Tim Bright

Cost-effectiveness of endoscopic surveillance of non-dysplastic Barrett's esophagus

BACKGROUND Endoscopic surveillance for non-dysplastic Barretts esophagus (BE) is contentious and its cost effectiveness unclear. OBJECTIVE To perform an economic analysis of endoscopic surveillance strategies. DESIGN Cost-utility analysis by using a simulation Markov model to synthesize evidence from large epidemiologic studies and clinical data for surveillance, based on international guidelines, applied in a coordinator-managed surveillance program. SETTING Tertiary care hospital, South Australia. PATIENTS A total of 2040 patient-years of follow-up. INTERVENTION (1) No surveillance, (2) 2-yearly endoscopic surveillance of patients with non-dysplastic BE and 6-monthly surveillance of patients with low-grade dysplasia, (3) a hypothetical strategy of biomarker-modified surveillance. MAIN OUTCOME MEASUREMENTS U.S. cost per quality-adjusted life year (QALY) ratios. RESULTS Compared with no surveillance, surveillance produced an estimated incremental cost per QALY ratio of

Randomized Trial of Argon Plasma Coagulation Versus Endoscopic Surveillance for Barrett Esophagus After Antireflux Surgery : Late Results

60,858. This was reduced to

MicroRNA-143 and -205 Expression in Neosquamous Esophageal Epithelium Following Argon Plasma Ablation of Barrett’s Esophagus

38,307 when surveillance practice was modified by a hypothetical biomarker-based strategy. Sensitivity analyses indicated that the likelihood that surveillance alone was cost-effective compared with no surveillance was 16.0% and 60.6% if a hypothetical biomarker-based strategy was added to surveillance, at an acceptability threshold of

Outcome of endoscopy surveillance for Barrett's oesophagus

100,000 per QALY gained. LIMITATIONS Treatment options for BE that overlap those for symptomatic GERD were omitted. CONCLUSION By using best available estimates of the malignant potential of BE, endoscopic surveillance of patients with non-dysplastic BE is unlikely to be cost-effective for the majority of patients and depends heavily on progression rates between dysplasia grades. However, strategies that modify surveillance according to cancer risk might be cost-effective, provided that high-risk individuals can be identified and prioritized for surveillance.

Argon plasma coagulation ablation versus endoscopic surveillance of Barrett's esophagus: Late outcomes from two randomized trials

Objective:To determine the efficacy of endoscopic argon plasma coagulation (APC) for ablation of Barrett esophagus. Summary Background Data:APC has been used to ablate Barrett esophagus. However, the long-term outcome of this treatment is unknown. This study reports 5-year results from a randomized trial of APC versus surveillance for Barrett esophagus in patients who had undergone a fundoplication for the treatment of gastroesophageal reflux. Methods:Fifty-eight patients with Barrett esophagus were randomized to undergo either ablation using APC or ongoing surveillance. At a mean 68 months after treatment, 40 patients underwent endoscopy follow-up. The efficacy of treatment, durability of the neosquamous re-epithelialization, and safety of the procedure were determined. Results:Initially, at least 95% ablation of the metaplastic mucosa was achieved in all treated patients. At the 5-year follow-up, 14 of 20 APC patients continued to have at least 95% of their previous Barrett esophagus replaced by neosquamous mucosa, and 8 of these had complete microscopic regression of the Barrett esophagus. Five of the 20 surveillance patients had more than 95% regression of their Barrett esophagus, and 4 of these had complete microscopic regression (1 after subsequent APC treatment). The length of Barrett esophagus shortened significantly in both study groups, although the extent of regression was greater after APC treatment (mean 5.9–0.8 cm vs. 4.6–2.2 cm). Two patients who had undergone APC treatment developed a late esophageal stricture, which required endoscopic dilation, and 2 patients in the surveillance group developed high-grade dysplasia during follow-up. Conclusions:Regression of Barrett esophagus after fundoplication is more likely, and greater in extent, in patients who undergo ablation with APC. In most patients treated with APC the neosquamous mucosa remains stable at up to 5-year follow-up. The development of high-grade dysplasia only occurred in patients who were not treated with APC.

