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Introduction: "Push" or "pull" techniques with the use of snares, forceps, baskets, and grasping devices are conventionally used to manage esophageal food bolus impaction (FBI). A novel cap-assisted technique has recently been advocated to reduce time taken for food bolus (FB) removal. This study aimed to compare the effectiveness of the cap-assisted technique against conventional methods of esophageal FB removal in a randomized controlled trial., Methods: Consecutive patients with esophageal FBI requiring endoscopic removal, from 3 Australian tertiary hospitals between 2017 and 2019, were randomized to either the cap-assisted technique or the conventional technique. Primary outcomes were technical success and FB retrieval time. Secondary outcomes were technical success rate, en bloc removal rate, procedure-related complication, length of hospital stay, and cost of consumables., Results: Over 24 months, 342 patients with esophageal FBI were randomized to a cap-assisted (n = 171) or conventional (n = 171) technique. Compared with the conventional approach, the cap-assisted technique was associated with (i) shorter FB retrieval time (4.5 ± 0.5 minutes vs 21.7 ± 0.9 minutes, P < 0.001), (ii) shorter total procedure time (23.0 ± 0.6 minutes vs 47.0 ± 1.3 minutes, P < 0.0001), (iii) higher technical success rate (170/171 vs 160/171, P < 0.001), (iv) higher rate of en bloc removal (159/171 vs 48/171, P < 0.001), and (v) lower rate of procedure-related mucosal tear and bleeding (0/171 vs 13/171, P < 0.001). There were no major adverse events or deaths within 30 days in either group. The total cost of consumables was higher in the conventional group (A$19,644.90 vs A$6,239.90)., Discussion: This multicenter randomized controlled trial confirmed that the cap-assisted technique is more effective and less costly than the conventional approach and should be first-line treatment for esophageal FBI., (Copyright © 2021 by The American College of Gastroenterology.)

Objectives: Eosinophilic esophagitis (EoE) has rapidly become a major cause of upper GI morbidity, but health-care costs related to EoE have not been described. This study aimed to estimate EoE-related health-care costs and utilization in the United States., Methods: We performed a study on health-care utilization of EoE cases compared with age- and sex-matched controls using administrative claims data, representative of the commercially insured population in the United States. Cases of EoE were identified using a previously validated definition. We assessed inpatient, outpatient, emergency department, outpatient prescription, and endoscopy-related costs for patients with EoE, and estimated total costs related to EoE extrapolated to the US population., Results: We identified 8,135 cases of EoE and 32,540 controls. The median total annual cost per EoE case was $3,304 compared with $1,001 for controls (P<0.001). For EoE, the median costs included $2,508/year for outpatient visits, $157 for endoscopies, and $325 for pharmacy claims, compared with $699, $0, and $76 for controls (P<0.001 for all). The overall median cost associated with EoE was $2,302/year/patient. Total costs in the United States ranged from $503 million to $1.36 billion/year, depending on the prevalence estimate, with costs attributable to EoE ranging from $350 to $947 million/year., Conclusions: Patients with EoE have an estimated annual health-care cost of as much as $1.4 billion in the United States. This represents a remarkable burden of disease for an entity that was essentially unknown two decades ago. These cost data can be used by policy makers to guide resource allocation.

