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Papers by Irfan Qureshi

Annals of International medical and Dental Research, 2018

Background: To compare the outcome of Modified Radical Mastectomy and breast conserving surgery i... more Background: To compare the outcome of Modified Radical Mastectomy and breast conserving surgery in early breast carcinoma Retrospective analysis of 100 patients with early breast cancer done in Index Medical College Hospital and Research Centre, Indore, MP( India), from June 2015 to July 2016. Methods: With early breast cancer were divided into conserving group (n=30) and radical (n=30) according to the different surgical operations. Patients were female, aged 30 to 60 y, with normal breast development. Results: The operative time, blood loss, hospital stay and the incidence of postoperative complications were compared between the two groups. The local recurrence rate, distant metastasis rate, and the 3 years and 5 years survival rate of patients after operation were compared according to the follow-up data. Patients follow up done monthly in first year and every 3 months after the first year of operation. Conclusion: Breast conserving surgery and modified radical mastectomy surgery results were similar for early breast cancer patients.

The American Surgeon, 2010

The American Surgeon, 2010

Small bowel obstruction (SBO) is a common cause of hospital admission. Our objective is to determ... more Small bowel obstruction (SBO) is a common cause of hospital admission. Our objective is to determine variables that correlate with failure of the laparoscopic approach for SBO. Twenty-three consecutive patients underwent diagnostic laparoscopy with curative intent for treatment of SBO by a single surgeon over a 3-year period. The laparoscopic approach was successful in 18 patients (78%); there were five (22%) conversions to laparotomy. The causes of obstruction included adhesive band in 16 patients; and small bowel lymphoma, metastatic esophageal cancer, small bowel gangrene, Meckel diverticulum, gallstones ileus, and incarcerated incisional hernia in two. Using the Fisher two-sided test, no significant predictor for conversion was identified using gender, American Society of Anesthesiologists class, previous bowel obstruction, history of adhesiolysis, abdominal distention, pelvic surgeries, chemotherapy, radiation, malignancy, chronic obstructive pulmonary disease, asthma, coronary...

Surgical Oncology Clinics of North America, 2009

Risk stratification for the development of a subsequent pneumonia after a nondiagnostic bronchoalveolar lavage

Surgery, 2011

Broncho-alveolar lavage (BAL) is an invasive bedside procedure to define type and concentration o... more Broncho-alveolar lavage (BAL) is an invasive bedside procedure to define type and concentration of pathologic organisms causing ventilator associated pneumonia (VAP). We evaluated if the absence of pathogens on final results represented a lavage aspect of the BAL as a therapeutic procedure to eliminate organisms. BAL results collected from 2008 to 2009 were stratified as positive (POS) ≥ 100,000 cfu), indeterminate (INT) ≤ 100,000 cfu pathologic organisms, or negative defined as mixed flora (MF) or sterile (STR). The INT, MF, and STR results were assessed by incidence of a subsequent POS sample. Nine-hundred forty-nine BALs performed on 490 SICU patients were interpreted as POS in 227 patients (46%). 237 non- POS patients needed a subsequent BAL. Any pathogen on the first BAL (INT group) indicates a high likelihood for subsequent BAL which will be POS. Monthly cumulative sum analysis (CUSUM) of yield was unable to identify any specific period in which BAL performance varied from tre...

Probiotics for symptoms of IBS: A review of controlled trials

Evaluation of the safety of the dietary antioxidant ergothioneine using the bacterial reverse mutation assay

Toxicology, 2010

The dietary antioxidant L-(+)-ergothioneine was tested for its potential mutagenic activity using... more The dietary antioxidant L-(+)-ergothioneine was tested for its potential mutagenic activity using the bacterial reverse mutation assay. The experiments were carried out using histidine-requiring auxotrophic strains of Salmonella typhimurium (Salmonella typhimurium TA98, TA100, TA1535 and TA1537), and the tryptophan-requiring auxotrophic strain of Escherichia coli (Escherichia coli WP2 uvrA) in the presence and absence of a post-mitochondrial supernatant (S9) prepared from livers of phenobarbital/β-naphthoflavone-induced rats. The revertant colony numbers of vehicle control plates with and without S9 Mix were within the corresponding historical control data ranges. The reference mutagen treatments (positive controls) showed the expected, biologically relevant increases in induced revertant colonies in all experimental phases in all tester strains. No biologically relevant increases were observed in revertant colony numbers of any of the five test strains following treatment with L-(+)-ergothioneine at any concentration level, either in the presence or absence of metabolic activation (S9 Mix) in the performed experiments. On the basis of the data reported, it can be concluded that L-(+)-ergothioneine did not induce gene mutations by base pair changes or frameshifts in the genome of the strains used. Thus L-(+)-ergothioneine has no mutagenic activity on the applied bacteria tester strains under the test conditions used in this study. Research is continuing to define the role of L-(+)-ergothioneine in disease pathophysiology. Further studies on its safety are suggested.

