Estimated Cost-effectiveness of Endoscopic Screening for Upper Gastrointestinal Tract Cancer in High-Risk Areas in China

IMPORTANCE

Upper gastrointestinal tract cancer, including esophageal and gastric cancers, in China accounts for 50% of the global burden. Endoscopic screening may be associated with a decreased incidence of and mortality from upper gastrointestinal tract cancer.

OBJECTIVE

To evaluate the cost-effectiveness of endoscopic screening for esophageal and gastric cancers among people aged 40 to 69 years in areas of China where the risk of these cancers is high.

DESIGN, SETTING, AND PARTICIPANTS

For this economic evaluation, a Markov model was constructed for initial screening at different ages from a health care system perspective, and 5 endoscopic screening strategies with different frequencies (once per lifetime and every 10 years, 5 years, 3 years, and 2 years) were evaluated. The study was conducted between January 1, 2019, and October 31, 2020. Model parameters were estimated based on this project, government documents, and published literature. For each initial screening age (40-44, 45-49, 50-54, 55-59, 60-64, and 65-69 years), a closed cohort of 100 000 participants was assumed to enter the model and follow the alternative strategies.

MAIN OUTCOMES AND MEASURES

Cost-effectiveness was measured by calculating the incremental cost-effectiveness ratio (ICER), and the willingness-to-pay threshold was assumed to be 3 times the per capita gross domestic product in China (US $10 276). Univariate and probabilistic sensitivity analyses were conducted to assess the robustness of model findings.

RESULTS

The study included a hypothetical cohort of 100 000 individuals aged 40 to 69 years. All 5 screening strategies were associated with improved effectiveness by 1087 to 10 362 quality-adjusted life-years (QALYs) and increased costs by US $3 299 000 to $22 826 000 compared with no screening over a lifetime, leading to ICERs of US $1343 to $3035 per QALY. Screening at a higher frequency was associated with an increase in QALYs and costs; ICERs for higher frequency screening compared with the next-lower frequency screening were between US $1087 and $4511 per QALY. Screening every 2 years would be the most cost-effective strategy, with probabilities of 90% to 98% at 3 times the per capita gross domestic product of China. The model was the most sensitive to utility scores of esophageal cancer- or gastric cancer-related health states and compliance with screening.

CONCLUSIONS AND RELEVANCE

The findings suggest that combined endoscopic screening for esophageal and gastric cancers may be cost-effective in areas of China where the risk of these cancers is high; screening every 2 years would be the optimal strategy. These data may be useful for development of policies targeting the prevention and control of upper gastrointestinal tract cancer in China.

Cost-Effectiveness of Screening, Surveillance, and Endoscopic Eradication Therapies for Managing the Burden of Esophageal Adenocarcinoma

The authors conducted a review of the literature of cost-effectiveness analyses regarding management of Barrett's esophagus, including screening, surveillance, and treatment strategies. Because of the presence of multiple systematic reviews on this topic, they chose to focus on more recent economic analyses, with an emphasis on comparative modeling because these analyses have been demonstrated to achieve greater validity and impact when there are multiple competing strategies that are clinically reasonable to pursue. The authors identified areas of consensus across studies regarding management strategies and also areas that require additional empirical data.

Advanced imaging in surveillance of Barrett’s esophagus: Is the juice worth the squeeze?

Esophageal cancer is on the rise. The known precursor lesion is Barrett’s esophagus (BE). Patients with dysplasia are at higher risk of developing esophageal cancer. Currently the gold standard for surveillance endoscopy involves taking targeted biopsies of abnormal areas as well as random biopsies every 1-2 cm of the length of the Barrett’s. Unfortunately studies have shown that this surveillance can miss dysplasia and cancer. Advanced imaging technologies have been developed that may help detect dysplasia in BE. This opinion review discusses advanced imaging in BE surveillance endoscopy and its utility in clinical practice.

Endoscopic therapy and surveillance versus esophagectomy for early esophageal adenocarcinoma: A review of early outcomes and cost analysis

BACKGROUND

Endoscopic therapy is considered to be comparable to esophagectomy with respect to oncologic outcomes in early (cT1) esophageal adenocarcinoma (EC). The current study aims to compare early outcomes and financial costs, associated with endoscopic versus surgical therapy for early esophageal adenocarcinoma.

METHODS

Retrospective review of patients undergoing either endoscopic or surgical therapy for cT1 EC between 2010 and 2015.

RESULTS

Age, BMI, and Charlson Comorbidity Scores were similar in patients undergoing endoscopic therapy (N = 20) and esophagectomy (N = 23). For patients undergoing endoscopic therapy a median of 6 endoscopic interventions, were performed per patient (range 2-18). Esophagectomy was associated with a median hospital stay of 9 (8-13) days and greater procedure specific morbidity compared to endoscopic therapy. Costs related to endoscopic therapy were significantly lower compared to esophagectomy ($22,640 vs. $53,849, P < 0.001).

CONCLUSIONS

Endoscopic treatment is associated with decreased morbidity and financial costs when compared to esophagectomy.

Estimation of Cost for Endoscopic Screening for Esophageal Cancer in a High-Risk Population in Rural China: Results from a Population-Level Randomized Controlled Trial

BACKGROUND AND OBJECTIVE

Population-level endoscopic screening for esophageal cancer has been conducted in China for years. In this study, we aim to provide an updated and precise cost estimation for esophageal cancer screening based on a randomized controlled trial in a high-risk area in China.

METHODS

We estimated the cost of esophageal cancer screening with chromoendoscopy using a micro-costing approach based on primary data of the ESECC (Endoscopic Screening for Esophageal Cancer in China) randomized controlled trial (NCT01688908) from a health sector perspective. Unit costs and quantities of resources were collected to obtain annual screening costs. The screening project was then theoretically expanded to a 10-year period to explore long-term trends of costs. Costs were adjusted to US dollars for the year 2018.

RESULTS

In the ESECC trial, screening cost per endoscopy with a valid pathologic diagnosis was $196, accounting for 3.82% of the gross domestic product per capita in Hua County, and the costs for detecting one esophageal cancer and one early-stage esophageal cancer were $26,347 and $37,687, respectively. In conventional screening in which protocol-driven costs were excluded, costs as above were $134, $18,074, and $25,853. The cost for detecting one gastric cardia cancer or stomach cancer was nine times higher than detecting one esophageal cancer owing to low prevalences of the two cancers. In a simulated 10-year screening project, annual cost decreased notably over time.

CONCLUSIONS

Despite the relatively low absolute cost, population-level endoscopic screening will still be a heavy burden on local government considering the socioeconomic conditions. Long-lasting programs would be less costly and population-level screening would make little sense in non-high-risk regions.

