision should be individualized, based on the distinct characteristics of the patient and her disease. Considering all the above, there is a need for more clinical studies regarding the effect of anti-TNF therapeutic agents on pregnancy outcomes. Core tip: Modern inflammatory bowel disease treatment includes biological therapy, such as anti-tumor necrosis factor (TNF) agents. There are concerns over the use of anti-TNF agents during pregnancy, although the data available to date are limited. No significant increases in the adverse outcomes of pregnancy have been reported in women who continued their treatment from conception to the first trimester of pregnancy.

Gastrointestinal Endoscopy, 2006

Therapeutic ERCP has an established role in the treatment of pancreatobiliary diseases, but littl... more Therapeutic ERCP has an established role in the treatment of pancreatobiliary diseases, but little information is available on the outcomes of this procedure in patients 90 years of age and older. To evaluate the efficacy and the safety of therapeutic ERCP in an extremely elderly cohort. Retrospective study. Two Greek cohorts of patients > or =90 and 70 to 89 years of age who underwent therapeutic ERCPs. Sixty-three patients aged 90 years and older (group A) and 350 patients 70 to 89 years of age (group B). A retrospective review of therapeutic ERCPs was performed between 1994 and 2000 on both groups, identified by using a database linked to the endoscopy reporting system in our department. Efficacy and safety of therapeutic ERCPs. Concomitant diseases, complications, and outcome were also evaluated. Group A patients had a higher incidence of concomitant diseases than group B patients (100% vs 72.8%, respectively). The rate of post-ERCP early complications was low in both groups: 6.3% in group A and 8.4% in group B. The frequency of ERCP-related mortality was 1.6% (1 patient) in group A and 0.6% (2 patients) in group B. Group A required endoscopic sessions for stone clearance and mechanical lithotripsy more frequently than group B (20.6% vs 11.4% and 17.5% vs 10.3%, respectively). No patient in either group experienced subjective deterioration in mental status, and the 3 patients who died required ventilatory support before death. Late complications occurred in 2.3% of patients in group B. Therapeutic ERCP is safe and effective for the treatment of pancreatobiliary diseases in extremely elderly patients, and advanced age per se should not impinge on decisions relating to its use.

Gastrointestinal Endoscopy, 2006

Therapeutic ERCP has an established role in the treatment of pancreatobiliary diseases, but littl... more Therapeutic ERCP has an established role in the treatment of pancreatobiliary diseases, but little information is available on the outcomes of this procedure in patients 90 years of age and older. To evaluate the efficacy and the safety of therapeutic ERCP in an extremely elderly cohort. Retrospective study. Two Greek cohorts of patients > or =90 and 70 to 89 years of age who underwent therapeutic ERCPs. Sixty-three patients aged 90 years and older (group A) and 350 patients 70 to 89 years of age (group B). A retrospective review of therapeutic ERCPs was performed between 1994 and 2000 on both groups, identified by using a database linked to the endoscopy reporting system in our department. Efficacy and safety of therapeutic ERCPs. Concomitant diseases, complications, and outcome were also evaluated. Group A patients had a higher incidence of concomitant diseases than group B patients (100% vs 72.8%, respectively). The rate of post-ERCP early complications was low in both groups: 6.3% in group A and 8.4% in group B. The frequency of ERCP-related mortality was 1.6% (1 patient) in group A and 0.6% (2 patients) in group B. Group A required endoscopic sessions for stone clearance and mechanical lithotripsy more frequently than group B (20.6% vs 11.4% and 17.5% vs 10.3%, respectively). No patient in either group experienced subjective deterioration in mental status, and the 3 patients who died required ventilatory support before death. Late complications occurred in 2.3% of patients in group B. Therapeutic ERCP is safe and effective for the treatment of pancreatobiliary diseases in extremely elderly patients, and advanced age per se should not impinge on decisions relating to its use.

VASA, 2008

Congenital afibrinogenemia is a rare genetic disorder characterized by the complete absence of fu... more Congenital afibrinogenemia is a rare genetic disorder characterized by the complete absence of functional fibrinogen. We report a 22-year-old female who developed nephrogenic arterial hypertension and intestinal ischemia due to congenital afibrinogenemia-associated angiopathy of large abdominal arteries. We describe, for the first time, the capsule findings and discuss the pathophysiology of this unusual condition.