Journal of Vascular Surgery, 2005

Background. Homocysteine, a risk factor for atherosclerosis, increases intimal hyperplasia after ... more Background. Homocysteine, a risk factor for atherosclerosis, increases intimal hyperplasia after carotid endarterectomy with associated smooth muscle cell proliferation and modulation of cytokines. The N-methyl-D-aspartate receptor (NMDAr), a glutamate-gated ion channel receptor, is associated with homocysteine-induced cerebrovascular injury; however, the receptor has not been identified in peripheral vascular cells, nor has any interaction with homocysteine been clarified. Our objectives were first, to identify NMDAr in rat carotid artery and rat aorta endothelial cells (RAEC); and second, to determine whether homocysteine activates NMDAr in the endothelium. . NR1 and NR2A, two NMDAr subunits, were probed in rat carotid arteries by immunohistochemistry. RNA was isolated from RAECs, and expression of all NMDAr subunits (NR1, 2A, 2B, 2C, and 2D) were examined by RT-PCR and sequencing. For receptor protein expression, RAEC were incubated with different homocysteine concentrations and incubation times and also were treated with 50 M homocysteine and/or preincubated with 50 M dizocilpine MK-801, an NMDAr inhibitor. Results. Both NR1 and NR2A were expressed in rat carotid arteries. All NMDAr subunits were expressed in the RAECs, and there was 92% to 100% similarity compared with rat NMDAr from the National Center for Biotechnology Information (NCBI) GenBank. Homocysteine upregulated NR1 expression and increased cell proliferation. RAEC pretreatment with MK-801 reduced homocysteine-mediated cell proliferation. Conclusion. This study is the first to show that NMDAr exists in the peripheral vasculature, and that homocysteine may act via NMDAr to increase intimal hyperplasia. ( J Vasc Surg 2005;41:853-60.) Clinical Relevance: Our objectives included the identification of a homocysteine receptor in the peripheral vasculature. The possible inhibition of a homocysteine receptor to prevent intimal hyperplasia rather than treat established stenosis would make a significant clinical impact. This will open further avenues of study in determining the role of homocysteine in the pathogenesis of intimal hyperplasia.

The Journal of Thoracic and Cardiovascular Surgery, 2011

Objective: The minimally invasive, video-assisted thoracoscopic surgical (VATS) approach to resec... more Objective: The minimally invasive, video-assisted thoracoscopic surgical (VATS) approach to resection of the thymus is frequently practiced for benign disease; however, a VATS approach for thymoma remains controversial. The objective of the present study was to evaluate the feasibility of VATS thymectomy for the treatment of early-stage thymoma and to compare the outcomes with those after open resection. Methods: A retrospective review of 40 patients who underwent surgical resection of early-stage thymoma during a 12-year period was conducted. Data on patient characteristics, morbidity, recurrence, and survival were collected. The primary endpoint studied was overall survival. Results: Of the 40 patients, 14 underwent thymectomy for stage I and 26 for stage II thymoma; 19 were men and 21 were women (median age, 64 years; range, 35-86 years). Open thymectomy was performed in 22 patients, and VATS was performed in 18. The operative mortality rate was 0%. The tumor stage and number of patients undergoing adjuvant radiotherapy were comparable in both surgical groups. The median length of hospital stay was shorter in the VATS group (3 days) than in the open group (5 days) (P ¼ .0001). The median follow-up was 36 months. No significant differences were found in the estimated recurrence-free and overall 5-year survival rates (83%-100%) between the 2 groups. Conclusions: VATS of early-stage thymoma appears safe and feasible and was associated with a shorter hospital stay. The oncologic outcomes were comparable in the open and VATS groups during intermediate-term follow-up. Additional follow-up is required to evaluate the long-term results of thoracoscopic thymectomy for early-stage thymoma. (

JSLS : Journal of the Society of Laparoendoscopic Surgeons, 2009

Background: Aberrant gallbladder transposed to the left side is a rare congenital anomaly that ha... more Background: Aberrant gallbladder transposed to the left side is a rare congenital anomaly that has been seen in as many as 0.7% of the population. These gallbladders are situated under the left lobe of the liver between Segment III and IV and to the left of the falciform ligament. Many preoperative studies fail to identify the anomaly, causing confusion to the surgeon during laparoscopic resection. Selective use of intraoperative cholangiography and meticulous dissection can aid in safe resection. A 61-year-old female was admitted with ultrasound confirmation of cholecystitis and subsequently taken to the operating room for a laparoscopic cholecystectomy. Results: Evaluation of the gallbladder under laparoscopic view revealed an inflamed left aberrant gallbladder. An intraoperative cholangiogram was obtained to delineate the biliary anatomy that showed the cystic duct entering the common hepatic duct on the right side. A left aberrant gallbladder is a rare presentation that requires awareness of biliary anatomy and selective use of intraoperative cholangiography to aid in the safe laparoscopic resection of the gallbladder.

