Alexander S Farivar

Swedish Medical Center Seattle, Seattle, Washington, United States

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Publications (94)438.09 Total impact

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    ABSTRACT: Application of the International Association for the Study of Lung Cancer/American Thoracic Society/European Respiratory Society (IASLC/ATS/ERS) classification of lepidic adenocarcinomas together with American Joint Committee on Cancer (AJCC) staging has been challenging. We aimed to compare IASLC/ATS/ERS and AJCC classifications to determine if they could be integrated as a single staging system.
    No preview · Article · Jan 2016
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    ABSTRACT: Background: Up to 18% of patients undergoing antireflux operations will require reoperation. Authors caution that with each additional reoperation, fewer patients achieve satisfaction. The quality of life in patients who underwent revision operations was compared with patients who underwent primary antireflux operations to determine the effectiveness of revision operations. Methods: We retrospectively reviewed patients who underwent revision after failed antireflux operations from 2004 to 2014. Patients were divided into two groups: first reoperation (Reop[1]) and more than one reoperation (Reop[>1]). For comparison, a control group of patients who underwent primary antireflux operations was included. Patients underwent quality of life assessment preoperatively and postoperatively. Results: We identified 105 reoperative patients: 94 Reop(1), 11 Reop(>1), and 112 controls. The primary reason for failure was combined fundoplication herniation and slippage. Morbidity, mortality, and readmission rates were similar in all groups. Postoperative outcomes were improved in all groups but to a lesser degree in subsequent reoperations. Gastroesophageal Reflux Disease Health-Related Quality of Life: controls, 20.0 to 2.0; Reop(1), 26.5 to 4.0; and Reop(>1), 13.0 to 2.0. Quality of Life in Reflux and Dyspepsia: controls, 4.5 to 7.0; Reop(1), 3.7 to 6.7; and Reop(>1), 3.5 to 5.8. Dysphagia Severity Score: controls, 44.0 to 45.0; Reop(1), 36.0 to 45.0; and Reop(>1), 30.8 to 45.0. Conclusions: Patients undergoing revision antireflux operations have improved quality of life, relatively normal swallowing, and primary symptom resolution at a median of 20 months postoperatively. However, patients who undergo more than one reoperation have lower quality of life scores and less improvement in dysphagia, suggesting that other procedures such as Roux-en-Y or short colon interposition, should be considered after a failed initial reoperation.
    No preview · Article · Dec 2015 · The Annals of thoracic surgery
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    ABSTRACT: Background: Magnetic sphincter augmentation (MSA) has emerged as an alternative surgical treatment of gastroesophageal reflux disease (GERD). The safety and efficacy of MSA has been previously demonstrated, although adequate comparison to Nissen fundoplication (NF) is lacking, and required to validate the role of MSA in GERD management. Methods: A multi-institutional retrospective cohort study of patients with GERD undergoing either MSA or NF. Comparisons were made at 1 year for the overall group and for a propensity-matched group. Results: A total of 415 patients (201 MSA and 214 NF) underwent surgery. The groups were similar in age, gender, and GERD-HRQL scores but significantly different in preoperative obesity (32 vs. 40 %), dysphagia (27 vs. 39 %), DeMeester scores (34 vs. 39), presence of microscopic Barrett's (18 vs. 31 %) and hiatal hernia (55 vs. 69 %). At a minimum of 1-year follow-up, 354 patients (169 MSA and 185 NF) had significant improvement in GERD-HRQL scores (pre to post: 21-3 and 19-4). MSA patients had greater ability to belch (96 vs. 69 %) and vomit (95 vs. 43 %) with less gas bloat (47 vs. 59 %). Propensity-matched cases showed similar GERD-HRQL scores and the differences in ability to belch or vomit, and gas bloat persisted in favor of MSA. Mild dysphagia was higher for MSA (44 vs. 32 %). Resumption of daily PPIs was higher for MSA (24 vs. 12, p = 0.02) with similar patient-reported satisfaction rates. Conclusions: MSA for uncomplicated GERD achieves similar improvements in quality of life and symptomatic relief, with fewer side effects, but lower PPI elimination rates when compared to propensity-matched NF cases. In appropriate candidates, MSA is a valid alternative surgical treatment for GERD management.
    Full-text · Article · Nov 2015 · Surgical Endoscopy