Objectives: The population prevalence of eosinophilic esophagitis (EoE) is ~7% in adults. Current American Gastroenterology Association guidelines recommend endoscopic biopsy (Bx) in patients with symptoms of dysphagia. We conducted a cost-effectiveness model to determine if endoscopic Bx is cost effective in patients with refractory gastroesophageal reflux disease (GERD) without dysphagia., Methods: We designed a 5-year Markov model to compare costs and quality-adjusted life years for a cohort of 35-year-old patients with GERD refractory to proton pump inhibitor (PPI) therapy. We compared upper endoscopy (EGD) with and without Bx for EoE. We modeled that patients with EoE who did not undergo initial biopsy would wait 5 years until the diagnosis would be established via a second endoscopy with biopsy., Results: In patients with refractory GERD without dysphagia, endoscopic Bx for EoE was associated with an incremental cost-effectiveness ratio (ICER) of $51,420 per quality of life year (QALY). The upper endoscopy with biopsy arm cost $12,490 per patient and was associated with 4.080 QALYs, compared with EGD without Bx arm that cost $12,280 and was associated with 4.076 QALYs. The ICER was <$50,000 per QALY when the prevalence of EoE exceeded 8%, or the time of missed diagnosis was 6 years or greater. The biopsy arm was also cost effective if the QALY associated with symptomatic GERD was ≤0.93, cost of 3-month course of PPI therapy ≥$770 cost of fluticasone <$650, probability of EoE resolved on PPI ≤25%, symptom resolution on fluticasone ≥70%, cost endoscopy with biopsy ≤$520, or the cost of endoscopy without biopsy exceeded $300., Conclusions: Upper endoscopy with Bx for EoE appears to be a cost-effective approach in patients when the prevalence of EoE is 8% or greater.

Objective: Cost-effective strategies for identifying patients with Barrett's esophagus who are most likely to develop cancer have not been developed. Surveillance endoscopy is currently used, and we hypothesized that more frequent surveillance intervals would identify patients with "transient positive" diagnoses of dysplasia--dysplasia found on one examination but not on subsequent ones. Our aim was to explore the potential economic impact of transient positive diagnoses of dysplasia on alternative surveillance strategies over a 10-yr period., Methods: Data were derived from a 2-yr randomized, prospective study comparing omeprazole to ranitidine in 95 patients with Barrett's esophagus. A transient positive diagnosis of dysplasia was defined as a patient who was diagnosed with dysplasia during the study period but whose 24-month biopsies revealed no dysplasia. We calculated the number of transient positive diagnoses of dysplasia and modeled the potential economic impact of a diagnosis of dysplasia over a 10-yr period., Results: Thirty patients (31%) had at least one reading of dysplasia during the study period. Nineteen patients (20%) had a transient positive diagnosis of dysplasia. During the study period, no cancers were found. A surveillance strategy of every other year and every 6 months for dysplasia would result in 1072 endoscopies over a 10-yr period at a discounted cost of $1,587,184. A total of 61% of endoscopies would be because of transient positive diagnoses of dysplasia. A strategy of yearly surveillance and every 6 months for dysplasia would result in 1404 endoscopies at a discounted cost of $2,096,733, of which 28% would result from transient positive diagnoses of dysplasia. The discounted incremental costs of more frequent surveillance in this cohort of patients over 10 yr is $509,549., Conclusions: Based on current practice strategies, transient positive diagnoses of dysplasia account for 28-61% of endoscopies in Barrett's surveillance programs. This analysis suggests that the endoscopy workload and costs associated with surveillance could be substantially reduced if patients with transient positive diagnoses of dysplasia reverted to usual surveillance after two negative examinations.

Objective: Recent guidelines recommend that all cirrhotics undergo screening upper endoscopy to identify those patients at risk for bleeding from varices. However, this practice may not be cost effective as large esophageal varices are seen only in 9-36% of these patients. The aim of this study was to determine whether clinical variables were predictive of the presence of large esophageal varices., Methods: This is a retrospective analysis of cirrhotics who had a screening upper endoscopy during an evaluation for liver transplantation at three different centers and who had not previously bled from varices. A multivariate model was derived on the combined cohort using logistic regression. Three hundred forty-six patients were eligible for the study., Results: The prevalence of large esophageal varices was 20%. On multivariate analysis, splenomegaly detected by computed tomographic scan (odds ratio: 4.3; 95% confidence interval: 1.6-11.5) or by physical examination (odds ratio: 2.0; 95% confidence interval: 1.1-3.8), and low platelet count were independent predictors of large esophageal varices. On the basis of these variables, cirrhotics were stratified into high- and low-risk groups for the presence of large esophageal varices. Patients with a platelet count of > or = 88,000/mm3 (median value) and no splenomegaly by physical examination had a risk of large esophageal varices of 7.2%. Those with splenomegaly or platelet count < 88,000/mm3 had a risk of large esophageal varices of 28% (p < 0.0001)., Conclusions: Our data show that clinical predictors could be used to stratify cirrhotic patients for the risk of large esophageal varices and such stratification could be used to improve the cost effectiveness of screening endoscopy.