W1669 The Use of Alveolus Stents in the Treatment of Esophageal Leaks, Perforation or Fistulae

Gastroenterology, 2008

Gastroenterology, 2008

Background: Laparoscopic repair of giant paraesophageal hernias (LRGPEH) is increasingly utilized... more Background: Laparoscopic repair of giant paraesophageal hernias (LRGPEH) is increasingly utilized with excellent short-term results. Long-term (>60 months) clinical and radiographic results, however, are poorly described. Our objective was to evaluate the long term results after minimally invasive repair of GPEH. Methods: We performed a review of patients undergoing elective LRGPEH (1995LRGPEH ( to 2002) ) who had a minimum of 60-month clinical or radiographic follow-up. Clinical outcomes, barium swallow and quality-of-life measures were reviewed. Results: There were 256 patients who underwent LRGPEH in this time-period. A minimum of 60-month clinical or radiographic follow-up was available on 105 patients. Hernia reduction, sac excision, crural repair (13.7% mesh-reinforcement) and fundoplication were performed in 98%. A Collis-gastroplasty was performed in 89 patients (85%). Median time for clinical follow-up was 82 months (60-124). GERD-Health-Related-Quality-of-Life (GERD-HRQL) scores were available for 98 patients, with a mean 3.9 ±6 (median 1, range 0-23; 0=no symptoms-45= worst). Occasional heartburn and dysphagia to solids were the most common persistent symptoms in 30% of patients. According to the GERD-HRQL scale (excellent=0-5; good=6-10; fair=11-15; poor=16-45), the results were excellent to good in 86.8% of patients, confirming the mild nature of the symptoms. Barium-swallow was obtained in 79/105 (75%) at a median time of 80 months (60-126). Radiographic recurrence of a hiatal hernia was identified in 9 (11%). GERD-HRQL scores were excellent in 77% of patients with radiographic recurrence compared to 72% in patients without radiographic recurrence. When patients were queried regarding satisfaction with surgery, over 90% (83/90) were satisfied or very satisfied. Re-operation was required in 5 (4.7%) patients for symptomatic recurrence at a median 44 months post-operative (range 8-80). Conclusions: This report summarizes the long-term results (7 years) of LRGPEH in 105 patients. Reoperation was required for symptomatic recurrence in only 4.7%. The GERD-related quality of life was well preserved and 90% of patients were satisfied with their surgery.

Expert Review of Anticancer Therapy, 2008

The Annals of Thoracic Surgery, 2009

symptoms resulting from obstruction of the SVC or bilateral brachiocephalic veins [3]. Compressio... more symptoms resulting from obstruction of the SVC or bilateral brachiocephalic veins [3]. Compression of the SVC results in increased venous pressure in the upper extremities, upper chest, head, and neck. This may cause plethora or cyanosis, cerebral edema leading to headache, confusion, or coma, as well as laryngopharyngeal edema manifesting as cough, dyspnea, or dysphagia [3]. SVC syndrome may result from extrinsic compression, direct invasion, or thrombosis; malignancy, benign tumors, idiopathic fibrosing mediastinitis, sarcoidosis, and indwelling venous catheters are the most common causes [4]. Malignancies most commonly include nonsmall cell lung cancer (50%), small cell lung cancer (22%), lymphoma (12%), and metastatic disease (9%) [3]. The severity of the symptoms usually depends on the rapidity of onset and the degree of SVC compression [3]. Gradual narrowing of the SVC, particularly in association with a patent azygos vein, generally allows for the development of collateral venous drainage, with mild or no symptoms. Sudden SVC occlusion, however, can cause upper body edema, life-threatening neurologic changes, and respiratory failure. Depending on the underlying cause, SVC syndrome can be treated by a combination of the following therapies: medical management with anticoagulation, diuretics, and elevation of the upper body; radiation or chemotherapy, or both; surgical bypass, and SVC stenting [5]. For patients with SVC syndrome secondary to nonsmall cell lung cancer, radiation therapy and SVC stenting are the mainstays of treatment [6]. Tanigawa and colleagues [7] compared radiation and stenting in a nonrandomized study and found similar rates of symptom resolution for both treatments of 80% and 78%, respectively. Nicholson and colleagues [8] found that stent insertion provided faster relief and greater improvement of symptoms, as well as fewer recurrent symptoms vs radiation therapy. More recently, de Gregorio Ariza and colleagues [5] examined treatment of SVC syndrome with stenting in patients with malignant and benign causes. Clinical success was achieved in 95% of patients within 2 to 3 days. In 78 patients with malignancy, 96% assisted stent patency (4 required thrombolytics and 1 required restenting) was reported. This article reports the complication of tracheal and esophageal stenting leading to acute SVC syndrome. Two other reports of simultaneous tracheal and SVC stenting in patients with lung cancer causing tracheal compression and SVC syndrome have been published [4, 9]. In those patients, the obstructive symptoms developed slowly over time, and stenting alleviated the symptoms. In our patient, placement of dilating stents in both the esophagus and trachea occupied space in an already crowded mediastinum. The resulting critical compression of the SVC (and possibly the azygos-caval junction) resulted in increased intracranial pressure and depressed mental state. Stenting of the SVC is a wellaccepted treatment strategy for SVC syndrome and here resulted in rapid resolution of signs and symptoms.

