Alexander S Farivar

Swedish Medical Center Seattle, Seattle, Washington, United States

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Publications (72)260.07 Total impact

  • [Show abstract] [Hide abstract]
    ABSTRACT: Radiofrequency ablation (RFA) ± endoscopic resection (EMR) is an established treatment strategy for neoplastic Barrett's and intramucosal cancer. Most patients are managed with proton pump inhibitors. The incidence of recurrent Barrett's metaplasia, dysplasia, or cancer after complete eradication is up to 43 % using this strategy. We hypothesize the addition of fundoplication should result in a lower recurrence rates after complete eradication. Multi-institutional retrospective review of patients undergoing endotherapy followed by Nissen fundoplication RESULTS: A total of 49 patients underwent RFA ± EMR followed by Nissen fundoplication. Complete remission of intestinal metaplasia (CR-IM) was achieved in 26 (53 %) patients, complete remission of dysplasia (CR-D) in 16 (33 %) patients, and 7 (14 %) had persistent neoplastic Barrett's. After fundoplication, 18/26 (70 %) remained in CR-IM. An additional 10/16 CR-D achieved CR-IM and 4/7 with persistent dysplasia achieved CR-IM. One patient progressed to LGD while no patient developed HGD or cancer. Endoscopic therapy for Barrett's dysplasia and/or intramucosal cancer followed by fundoplication results in similar durability of CR-IM to patients being managed with PPIs alone after endoscopic therapy. However, fundoplication may be superior in preventing further progression of disease and the development of cancer. Fundoplication is an important strategy to achieve and maintain CR-IM, and facilitate eradication of persistent dysplasia.
    Journal of Gastrointestinal Surgery 03/2015; 146(5). DOI:10.1007/s11605-015-2783-6 · 2.39 Impact Factor
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    ABSTRACT: Lepidic growth pattern lung adenocarcinoma commonly presents as a dominant lesion (DL) with associated pulmonary nodules either in the ipsilateral or contralateral lung fields, posing a challenge in clinical decision-making. These tumours may be clinically upstaged compared with those who present with solitary lesions and, as a result, may be offered different therapies. The purpose of this study is to compare recurrence rates, the development of new lesions and survival in patients with adenocarcinoma with a lepidic component presenting with a DL with or without additional nodules.
    Interactive Cardiovascular and Thoracic Surgery 11/2014; DOI:10.1093/icvts/ivu366 · 1.11 Impact Factor
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    ABSTRACT: Axial shortening of the esophagus is caused by repetitive esophageal injury from gastroesophageal reflux disease resulting in esophagitis, submucosal fibrosis, and esophageal dysmotility. A short esophagus (<2 cm of intraabdominal length after type II mediastinal dissection) is encountered in 20% to 63% of patients undergoing paraesophageal hernia repair. An esophageal lengthening procedure can be a useful adjunct to fundoplication to reduce the 50% recurrence rate reported at 5 years. We describe a simplified Collis gastroplasty technique that negates the need for wedge fundectomy, potentially saving operating room time and cost, while hypothetically reducing morbidity. Copyright © 2014 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.
    The Annals of Thoracic Surgery 11/2014; 98(5):1860-2. DOI:10.1016/j.athoracsur.2014.04.131 · 3.63 Impact Factor
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    ABSTRACT: In the presence of esophageal pathology, there is risk of worse outcomes after laparoscopic adjustable gastric banding (LAGB) and sleeve gastrectomy (SG). This study reviewed how an esophageal workup affected a bariatric operative plan in patients with concurrent esophageal pathology. We retrospectively reviewed patients planning bariatric surgery referred with significant reflux, dysphagia, and hiatal hernia (>3 cm) to determine how and why a thorough esophageal workup changed a bariatric operative plan. We identified 79 patients for analysis from 2009 to 2013. In 10/41 patients (24.3 %) planning LAGB and 5/9 patients planning SG (55.5 %), a Roux was preferred because of severe symptoms of reflux and aspiration, dysphagia, manometric abnormalities (aperistaltic or hypoperistaltic esophagus with low mean wave amplitudes), large hiatal hernia (>5 cm), and/or presence of Barrett's esophagus. Patients without these characteristics had a decreased risk of foregut symptoms after surgery. We recommend a thorough esophageal workup in bariatric patients with known preoperative esophageal pathology. The operative plan might need to be changed to a Roux to prevent adverse outcomes including dysphagia, severe reflux, or suboptimal weight loss. An esophageal workup may improve surgical decision making and improve patient outcomes.
