Gregorios Chlouverakis

A Prospective, Randomized Comparison of Adrenaline Injection in Combination with Detachable Snare Versus Adrenaline Injection Alone in the Prevention of Postpolypectomy Bleeding in Large Colonic Polyps

OBJECTIVES:Our study sought to compare the efficacy of adrenaline injection in combination with detachable snare versus adrenaline injection alone in the prevention of postpolypectomy bleeding in large colonic polyps.METHODS:At the time of colonoscopy, patients with at least one colonic polyp ≥2 cm were randomized to receive treatment either by the injection of a 1:10.000 solution of adrenaline and the position of a detachable snare followed by a conventional snare polypectomy (group A) or injection of adrenaline followed by a conventional snare polypectomy (group B). A total of 159 consecutive patients were randomly assigned to one of the above groups. Out of them, 84 patients (47 men, 37 women, mean age 61 yr) were assigned to group A and 75 (37 men, 38 women, mean age 64 yr) to group B. Early (<24 h) and late (>24 h–30 days) bleeding complications were assessed.RESULTS:Overall bleeding complications occurred in 10/159 (6.2%) of the patients. There were two cases of bleeding in group A (2.3%), and eight in group B (10.6%) (P = 0.04). The number of early bleeding episodes was significantly reduced in group A patients (1 case) compared to that of group B (7 cases) (P = 0.02). In contrast, there was no significant difference between group A and B as far as late bleeding is concerned.CONCLUSIONS:Our data suggest that the use of adrenaline injection in combination with detachable snare may significantly decrease the number of early postpolypectomy bleeding episodes in patients with large colonic polyps.

An epidemiological study of acute upper gastrointestinal bleeding in Crete, Greece

Objectives Information about the epidemiology of acute upper gastrointestinal bleeding (UGIB) in southern Europe is very limited and especially in Greece non‐existent. Our study sought to determine the current epidemiology of acute UGIB (incidence, mortality and case fatality) in the prefecture of Heraklion‐Crete. Design/methods From February 1998 to February 1999, we prospectively obtained data on all patients with acute UGIB in the prefecture of Heraklion‐Crete. All patients who were permanent residents of the prefecture of Heraklion, aged 16 years and over with acute UGIB were included in the study. Results During this period, 353 cases of acute UGIB were included in the study. The overall incidence of acute UGIB is 160/100 000 adults per year with a male‐to‐female ratio of 1.7 and a mean age 66.2 ± 17.1 years. The incidence rises from 30 in those aged under 30 years to 609 in those aged over 75 years. The overall population mortality was 9/100 000 adults per year. Overall case fatality during hospitalization was 5.6%. All deaths occurred in patients older than 60 years. One or more comorbid illnesses were noted in 61% of cases. Recent intake of non‐steroidal antiinflammatory drugs (NSAIDs) was reported in 49% of the cases. The most common recorded diagnoses were erosive disease in 108 (30.5%) patients, duodenal ulcer in 97 (27.4%) and gastric ulcer in 75 (21.2%). Rebleeding occurred in 41 patients (12%). Twelve patients (3.3%) had surgery during hospitalization. Conclusions The overall annual incidence of acute UGIB in the prefecture of Heraklion‐Crete is one of the highest reported in Europe and increases appreciably with age. Both population mortality and case fatality are slightly lower compared to those reported in most previous studies.

Endoscopic sedation in Greece: Results from a nationwide survey for the Hellenic Foundation of gastroenterology and nutrition

BACKGROUND AND STUDY AIMS Recent surveys regarding practices in sedation during endoscopic procedures are limited, particularly in Greece where they are nonexistent. This survey was designed to provide national data on sedation practices in Greece. METHODS A 27-item survey regarding practices of endoscopy and sedation was mailed nationwide to 502 members of the Hellenic Society of Gastroenterology. RESULTS A total of 201 questionnaires were returned (40%). Survey respondents performed an average of 48 oesophagogastroduodenoscopies (EGD) and 35 colonoscopies per month. 50 of the respondents, who perform endoscopic retrograde cholangiopancreatography (ERCP), conducted an average of 10 ERCP per month. 15 of the respondents, who perform endoscopic ultrasound (EUS), conducted an average of 6 EUS per month. Respondents administered sedation intravenously in 64% of EGD, 78% of colonoscopies, 100% of ERCP and 100% of EUS. 125 of the respondents (62.1%) reported the use of synergistic sedation (benzodiazepines plus opioids), 71 of the respondents (35.3%) reported the use of benzodiazepines alone and 68 of the respondents (33.8%) reported the use of propofol based sedation in selected cases (more than one response was permitted). In most cases, propofol administration was directed by an anaesthesiologist. The majority of the respondents monitored vital signs and pulse oximetry (90% and 96%, respectively). CONCLUSION The use of sedation and physiologic monitoring in Greece is now standard practice during endoscopy. Benzodiazepines, either alone or combined with an opioid, are used by the majority of endoscopists, while propofol is used in selected cases, mainly in the presence of an anaesthesiologist.