The Annals of Thoracic Surgery, 2009

Objectives-Surgical resection is the preferred treatment in selected patients with pulmonary meta... more Objectives-Surgical resection is the preferred treatment in selected patients with pulmonary metastases. In high-risk patients, radiofrequency ablation (RFA) may offer an alternative option. RFA may be used either alone or in combination with surgical resection as a lung parenchymalsparing approach. Our objectives were to evaluate the intermediate term outcomes after RFA and to determine the prognostic variables associated with outcome in patients with pulmonary metastases Methods-Thoracic surgeons evaluated and performed RFA under computed-tomography (CT) guidance or in combination with surgical resection as a lung parenchymal-sparing modality. Patients were monitored in the thoracic surgery clinic for recurrence and survival. Results-Twenty-two patients {10 men, 12 women; median age 63 years (37-88)} underwent RFA. The primary cancer was colorectal in 9 (41%), renal in 2 (9%), sarcoma in 4 (18%) and other in 7 (32%) patients. CT-guided RFA was performed as a sole modality of treatment in 17 patients (77%), and in combination with surgical resection in 5 (23%) patients. There were no procedure-related mortalities. At a mean follow-up of 27 months (13.3-53.6 months), 9 patients are alive. The median survival was 29 months ). Size of the lesion was an important prognostic variable associated with overall and disease-free survival (P<0.05). Conclusions-Our experience indicates that RFA is safe in this group of pulmonary metastases patients with reasonable results. Surgery remains the standard for resectable patients, but RFA offers an alternative option in selected patients or may be used as a parenchymal-sparing approach in combination with surgical resection in selected patients.

Annals of Surgery, 2000

To summarize the authors' laparoscopic experience for paraesophageal hernia (PEH). Laparoscopic a... more To summarize the authors' laparoscopic experience for paraesophageal hernia (PEH). Laparoscopic antireflux surgery and repair of small hiatal hernias are now routinely performed. Repair of a giant PEH is more complex and requires conventional surgery in most centers. Giant PEH accounts for approximately 5% of all hiatal hernias. Medical management may be associated with a 50% progression of symptoms and a significant death rate. Conventional open surgery has a low death rate, but complications are significant and return to routine activities is delayed in this frequently elderly population. Recently, short-term outcome studies have reported that minimally invasive approaches to PEH may be associated with a lower complication rate, a shorter hospital stay, and faster recovery. From July 1995 to February 2000, 100 patients (median age 68) underwent laparoscopic repair of a giant PEH. Follow-up included heartburn scores and quality of life measurements using the SF-12 physical component and mental component summary scores. There were 8 type II hernias, 85 type III, and 7 type IV. Sac removal, crural repair, and antireflux procedures were performed (72 Nissen, 27 Collis-Nissen). The 30-day death rate was zero; there was one surgery-related death at 5 months from a perioperative stroke. Intraoperative complications included pneumothorax, esophageal perforation, and gastric perforation. There were three conversions to open surgery. Major postoperative complications included stroke, myocardial infarction, pulmonary emboli, adult respiratory distress syndrome, and repeat operations (two for abscess and one each for hematoma, repair leak, and recurrent hernia). Median length of stay was 2 days. Median follow-up at 12 months revealed resumption of proton pump inhibitors in 10 patients and one repeat operation for recurrence. The mean heartburn score was 2.3 (0, best; 45, worst); the satisfaction score was 91%; physical and mental component summary scores were 49 and 54, respectively (normal, 50).

Gastrointestinal Endoscopy, 2008

Background: EMR is an accepted treatment for early esophageal cancer and high-grade dysplasia. On... more Background: EMR is an accepted treatment for early esophageal cancer and high-grade dysplasia. One of the limitations of this technique is that extensive mucosal resection and endoscopic submucosal dissection may be required to obtain complete removal of the neoplasm, which may result in significant stricture formation. Objective: The objective of the current study was to evaluate the efficacy of an endoscopically deployed extracellular matrix (ECM) scaffold material for prevention of esophageal stenosis after circumferential EMR. Design: Ten mongrel dogs were subjected to surgical plane anesthesia and circumferential esophageal EMR by the cap technique. In 5 animals, an ECM scaffold material was endoscopically placed at the resection site; the remaining 5 animals were subjected to circumferential esophageal EMR without ECM placement. Follow-up endoscopy was performed at 4 and 8 weeks; necropsy with histologic assessment was performed at 8 weeks. Setting: Animal laboratory. Interventions: Circumferential esophageal EMR by the cap technique, followed by endoscopic placement of an ECM scaffold material. Main Outcome Measurements: Degree of esophageal stricture and histologic assessment of remodeled esophageal tissue. Results: All 5 control dogs had endoscopic evidence of esophageal stenosis. Three required early euthanasia because of inability to tolerate oral intake. Incomplete epithelialization and inflammation persisted at the EMR site in control animals. Endoscopic placement of an ECM scaffold material prevented clinically significant esophageal stenosis in all animals. Histologic assessment showed near-normal esophageal tissue with a lack of inflammation or scar tissue at 8 weeks. Conclusions: Endoscopic placement of an ECM scaffold material prevented esophageal stricture formation after circumferential EMR in this canine model during short-term observation.