Economic value of narrow-band imaging versus white light endoscopy for the diagnosis and surveillance of Barrett's esophagus: Cost-consequence model

Barrett’s esophagus (BE) is an abnormality arising from gastroesophageal reflux disease that can progressively evolve into a sequence of dysplasia and adenocarcinoma. Progression of Barrett’s esophagus into dysplasia is monitored with endoscopic surveillance. The current surveillance standard requests random biopsies plus targeted biopsies of suspicious lesions under white-light endoscopy, known as the Seattle protocol. Recently, published evidence has shown that narrow-band imaging (NBI) can guide targeted biopsies to identify dysplasia and reduce the need for random biopsies. We aimed to assess the health economic implications of adopting NBI-guided targeted biopsy vs. the Seattle protocol from a National Health Service England perspective. A decision tree model was developed to undertake a cost-consequence analysis. The model estimated total costs (i.e. staff and overheads; histopathology; adverse events; capital equipment) and clinical implications of monitoring a cohort of patients with known/suspected BE, on an annual basis. In the simulation, BE patients (N = 161,657 at Year 1; estimated annual increase: +20%) entered the model every year and underwent esophageal endoscopy. After 7 years, the adoption of NBI with targeted biopsies resulted in cost reduction of £458.0 mln vs. HD-WLE with random biopsies (overall costs: £1,966.2 mln and £2,424.2 mln, respectively). The incremental investment on capital equipment to upgrade hospitals with NBI (+£68.3 mln) was offset by savings due to the reduction of histological examinations (-£505.2 mln). Reduction of biopsies also determined savings for avoided adverse events (-£21.1 mln). In the base-case analysis, the two techniques had the same accuracy (number of correctly identified cases: 1.934 mln), but NBI was safer than HD-WLE. Budget impact analysis and cost-effectiveness analyses confirmed the findings of the cost-consequence analysis. In conclusion, NBI-guided targeted biopsies was a cost-saving strategy for NHS England, compared to current practice for detection of dysplasia in patients with BE, whilst maintaining at least comparable health outcomes for patients.

Cost analysis of office-based transnasal esophagoscopy

Purpose

Although office-based transnasal esophagoscopy has been investigated extensively, a cost analysis is still lacking. We performed a cost analysis combined with feasibility study for two diagnostic processes: patients with globus pharyngeus and/or dysphagia, and hypopharyngeal carcinoma.

Methods

Prospective cohort study.

Results

Forty-one procedures were performed, of which 35 were fully completed. The procedure was well tolerated with mild complaints such as nasal or pharyngeal pain and burping. Four complications occurred: two minor epistaxis and two vasovagal reactions. In patients with globus pharyngeus and/or dysphagia, transnasal esophagoscopy resulted in a cost saving of €94.43 (p 0.026) per procedure, compared to our regular diagnostic process. In patients with suspicion of hypopharyngeal carcinoma, cost savings were €831.41 (p 0.000) per case.

Conclusions

Cost analysis showed that office-based transnasal esophagoscopy can provide significant cost savings for the current standard of care. Furthermore, this procedure resulted in good patient acceptability and few complications.

Barrett’s oesophagus: Current controversies

Oesophageal adenocarcinoma is rapidly increasing in Western countries. This tumour frequently presents late in its course with metastatic disease and has a very poor prognosis. Barrett’s oesophagus is an acquired condition whereby the native squamous mucosa of the lower oesophagus is replaced by columnar epithelium following prolonged gastro-oesophageal reflux and is the recognised precursor lesion for oesophageal adenocarcinoma. There are multiple national and society guidelines regarding screening, surveillance and management of Barrett’s oesophagus, however all are limited regarding a clear evidence base for a well-demonstrated benefit and cost-effectiveness of surveillance, and robust risk stratification for patients to best use resources. Currently the accepted risk factors upon which surveillance intervals and interventions are based are Barrett’s segment length and histological interpretation of the systematic biopsies. Further patient risk factors including other demographic features, smoking, gender, obesity, ethnicity, patient age, biomarkers and endoscopic adjuncts remain under consideration and are discussed in full. Recent evidence has been published to support earlier endoscopic intervention by means of ablation of the metaplastic Barrett’s segment when the earliest signs of dysplasia are detected. Further work should concentrate on establishing better risk stratification and primary and secondary preventative strategies to reduce the risk of adenocarcinoma of the oesophagus.

Healthcare Cost of Over-Diagnosis of Low-Grade Dysplasia in Barrett's Esophagus

INTRODUCTION

Published reports have demonstrated that many Barrett's esophagus patients are over-diagnosed as low-grade dysplasia (BE-LGD). We performed an analysis of the surveillance and treatment costs associated with the over-diagnosis of BE-LGD.

METHODS

As the principal cost variables, we used endoscopic and histologic procedures performed during the recommended surveillance intervals for patients with BE-LGD, the national average Medicare reimbursement for the Current Procedural Terminology codes of the procedures performed, and a spreadsheet-based tool we created to determine the overall healthcare cost associated with the over-diagnosis of BE-LGD in the US population.

RESULTS

The average excess cost (range) for every patient in the US who is over-diagnosed with BE-LGD is estimated to be $5557 ($3115 to $8072). The principal contributors to the excess cost of over-diagnosis of BE-LGD in these patients are: endoscopy ($2626 to $4639), pathologist biopsy review ($275 to $2185), and esophagogastroduodenoscopy-guided endoscopic ablation ($214 to $1249).

CONCLUSIONS

The healthcare cost of over-diagnosis of BE-LGD is significant. To reduce the overall healthcare cost impact of over-diagnosis of BE-LGD, strict adherence to the recommendations of the American Gastroenterological Association, American College of Gastroenterology, and American Society for Gastrointestinal Endoscopy that pathology review of all BE biopsy specimens be performed by a gastrointestinal pathologist is warranted.

Glucagon Is a Safe and Inexpensive Initial Strategy in Esophageal Food Bolus Impaction

BACKGROUND

Controversy exists about the utility of pharmacologic agents and endoscopic technique used for esophageal food bolus impaction.

AIM

To evaluate the utility of glucagon and the technique used for endoscopic removal, including the rate of success and the adverse events of the techniques.

METHODS

The database of the largest healthcare provider in southeastern Wisconsin was retrospectively reviewed for patients presenting with esophageal food bolus impaction. Data extracted included glucagon administration and its success rate, outcome of radiographic studies, and the endoscopic method of removal and adverse events associated with it, including 30-day mortality.

RESULTS

A total of 750 patients were identified with food bolus impaction from 2007 to 2012. Glucagon was administered in 440 patients and was successful in 174 (39.5%). Endoscopic removal was performed in 470 patients and was successful in 469 (99.8%). The push technique was utilized in 209 patients, reduction in the bolus size by piecemeal removal followed by the push technique was utilized in 97 patients, and the pull technique was utilized in 107 patients. There were no perforations with endoscopic removal. Only 4.5% of the X-rays performed reported a possible foreign body within the esophagus. Glucagon was a significantly less-expensive strategy than endoscopic therapy (p < 0.0001).

CONCLUSION

Glucagon is low cost, is moderately effective, and may be considered as an initial strategy. Endoscopic removal regardless of technique is safe and effective. The yield of radiography is poor in the setting of food bolus impaction.

[Cost-effectiveness analysis of esophageal cancer once-in-a-lifetime endoscopic screening in high-risk areas of rural China]

OBJECTIVE

To estimate the cost-effectiveness of esophageal cancer endoscopic screening once-in-a-lifetime and to predict the optimal screening age for people in high-risk areas of rural China.

METHODS

A Markov model was constructed to predict and compare the effect of four esophageal cancer endoscopic screening modalities which varied with different screening ages. Long-term epidemiological effectiveness and cost-effectiveness were predicted by simulation of the model.