  • No preview · Article · Oct 2015 · Chest
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    Full-text · Article · Aug 2015
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    Full-text · Article · Aug 2015
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    ABSTRACT: The International Association for the Study of Lung Cancer/American Thoracic Society/European Respiratory Society classification of pulmonary adenocarcinomas identifies indolent lesions associated with low recurrence, superior survival, and the potential for sublobar resection. The distinction, however, is determined on the pathologic evaluation, limiting preoperative surgical planning. We sought to determine whether preoperative computed tomography (CT) characteristics could guide decisions about the extent of the pulmonary resection. We reviewed the preoperative CT scans for 136 patients identified to have adenocarcinomas with lepidic features on the final pathologic evaluation. The solid component on CT was substituted for the invasive component, and patients were radiologically classified as adenocarcinoma in situ, 3 cm or less with no solid component; minimally invasive adenocarcinoma, 3 cm or less with a solid component of 5 mm or less; or invasive adenocarcinoma, exceeding 3 cm or solid component exceeding 5 mm, or both. Analysis of variance, t test, χ(2) test, and Kaplan-Meier methods were used for analysis. The radiologic classification identified 35 adenocarcinomas in situ (26%) and 12 minimally invasive (9%) and 89 invasive adenocarcinoma (65%) lesions. At a 32-month median follow-up, patient outcomes associated with the radiologic classification were similar to the pathologic-based classification: the radiologic classification identified 14 of 16 patients with recurrent disease and all 6 who died of lung cancer. In addition, patients with radiologic adenocarcinoma in situ and minimally invasive adenocarcinoma who underwent sublobar resections had no recurrence and 100% disease-free and overall survival at 5 years. The radiologic classification of patients with lepidic adenocarcinomas is associated with similar oncologic and survival outcomes compared with the pathologic classification and may guide decision making in the approach to surgical resection. Copyright © 2015 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.
    Full-text · Article · Jul 2015 · The Annals of thoracic surgery
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    ABSTRACT: Rationale Tunneled pleural catheters have been established to be safe and effective in the management of recurrent symptomatic pleural effusions. Obstruction of the tunneled pleural catheter is rare; however, when obstructed the catheter fails to achieve its primary goal of symptom palliation. The management of pleural catheter obstruction has not been studied. Objectives We thus aim to determine if the use of intracatheter fibrinolytic therapy is safe and effective in restoring catheter function. Methods One-hundred and seventy-two patients with tunneled pleural catheters placed from 2009-2014 were reviewed to identify patients who received fibrinolysis for catheter obstruction, defined by a sudden reduction to less than 10mls in pleural fluid drainage with fluid visualized in the thorax on ultrasound/radiography. The technique involved intracatheter instillation of 2-5mg of alteplase and allowed to remain in the catheter for 60-120 minutes, following which drainage was performed. Measurements and Main Results Obstruction occurred in 37 pleural catheters at a median of 2 months from insertion. One-hundred percent (37/37) of obstructed catheters resumed drainage following fibrinolytic instillation, from a median of 4mls pre- to 300mls post-fibrinolysis, p<0.001. Twenty-four (65%) were performed in an outpatient setting, and no complications were encountered during or following fibrinolytic