Annals of International medical and Dental Research, 2018

Background: To compare the outcome of Modified Radical Mastectomy and breast conserving surgery i... more Background: To compare the outcome of Modified Radical Mastectomy and breast conserving surgery in early breast carcinoma Retrospective analysis of 100 patients with early breast cancer done in Index Medical College Hospital and Research Centre, Indore, MP( India), from June 2015 to July 2016. Methods: With early breast cancer were divided into conserving group (n=30) and radical (n=30) according to the different surgical operations. Patients were female, aged 30 to 60 y, with normal breast development. Results: The operative time, blood loss, hospital stay and the incidence of postoperative complications were compared between the two groups. The local recurrence rate, distant metastasis rate, and the 3 years and 5 years survival rate of patients after operation were compared according to the follow-up data. Patients follow up done monthly in first year and every 3 months after the first year of operation. Conclusion: Breast conserving surgery and modified radical mastectomy surgery results were similar for early breast cancer patients.

The American Surgeon, 2010

The American Surgeon, 2010

Small bowel obstruction (SBO) is a common cause of hospital admission. Our objective is to determ... more Small bowel obstruction (SBO) is a common cause of hospital admission. Our objective is to determine variables that correlate with failure of the laparoscopic approach for SBO. Twenty-three consecutive patients underwent diagnostic laparoscopy with curative intent for treatment of SBO by a single surgeon over a 3-year period. The laparoscopic approach was successful in 18 patients (78%); there were five (22%) conversions to laparotomy. The causes of obstruction included adhesive band in 16 patients; and small bowel lymphoma, metastatic esophageal cancer, small bowel gangrene, Meckel diverticulum, gallstones ileus, and incarcerated incisional hernia in two. Using the Fisher two-sided test, no significant predictor for conversion was identified using gender, American Society of Anesthesiologists class, previous bowel obstruction, history of adhesiolysis, abdominal distention, pelvic surgeries, chemotherapy, radiation, malignancy, chronic obstructive pulmonary disease, asthma, coronary...

Surgical Oncology Clinics of North America, 2009

Risk stratification for the development of a subsequent pneumonia after a nondiagnostic bronchoalveolar lavage

Surgery, 2011

Broncho-alveolar lavage (BAL) is an invasive bedside procedure to define type and concentration o... more Broncho-alveolar lavage (BAL) is an invasive bedside procedure to define type and concentration of pathologic organisms causing ventilator associated pneumonia (VAP). We evaluated if the absence of pathogens on final results represented a lavage aspect of the BAL as a therapeutic procedure to eliminate organisms. BAL results collected from 2008 to 2009 were stratified as positive (POS) ≥ 100,000 cfu), indeterminate (INT) ≤ 100,000 cfu pathologic organisms, or negative defined as mixed flora (MF) or sterile (STR). The INT, MF, and STR results were assessed by incidence of a subsequent POS sample. Nine-hundred forty-nine BALs performed on 490 SICU patients were interpreted as POS in 227 patients (46%). 237 non- POS patients needed a subsequent BAL. Any pathogen on the first BAL (INT group) indicates a high likelihood for subsequent BAL which will be POS. Monthly cumulative sum analysis (CUSUM) of yield was unable to identify any specific period in which BAL performance varied from tre...

Probiotics for symptoms of IBS: A review of controlled trials

Evaluation of the safety of the dietary antioxidant ergothioneine using the bacterial reverse mutation assay

Toxicology, 2010

The dietary antioxidant L-(+)-ergothioneine was tested for its potential mutagenic activity using... more The dietary antioxidant L-(+)-ergothioneine was tested for its potential mutagenic activity using the bacterial reverse mutation assay. The experiments were carried out using histidine-requiring auxotrophic strains of Salmonella typhimurium (Salmonella typhimurium TA98, TA100, TA1535 and TA1537), and the tryptophan-requiring auxotrophic strain of Escherichia coli (Escherichia coli WP2 uvrA) in the presence and absence of a post-mitochondrial supernatant (S9) prepared from livers of phenobarbital/β-naphthoflavone-induced rats. The revertant colony numbers of vehicle control plates with and without S9 Mix were within the corresponding historical control data ranges. The reference mutagen treatments (positive controls) showed the expected, biologically relevant increases in induced revertant colonies in all experimental phases in all tester strains. No biologically relevant increases were observed in revertant colony numbers of any of the five test strains following treatment with L-(+)-ergothioneine at any concentration level, either in the presence or absence of metabolic activation (S9 Mix) in the performed experiments. On the basis of the data reported, it can be concluded that L-(+)-ergothioneine did not induce gene mutations by base pair changes or frameshifts in the genome of the strains used. Thus L-(+)-ergothioneine has no mutagenic activity on the applied bacteria tester strains under the test conditions used in this study. Research is continuing to define the role of L-(+)-ergothioneine in disease pathophysiology. Further studies on its safety are suggested.