Surgical Laparoscopy, Endoscopy & Percutaneous Techniques, 2010

Endoscopic sphincterotomy (ES) is the cornerstone of therapeutic ERCP and bleeding is one of its ... more Endoscopic sphincterotomy (ES) is the cornerstone of therapeutic ERCP and bleeding is one of its most frequent and serious complications. Monopolar coagulation has been used effectively for many causes of gastrointestinal hemorrhages. We investigated the efficacy and safety of endoscopically delivered monopolar coagulation through a polypectomy snare in patients with ES-induced bleeding not responding to injection treatment. The study included 672 consecutive patients who underwent ES between June 2007 and January 2009. Bleeding patterns (trickle, oozing, spurting) were recorded. Patients with bleeding not responding to spray irrigation or injection of 0.9% NaCl+epinephrine 1: 10,000 solution were treated with monopolar coagulation. Complications related to the technique were assessed. ES-induced bleeding occurred in 59 patients (8.78%). Visible bleeding patterns immediately after ES were: 32 trickle, 21 oozing, and 4 spurting. Delayed bleeding was observed in 2 patients. In 11 patients with intraprocedural bleeding (7 oozing and 4 spurting) not responding to spray irrigation and injection treatment with epinephrine solution, bleeding was successfully treated with monopolar coagulation. There were no procedure-related complications in this series. Monopolar coagulation is an effective and safe treatment modality and is recommended as an alternative method to other therapeutic modalities for post-ES bleeding not responding to injection treatment.

Surgical Endoscopy, 2007

Background: Colonoscopy remains an uncomfortable examination and many patients prefer to be sedat... more Background: Colonoscopy remains an uncomfortable examination and many patients prefer to be sedated. The aim of this study was to evaluate the efficacy and safety of intravenous administration of fentanyl in titrated doses compared with intravenous administration of the well-known midazolam in titrated doses. Methods: One hundred twenty-six patients scheduled for ambulatory colonoscopy were randomly assigned to receive either 25 mcg fentanyl (Fentanyl group, n = 66, 35 females, mean age = 61.5 years) and titrated up to 50 mcg or 2 mg midazolam (Midazolam group, n = 60, 33 females, mean age = 63.2 years) and titrated up to 5 mg. Patients graded discomfort on a scale from 0 to 4 and pain on a scale from 0 to 10. Success of the procedure, time to cecum, complications, and recovery time for each patient were independently recorded. Results: Mean discomfort scores were 0.4 in the Fentanyl group and 1.0 in the Midazolam group (p = 0.002). Similarly, mean scores for pain and anus to cecum time were lower in the Fentanyl group than in the Midazolam group [2.59 vs. 4.43 (p = 0.002) and 8.7 vs. 12.9 min (p = 0.012), respectively]. No adverse events were reported in the Fentanyl group, while in the Midazolam group a decrease in oxygen saturation was noted in 23/ 60 (35%) patients. Mean recovery time was 5.6 min in the Fentanyl group and 16 min in the Midazolam group (p = 0.014). Mean dosage was36 mcg for fentanyl and 4.6 mg for midazolam. Conclusion: Administration of fentanyl in low incremental doses is sufficient to achieve a satisfactory level of comfort during colonoscopy.

Journal of Clinical Gastroenterology, 2008

Endoscopic stent insertion is the optimum method of palliation for malignant biliary obstruction.... more Endoscopic stent insertion is the optimum method of palliation for malignant biliary obstruction. Various types of self-expanding metal stents have been introduced in the market. Whether one type of stents is superior to the others in terms of stent patency remains undefined. This randomized trial compared 2 uncovered metal stents with similar technical characteristics, but significant cost difference, in the palliation of inoperable malignant biliary strictures. Ninety-two patients with inoperable biliary obstruction were randomized to receive either a 10-mm diameter Hanaro or Luminex uncovered metal stent. The duration of stent patency, the overall patient survival, the mechanism of stent occlusion, and the adverse events were analyzed. Eighty-nine patients were included in the analysis; 44 received Hanaro stents and 45 Luminex stents. The overall median patency rates between the 2 stents did not differ (328 d for the Hanaro vs. 289 d for the Luminex stent; P=0.815). Similarly, no difference was found between the overall median survival rates by the 2 stents (347 d for the Hanaro vs. 307 d for the Luminex stent; P=0.654). Two major procedure-related complications occurred, perforation (Hanaro stent) and proximal stent migration (Luminex stent). Stent occlusion requiring reintervention occurred in 25 patients (11 with the Hanaro vs. 14 with the Luminex stent; P=0.521). The 2 uncovered metal stents are comparable in terms of placement, occlusion rates, overall stent patency, and patient survival; Hanaro stent insertion, however, seems to be a cost-saving strategy at least in Greece.