RESULTS

Compared with the control group, strategies starting at 40, 45, 50 and 55 year-old had saved life-years of 629.51, 769.88, 738.98 and 533.21 years per 100 000 people, respectively, of which the strategy starting at 45 year-old saved the maximum life years. All strategies were cost-effective and starting at 40 year-old cost the most per life-year saved. Among all alternatives, strategies starting age at 45 year-old and 50 year-old were incremental cost-effective, and the incremental cost-effective ratios were 34 962.87 and 3 346.43 RMB per life year saved, respectively.

CONCLUSIONS

The strategy starting at 40 year-old implemented at present and other strategies were cost-effective in high-risk areas of rural China. However, the 45-year-old group is more aligned with the principle of cost-effectiveness. Considering the cost-effectiveness of different strategies and social economic status, 45 year-old is regarded as the optimal starting age of esophageal cancer once-in-a-lifetime endoscopic screening and is recommended in areas lacking health resources. The strategy of starting age at 40 year-old which could obtain better screening effects would be preferable in wealthy regions.

High-resolution microendoscopy for esophageal cancer screening in China: A cost-effectiveness analysis

AIM

To study the cost-effectiveness of high-resolution microendoscopy (HRME) in an esophageal squamous cell carcinoma (ESCC) screening program in China.

METHODS

A decision analytic Markov model of ESCC was developed. Separate model analyses were conducted for cohorts consisting of an average-risk population or a high-risk population in China. Hypothetical 50-year-old individuals were followed until age 80 or death. We compared three different strategies for both cohorts: (1) no screening; (2) standard endoscopic screening with Lugol's iodine staining; and (3) endoscopic screening with Lugol's iodine staining and an HRME. Model parameters were estimated from the literature as well as from GLOBOCAN, the Cancer Incidence and Mortality Worldwide cancer database. Health states in the model included non-neoplasia, mild dysplasia, moderate dysplasia, high-grade dysplasia, intramucosal carcinoma, operable cancer, inoperable cancer, and death. Separate ESCC incidence transition rates were generated for the average-risk and high-risk populations. Costs in Chinese currency were converted to international dollars (I$) and were adjusted to 2012 dollars using the Consumer Price Index.

RESULTS

The main outcome measurements for this study were quality-adjusted life years (QALYs) and incremental cost-effectiveness ratio (ICER). For the average-risk population, the HRME screening strategy produced 0.043 more QALYs than the no screening strategy at an additional cost of I$646, resulting in an ICER of I$11808 per QALY gained. Standard endoscopic screening was weakly dominated. Among the high-risk population, when the HRME screening strategy was compared with the standard screening strategy, the ICER was I$8173 per QALY. For both the high-risk and average-risk screening populations, the HRME screening strategy appeared to be the most cost-effective strategy, producing ICERs below the willingness-to-pay threshold, I$23500 per QALY. One-way sensitivity analysis showed that, for the average-risk population, higher specificity of Lugol's iodine (> 40%) and lower specificity of HRME (< 70%) could make Lugol's iodine screening cost-effective. For the high-risk population, the results of the model were not substantially affected by varying the follow-up rate after Lugol's iodine screening, Lugol's iodine test characteristics (sensitivity and specificity), or HRME specificity.

CONCLUSION

The incorporation of HRME into an ESCC screening program could be cost-effective in China. Larger studies of HRME performance are needed to confirm these findings.

Novel low-cost endoscopic cap for esophageal foreign objects: a case report

A 57-year-old man presented to the hospital because of swallowing of a small marble precipitated by a hallucination. He subsequently developed chest discomfort. He had a history of psychiatric problem and an esophageal corrosive injury complicated by stricture of the middle esophagus.This report describes the novel idea of endoscopic intervention for the retrieval of an esophageal foreign body. Its inventiveness and the use of limited resources, by adapting a 30-mm aseptic common tubing into an endoscopic retrieving device, make the method novel. This novel low-cost endoscopic cap (NLCEC) was adapted to 25 mm of the front end of the endoscope, with 5 mm maintained for the soft part to prevent esophageal mucosal injury during the retrieval process. An 8-mm green marble was found impacted in the esophagus 32 cm from the incisors. The use of forced suction allowed for the successful retrieval of the marble within minutes. The patient had an uneventful recovery without any serious complications.This NLCEC may be a viable and safe tool for the endoscopic retrieval of esophageal foreign objects without general anesthesia. This innovative design is beneficial in terms of patient safety, easy preparation, and low cost.

Resource utilization patterns of pediatric esophageal foreign bodies

BACKGROUND

Ingested foreign bodies are a frequent presentation in pediatric emergency departments. Although some pass spontaneously through the gastrointestinal tract, the majority of esophageal-ingested foreign bodies (EFB) require removal.

MATERIALS AND METHODS

Kids' Inpatient Database (1997-2009) was used to identify children (aged <20 y) with EFB (International Classification of Diseases, Ninth Revision, Clinical Modification code 935.1). Multivariate logistic regression analyses were constructed to identify predictors of resource utilization.

RESULTS

Overall, 14,767 EFB cases were identified. Most patients were <5 y of age (72%), boys (57%), and non-Caucasian (55%), with a median (interquartile range) length of stay (LOS) of 1 (1) d, and total charges of $11,003 (8503). A total of 11,180 procedures were performed, most commonly esophagoscopy (77%), followed by bronchoscopy (20%), gastroscopy (2%), and rarely surgery (0.8%). By multivariate logistic regression, increased total charges were associated with a diagnosis of esophageal ulceration (odds ratio [OR] = 1.57), esophagoscopy (OR = 1.42), and bronchoscopy (OR = 1.62), all P < 0.001. Total charges also increased with admission to urban nonteaching hospitals (OR = 1.51) versus urban teaching hospitals, P < 0.001. Prolonged LOS (≥1 d) was associated with admission to a hospital in the Midwest (OR = 3.18) and with esophageal ulceration (OR = 2.11) and esophagoscopy (OR = 1.13), P < 0.03. Boys had higher odds of longer hospitalization (OR = 1.21), P < 0.001. Overall hospital mortality was 0.1% (n = 16).

CONCLUSIONS

Most EFB occur in children <5 y of age. Esophageal ulceration, esophagoscopy, and bronchoscopy are associated with increased total charges. Esophageal ulceration, esophagoscopy, and boys are associated with an increased LOS. Surgery and hospital mortality are both extremely rare in children with EFB.

Modeling the cost-effectiveness of strategies for treating esophageal adenocarcinoma and high-grade dysplasia

OBJECTIVE

This study aims to synthesize cost and health outcomes for current treatment pathways for esophageal adenocarcinoma and high-grade dysplasia (HGD) and to model comparative net clinical and economic benefits of alternative management scenarios.

METHODS

A decision-analytic model of real-world practices for esophageal adenocarcinoma treatment by tumor stage was constructed and validated. The model synthesized treatment probabilities, survival, quality of life, and resource use extracted from epidemiological datasets, published literature, and expert opinion. Comparative analyses between current practice and five hypothetical scenarios for modified treatment were undertaken.