Journal of Vascular Surgery, 2005

Background. Homocysteine, a risk factor for atherosclerosis, increases intimal hyperplasia after ... more Background. Homocysteine, a risk factor for atherosclerosis, increases intimal hyperplasia after carotid endarterectomy with associated smooth muscle cell proliferation and modulation of cytokines. The N-methyl-D-aspartate receptor (NMDAr), a glutamate-gated ion channel receptor, is associated with homocysteine-induced cerebrovascular injury; however, the receptor has not been identified in peripheral vascular cells, nor has any interaction with homocysteine been clarified. Our objectives were first, to identify NMDAr in rat carotid artery and rat aorta endothelial cells (RAEC); and second, to determine whether homocysteine activates NMDAr in the endothelium. . NR1 and NR2A, two NMDAr subunits, were probed in rat carotid arteries by immunohistochemistry. RNA was isolated from RAECs, and expression of all NMDAr subunits (NR1, 2A, 2B, 2C, and 2D) were examined by RT-PCR and sequencing. For receptor protein expression, RAEC were incubated with different homocysteine concentrations and incubation times and also were treated with 50 M homocysteine and/or preincubated with 50 M dizocilpine MK-801, an NMDAr inhibitor. Results. Both NR1 and NR2A were expressed in rat carotid arteries. All NMDAr subunits were expressed in the RAECs, and there was 92% to 100% similarity compared with rat NMDAr from the National Center for Biotechnology Information (NCBI) GenBank. Homocysteine upregulated NR1 expression and increased cell proliferation. RAEC pretreatment with MK-801 reduced homocysteine-mediated cell proliferation. Conclusion. This study is the first to show that NMDAr exists in the peripheral vasculature, and that homocysteine may act via NMDAr to increase intimal hyperplasia. ( J Vasc Surg 2005;41:853-60.) Clinical Relevance: Our objectives included the identification of a homocysteine receptor in the peripheral vasculature. The possible inhibition of a homocysteine receptor to prevent intimal hyperplasia rather than treat established stenosis would make a significant clinical impact. This will open further avenues of study in determining the role of homocysteine in the pathogenesis of intimal hyperplasia.

The Journal of Thoracic and Cardiovascular Surgery, 2011

Objective: The minimally invasive, video-assisted thoracoscopic surgical (VATS) approach to resec... more Objective: The minimally invasive, video-assisted thoracoscopic surgical (VATS) approach to resection of the thymus is frequently practiced for benign disease; however, a VATS approach for thymoma remains controversial. The objective of the present study was to evaluate the feasibility of VATS thymectomy for the treatment of early-stage thymoma and to compare the outcomes with those after open resection. Methods: A retrospective review of 40 patients who underwent surgical resection of early-stage thymoma during a 12-year period was conducted. Data on patient characteristics, morbidity, recurrence, and survival were collected. The primary endpoint studied was overall survival. Results: Of the 40 patients, 14 underwent thymectomy for stage I and 26 for stage II thymoma; 19 were men and 21 were women (median age, 64 years; range, 35-86 years). Open thymectomy was performed in 22 patients, and VATS was performed in 18. The operative mortality rate was 0%. The tumor stage and number of patients undergoing adjuvant radiotherapy were comparable in both surgical groups. The median length of hospital stay was shorter in the VATS group (3 days) than in the open group (5 days) (P ¼ .0001). The median follow-up was 36 months. No significant differences were found in the estimated recurrence-free and overall 5-year survival rates (83%-100%) between the 2 groups. Conclusions: VATS of early-stage thymoma appears safe and feasible and was associated with a shorter hospital stay. The oncologic outcomes were comparable in the open and VATS groups during intermediate-term follow-up. Additional follow-up is required to evaluate the long-term results of thoracoscopic thymectomy for early-stage thymoma. (

JSLS : Journal of the Society of Laparoendoscopic Surgeons, 2009

Background: Aberrant gallbladder transposed to the left side is a rare congenital anomaly that ha... more Background: Aberrant gallbladder transposed to the left side is a rare congenital anomaly that has been seen in as many as 0.7% of the population. These gallbladders are situated under the left lobe of the liver between Segment III and IV and to the left of the falciform ligament. Many preoperative studies fail to identify the anomaly, causing confusion to the surgeon during laparoscopic resection. Selective use of intraoperative cholangiography and meticulous dissection can aid in safe resection. A 61-year-old female was admitted with ultrasound confirmation of cholecystitis and subsequently taken to the operating room for a laparoscopic cholecystectomy. Results: Evaluation of the gallbladder under laparoscopic view revealed an inflamed left aberrant gallbladder. An intraoperative cholangiogram was obtained to delineate the biliary anatomy that showed the cystic duct entering the common hepatic duct on the right side. A left aberrant gallbladder is a rare presentation that requires awareness of biliary anatomy and selective use of intraoperative cholangiography to aid in the safe laparoscopic resection of the gallbladder.