    Journal of Gastrointestinal Surgery 09/2014; 19(1). DOI:10.1007/s11605-014-2626-x · 2.39 Impact Factor
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    ABSTRACT: Background In 2012 the United States Food and Drug Administration approved implantation of a magnetic sphincter to augment the native reflux barrier based on single-series data. We sought to compare our initial experience with magnetic sphincter augmentation (MSA) with laparoscopic Nissen fundoplication (LNF). Methods A retrospective case-control study was performed of consecutive patients undergoing either procedure who had chronic gastrointestinal esophageal disease (GERD) and a hiatal hernia of less than 3 cm. Results Sixty-six patients underwent operations (34 MSA and 32 LNF). The groups were similar in reflux characteristics and hernia size. Operative time was longer for LNF (118 vs 73 min) and resulted in 1 return to the operating room and 1 readmission. Preoperative symptoms were abolished in both groups. At 6 months or longer postoperatively, scores on the Gastroesophageal Reflux Disease Health Related Quality of Life scale improved from 20.6 to 5.0 for MSA vs 22.8 to 5.1 for LNF. Postoperative DeMeester scores (14.2 vs 5.1, p = 0.0001) and the percentage of time pH was less than 4 (4.6 vs 1.1; p = 0.0001) were normalized in both groups but statistically different. MSA resulted in improved gassy and bloated feelings (1.32 vs 2.36; p = 0.59) and enabled belching in 67% compared with none of the LNFs. Conclusions MSA results in similar objective control of GERD, symptom resolution, and improved quality of life compared with LNF. MSA seems to restore a more physiologic sphincter that allows physiologic reflux, facilitates belching, and creates less bloating and flatulence. This device has the potential to allow individualized treatment of patients with GERD and increase the surgical treatment of GERD.
    The Annals of Thoracic Surgery 08/2014; 98(2). DOI:10.1016/j.athoracsur.2014.04.074 · 3.63 Impact Factor
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    ABSTRACT: During hiatal hernia repair there are two vectors of tension: axial and radial. An optimal repair minimizes the tension along these vectors. Radial tension is not easily recognized. There are no simple maneuvers like measuring length that facilitate assessment of radial tension. The aims of this project were to: (1) establish a simple intraoperative method to evaluate baseline tension of the diaphragmatic hiatal muscle closure; and, (2) assess if tension is reduced by relaxing maneuvers and if so, to what degree.
    Surgical Endoscopy 07/2014; 29(4). DOI:10.1007/s00464-014-3744-y · 3.31 Impact Factor
  • Interactive Cardiovascular and Thoracic Surgery 06/2014; 18(suppl 1):S8-S8. DOI:10.1093/icvts/ivu167.29 · 1.11 Impact Factor
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    ABSTRACT: Adenocarcinomas, commonly present as a dominant lesion (DL) with additional nodules in the ipsilateral or contralateral lung. We sought to determine the fate and management of the secondary nodules and to assess the risk of these nodules using the Lung CT Screening Reporting and Data System (Lung-RADS) criteria and the National Comprehensive Cancer Network (NCCN) Guidelines to determine if surveillance is an appropriate strategy. We retrospectively evaluated patients with lepidic growth pattern adenocarcinoma and secondary nodules from 2000 to 2013. Risk assessment of the additional lesions was completed with a simplified model of Lung-RADS and NCCN-Guidelines. Eighty-seven patients underwent resection of 87 DLs (Group 1) concurrently with 60 additional pulmonary nodules (Group 2), while 157 non-DLs were radiologically surveyed over a median follow-up time of 3.2 years (Group 3). Malignancy was found in 29/60 (48%) nodules in Group 2. Whereas, only 9/157 (6%) of the lesions in Group 3 enlarged, 4 of which (2.5% of total) were found to be malignant, and then treated, while the remaining nodules continued surveillance. After applying the Lung-RADS and NCCN simplified models, nodules in Group 2 were at higher risk for lung cancer than those in Group 3. In patients with lepidic growth pattern adenocarcinoma associated with multiple secondary nodules, surveillance of the remaining nodules, after resection of the DL, is a reasonable strategy since these nodules exhibited a slow rate of growth and minimal malignancy. In contrast, nodules resected from the ipsilateral lung at the time of the DL, harbor malignancy in 48%. Risk assessment models may provide a useful and standardized tool for clinical assessment of pulmonary nodules.