RESULTS

Over 5 years, outcomes across T stage ranged from 4.06 quality-adjusted life-years and costs of $3,179 for HGD to 1.62 quality-adjusted life-years and costs of $50,226 for stage T4. Greater use of endoscopic mucosal resection for stage T1 and measures to reduce esophagectomy mortality to 0-3 % produced modest gains, whereas a 20 % reduction in the proportion of patients presenting at stage T3 produced large incremental net benefits of $4,971 (95 % interval, $1,560-8,368).

CONCLUSION

These findings support measures that promote earlier diagnosis, such as developing risk assessment processes or endoscopic surveillance of Barrett's esophagus. Incremental net monetary benefits for other strategies are relatively small in comparison to predicted gains from early detection strategies.

Timely confirmation of gastro-esophageal reflux disease via pH monitoring: estimating budget impact on managed care organizations

BACKGROUND

Current guidelines recommend the use of pH monitoring to confirm the diagnosis of acid reflux in patients with a normal endoscopy. This analysis evaluated the financial impact of pH monitoring with the wireless pH capsule on a managed care organization (MCO) in the United States.

METHODS

A decision model was constructed to project total 1-year costs to manage GERD symptoms with and without the adoption of wireless pH capsules in a hypothetical MCO with 10 000 eligible adult enrollees, of whom 600 presented with GERD-like symptoms. Costs of GERD diagnosis, treatment, and symptom management for those in whom a GERD diagnosis was ruled out by pH monitoring were assessed. The incremental per-member-per-month (PMPM) and per-treated-member-per-month (PTMPM) costs were the primary outcomes. Data sources included literature, expert input, and standardized fee schedules.

RESULTS

An increase of 10 percentage points in the use of pH monitoring with wireless pH capsules yielded incremental PMPM and PTMPM costs of $0.029 and $0.481, respectively. The costs of proton pump inhibitor (PPI) therapy to the plan dropped to $236,363 from $238,086, while increases were observed in pH monitoring (from $16 739 to $21 973) and non-GERD therapy costs (from $1392 to $1740). The results were sensitive to the percentage of patients requiring repeat endoscopy before wireless pH monitoring and the cost of PPIs.

CONCLUSIONS

Timely and increased use of pH monitoring as recommended in published guidelines leads to less unnecessary use of PPIs with a modest budgetary impact on health plans.

Cost-effective diagnosis of ingested foreign bodies

OBJECTIVES

To compare the cost effectiveness of plain film radiography, computed tomography (CT), and endoscopy as initial diagnostic modalities in adult patients complaining of retained ingested foreign bodies.

DESIGN

A systematic literature review was conducted to determine key statistics for the analysis, such as prevalence of disease, prevalence of complications, and the sensitivity and specificity of each diagnostic modality. Costs were estimated using 2006 Medicare reimbursement for hospital and professional fees. A deterministic cost-effectiveness analysis was then conducted using decision analysis software and a decision tree model to evaluate the various diagnostic strategies. After identifying initial results, we also performed sensitivity and threshold analysis to assess the strength of the recommendations.

RESULTS

We reviewed 316 abstracts, identified 16 pertinent studies that included a total of 7,088 patients with possible foreign bodies, and extracted key statistics from those papers. Decision analysis showed that CT scanning as an initial diagnostic strategy proved more cost effective than plain film or operative endoscopy. The incremental cost of immediate endoscopy for every additional correctly diagnosed patient was $5,238. Plain radiography was more costly and less effective, even with the addition of confirmatory CT scanning after a negative plain film. Sensitivity and threshold analyses demonstrated that these results are robust.

CONCLUSIONS

Patients presenting with a complaint of a retained ingested foreign body are most cost-effectively managed with CT scan, after history and physical. Immediate endoscopy may be considered if CT is not available, although it adds significant cost. Plain films are dominated by these two diagnostic strategies.

Health economic evaluation of therapeutic strategies in patients with idiopathic achalasia: results of a randomized trial comparing pneumatic dilatation with laparoscopic cardiomyotomy

BACKGROUND

We have prospectively collected information concerning the costs incurred during the management of patients allocated to either forceful dilatation or to an immediate laparoscopic operation because of newly diagnosed achalasia.

METHODS

Fifty-one patients with newly diagnosed achalasia were randomized to either pneumatic dilatation to a diameter of 30-40 mm or to a laparoscopic myotomy to which was added a posterior partial fundoplication. Follow-ups were scheduled at 1, 3, 6, and 12 months after inclusion. At each follow-up visit a study nurse interviewed the patients regarding symptoms and their quality of life (QoL) and a health economic questionnaire was completed. In the latter questionnaire, patients were asked to report the presence and character of contacts with the healthcare system since the last visit.

RESULTS

In the dilatation group six patients (23%), including the patient who was operated on because of perforation, were classified as failures during the first 12 months of follow-up compared to one (4%) in the myotomy group (p = 0.047). Five of those classified as failures in the dilatation group subsequently had a surgical myotomy and the sixth patient was treated with repeated dilatations. The patient classified as failure in the myotomy group was treated with endoscopic dilatation. The initial treatment cost and the total costs were significantly higher for laparoscopic myotomy compared to a pneumatic dilatation-based strategy (p = 0.0002 and p = 0.0019, respectively). When the total costs were subdivided into the different resources used, we found that the single largest cost item for pneumatic dilatation was that for hospital stay and that for laparoscopic myotomy was the actual operative treatment (operating room time). The cost-effectiveness analysis, relating to the actual treatment failures, revealed that the cost to avoid one treatment failure (incremental cost-effectiveness ratio) amounted to 9239 euros.

CONCLUSION

The current prospective, controlled clinical trial shows that despite a higher level of clinical efficacy of laparoscopic myotomy to prevent treatment failure in newly diagnosed achalasia, the cost effectiveness of pneumatic dilatation is superior, at least when a reasonable time horizon is applied.

The cost of laparoscopic myotomy versus pneumatic dilatation for esophageal achalasia

BACKGROUND

The two main treatment options for esophageal achalasia are laparoscopic distal esophageal myotomy (LM) and pneumatic dilatation (PD). Our objective was to compare the costs of these management strategies.

METHODS

We constructed a decision analytic model consisting of two treatment strategies for patients diagnosed with achalasia. Probabilities of events were systematically derived from a literature review, supplemented by expert opinion when necessary. Costs were estimated from the perspective of a third-party payer and society, including both direct and indirect costs. Future costs were discounted at a rate of 5.5% over a time horizon of 5 and 10 years. Uncertainty in the probability estimates was incorporated using probabilistic sensitivity analyses. We tested uncertainty in the model by modifying key assumptions and repeating the analysis.

RESULTS

From the societal perspective, the expected cost per patient was $10,789 (LM) compared with $5,315 (PD) five years following diagnosis, and $11,804 (LM) compared with $7,717 (PD) after 10 years. The 95% confidence interval of the incremental cost per patient treated with LM was ($5,280, $5,668) after five years, and ($3,863, $4,311) after 10 years. The incremental cost of LM was similar from the third-party payer perspective and in the secondary model analyzed.

CONCLUSIONS

Initial LM is a more costly management strategy under all clinically plausible scenarios tested in this model. Further research is needed to determine patients' preferences for the two treatment modalities, and society's willingness to bear the incremental cost of LM for those who choose it.