Inflammatory Bowel Diseases, 2014

Osteopenia and osteoporosis are common manifestations in inflammatory bowel diseases (IBD) but th... more Osteopenia and osteoporosis are common manifestations in inflammatory bowel diseases (IBD) but the pathogenetic mechanism of bone loss in IBD is only partially understood. There is evidence that fat mass is an important determinant of the bone mineral density and adipose-derived factors seem to play an important role for the association between fat mass and bone mass. The association between adiposity and low bone density is rather poorly studied in IBD, but emerging data on adipokines in IBD in relation to osteoporosis provide a novel pathophysiological concept that may shed light on the etiology of bone loss in IBD. It could be suggested that adipokines interfere in bone metabolism by altering the sensitive balance between osteoblasts and osteoclasts although further studies in this setting are needed. (Inflamm Bowel Dis 2014;0:1-11) Ghrelin is a new amino acid polypeptide mainly secreted by the neuroendocrine cells of the fundus of the stomach and in smaller amounts from the hypothalamus cells. It is believed to Inflamm Bowel Dis Volume 0, Number 0, Month 2014 Adiposity and Bones and in IBD www.ibdjournal.org | 7

ImmunoGastroenterology, 2012

ImmunoGastroenterology, 2012

European Journal of Gastroenterology & Hepatology, 2014

Surgical Laparoscopy, Endoscopy & Percutaneous Techniques, 2012

Normal saline (NS) plus epinephrine (E) is the traditionally used solution as submucosal fluid cu... more Normal saline (NS) plus epinephrine (E) is the traditionally used solution as submucosal fluid cushion for a safe and effective endoscopic mucosal resection (EMR) of sessile colorectal polyps. It was hypothesized that hydroxyethyl starch (HES), an inexpensive and easily available solution might be an ideal solution for prolonged elevation of submucosal cushion for an easy and safe EMR of giant colorectal lateral spreading tumors (LSTs). During a 6-year period, patients suffering from colorectal LSTs with a diameter of ≥ 30 mm were randomized to undergo EMR by using either HES+E (group A) or NS+E (group B) for submucosal fluid cushion. All patients who had undergone a colonoscopy set the diagnosis of LSTs. The LSTs were examined with standard white light and narrow-band imaging to accurately delinate their margins before resection. The initial volume of injected solution, the additional amount to maintain the submucosal cushion, the duration of submucosal elevation and post-EMR-related complications were recorded. After EMR, patients had a standard follow-up at 3, 6, and 12 months and further if it was necessary using total colonoscopy. Forty-nine patients suffering from giant LSTs were included in the study. No difference between the 2 groups was observed in patients' characteristics, size of LSTs, and the initial volume of injected solution. However, the additional amount of solution to maintain submucosal elevation was lower in group A (median, 4 mL; range, 2 to 25) than in group B (median, 6 mL; range, 3 to 8; P=0.001). Moreover, submucosal elevation had a statistically longer duration in group A (median, 18.5 min; range, 14.5 to 28.4) than in group B (median, 20.15 min, range, 9.6 to 13.4; P<0.001), and there was a statistical difference on total procedure time in favor of group A [group A, 20.15 min (12 to 32.5) vs. group B, 22.8 min (18 to 34.5)]. One case of macroperforation, 2 cases of postpolypectomy syndrome, and 1 case of EMR-related bleeding were observed in the HES+E group, whereas 6 cases of EMR-related bleeding were observed in the NS+E group. During a median follow-up of 32 and 34 months, for HES+E and NS+E groups, respectively, 5 and 7 recurrences were observed, which were all treated endoscopically. HES+E injection produces a more prolonged submucosal elevation and lowers total procedure time than NS+E; however, the safety of EMR is not influenced.