therapy. There were 18 episodes of reobstruction, all of which were successfully treated with intracatheter fibrinolytic therapy without complication. Conclusions Fibrinolytic instillation through a tunneled pleural catheter is safe and effective in restoring function of an obstructed catheter, as evidenced by the lack of complications and success in achieving catheter patency. The procedure can also be performed safely in an outpatient setting. Patients who experience catheter obstruction may be prone to reobstruction; however, fibrinolysis was safe and effective in re-establishing patency of the reobstructed catheter.
    Full-text · Article · Jul 2015 · Annals of the American Thoracic Society
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    ABSTRACT: A novel antireflux procedure combining laparoscopic Nissen fundoplication and Hill repair components was tested in 50 patients with paraesophageal hernia (PEH) and/or Barrett's esophagus (BE) because these two groups have been found to have a high rate of recurrence with conventional repairs. Patients with symptomatic PEH and/or non-dysplastic BE underwent repair. Quality of life (QOL) metrics, manometry, EGD, and pH testing were administered pre- and postoperatively. Fifty patients underwent repair. There was no mortality and four major complications. At 13-month follow-up, there was one (2 %) clinical recurrence, and two (4 %) asymptomatic fundus herniations. Mean DeMeester scores improved from 57.2 to 7.7 (p < 0.0001). Control of preoperative symptoms was achieved in 90 % with 6 % resumption of antisecretory medication. All QOL metrics improved significantly. The hybrid Nissen-Hill repair for patients with PEH and BE appears safe and clinically effective at short-term follow-up. It is hoped that the combined structural components may reduce the rate of recurrence compared to existing repairs.
    No preview · Article · Jun 2015 · Surgical Endoscopy
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    ABSTRACT: The management of potentially resectable stage III non-small cell lung carcinoma (NSCLC) is controversial. Options include induction chemotherapy or induction chemoradiation followed by resection, or chemoradiation without surgery. No trial has compared the outcomes of induction chemoradiation using different radiation doses. We reviewed our experience involving patients with clinical stage III disease treated with trimodality therapy involving two radiation strategies to determine the response rates, operative results, recurrence patterns, and long-term survival. A retrospective review was made of consecutive stage III NSCLC patients treated from 2004 to 2011. Fifty-two patients with clinical stage IIIa NSCLC were treated with trimodality therapy. Eighteen patients were treated to doses of 60 Gy or higher, and 34 to lower doses (45, 50, or 54 Gy). There were significantly more postoperative complications in the higher radiation group (p < 0.001). Pathologic complete response (50% versus 15%, p = 0.016) and mediastinal nodal clearance (75% versus 42%, p = 0.254) rates were also higher in the high-dose group. That did not, however, translate into better disease-free and overall survival rates. Importantly, long-term noncancer mortality was significantly higher after higher dose preoperative radiation therapy. In this series of patients with clinical stage IIIa NSCLC treated with trimodality therapy, a higher dose of preoperative radiation therapy resulted in better response rates but that did not translate to better cancer-specific survival. Of significance, we observed a notably higher delayed noncancer mortality in the high-dose group. Copyright © 2015 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.
    Full-text · Article · Jun 2015 · The Annals of thoracic surgery
  • Andreas M. Schneider · Brian E. Louie · Ralph W. Aye · Alexander S. Farivar