    Interactive Cardiovascular and Thoracic Surgery 06/2014; 1(suppl 1):52. DOI:10.3389/fsurg.2014.00052 · 1.11 Impact Factor
  • Gastrointestinal Endoscopy 05/2014; 79(5):AB228. DOI:10.1016/j.gie.2014.05.097 · 4.90 Impact Factor
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    ABSTRACT: A regional quality improvement effort does not exist for thoracic surgery in the United States. To initiate the development of one, we sought to describe temporal trends and hospital-level variability in associated outcomes and costs of pulmonary resection in Washington (WA) State. A cohort study (2000-2011) was conducted of operated-on lung cancer patients. The WA State discharge database was used to describe outcomes and costs for operations performed at all nonfederal hospitals within the state. Over 12 years, 8,457 lung cancer patients underwent pulmonary resection across 49 hospitals. Inpatient deaths decreased over time (adjusted p-trend = 0.023) but prolonged length of stay did not (adjusted p-trend = 0.880). Inflation-adjusted hospital costs increased over time (adjusted p-trend < 0.001). Among 24 hospitals performing at least 1 resection per year, 5 hospitals were statistical outliers in rates of death (4 lower and 1 higher than the state average), and 13 were outliers with respect to prolonged length of stay (7 higher and 6 lower than the state average) and costs (5 higher and 8 lower than the state average). When evaluated for rates of death and costs, there were hospitals with fewer deaths/lower costs, fewer deaths/higher costs, more deaths/lower costs, and more deaths/higher costs. Variability in outcomes and costs over time and across hospitals suggest opportunities to improve the quality and value of thoracic surgery in WA State. Examples from cardiac surgery suggest that a regional quality improvement collaborative is an effective way to meaningfully and rapidly act upon these opportunities.
    The Annals of thoracic surgery 04/2014; 98(1). DOI:10.1016/j.athoracsur.2014.03.014 · 3.65 Impact Factor
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    ABSTRACT: Pathologic nodal upstaging can be considered a surrogate for completeness of nodal evaluation and quality of surgery. We sought to determine the rate of nodal upstaging and disease-free and overall survival with a robotic approach in clinical stage I NSCLC. We retrospectively reviewed patients with clinical stage I NSCLC after robotic lobectomy or segmentectomy at three centers from 2009 to 2012. Data were collected primarily based on Society of Thoracic Surgeons database elements. Robotic anatomic lung resection was performed in 302 patients. The majority were right sided (192; 63.6%) and of the upper lobe (192; 63.6%). Most were clinical stage IA (237; 78.5%). Pathologic nodal upstaging occurred in 33 patients (10.9% [pN1 20, 6.6%; pN2 13, 4.3%]). Hilar (pN1) upstaging occurred in 3.5%, 8.6%, and 10.8%, respectively, for cT1a, cT1b, and cT2a tumors. Comparatively, historic hilar upstage rates of video-assisted thoracoscopic surgery (VATS) versus thoracotomy for cT1a, cT1b, and cT2a were 5.2%, 7.1%, and 5.7%, versus 7.4%, 8.8%, and 11.5%, respectively. Median follow-up was 12.3 months (range, 0 to 49). Forty patients (13.2%) had disease recurrence (local 11, 3.6%; regional 7, 2.3%; distant 22, 7.3%). The 2-year overall survival was 87.6%, and the disease-free survival was 70.2%. The rate of nodal upstaging for robotic resection appears to be superior to VATS and similar to thoracotomy data when analyzed by clinical T stage. Both disease-free and overall survival were comparable to recent VATS and thoracotomy data. A larger series of matched open, VATS and robotic approaches is necessary.