Bougienage versus endoscopy for esophageal coin removal in children

BACKGROUND

Foreign body ingestion is a common pediatric problem. Coins are by far the most common ingested foreign bodies. When ingested coins become lodged in the esophagus, they may cause serious complications if they are not removed in a timely manner. Endoscopic removal is the preferred treatment in many pediatric centers as its safety and effectiveness are well established.

OBJECTIVES

We performed this study to evaluate safety and effectiveness of an alternative method of managing esophageal coins, using bougienage technique.

METHODS

Previously healthy children presenting to the local emergency room with uncomplicated, witnessed coin ingestion of less than 24 hours duration were prospectively recruited with an intent-to-treat analysis. A single oral passage of a Hurst bougie dilator was performed by a gastroenterologist to dislodge the esophageal coin into the stomach. If bougienage was successful (x-ray showing coin in the stomach), patients were discharged and instructions were given for monitoring stools until passage of the coin through anus was confirmed. If bougienage was unsuccessful, the child developed symptoms at any time or if a coin remained intragastric for 4 weeks, endoscopic removal was planned. Children whose parents declined to participate in the bougienage treatment received the standard endoscopic removal and their hospital records were used as controls.

RESULTS

A total of 10 children were enrolled in this study, with a mean age of 3.2 years (11 mo to 10 y), 6 boys and 4 girls. All received little or no sedation. Nine children (90%) were successfully treated using bougienage, all of whom spontaneously passed the ingested coins, with a mean duration of 2.6 days (1 to 7 d) without subsequent intervention. A single case failed bougienage and underwent endoscopic removal. Three children declined bougienage treatment and underwent endoscopic removal. There were no reported minor or major adverse events with any of our cases. The mean health care cost for the hospital visit for bougienage treatment was $1210, compared with $3100 for the endoscopic removal (P<0.001). Furthermore, the mean time spent in the hospital from diagnosis to discharge was 2 hours for bougienage-treated patients compared with 8 hours for endoscopic treatment (P<0.001).

CONCLUSIONS

Bougienage of impacted esophageal coins is an effective, safe, and more economic treatment modality for selected pediatric patients with uncomplicated coin ingestion. This simple technique may provide a valuable tool to emergency room physicians or primary care doctors especially when endoscopy is not readily available.

Cost-benefit analysis of capsule endoscopy compared with standard upper endoscopy for the detection of Barrett's esophagus

BACKGROUND & AIMS

Esophageal capsule endoscopy (ECE) is a promising new technology for the detection of esophageal pathology. Potential advantages for Barrett's esophagus (BE) screening include ability to return to work as a result of lack of intravenous sedation.

METHODS

We designed a Markov model to compare lifetime costs and life expectancy for a cohort of 50-year old men with chronic GERD for the presence of BE. We compared the base-case strategy of no screening for BE to 2 competing screening strategies: (1) ECE followed by upper endoscopy (EGD) if BE were suspected or if there was poor visualization on the ECE; and (2) standard sedated EGD with biopsy. Cost estimates were obtained from a third-party payer perspective. For each strategy we determined lifetime costs, life-years gained, numbers of esophageal cancers detected, death rates from esophageal cancer, and procedural deaths.

RESULTS

Initial EGD was more expensive but more effective compared with the no screening strategy. Assuming a theoretical cohort of 10,000 patients with GERD, initial EGD cost $1988 and was associated with 18.54 life-years compared with $2392 and 18.36 life-years for the ECE arm and $901 and 18.30 life-years for the no screening arm. The incremental cost-effectiveness ratio of screening with EGD compared with the no screening arm was $4530 per life-year gained. The model was robust to a wide range of sensitivity analyses.

CONCLUSIONS

Initial EGD appears more effective and less costly compared with ECE under base-case conditions for patients with chronic GERD undergoing screening for BE.

Cost utility of screening for Barrett's esophagus with esophageal capsule endoscopy versus conventional upper endoscopy

BACKGROUND & AIMS

Screening for Barrett's esophagus with conventional esophagoduodenoscopy (EGD) is recommended to decrease mortality from esophageal adenocarcinoma. Esophageal capsule endoscopy (ECE) has recently been shown to be accurate in detecting Barrett's esophagus. We aimed to compare the cost-effectiveness of screening by ECE with screening by EGD.

METHODS

A Markov model of 50-year-old white men with symptoms of gastroesophageal reflux was constructed to compare screening modalities. The model incorporated direct medical costs and indirect costs of lost productivity and followed the patients until age 80 years or death. Outcomes were analyzed from the societal perspective.

RESULTS

EGD screening prevented 60% of cancer deaths at a cost of $11,254 per quality-adjusted life year gained compared with no screening. ECE prevented 53% of cancer deaths and provided 9 fewer quality-adjusted days at greater cost than EGD. If society were only willing to pay $50,000 per quality-adjusted life year gained, then capsule screening would be preferred if the income of the patient and driver were each greater than $280,682. Otherwise, the findings were robust to all sensitivity analyses.

CONCLUSIONS

Screening for Barrett's esophagus with either EGD or ECE results in similar outcomes, but EGD is the preferred strategy. Both strategies appear cost-effective, and the model does not take into account patient preferences for screening modality or adherence.

How we do it: transnasal fibreoptic oesophagoscopy

KEYPOINTS: Transnasal fibreoptic oesophagoscopy (TFO) allows the upper aerodigestive tract, from the nasal vestibule to the gastric cardia to be examined in the outpatients department without sedation. This permits patients with symptoms of upper aerodigestive pathology to be investigated at the initial consultation without the need for inpatient endoscopy or swallow studies. The technique is easily learned, and is statistically comparable with standard flexible nasoendoscopy in respect of procedural pain and discomfort. It is highly cost-efficient, paying for itself within 1 year, and thereafter leading to cost savings of over 80%. Its role can be expanded to encompass investigating patients with potentially malignant disease processes, as well as outpatients "panendoscopy" and biopsy, and a number of therapeutic interventions.

Pretreatment endoscopy--pro & contra: is endoscopy needed before treatment in all patients with gastroesophageal reflux disease?

The role of endoscopy in reflux disease has changed from being primarily diagnostic to one of risk management. Objective studies of routine endoscopy have shown little change in outcomes after the examination. Screening and surveillance for Barrett's esophagus is still an unconfirmed strategy. In most developed countries, including western Europe and North America, middle-aged patients (over the age of 50) with gastroesophageal reflux disease would benefit more from colonoscopy than upper endoscopy.

CPT coding for upper airway endoscopies

The Spring issue (Rudy, 2005) of ORL-Head and Neck Nursing presented a broad review of endoscopic procedures for evaluation and management of upper airway problems. Zarnitz (2005) briefly addressed billing for the most commonly performed upper airway endoscopies in that issue. This paper presents, in detail, the coding for a wider range of upper airway endoscopies performed in the office setting, along with how to report them to third-party payors.

[Recommended endoscopic surveillance of patients with Barrett's esophagus (BE) is a cost-effective strategy?]

OBJECTIVE

Evaluate the cost-effectiveness of the American College of Gastroenterology (ACG) guidelines for the surveillance of Barrett's esophagus (BE) in the context of a Mexican cohort of patients with BE and no dysplasia.