    No preview · Article · Apr 2015 · Gastroenterology
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    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.
    No preview · Article · Mar 2015 · Journal of Gastrointestinal Surgery

  • No preview · Article · Dec 2014 · The Annals of thoracic surgery
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    ABSTRACT: OBJECTIVES 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.
    Full-text · Article · Nov 2014 · Interactive Cardiovascular and Thoracic Surgery
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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.
    Full-text · Article · Nov 2014 · The Annals of Thoracic Surgery
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    ABSTRACT: Objectives: Identification of mediastinal nodal involvement (N2) in non-small-cell lung cancer (NSCLC) significantly impacts prognosis and treatment. Imaging raises suspicion for N2 disease whereas mediastinoscopy (MED) and endobronchial ultrasound (EBUS) can confirm pathologic diagnosis. We sought to determine the relative contribution of each modality for detecting N2 disease. Methods: A 5-year retrospective review of all patients with pathologic stage IIIA-N2 NSCLC. Patients were grouped based on the maximum standardised uptake value (SUV) of N2 nodes on preoperative PET/CT: G1 = SUV ≤ 2.5 and G2 = SUV > 2.5. Pathologic mediastinal node staging is standard practice at this institution but the choice of staging modalities was at the discretion of the clinician. Results: We identified 89 patients: 44 in G1 and 45 in G2 (Table 1). MED had a higher yield than selective EBUS in G1. EBUS and MED had similar performance in G2, but EBUS/MED failed to identify 20% of N2 disease in both groups, 67% of which were accessible. In G1 36% of patients had cN1 vs 58% in G2 (P = 0.043). G1 primary tumours showed lower max SUV (10.3 ± 7.8 vs 12.9 ± 5.5; P = 0.010) and adenocarcinomas were predominant (82% vs 49%; P = 0.001). View this table: In this window In a new window
    Preview · Article · Oct 2014 · Interactive Cardiovascular and Thoracic Surgery
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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.
    No preview · Article · Sep 2014 · Journal of Gastrointestinal Surgery
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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.
    No preview · Article · Aug 2014 · The Annals of Thoracic Surgery
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    ABSTRACT: Background: 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. Methods: Diaphragmatic characteristics and tension were assessed during hiatal hernia repair with a tension gage. We compared tension measured after hiatal dissection and after relaxing maneuvers were performed. Results: Sixty-four patients (29 M:35F) underwent laparoscopic hiatal hernia repair. Baseline hiatal width was 2.84 cm and tension 13.6 dag. There was a positive correlation between hiatal width and tension (r = 0.55) but the strength of association was low (r (2) = 0.31). Four different hiatal shapes (slit, teardrop, "D", and oval) were identified and appear to influence tension and the need for relaxing incision. Tension was reduced by 35.8 % after a left pleurotomy (12 patients); by 46.2 % after a right crural relaxing incision (15 patients); and by 56.1 % if both maneuvers were performed (6 patients). Conclusions: Tension on the diaphragmatic hiatus can be measured with a novel device. There was a limited correlation with width of the hiatal opening. Relaxing maneuvers such as a left pleurotomy or a right crural relaxing incision reduced tension. Longer term follow-up will determine whether outcomes are improved by quantifying and reducing radial tension.
    Full-text · Article · Jul 2014 · Surgical Endoscopy
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    ABSTRACT: Objectives: The term “BAC” includes newly defined adenocarcinoma-in situ (AIS), minimally invasive adenocarcinoma (MIA) or lepidic predominant adenocarcinoma (LPA). It presents as one or multiple lesions. In the IASLC classification, AIS and MIA are more indolent with a highly favourable prognosis, but TNM upstages multifocality to a worse prognosis. The differences in outcomes in patients with multifocal (MF) compared to unifocal (UF) disease are unclear. We hypothesized that outcomes are similar regardless of presentation. Methods: A retrospective chart review of patients with lung adenocarcinoma with “BAC” features. Results: A total of 143 patients were identified: MF in 81 (57%) and UF in 62 (43%). In addition to the dominant lesion, the MF group included 187 nodules: 45 were resected concomitantly (23 in the same lobe and 22 in an ipsilateral lobe) while 142 were radiologically surveyed. Lobectomy was performed mainly in the UF group (66% vs 44%; P < 0.01) while wedge resections in the MF group (41% vs 21%; P < 0.01). LPA was the most prevalent pathologic subtype and primarily in the UF group (71% vs 52%, P = 0.01). At 3.5 years of follow-up, local (3 vs 1), regional (16 vs 15) and distant recurrences (4 vs 3) were detected in the MF and UF group (P = 0.67). No new lesions occurred in the MF group; one in the UF. Only 1/142 surveyed pre-existing lesion required further treatment. No significant differences were observed in disease-free or overall survival at 5 years respectively (67.9% vs 68.5%, P = 0.38 and 90.9% vs 87.6%, P = 0.47). Conclusions: After resection of the dominant adenocarcinoma, patients with multifocal lesions behaved similarly to patients with unifocal disease. Recurrent disease, the development of new pulmonary lesions and survival were similar. This suggests that patients with multifocal disease should not be upstaged and should be treated with the same curative intent as those with unifocal disease. Disclosure: No significant relationships.
    Full-text · Article · Jun 2014 · Interactive Cardiovascular and Thoracic Surgery

Publication Stats

950 Citations
438.09 Total Impact Points

Institutions

  • 2010-2016
    • Swedish Medical Center Seattle
      Seattle, Washington, United States
  • 2014
    • Moncrief Cancer Institute
      Fort Worth, Texas, United States
  • 2003-2010
    • University of Washington Seattle
      • Division of Cardiothoracic Surgery
      Seattle, Washington, United States
    • VU University Amsterdam
      • Department of Molecular Cell Biology and Immunology
      Amsterdamo, North Holland, Netherlands