    The Annals of thoracic surgery 04/2014; DOI:10.1016/j.athoracsur.2014.01.064 · 3.65 Impact Factor
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    ABSTRACT: The use of robotic lung surgery has increased dramatically despite being a new, costly technology with undefined benefits over standard of care. There is a paucity of published comparative articles justifying its use or cost. Furthermore, outcomes regarding robotic lung resection are either from single institutions with in-house historical comparisons or based on limited numbers. We compared consecutive robotic anatomic lung resections performed at two institutions with matched data from The Society of Thoracic Surgeons (STS) National Database for all open and video-assisted thoracoscopic surgery (VATS) resections. We sought to define any benefits to a robotic approach versus national outcomes after thoracotomy and VATS. Data from all consecutive robotic anatomic lung resections were collected from two institutions (n = 181) from January 2010 until January 2012 and matched against the same variables for anatomic resections via thoracotomy (n = 5913) and VATS (n = 4612) from the STS National Database. Patients with clinical N2, N3, and M1 disease were excluded. There was a significant decrease in 30-day mortality and postoperative blood transfusion after robotic lung resection relative to VATS and thoracotomy. The patients stayed in the hospital 2 days less after robotic surgery than VATS and 4 days less than after thoracotomy. Robotic surgery led to fewer air leaks, intraoperative blood transfusions, need for perioperative bronchoscopy or reintubation, pneumonias, and atrial arrhythmias compared with thoracotomy. This is the first comparative analysis using national STS data. It suggests potential benefits of robotic surgery relative to VATS and thoracotomy, particularly in reducing length of stay, 30-day mortality, and postoperative blood transfusion.
    Innovations Technology and Techniques in Cardiothoracic and Vascular Surgery 02/2014; DOI:10.1097/IMI.0000000000000043
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    ABSTRACT: Knowledge about the cost of open, video-assisted thoracoscopic (VATS), or robotic lung resection and drivers of cost is crucial as the cost of care comes under scrutiny. This study aims to define the cost of anatomic lung resection and evaluate potential cost-saving measures. A retrospective review of patients who had anatomic resection for early stage lung cancer, carcinoid, or metastatic foci between 2008 and 2012 was performed. Direct hospital cost data were collected from 10 categories. Capital depreciation was separated for the robotic and VATS cases. Key costs were varied in a sensitivity analysis. In all, 184 consecutive patients were included: 69 open, 57 robotic, and 58 VATS. Comorbidities and complication rates were similar. Operative time was statistically different among the three modalities, but length of stay was not. There was no statistically significant difference in overall cost between VATS and open cases (Δ = $1,207) or open and robotic cases (Δ = $1,975). Robotic cases cost $3,182 more than VATS (p < 0.001) owing to the cost of robotic-specific supplies and depreciation. The main opportunities to reduce cost in open cases were the intensive care unit, respiratory therapy, and laboratories. Lowering operating time and supply costs were targets for VATS and robotic cases. VATS is the least expensive surgical approach. Robotic cases must be shorter in operative time or reduce supply costs, or both, to be competitive. Lessening operating time, eradicating unnecessary laboratory work, and minimizing intensive care unit stays will help decrease direct hospital costs.
    The Annals of thoracic surgery 01/2014; 97(3). DOI:10.1016/j.athoracsur.2013.11.021 · 3.65 Impact Factor
  • 01/2014; 1. DOI:10.13070/rs.en.1.813
  • Article: Reply.