BACKGROUND

For patients with BE and no dysplasia, the ACG has recommended endoscopic surveillance every three years. The cost-benefit of this strategy has been evaluated in populations with an annual incidence of esophageal adenocarcinoma (EA) of 1%-5%.

METHODS

Demographic, clinical, surveillance and disease progression characteristics were analysed in patients with BE and no dysplasia seen at a terciary care center. Four surveillance strategies were considered, namely endoscopy every one, two, three and four years. Direct medical cost of endoscopy was dollar 2,950.00 Mexican pesos (dollar 256.52 USD). Total costs, cost-effectiveness ratios and marginal costs were determined assuming a cohort of 100 BE patients followed for a period of 10 years.

RESULTS

A cohort of 185 BE patients was incepted, with a male:female ratio of 1.28:1, mean age of 55.14 years and mean follow-up of 7.1 years. Annual progression rate from no dysplasia to high grade dysplasia and AE was 0.30%. The lowest cost-effectiveness ratio was observed with endoscopic surveillance every five years, with a cost of dollar 202,913.86 Mexican pesos (dollar 17,644.68 USD) per high grade dysplasia and AE diagnosed.

CONCLUSIONS

In Mexican patients with BE and no dysplasia, progression to high grade dysplasia and AE is lower than reported. This makes the performance of endoscopy every five years a more cost-effective surveillance strategy in our environment.

The rationale for screening and surveillance of Barrett's metaplasia

Oesophageal adenocarcinoma is a rare cancer; however, it is the most rapidly increasing cancer in the western world. Barrett's oesophagus is the only recognised precursor and is associated with the majority of cases of adenocarcinoma. The role of screening and surveillance in patients with Barrett's oesophagus remains controversial. There is insufficient evidence to show that screening improves survival and is cost-effective. Indirect evidence suggests that patients diagnosed with cancer while undergoing surveillance endoscopy are diagnosed at an earlier stage and have an improved survival. The problems with current surveillance techniques include lack of data on natural history of Barrett's oesophagus, test invasiveness, costs, lack of standardisation and validation of biopsy and treatment protocols, and endoscopy intervals. The use of novel endoscopic techniques and biomarkers combined with better identification of high-risk groups could make screening and surveillance a cost-effective practice in the future.

Barrett’s Esophagus: Diagnostic Approaches and Surveillance

In an effort to identify those patients at risk for developing esophageal adenocarcinoma, the American College of Gastroenterology recommends screening endoscopy in patients with chronic gastroesophageal reflux disease. Surveillance endoscopy is recommended every 3 years in those patients without dysplasia. For those patients with verified low-grade dysplasia, yearly surveillance endoscopy is recommended. In the case of high-grade dysplasia (HGD), either intensive endoscopic surveillance (focal HGD) or ablation/resection can be performed (multifocal HGD). Both observational and cost-effectiveness analyses suggest a potential benefit of endoscopic screening and surveillance, though these findings remain to be validated in controlled clinical trials. The development of new endoscopic imaging modalities may enhance the yield of biopsies obtained during screening and surveillance regimens.

Are screening and surveillance for Barrett's oesophagus really worthwhile?

Oesophageal adenocarcinoma has a low incidence and still remains an uncommon cancer; however, it has been on the rise over the past 20 years. Barrett's oesophagus, a complication of gastro-oesophageal reflux disease, is the only known precursor of this adenocarcinoma. It can often be asymptomatic and probably goes undiagnosed in the majority of the population. There are no direct data supporting the practice of screening for Barrett's oesophagus and oesophageal adenocarcinoma among the general population or even in patients with chronic reflux symptoms. However, many argue that the detection of neoplasms at a curable state in a high risk population can perhaps justify screening endoscopy. No prospective, controlled trials have been conducted to support the effectiveness of surveillance, but some indirect evidence does exist. The cost effectiveness of surveillance programmes needs to be further assessed in prospective studies. Ultimately, the use of better tools to diagnose Barrett's oesophagus and dysplasia and the identification of high risk groups for progression to oesophageal adenocarcinoma could potentially make screening and surveillance a cost effective practice.

What is the best management strategy for high grade dysplasia in Barrett's oesophagus? A cost effectiveness analysis

BACKGROUND

Multiple treatment strategies for subjects with high grade dysplasia (HGD) in Barrett's oesophagus (BO) have been suggested. However, it is unclear which of these strategies provides the greatest life expectancy, and the costs associated with the management strategies are unknown.

AIM

To compare the efficacy and cost effectiveness of competing management strategies for BO with HGD.

METHODS

We created a decision analysis model in Data 4.0 to assess possible treatment strategies for BO with HGD. The strategies included: (1) no preventative strategy, (2) elective surgical oesophagectomy, (3) endoscopic ablation, and (4) surveillance endoscopy. The base case was a healthy 50 year old White male with an initial diagnosis of BO with HGD. The model allowed for complications of surgery, including death. Ablative therapy could cause stricture or perforation. Pathological misinterpretation was allowed, and modelled after reported rates. Estimates were derived from the literature for the rate of progression of HGD to cancer and for complication rates for the various treatment modalities. The endoscopic ablation arm was modelled as photodynamic therapy. Sensitivity analyses were performed over a wide range of cancer incidences, complication rates, and procedure costs.

RESULTS

Endoscopic ablation was the most effective strategy, yielding 15.5 discounted quality adjusted life years (dQALY), compared with 15.0 for endoscopic surveillance and 14.9 for oesophagectomy. No preventative strategy was the most inexpensive option, yielding an average cost per quality adjusted life year of US dollars 54 (44) per dQALY, but resulted in high rates of cancer. Endoscopic surveillance dominated oesophagectomy, being both less costly and more effective. The condition of extended dominance occurred when comparing endoscopic ablation to endoscopic surveillance because, although the total costs of ablation were greater than those of surveillance, it was less expensive to buy an additional life year using endoscopic ablation than endoscopic surveillance. The incremental cost effectiveness ratio when moving from no therapy to ablative therapy was a reasonable US dollars 25 621/dQALY (21 009/dQALY). Sensitivity analysis demonstrated that when yearly rates of progression to cancer from HGD exceeded 30%, oesophagectomy became the most cost effective option.

CONCLUSIONS

A strategy of endoscopic ablation provided the longest quality adjusted life expectancy for BO with HGD. Although endoscopic surveillance was less expensive than endoscopic ablation, it was associated with shorter survival. Optimal utilisation of healthcare resources may be achieved with endoscopic ablative therapy for BO with HGD.

Cost-effectiveness model of endoscopic screening and surveillance in patients with gastroesophageal reflux disease

BACKGROUND & AIMS

Endoscopic screening and periodic surveillance for patients with Barrett's esophagus has been shown to be cost-effective in patients with esophageal dysplasia, with treatment for esophageal cancer limited to esophagectomy. Most gastroenterologists refer patients with high-grade dysplasia for esophagectomy, and effective endoscopic therapies are available for nonoperative patients with esophageal cancer. The cost-effectiveness of screening strategies that incorporate these nonsurgical treatment modalities has not been determined.