W1669 The Use of Alveolus Stents in the Treatment of Esophageal Leaks, Perforation or Fistulae

Gastroenterology, 2008

Gastroenterology, 2008

Background: Laparoscopic repair of giant paraesophageal hernias (LRGPEH) is increasingly utilized... more Background: Laparoscopic repair of giant paraesophageal hernias (LRGPEH) is increasingly utilized with excellent short-term results. Long-term (>60 months) clinical and radiographic results, however, are poorly described. Our objective was to evaluate the long term results after minimally invasive repair of GPEH. Methods: We performed a review of patients undergoing elective LRGPEH (1995LRGPEH ( to 2002) ) who had a minimum of 60-month clinical or radiographic follow-up. Clinical outcomes, barium swallow and quality-of-life measures were reviewed. Results: There were 256 patients who underwent LRGPEH in this time-period. A minimum of 60-month clinical or radiographic follow-up was available on 105 patients. Hernia reduction, sac excision, crural repair (13.7% mesh-reinforcement) and fundoplication were performed in 98%. A Collis-gastroplasty was performed in 89 patients (85%). Median time for clinical follow-up was 82 months (60-124). GERD-Health-Related-Quality-of-Life (GERD-HRQL) scores were available for 98 patients, with a mean 3.9 ±6 (median 1, range 0-23; 0=no symptoms-45= worst). Occasional heartburn and dysphagia to solids were the most common persistent symptoms in 30% of patients. According to the GERD-HRQL scale (excellent=0-5; good=6-10; fair=11-15; poor=16-45), the results were excellent to good in 86.8% of patients, confirming the mild nature of the symptoms. Barium-swallow was obtained in 79/105 (75%) at a median time of 80 months (60-126). Radiographic recurrence of a hiatal hernia was identified in 9 (11%). GERD-HRQL scores were excellent in 77% of patients with radiographic recurrence compared to 72% in patients without radiographic recurrence. When patients were queried regarding satisfaction with surgery, over 90% (83/90) were satisfied or very satisfied. Re-operation was required in 5 (4.7%) patients for symptomatic recurrence at a median 44 months post-operative (range 8-80). Conclusions: This report summarizes the long-term results (7 years) of LRGPEH in 105 patients. Reoperation was required for symptomatic recurrence in only 4.7%. The GERD-related quality of life was well preserved and 90% of patients were satisfied with their surgery.

Expert Review of Anticancer Therapy, 2008

The Annals of Thoracic Surgery, 2009

symptoms resulting from obstruction of the SVC or bilateral brachiocephalic veins [3]. Compressio... more symptoms resulting from obstruction of the SVC or bilateral brachiocephalic veins [3]. Compression of the SVC results in increased venous pressure in the upper extremities, upper chest, head, and neck. This may cause plethora or cyanosis, cerebral edema leading to headache, confusion, or coma, as well as laryngopharyngeal edema manifesting as cough, dyspnea, or dysphagia [3]. SVC syndrome may result from extrinsic compression, direct invasion, or thrombosis; malignancy, benign tumors, idiopathic fibrosing mediastinitis, sarcoidosis, and indwelling venous catheters are the most common causes [4]. Malignancies most commonly include nonsmall cell lung cancer (50%), small cell lung cancer (22%), lymphoma (12%), and metastatic disease (9%) [3]. The severity of the symptoms usually depends on the rapidity of onset and the degree of SVC compression [3]. Gradual narrowing of the SVC, particularly in association with a patent azygos vein, generally allows for the development of collateral venous drainage, with mild or no symptoms. Sudden SVC occlusion, however, can cause upper body edema, life-threatening neurologic changes, and respiratory failure. Depending on the underlying cause, SVC syndrome can be treated by a combination of the following therapies: medical management with anticoagulation, diuretics, and elevation of the upper body; radiation or chemotherapy, or both; surgical bypass, and SVC stenting [5]. For patients with SVC syndrome secondary to nonsmall cell lung cancer, radiation therapy and SVC stenting are the mainstays of treatment [6]. Tanigawa and colleagues [7] compared radiation and stenting in a nonrandomized study and found similar rates of symptom resolution for both treatments of 80% and 78%, respectively. Nicholson and colleagues [8] found that stent insertion provided faster relief and greater improvement of symptoms, as well as fewer recurrent symptoms vs radiation therapy. More recently, de Gregorio Ariza and colleagues [5] examined treatment of SVC syndrome with stenting in patients with malignant and benign causes. Clinical success was achieved in 95% of patients within 2 to 3 days. In 78 patients with malignancy, 96% assisted stent patency (4 required thrombolytics and 1 required restenting) was reported. This article reports the complication of tracheal and esophageal stenting leading to acute SVC syndrome. Two other reports of simultaneous tracheal and SVC stenting in patients with lung cancer causing tracheal compression and SVC syndrome have been published [4, 9]. In those patients, the obstructive symptoms developed slowly over time, and stenting alleviated the symptoms. In our patient, placement of dilating stents in both the esophagus and trachea occupied space in an already crowded mediastinum. The resulting critical compression of the SVC (and possibly the azygos-caval junction) resulted in increased intracranial pressure and depressed mental state. Stenting of the SVC is a wellaccepted treatment strategy for SVC syndrome and here resulted in rapid resolution of signs and symptoms.