Sixty- versus thirty-seconds papillary balloon dilation after sphincterotomy for the treatment of large bile duct stones: A randomized controlled trial

BACKGROUND Endoscopic biliary sphincterotomy followed by endoscopic papillary balloon dilation is a promising method for large stones. However, there are no data on the optimal duration of papillary balloon dilation after a biliary sphincterotomy. AIMS To compare the effectiveness and complications of the endoscopic papillary balloon dilation for 60s versus 30s after endoscopic biliary sphincterotomy. METHODS A total of 124 patients with bile duct stones, submitted for endoscopic biliary sphincterotomy plus endoscopic papillary balloon dilation, were prospectively randomized to either the 60-s dilation group (G60, n = 60) or the 30-s dilation group (G30, n = 64). RESULTS The complete removal of bile duct stones was similar: group G30, 55/64 (86%) versus group G60, 51/60 (85%); p = 0.9. The rates of post-endoscopic retrograde cholangio-pancreatography pancreatitis were also similar: 2 (3.1%) in group G30 versus 2 (3.3%) in group G60, p = 0.9. Post-procedural bleeding occurred in 2 cases (3.1%) in group G30 versus 4 (6.6%) in group G60, (p = 0.17). Two perforations of moderate severity were observed, one in each group. CONCLUSIONS 30-s papillary balloon dilation, performed after endoscopic biliary sphincterotomy for the management of bile duct stones, was equally effective to the 60-s papillary balloon dilation.

A prospective, randomized comparison of 10-Fr versus 7-Fr bipolar electrocoagulation catheter in combination with adrenaline injection in the endoscopic treatment of bleeding peptic ulcers

OBJECTIVES:Our study compared the efficacy of bipolar electrocoagulation (gold probe) with 10-Fr (group A) versus 7-Fr (group B) catheter after adrenaline injection in the treatment of bleeding peptic ulcers.METHODS:A total of 77 consecutive patients with endoscopic evidence of peptic ulcer with active bleeding or a nonbleeding visible vessel were randomly assigned to one of the above protocols. Thirty-nine patients (31 male, eight female, mean age 62 yr) were included in group A and 38 (28 male, 10 female, mean age 61 yr) in group B.RESULTS:The initial hemostasis rate, rebleeding rate, duration of hospital stay, volume of blood transfused, number of operations needed, and number of deaths were not significantly different between the two groups. The mean number of electrocoagulations and the subsequent mean duration of electrocoagulations were significantly higher in group B patients (7.0 ± 3.8 and 14.1 ± 7.6 s, respectively) compared with those of group A (4.6 ± 2.6 and 9.3 ± 5.3 s, respectively) (p < 0.01). Multivariate stepwise logistic regression analysis revealed that among sex, age, location of bleeding, ulcer size, endoscopic severity of bleeding, and the size of the gold probes, lesser endoscopic severity of bleeding (χ2= 31.1, p < 0.01), large size of the gold probe (χ2= 23.9, p < 0.01), and small ulcer size (χ2= 13.4, p < 0.01) were the only factors significantly associated with a smaller number of electrocoagulations.CONCLUSIONS:In this study, the use of large-size gold probes was significantly associated with a lower number of electrocoagulations, resulting in the reduction of electrocoagulation duration. However, the clinical relevance of these findings is questionable because the efficacy of both sizes of gold probe after adrenaline injection in the treatment of bleeding peptic ulcers was similar.

Proliferative patterns of rectal mucosa as predictors of advanced colonic neoplasms in routinely processed rectal biopsies

Objectives:We sought to determine whether the evaluation of rectal cell proliferation in routinely processed rectal biopsies of apparently normal mucosa can predict the presence of advanced colonic neoplasms.Methods:Fifty consecutive patients, who did not meet any of the following exclusion criteria, underwent total colonoscopy. Patients with nonadvanced adenomas, inflammatory bowel disease, hereditary predisposition to colonic cancer, or a history of colonic neoplasms were excluded. Patients with neoplasms in the distal 40 cm of the large bowel were also excluded. An adenoma was considered advanced if it had a diameter > 1 cm, or villous or severe dysplasia histology were present. In 26 of the 50 patients (Group A: 16 men, 10 women; mean age, 65 yr) advanced colonic neoplasms (advanced adenomas or cancer) were detected; in the remaining 24 (Group B: 13 men, 11 women; mean age, 66 yr) the large bowel was free of neoplasms. In all patients the proliferative patterns of apparently normal rectal mucosa were evaluated using the monoclonal antibody MIB-1 to assess the expression of Ki-67 antigen in routinely processed tissues. Proliferation index for the entire crypt, as well as proliferation indices for each of the five equal compartments, into which the crypt had been divided longitudinally, were calculated for each patient.Results:The mean proliferation indices were similar between the two groups compared. The mean proliferation index for the upper crypt compartments (4 + 5) in the Group A patients was significantly higher than for those of the Group B patients (p < 0.01). Multivariate stepwise logistic regression analysis revealed that among gender, age, and proliferative parameters, the pattern of cell proliferation in the upper rectal crypt (4 + 5) compartment was the only predictor of advanced colonic neoplasms (β= 11.01, p < 0.001).Conclusions:Our data suggest that the evaluation of the upward expansion of the rectal crypt proliferative zone in routinely processed rectal biopsies of apparently normal mucosa appears to predict the presence of advanced colonic neoplasms. These preliminary results should be confirmed in larger studies.