METHODS

We designed a Markov model to compare lifetime costs and life expectancy for a cohort of 50-year-old men with chronic reflux symptoms. We compared 10 clinical strategies incorporating combinations of screening and surveillance protocols (no screening, screening with periodic surveillance for both dysplastic and nondysplastic Barrett's esophagus, or periodic surveillance for dysplasia only), treatment for high-grade dysplasia (esophagectomy or intensive surveillance), and treatment for cancer (esophagectomy or surgical and endoscopic treatment options).

RESULTS

Screening and surveillance of patients with both dysplastic and nondysplastic Barrett's esophagus followed by esophagectomy for surgical candidates with high-grade dysplasia or esophageal cancer and endoscopic therapy for cancer patients who were not operative candidates cost $12,140 per life-year gained compared to no screening. Other screening strategies, including strategies that had no endoscopic treatment options, were either less effective at the same cost, or equally effective at a higher cost.

CONCLUSIONS

The cost-effectiveness of screening and subsequent surveillance of patients with dysplastic as well as nondysplastic Barrett's esophagus followed by endoscopic or surgical therapy in patients who develop cancer compares favorably to many widely accepted screening strategies for cancer.

High-Energy Laser Therapy of Barrett’s Esophagus: Preliminary Results

We present the preliminary results obtained by our research group utilizing Nd:YAG and diode lasers to treat Barrett's esophagus (BE). A total of 15 patients with BE (mean age 58 years) underwent endoscopic laser therapy: 11 with intestinal metaplasia, 2 with low-grade dysplasia, and 2 with high-grade dysplasia. The mean length of BE was 4 cm (range 1-12 cm). Six of these patients also underwent antireflux surgery, and nine were prescribed acid-suppressive medication. Endoscopic Nd:YAG laser treatment was carried out from 1997 to 1999; thereafter, diode laser was employed. The mean follow-up of these patients after the first laser session was 28 months. Patients underwent a mean of 6.5 laser sessions (range 3-17 sessions), with no apparent complications. The mean energy per session was 1705 JJ. Only six of these patients (40%) showed complete endoscopic and histologic remission, but a mean of 77% (SD 23.8%) of the total metaplastic tissue in all these patients was ablated. The percentage of healed mucosa was higher in patients with short-segment BE (92%) ( p < 0.05) and in subjects treated by two or more laser sessions per centimeter of BE length (89%) ( p < 0.05). All four patients with dysplasia showed histologic regression to nondysplastic BE or to squamous epithelium, without recurrence during a mean follow-up of 30 months. The patients who underwent antireflux surgery and those prescribed pharmacologic treatment had similar results. Nd:YAG and diode laser treatment of BE is a safe, effective procedure; it required two sessions per centimeter of metaplasia; and it achieved complete regression of the dysplasia. Further studies are necessary to quantify its effect on cancer incidence.

Role of surveillance in intestinal metaplasia of the esophagus and gastroesophageal junction

This article reviews current concepts of cancer surveillance in esophageal columnar metaplasia (Barrett's esophagus) and intestinal metaplasia at the gastroesophageal junction. An overview is given of the available data on the prevalence of intestinal metaplasia in biopsies from the distal esophagus and from the gastroesophageal junction. Furthermore, special attention is given to the endoscopic detection of dysplasia and early malignancy. Finally, the costs of endoscopic surveillance and its effect on mortality rates from esophageal adenocarcinoma are discussed.

Cost-effectiveness of photodynamic therapy for treatment of Barrett's esophagus with high grade dysplasia

The purpose of this study was to compare the effectiveness and cost-effectiveness of photodynamic therapy (PDT) versus surgical esophagectomy and intensive endoscopic surveillance for patients with Barrett's esophagus and high-grade dysplasia (HGD) who are operative candidates. The results of our Markov Monte Carlo model show that PDT increased life expectancy by 1.8 years and quality-adjusted life expectancy (QALE) by 1.65 years when compared to the surveillance strategy. Relative to the esophagectomy strategy, PDT resulted in a greater life expectancy by 0.8 years and 2.17 additional quality-adjusted life years (QALYs). Although PDT cost 20,400 dollars and 7,100 dollars more than surveillance and esophagectomy respectively, the resulting incremental cost-effective ratios (ICERs) of 12,400 dollars/QALY and 3,300 dollars/QALY are within commonly accepted values. These findings were sensitive to the value assigned to the quality of life after PDT, but only at unrealistic values. In conclusion, PDT increases life expectancy and is cost-effective when compared to endoscopic surveillance and surgical esophagectomy.

Cost-effectiveness of screening a population with chronic gastroesophageal reflux

BACKGROUND

Persons with chronic esophageal reflux are at increased risk for the development of Barrett's esophagus and adenocarcinoma. Recently developed ultrathin endoscopes are less expensive and better tolerated than standard endoscopes, they can be used without sedation, and are sensitive and specific for Barrett's esophagus. The cost-effectiveness of one-time screening strategies were evaluated for 50-year-old patients with chronic reflux: no screening, standard endoscopy, and screening by an ultrathin endoscope.

METHODS

Markov models were created to simulate the clinical course for patients with chronic reflux. Costs and quality-adjusted life-years were estimated from cancer registry data, published medical data, and expert opinion.

RESULTS

Under baseline assumptions, no screening resulted in average costs of $11,785 per person and 19.3226 quality-adjusted life-years. Ultrathin endoscopy screening resulted in costs of $12,119 per person and 19.3326 quality-adjusted life-years, yielding a marginal cost-effectiveness ratio of $55,764 per quality-adjusted life-year. Using standard endoscopy yielded costs of $12,332 with only slightly greater effectiveness, yielding a marginal cost-effectiveness ratio of $709,260 when compared with ultrathin endoscopy and $86,833 compared with no screening. Results were most sensitive to variation in the incidence of cancer in the population with Barrett's esophagus.

CONCLUSIONS

Screening for Barrett's esophagus with ultrathin endoscopy is more cost-effective than standard endoscopy, and both strategies appear to improve quality-adjusted life-years among patients with chronic reflux at costs that are similar to those of other accepted preventive measures.

Accuracy of esophagoscopy performed by a non-physician endoscopist with a 4-mm diameter battery-powered endoscope

BACKGROUND

A cost-effective technique is needed for screening of a broad population at risk for esophageal cancer. A solution would be to have non-physician endoscopists perform esophagoscopy with small-caliber battery-powered endoscopes.

METHODS

In a prospective blinded study, the diagnostic accuracy of sedated esophagoscopy performed by a trained nurse practitioner with a battery-powered 4-mm diameter endoscope was compared with that for a sedated standard video-endoscopy performed by a gastroenterologist. Patients were recruited to undergo peroral esophagoscopy by the nurse practitioner followed by sedated standard endoscopy by the supervising gastroenterologist, each blinded to the findings of the other. Major esophageal findings of nurse practitioner and gastroenterologist were compared.

RESULTS

Findings in 40 patients were analyzed. In 4 patients both endoscopists could not assess the presence or absence of columnar-lined esophagus because of severe erosive esophagitis (n = 3) or severe candida-esophagitis (n = 1). By using sedated standard endoscopy as the standard, on a per finding basis, esophagoscopy by the nurse practitioner had a sensitivity for columnar-lined esophagus of 89%: 95% CI [75%, 97%] and specificity of 96%: 95% CI [84%, 99%]. The missed columnar epithelium was a 3 x 3-mm island. For all lesions, the sensitivity of endoscopy performed by the nurse practitioner with the battery-powered endoscope was 75%: 95% CI [67%, 82%] and specificity 98%: 95% CI [96%, 99%]. The nurse practitioner missed all of 4 rings (3 considered clinically irrelevant).