The Annals of Thoracic Surgery, 2009

Objectives-Surgical resection is the preferred treatment in selected patients with pulmonary meta... more Objectives-Surgical resection is the preferred treatment in selected patients with pulmonary metastases. In high-risk patients, radiofrequency ablation (RFA) may offer an alternative option. RFA may be used either alone or in combination with surgical resection as a lung parenchymalsparing approach. Our objectives were to evaluate the intermediate term outcomes after RFA and to determine the prognostic variables associated with outcome in patients with pulmonary metastases Methods-Thoracic surgeons evaluated and performed RFA under computed-tomography (CT) guidance or in combination with surgical resection as a lung parenchymal-sparing modality. Patients were monitored in the thoracic surgery clinic for recurrence and survival. Results-Twenty-two patients {10 men, 12 women; median age 63 years (37-88)} underwent RFA. The primary cancer was colorectal in 9 (41%), renal in 2 (9%), sarcoma in 4 (18%) and other in 7 (32%) patients. CT-guided RFA was performed as a sole modality of treatment in 17 patients (77%), and in combination with surgical resection in 5 (23%) patients. There were no procedure-related mortalities. At a mean follow-up of 27 months (13.3-53.6 months), 9 patients are alive. The median survival was 29 months ). Size of the lesion was an important prognostic variable associated with overall and disease-free survival (P<0.05). Conclusions-Our experience indicates that RFA is safe in this group of pulmonary metastases patients with reasonable results. Surgery remains the standard for resectable patients, but RFA offers an alternative option in selected patients or may be used as a parenchymal-sparing approach in combination with surgical resection in selected patients.

Annals of Surgery, 2000

To summarize the authors' laparoscopic experience for paraesophageal hernia (PEH). Laparoscopic a... more To summarize the authors' laparoscopic experience for paraesophageal hernia (PEH). Laparoscopic antireflux surgery and repair of small hiatal hernias are now routinely performed. Repair of a giant PEH is more complex and requires conventional surgery in most centers. Giant PEH accounts for approximately 5% of all hiatal hernias. Medical management may be associated with a 50% progression of symptoms and a significant death rate. Conventional open surgery has a low death rate, but complications are significant and return to routine activities is delayed in this frequently elderly population. Recently, short-term outcome studies have reported that minimally invasive approaches to PEH may be associated with a lower complication rate, a shorter hospital stay, and faster recovery. From July 1995 to February 2000, 100 patients (median age 68) underwent laparoscopic repair of a giant PEH. Follow-up included heartburn scores and quality of life measurements using the SF-12 physical component and mental component summary scores. There were 8 type II hernias, 85 type III, and 7 type IV. Sac removal, crural repair, and antireflux procedures were performed (72 Nissen, 27 Collis-Nissen). The 30-day death rate was zero; there was one surgery-related death at 5 months from a perioperative stroke. Intraoperative complications included pneumothorax, esophageal perforation, and gastric perforation. There were three conversions to open surgery. Major postoperative complications included stroke, myocardial infarction, pulmonary emboli, adult respiratory distress syndrome, and repeat operations (two for abscess and one each for hematoma, repair leak, and recurrent hernia). Median length of stay was 2 days. Median follow-up at 12 months revealed resumption of proton pump inhibitors in 10 patients and one repeat operation for recurrence. The mean heartburn score was 2.3 (0, best; 45, worst); the satisfaction score was 91%; physical and mental component summary scores were 49 and 54, respectively (normal, 50).

Gastrointestinal Endoscopy, 2008

Background: EMR is an accepted treatment for early esophageal cancer and high-grade dysplasia. On... more Background: EMR is an accepted treatment for early esophageal cancer and high-grade dysplasia. One of the limitations of this technique is that extensive mucosal resection and endoscopic submucosal dissection may be required to obtain complete removal of the neoplasm, which may result in significant stricture formation. Objective: The objective of the current study was to evaluate the efficacy of an endoscopically deployed extracellular matrix (ECM) scaffold material for prevention of esophageal stenosis after circumferential EMR. Design: Ten mongrel dogs were subjected to surgical plane anesthesia and circumferential esophageal EMR by the cap technique. In 5 animals, an ECM scaffold material was endoscopically placed at the resection site; the remaining 5 animals were subjected to circumferential esophageal EMR without ECM placement. Follow-up endoscopy was performed at 4 and 8 weeks; necropsy with histologic assessment was performed at 8 weeks. Setting: Animal laboratory. Interventions: Circumferential esophageal EMR by the cap technique, followed by endoscopic placement of an ECM scaffold material. Main Outcome Measurements: Degree of esophageal stricture and histologic assessment of remodeled esophageal tissue. Results: All 5 control dogs had endoscopic evidence of esophageal stenosis. Three required early euthanasia because of inability to tolerate oral intake. Incomplete epithelialization and inflammation persisted at the EMR site in control animals. Endoscopic placement of an ECM scaffold material prevented clinically significant esophageal stenosis in all animals. Histologic assessment showed near-normal esophageal tissue with a lack of inflammation or scar tissue at 8 weeks. Conclusions: Endoscopic placement of an ECM scaffold material prevented esophageal stricture formation after circumferential EMR in this canine model during short-term observation.