Journal of Neuroimmunology, 2013

Liver International, 2014

Cancer, 2014

To the authors&am... more To the authors' knowledge, little work has been done concerning adolescent precursors for gastroesophageal cancer. In the current study, the association of adolescent overweight as well as socioeconomic status (SES) with the incidence of esophageal adenocarcinoma (EAC), gastroesophageal junction adenocarcinoma (GEJAC), and noncardia gastric cancer (NCGC) was evaluated. Body mass index (BMI) was measured in 1 million Israeli adolescent males who underwent a general health examination at a mean age of 17.3 ± 0.5 years from 1967 to 2005. Overweight was defined as a BMI ≥ 85th percentile of the standard US distribution in adolescence. Incident cancer was identified by linkage with the Israeli National Cancer Registry. A total of 182 incident cancer cases were documented (52 combined EAC and GEJAC cases and 130 NCGC cases). Adolescent overweight at baseline (BMI ≥ 85th percentile) was associated with an increased risk in the combined group of cases of EAC and GEJAC (multivariable hazards ratio [HR], 2.1; 95% confidence interval [95% CI], 1.1-4.3 [P = .032]). Low SES (the lowest category vs the highest) as well as low number of years of education (≤ 9 years) were associated with an increased risk of intestinal-type NCGC (multivariable HR, 2.2; 95% CI, 1.0-4.8 [P = .041] and multivariable HR, 1.9; 95% CI, 1.1-3.19 [P = .020], respectively). The adjusted risk of NCGC was higher in immigrants born in Asian countries and the former Soviet Union. Overweight during adolescence was found to be substantially associated with the subsequent development of EAC and GEJAC. In addition, although potential confounding by Helicobacter pylori infection status or lifestyle factors was not fully accounted for in the analyses, lower SES as well as immigration from higher-risk countries are important determinants of NCGC.

Liver International, 2010

Surgical Laparoscopy, Endoscopy & Percutaneous Techniques, 2009

Management of giant pedunculated polyps can be a challenge for therapeutic endoscopists, mainly b... more Management of giant pedunculated polyps can be a challenge for therapeutic endoscopists, mainly because such polyps are not found in commonplace and experience from their management is limited. We describe a novel use of endoclips that induces significant polyp volume reduction, thereby facilitating the endoscopic removal of giant pedunculated polyps.

Clinical & Experimental Ophthalmology, 2008

European Journal of Gastroenterology & Hepatology, 2015

Melanoma Research, 2005

Although malignant melanoma has a great propensity (38-50%) for cardiac involvement, as indicated... more Although malignant melanoma has a great propensity (38-50%) for cardiac involvement, as indicated by autopsy findings, cardiac metastases are rarely identified ante-mortem. The aim of this study was to record abnormal electrocardiographic and echocardiographic findings in patients with malignant melanoma. One hundred and eighty-five consecutive patients (male/female, 99/86; mean age, 59.6 years) with histologically proven malignant melanoma (American Joint Committee on Cancer stages II-IV), and with no known history of heart disease, were evaluated prospectively over a period of 11 years. The cardiologic findings considered were an unexpected delayed conduction of an electrical stimulus, recorded by high-resolution signal-averaged electrocardiogram (presence of ventricular late potentials), prolongation of the PR, QRS and QTc segments in a surface electrocardiogram, and abnormal Q waves. Echocardiographic findings comprised pericardial implantation/effusion or presence of intracavitary/intramyocardial metastases. Forty-one abnormal findings were recorded, pertaining to 38 of the 185 patients (19.5%). In particular, PR interval prolongation was found in eight patients (4.3%) and QTc interval prolongation in 11 (6%). Abnormal Q waves were recorded in five patients (2.7%). The filtered QRS interval was prolonged in seven patients (3.8%). Finally, echocardiographic examination showed discrete pericardial implantations and small to moderate pericardial effusion in six patients (3.2%) and intracavitary/intramyocardial metastases in four (2.1%). The median survival of these patients was 33 months (95% confidence interval, 19.9-46.1 months). It can be concluded that abnormal electrocardiographic and echocardiographic findings are recorded at the time of diagnosis of the disease in a significant percentage of patients with malignant melanoma.