CONCLUSION

Esophagoscopy with a battery-powered 4-mm diameter endoscope by a non-physician endoscopist is feasible and accurate in detecting esophageal pathologies. It may be an efficient screening method for the detection of columnar-lined esophagus. There was a distinct underestimate of the presence of esophageal rings.

Endoscopic ultrasound-guided fine needle aspiration in esophageal cancer

Esophageal cancer has a poor prognosis since it is often diagnosed in the symptomatic and incurable state. Accurate staging at initial diagnosis is imperative as it determines prognosis and influences treatment. Computed tomography (CT) scan is sensitive for identifying metastatic disease but is insensitive for detecting the extent of wall involvement or nodal disease. Endoscopic ultrasound (EUS) has emerged as a powerful tool in staging esophageal cancer with an impressive accuracy. Use of endoscopic ultrasound-guided fine needle aspiration as an adjunct further improves accuracy in nodal staging and allows for histologic confirmation. The impact of this invaluable staging modality in the management of esophageal cancer continues to grow.

Inoperable adenocarcinoma of the oesophagogastric junction: a comparative clinical study of laser coagulation versus self-expanding metallic stents with special reference to cost analysis

AIMS

Neither clinical nor financial comparisons yet exist between self-expanding metallic stents (SEMS) and laser therapy, concentrating on the treatment of obstructive adenocarcinomas of the oesophagogastric junction. The aim of our study was to compare the relative lifetime costs and clinical results of the Nd:YAG laser to those of SEMS as alternative forms of primary palliation of dysphagia for adenocarcinoma near the oesophagogastric junction.

METHODS

Fifty-two patients with distal oesophageal or oesophagogastric adenocarcinomas underwent palliative treatment for dysphagia: 32 treated with laser therapy and 20 with SEMS in this retrospective study. The clinical outcome and real cumulative costs as physical units and in financial terms were analysed for these study groups.

RESULTS

Although patients palliated with SEMS underwent fewer procedures (1.9+/-1.6 vs 3.4+/-4.0, P=0.0048) and spent less time in endoscopic theatre (38+/-25min vs 118+/-152min, P=0.0048), they spent as many days in hospital (12.9 vs 15.1, P=0.370) and required as high overall costs for therapy (5360 EUR vs 5450 EUR, P=0.679) as those treated with laser therapy. In addition, they had higher morbidity rates (30 vs 6.3%, P=0.043), hospital mortality (20 vs 3.1%, P=0.066), and 30-day mortality (40 vs 3.1%, P=0.0011) than did patients with laser therapy, with no evidence of SEMS being the more effective treatment modality.

CONCLUSIONS

In patients with adenocarcinoma at the distal oesophagus or at the oesophagogastric junction, laser therapy palliates dysphagia effectively with lower morbidity and mortality rates and without increased costs or hospital stays than does use of self-expanding metallic stents.

Achalasia treatment in the elderly: is botulinum toxin injection the best option?

BACKGROUND

Achalasia treatment in elderly patients is a matter of controversy. Botulinum toxin injection has been proposed as the best option in this group of patients as it is a safe procedure. However, concern persists regarding its short-term effect.

AIMS

To analyse the clinical and economic effectiveness of botulinum toxin injection in the treatment of achalasia patients who are elderly.

METHODS

Seventeen consecutive achalasia patients older than 65 years were treated with 80 units of botulinum toxin. Clinical follow-up at 1, 6 and 12 months was performed. Control manometry when symptoms recurred was carried out. Results were compared with those of an historical control group of 16 achalasia patients also older than 65 years and who had been treated with endoscopic dilation. The costs of both procedures were compared.

RESULTS

Twenty-nine botulinum toxin injections were performed in the 17 patients of the botulinum toxin group (follow-up, 12-36 months). In the dilation group only two patients had to be retreated (follow-up, 12-108 months). No major complications were observed in either group. The average duration of symptom alleviation was 48 +/- 33 months for endoscopic dilation and 13.8 +/- 9.5 months for botulinum toxin injection. Maintaining a patient free of symptoms cost E348.31 per year for botulinum toxin injection, whilst if endoscopic dilation was chosen the cost was only E117.47 per year.

CONCLUSIONS

The effect of botulinum toxin injections wanes with time in elderly patients, necessitating repeated injections to keep the patients symptom-free. Due to the required repeated injections this procedure is more expensive than endoscopic dilation.

Endoscopic stapling technique for the treatment of Zenker diverticulum vs standard open-neck technique: a direct comparison and charge analysis

BACKGROUND

Presently, the 2 most widely used methods for the treatment of Zenker diverticulum are endoscopic stapling of the common party wall between the diverticulum sac and the esophagus and the standard open-neck technique involving diverticulectomy and cricopharyngeal myotomy.

OBJECTIVE

To perform an analysis of the hospital charges to determine the economic efficiency of each technique based on our experience at the Mt Sinai Medical Center, New York, NY.

METHODS

A retrospective analysis of 16 patients diagnosed as having Zenker diverticulum was conducted. Eight randomly chosen patients underwent endoscopic stapling with an EndoGIA 35-mm endoscopic stapler (Ethicon Inc, Somerville, NJ), and 8 randomly chosen patients underwent a standard open approach with diverticulectomy. Medical records were reviewed to determine operative time, length of hospital stay, time to oral intake, and postoperative complications. A charge analysis of the operative and postoperative fees was also performed. Statistical analysis between the 2 groups was conducted using analysis of variance and the paired t test.

RESULTS

The mean +/- SD operative time for the endoscopic stapling technique was 25.5 +/- 15.78 minutes, which was significantly less (P<.001) than that for the open procedure, 87.6 +/- 35.10 minutes. The mean operative charges were roughly equivalent at US$ 5178 for the endoscopic procedure and US$ 5113 for the open procedure. The endoscopic procedure, while shorter in operative time, had the added expense of specialized equipment, specifically the EndoGIA endoscopic stapler. The mean +/- SD length of hospital stay for the endoscopic procedure was significantly shorter (P<.001) at 1.3 +/- 0.59 days vs 5.2 +/- 1.03 days for the open procedure. The inpatient hospital charges for the endoscopic group was also significantly less (P<.001) at a mean of US$ 3589 per stay vs US$ 11,439 for the open group. The mean +/- SD time to oral intake was significantly shorter (<.001) at a mean of US$ 3589 per stay vs US$ 11,439 for the open group. The mean +/- SD time to oral intake was significantly shorter (P<.001) in the endoscopic group at 0.8 +/- 0.26 days vs 5.1 +/- 1.25 days for the open group. There were no major complications in either group, and all patients experienced resolution of preoperative symptoms.

CONCLUSIONS

Compared with the standard open technique, the endoscopic stapling technique for the treatment of Zenker diverticulum results in a statistically significant shorter operative time, hospital stay, and time to resume oral feedings. While the charges of the operative procedures were roughly equivalent, the total hospital charges were significantly less for the patients treated endoscopically.