The Community Standard Treatment of Barrettʼs With Dysplasia Is Endoscopic Therapy: Results of a National Database Study

Abstract

Introduction: The National Comprehensive Cancer Network recommends the use of endoscopic therapy with radiofrequency ablation (RFA) and Endoscopic Mucosal Resection (EMR) to treat Barrett's esophagus with dysplasia. Whether or not this recommendation is followed in practice, or if surgery is still the main modality of therapy is unclear. We aimed to determine the community standard of the treatment of Barrett's with dysplasia. Methods: We used the Clinformatics® Data Mart Database (OptumInsight, Eden Prairie, MN), a large, de-identified administrative dataset of patients enrolled in a large national commercial insurance plan and Medicare Advantage to study the treatment of Barrett's with dysplasia in the United States. We identified all adult patients who had an outpatient esophagogastroduodenoscopy (EGD) using the Current Procedural Terminology (CPT) code and the International Classification of Diseases, 9th revision and 10th revision (ICD-9, ICD-10) code for BE between January 1, 2015, and December 31, 2016. We studied EGDs with RFAs using CPT codes 43229, 43270 and EMRs using CPT codes 43211, 43254. We crossreferenced the results with the ICD-9 and 10 code for dysplasia (low grade or high grade) or carcinomain-situ. Using a similar concept, we studied patients who underwent an esophagectomy for Barrett's dysplasia. Our primary outcomes of interest were numbers of procedures performed. Our secondary outcomes were 30-day complication rates of stricture, perforation and upper GI bleeding as defined by an inpatient admission with the corresponding ICD-9 or ICD-10 code within 30 days of EGD. Results: We found 2,355 patients who underwent EGD for BE; 399 had an RFA, 101 had EMR and 11 had both. Of those, 253 (63.4%) endoscopies with RFA, 67 (74.4%) endoscopies with EMR and 6 (54.5%) endoscopies with EMR and RFA had a diagnosis of dysplasia at the time of the EGD We found that 1.3% of patients were hospitalized for treatment of stricture after RFA, and a 2.2% had a significant GI bleeding after EMR. There were no perforations or esophagectomies within 1 year of RFA or EMR. We could not identify patients with dysplasia who underwent surgery. Conclusion: In this clinical database study, the majority of Barrett's with dysplasia are treated using endoscopic treatment. The complications rates of the treatment modalities are low. We also found that both modalities are often reported used for Barrett's with non-dysplasia.