Changing trends in acute upper gastrointestinal bleeding in Crete, Greece: a population-based study.

From February 1998 to February 1999 (period A) and from February 2008 to February 2009 (period B), we prospectively obtained data on all patients with AUGIB (haematemesis, melaena, or other clinical or laboratory evidence of blood loss from the upper gastrointestinal tract) in the prefecture of Heraklion, Crete. All patients– permanent residents of the prefecture Heraklion–aged 16 years and over with AUGIB were included in the study. The two hospitals receiving emergency admissions in the area participated in the survey. The population over the age of 16 years was 220 000 for period A and 240 767 for period B (government national census figures).

Sex steroids and personality traits in the middle luteal phase of healthy normally menstruating young professional women

OBJECTIVESex steroids affect human behavior. The aim of the present study was to determine the associations, if any, between the circulating levels of gonadal and adrenal sex steroids in the mid luteal phase (21st day of a normal menstrual cycle, MC) of young professional women and psychometric parameters as assessed by the Minnesota Multiphasic Personality Inventory (MMPI).RESULTSOur results are as follows: (a) The metabolic product of activated adrenal and gonadal androgens, 3alpha-diolG, was modestly but significantly associated with the social introversion scale (10-SI) (r=0.36, p<0.05), independently accounting for 13% of its variation across participants (R2=0.13, F(1,45)=6.58, p=0.014). (b) Total testosterone was significantly associated with the paranoia scale (6-Pa) (r=0.27, p<0.05). Multiple regression analyses indicated that 10% of the variability in paranoia scores could be independently explained by total testosterone levels (R2=0.10, F(1,57)=6.23, p=0.016). We were unable to find any association between the circulating androgens and scores on the masculinity-femininity scale (Mf). We were also unable to document any association between the weak adrenal androgens DHEA and DHEA-S and depression in contrast to several published reports. (c) Our data suggest a marginally significant association between progesterone and scores on the 7-Pt (obsessive/compulsive/psychasthenia) scale (r=0.27, p<0.05). However, only 7% of the 7-Pt variance was explained by progesterone (R2=0.071, F(1,50)=3.81, p=0.057).CONCLUSIONSWe have found that total testosterone was associated with the paranoia score, the metabolic product of activated androgens, 3alpha-diolG, to social introversion and, finally, progesterone to obsessive-compulsive behavior.

Use of a Double-Channel Gastroscope Reduces Procedural Time in Large Left-Sided Colonic Endoscopic Mucosal Resections

Background/Aims Endoscopic mucosal resection (EMR) of large colorectal lesions is associated with increased procedural time. The objective of this study was to evaluate the effect of double-channel gastroscope (DCG) use on the procedural time of EMRs in the rectosigmoid area. Methods All EMRs for sessile or flat rectosigmoid lesions ≥2 cm performed between July 2011 and September 2012 were retrospectively analyzed. Results There were 55 lesions ≥2 cm in the rectosigmoid area in 55 patients, of which 26 were removed by EMR using a DCG (DC group) and 29 by using an ordinary colonoscope or gastroscope (OS group). The mean size of the removed polyps, morphology, adverse effects, and other parameters were similar between the two groups. The mean procedural time was significantly lower in the DC group than in the OS group (24.4±18.3 minutes vs. 36.3±24.4 minutes, p=0.015). Moreover, in a subgroup of patients with polyps >40 mm, the statistical difference in the mean procedural time between the DC and OS groups was even more pronounced (33±21 minutes vs. 58.7±20.6 minutes, p=0.004). Conclusions Our data suggest that the use of a DCG in the resection of large nonpedunculated rectosigmoid lesions significantly reduces the procedural time.

Interobserver variation in describing endoscopic features in inflammatory bowel disease using videotapes of colonoscopy

TO THE EDITOR: The evaluation of mucosal appearances is important in the management of patients with inflammatory bowel disease (IBD). There are few studies on the variability of the mucosal appearances in IBD (1–3). The aim of our study was to provide further information on the features that may present wide interobserver variability when videotapes of colonoscopic procedures are independently and blindly assessed. Videotape recordings of colonoscopic procedures were taken using an Olympus 200 video-colonoscope system. All 10 patients studied had previously been diagnosed with IBD using standard clinical, radiological, and histological criteria. The videotapes were independently assessed by three endoscopists, each with an experience of.500 procedures (G.P., A.M., C.J.). The assessors were asked to divide the colon into five segments: rectum, sigmoid, descending, transverse, and ascending/ cecum. Four parameters were assessed with respect to the whole colon and seven separate parameters for each of the five colonic segments. The colonoscopic examinations were performed as part of the medical care of the patients recruited to the study. All possible comparisons of the assessments of the three observers were analyzed in pairs by the k statistic using a standard statistical software package, BMDP. Significance levels of k were calculated according to Fleiss (4). Negativek values indicate disagreement, and positive values indicate agreement. This agreement is considered poor ifk , 0.40, good ifk