The Effect of Operator Experience on Treatment of Dysplastic Barrett's Esophagus With Radiofrequency Ablation

Abstract

BACKGROUND: Radiofrequency ablation (RFA) is an endoscopic ablation modality that typically requires multiple treatment sessions to fully eliminate dysplastic tissue. It is unclear if increasing experience reduces complications or the necessary number of ablation sessions, and how many ablations are necessary to achieve competence. AIM: To assess the learning curve for physicians performing RFA. METHODS: This was a retrospective study of patients treated with RFA for BE at a tertiary care referral center between June 2006 and November 2010. Pertinent information was extracted from medical records, including: demographics, pre-ablation histology, indicators of GERD activity (symptoms, erosive esophagitis), upper endoscopy findings (Prague criteria, hiatus hernia), ablation outcomes (elimination of metaplasia and dysplasia), and complications (stricture, bleeding). Endoscopist experience was measured by the number of treatment sessions performed prior to initiation of therapy for each patient. Patients with incomplete treatment and those who initiated treatment in the last 6 months were excluded. Patient characteristics and treatment outcomes were examined among 4 quartiles of endoscopist experience by non-parametric tests (Fisher's exact test for categorical variables and Kruskal-Wallis one-way ANOVA for continuous variables). Linear regression and Pearson's correlation were performed to assess the strength of the association between endoscopist experience and number of sessions necessary for complete ablation. RESULTS: Among 305 RFA treatments by 3 physicians in 113 patients, 245 treatments were in 77 patients who completed therapy more than 6 months prior and were included in the analysis. Over time, there was a significant reduction in the number of RFA sessions and time required to complete therapy, from an average of 4.4 sessions and 226 days in the earliest quartile to 2.3 sessions and 111 days in the most recent quartile (p<0.05 for both). Operator experience and number of RFA sessions to complete treatment were significantly correlated(r=0.38, p<0.001). Linear regression identified operator experience (p<0.001) and Prague M length (p<0.001) as independent predictors of number of treatment sessions to complete eradication of BE. By this model, an endoscopist needs to perform 81 ablations to average 3.0 treatments per patient. Complication rates did not differ significantly dependent on operator experience (p=0.26). CONCLUSIONS: There was a clinically and statistically significant learning curve associated with endoscopic ablation of BE, with initial subjects requiring approximately 2.1 additional treatment sessions for complete ablation. After 81 ablations an endoscopist is projected to average 3.0 treatments per patient. For optimal delivery, this procedure should be performed in high volume centers.