    The Annals of thoracic surgery 10/2013; 96(4):1526. DOI:10.1016/j.athoracsur.2013.06.042 · 3.65 Impact Factor
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    ABSTRACT: Self-expanding fully covered metal stents (CSs) are ideal for use in benign esophagogastric disease. We reviewed our experience with CS to evaluate outcomes, to determine a role for CS in a standard treatment for benign esophageal conditions, and to compare our results with recently published studies. We performed a retrospective chart review from 2005 to 2012. A total of 57 CSs were placed in 44 patients. Indications were stricture (11 patients), anastomotic leak (20), perforation (7), and tracheoesophageal fistulae (6). For GI tract disruptions, open repair or diversion was avoided in 31/33 patients (93.9 %) but required an associated drainage procedure in 22/33 (67 %) patients. Resolution does not depend on achieving radiological control with 6/26 (23 %) having evidence of a persistent leak. Benign strictures were dilated at a mean of 3.7 times prior to stenting. Adjunctive intra-mucosal steroid injections were used in 8/11 patients. Stents were removed at a mean of 33 days. At a mean of 283 days of follow-up, 6/11 (54.5 %) had symptom resolution. The most common complication was stent migration occurring in 17.5 % of patients overall. Covered stents are an effective adjunct in the management of benign upper gastrointestinal tract fistulae, leaks, perforations and benign strictures.
    Journal of Gastrointestinal Surgery 09/2013; 17(12). DOI:10.1007/s11605-013-2357-4 · 2.39 Impact Factor
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    ABSTRACT: Endoscopic therapy (ablation +/- endoscopic resection) for high-grade dysplasia and/or intramucosal carcinoma (IMC) of the esophagus has demonstrated promising results. However, there is a concern that a curable, local disease may progress to systemic disease with repeated endotherapy. We performed a retrospective review of patients who underwent esophagectomy after endotherapy at three tertiary care esophageal centers from 2006 to 2012. Our objective was to document the clinical and pathologic outcomes of patients who undergo esophagectomy after failed endotherapy. Fifteen patients underwent esophagectomy after a mean of 13 months and 4.1 sessions of endotherapy for progression of disease (53%), failure to clear disease (33%), or recurrence (13%). Initially, all had Barrett's, 73% had ≥3-cm segments, 93% had a nodule or ulcer, and 91% had multifocal disease upon presentation. High-grade dysplasia was present at index endoscopy in 80% and IMC in 33%, and some patients had both. Final pathology at esophagectomy was T0 (13%), T1a (60%), T1b (20%), and T2 (7%). Positive lymph nodes were found in 20%: one patient was T2N1 and two were T1bN1. Patients with T1b, T2, or N1 disease had more IMC on index endoscopy (75% vs. 18%) and more endotherapy sessions (median 6.5 vs. 3). There have been no recurrences a mean of 20 months after esophagectomy. Clinical outcomes were comparable to other series, but submucosal invasion (27%) and node-positive disease (20%) were encountered in some patients who initially presented with a locally curable disease and eventually required esophagectomy after failed endotherapy. An initial pathology of IMC or failure to clear disease after three treatments should raise concern for loco-regional progression and prompt earlier consideration of esophagectomy.