Anterior 180° Partial Fundoplication—How I Do It

IntroductionAblation of Barrett’s esophagus using Argon plasma coagulation (APC) is usually followed by the formation of a neosquamous epithelium. Investigating simple columnar or stratified squamous epithelium associated cytokeratin and microRNA (miRNA) expression in neo-squamous epithelium could help determine the identity and stability of the neosquamous epithelium.MethodsNine patients underwent ablation of Barrett’s esophagus with APC. Biopsies were collected from Barrett’s esophagus mucosa and proximal normal squamous epithelium before ablation, and from neosquamous and normal squamous epithelium after ablation. Additional esophageal mucosal biopsies from ten nonrefluxing subjects were used as a reference. RNA was extracted and real-time polymerase chain reaction was used to measure the expression of the cytokeratins CK-8 and CK-14 and the microRNAs miR-143 and miR-205.ResultsCK-8 and miR-143 expression were significantly higher in Barrett’s esophagus mucosa, compared to neosquamous and normal squamous epithelium before and after APC, whereas miRNA-205 and CK-14 expression was significantly lower in Barrett’s esophagus mucosa compared to all categories of squamous mucosa. The expression of CK-8, CK-14, miR-205, and miR-143 was similar between neosquamous epithelium compared to normal squamous epithelium in patients with Barrett’s esophagus. Only miR-143 expression was significantly higher in neosquamous and normal squamous epithelium before and after APC compared to normal squamous epithelium from control subjects (p < 0.004).ConclusionsThe expression levels of cytokeratins and miRNAs studied in post-ablation neosquamous epithelium and normal squamous epithelium in patients with Barrett’s esophagus are similar. In patients with Barrett’s esophagus, miR-143 expression is still elevated in both neosquamous mucosa, and the squamous mucosa above the metaplastic segment, suggesting that this mucosa may not be normal; i.e., it is different to that seen in subjects without Barrett’s esophagus. miR-143 could promote a Barrett’s epithelium gene expression pattern, and this could have a role in development of Barrett’s esophagus.

Improving care for patients with oesophageal and gastric cancer: impact of a statewide multidisciplinary team

Background:  Endoscopic surveillance of individuals with Barretts oesophagus is undertaken to detect early stage oesophageal malignancy. The impact of a surveillance programme on endoscopy resources and disease detection is uncertain.

Retrospective analysis of surgery and trans-arterial embolization for major non-variceal upper gastrointestinal bleeding

BACKGROUND AND STUDY AIM Argon plasma coagulation (APC) has been used to ablate dysplastic and nondysplastic Barretts esophagus. We determined the longer-term efficacy of APC ablation within two randomized controlled trials of APC versus surveillance for Barretts esophagus in patients in whom gastroesophageal reflux was controlled by either surgery or proton pump inhibitors. PATIENTS AND METHODS 129 patients (surgical trial 70, medical trial 59) with Barretts esophagus (nondysplastic or low grade dysplasia) were randomly allocated to either ablation using APC or to continuing endoscopy surveillance. Outcomes were determined at three time points: short-term (12 months), mid-term (42-75 months) and long-term (> 84 months). RESULTS In the APC groups, initial ablation of > 95 % of the Barretts esophagus was achieved in 61 of 63 patients; the > 95 % ablation persisted in 47 of 56 patients at short-term follow-up, in 33 of 49 at mid-term and in 21 of 32 at long-term follow-up. In the surveillance groups, the length of Barretts esophagus reduced from a mean of 4.2 cm to 2.7 cm at long-term follow-up. High grade dysplasia (HGD) developed in 1 patient in the APC groups and in 3 in the surveillance groups. Low grade dysplasia developed in 1 APC patient and in 6 surveillance patients. CONCLUSIONS APC ablation reduced the extent of Barretts esophagus, and this reduction was maintained in some patients at longer-term follow-up. However, progression to HGD can still occur despite APC ablation, suggesting endoscopic surveillance is still required. CLINICAL TRIAL REGISTRATION ACTRN012607000293460 and ACTRN12607000292471 (Australian Clinical Trials Registry).

Surgical management of peptic ulcer bleeding by Australian and New Zealand upper gastrointestinal surgeons.

Laparoscopic Nissen fundoplication is the standard operation for the surgical control of gastro-oesophageal reflux in many centres. However, in some patients, it can be followed by troublesome side effects, and to minimise the risk of these, partial fundoplications have been recommended. One approach is to construct an anterior 180° partial fundoplication. Randomised trials and a large outcome study have confirmed that in most patients, this approach achieves effective reflux control, as well as a reduced incidence of side effects. In this paper, we describe our approach to this procedure. The procedure entails full dissection of the oesophageal hiatus, hiatal repair with posteriorly placed sutures and then construction of an anterior 180° partial fundoplication using three sutures to attach the anterior gastric fundus to the oesophagus and right hiatal pillar, and two further sutures between the fundus and the apex of the hiatus.

The use of a balloon catheter to improve evaluation in anorectal manometry.

To standardize management of upper gastrointestinal (GI) cancer in South Australia, a statewide video linked multidisciplinary team (MDT) meeting was established in late 2009. Although cancer MDTs are recognized as a standard of care, it is important to audit their impact.