    Diseases of the Esophagus 06/2013; DOI:10.1111/dote.12096 · 2.06 Impact Factor
  • Shaun Deen, Alexander S. Farivar, Brian E. Louie
    06/2013; 4(2). DOI:10.1007/s13193-013-0211-5
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    ABSTRACT: BACKGROUND: Endoscopic therapy (ablation ± mucosal resection) for esophageal high-grade dysplasia (HGD) or intramucosal carcinoma has demonstrated promising results. Little is known about patients who have persistent or progressive disease despite endotherapy. We compared patients who had successful eradication of their disease with those in whom endotherapy failed to try to identify factors predictive of failure and outcomes after salvage therapy. METHODS: We performed a single-institution retrospective review of patients treated with endotherapy from 2007 to 2012. RESULTS: Thirty-eight patients underwent endotherapy: 28 had successful eradication of their disease and endotherapy failed in 10 patients. Patients in whom endotherapy failed were more likely to have high-grade dysplasia (HGD) on initial endoscopy, nodules or ulcers, multifocal dysplasia, and persistent nondysplastic Barrett's metaplasia. Patients in whom endotherapy failed also underwent significantly more endotherapy sessions. Seven patients had persistent dysplasia or progression to cancer, and 3 patients had complete eradication of HGD but presented with intramucosal carcinoma an average of 15 months after eradication. The 10 patients in whom endotherapy failed underwent salvage therapy with esophagectomy (7 patients), definitive chemoradiotherapy (1 patient), and endotherapy (2 patients). Patients treated with esophagectomy were disease free at a mean of 25 months postoperatively. CONCLUSIONS: HGD on initial endoscopy, multifocal dysplasia, mucosal abnormalities, and failure to eradicate nondysplastic Barrett's metaplasia were associated with failure of endotherapy. Patients with these characteristics should be considered at higher risk for treatment failure, and earlier consideration should be given to esophagectomy if there is persistent, progressive, or recurrent neoplasia. Clinical outcomes are good, even after salvage therapy. Continued endoscopic surveillance is mandatory after successful endotherapy because of the risk of recurrent disease.
    The Annals of thoracic surgery 04/2013; DOI:10.1016/j.athoracsur.2013.02.023 · 3.65 Impact Factor
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    ABSTRACT: BACKGROUND: Laparoscopic antireflux surgery is highly effective in patients with uncomplicated gastroesophageal reflux disease (GERD). However, long-term failure rates in paraesophageal hernia (PEH) and Barrett's metaplasia (BE) are higher and warrant a more durable repair. Outcomes for the laparoscopic Nissen fundoplication (LNF) and Hill repair (LHR) are equivalent, but their anatomic components are different and may complement each other (Aye R Ann Thorac Surg, 2012). We designed and tested the feasibility and safety of an operation that combines the essential components of each repair. METHODS: A prospective, phase II pilot study was performed on patients with symptomatic giant PEH hernias and/or GERD with nondysplastic Barrett's metaplasia. Pre- and postoperative esophagogastroduodenoscopy (EGD), upper gastrointestinal study (UGI), 48-hour pH testing, manometry, and three quality-of-life metrics were obtained. RESULTS: Twenty-four patients were enrolled in the study. Three patients did not complete the planned procedure, leaving 21 patients, including 12 with PEH, 7 with BE, and 2 with both. There were no 30-day or in-hospital mortalities. At a median follow-up of 13 (range 6.4-30.2) months, there were no reoperations or clinical recurrences. Two patients required postoperative dilation for dysphagia, with complete resolution. Mean DeMeester scores improved from 54.3 to 7.5 (p < 0.0036). Mean lower esophageal sphincter pressures (LESP) increased from 8.9 to 21.3 mmHg (p < 0.013). Mean short-term and long-term QOLRAD scores improved from 4.09 at baseline to 6.04 and 6.48 (p < 0.0001). Mean short-term and long-term GERD-HQRL scores improved from 22.9 to 7.5 and 6.9 (p < 0.03). Mean long-term Dysphagia Severity Score Index improved from 33.3 to 40.6 (p < 0.064). CONCLUSIONS: The combination of a Nissen plus Hill hybrid reconstruction of the gastroesophageal junction (GEJ) is technically feasible, safe, and not associated with increased side effects. Short-term clinical results in PEH and BE suggest that this may be an effective repair, supporting the value of further study.
    Surgical Endoscopy 01/2013; 27(6). DOI:10.1007/s00464-012-2692-7 · 3.31 Impact Factor

Publication Stats

685 Citations
260.07 Total Impact Points


  • 2010–2014
    • Swedish Medical Center Seattle
      Seattle, Washington, United States
  • 2012
    • Swedish Medical Center
      Englewood, Colorado, United States
  • 2003–2010
    • University of Washington Seattle
      • • Division of Pulmonary and Critical Care Medicine
      • • Division of Cardiothoracic Surgery
      Seattle, Washington, United States