Objectives: Although Barrett's esophagus (BE) may be associated with severe gastroesophageal reflux disease (GERD), there are currently no studies that evaluate resource utilization in Barrett's patients. The aims of this study were 1) to determine the cost and number of endoscopies and clinic visits to the GI clinic for GERD or its complications in patients with BE; 2) to determine the pattern and cost of medication use in patients with BE; and 3) to compare medication use by patients with BE to that of patients with insulin-requiring diabetes mellitus (DM)., Methods: Using the cost distribution report data and the pharmacy acquisition costs from the Durham VAMC, we calculated the monthly cost of endoscopies, clinic visits related to GERD, and medication use in 53 patients with BE between 1/1/94 and 1/1/97. We also calculated the average cost of medication use for 55 patients with insulin-requiring DM., Results: All patients with BE were male. Their median age was 64.0 yr (IQR 57-68). Of them, 92% were white; 23% had low-grade dysplasia (LGD). Patients with LGD were more likely to have more than three endoscopies in 3 yr than were those with no LGD (OR 6.3, 95% CI 1.11-35.67). There was no difference in clinic visits in the patients with and without dysplasia (OR 0.335, 95% CI 0.093-1.206). A total of 139 endoscopies and 172 clinic visits were observed. Outpatient care for patients with BE costs approximately $103/month or $1241/yr. Endoscopies and clinic visits accounted for 31.1% and 5.9% of the monthly medical cost, respectively. Medications accounted for 63% of the total cost of care. Prokinetic agents accounted for 0.8% of the total cost of medications, whereas histamine receptor antagonists (H2 blockers) and proton pump inhibitors (PPIs) accounted for 34.6% and 64.6%, respectively. Medication cost per month in patients with BE was approximately $65, similar to that of patients with insulin-requiring DM ($63)., Conclusions: Our conclusions were as follows: 1) Outpatient care for patients with BE costs approximately $1241/yr or ($103/month). 2) Medication use per month accounted for more than half of the total cost; PPIs accounted for 64.6% of total medication cost, suggesting that reflux was severe. 3) Consistent with current surveillance strategies, patients with LGD had more frequent endoscopy than patients with no dysplasia. 4) Medication cost per month in patients with BE is similar to that in patients with DM, another group with a chronic disorder. 5) Those who make health policy can use these results to compare the cost of care of patients with BE to the cost for those with other chronic medical disorders.

Objective: Surveillance of Barrett's patients is recommended, to detect dysplasia and early cancer. The reported risk for developing cancer varies substantially, however. Our previous analysis used an average cancer incidence of 1/75 patient-years (PY). Recent reports suggest that the risk may range from 1/251 to 1/208 PY in combined series of patients with long segment Barrett's esophagus (LSBE, >3 cm), and short segment Barrett's esophagus (SSBE), and up to 1% annually in patients with SSBE. Our goal was to consider these new estimates of cancer risk in a cost-utility analysis of surveillance of patients with Barrett's esophagus., Methods: Using our previously published model, we incorporated an average of the recent estimates of cancer risk (0.4% annually, 1/227 PY), and our primary data on quality of life after esophagectomy. We included actual variable (direct) costs and used a discount rate of 5%. From the perspective of an HMO, the model evaluates surveillance every 1-5 yr and no surveillance, with esophagectomy performed if high grade dysplasia is diagnosed, and calculates the incremental cost-utility ratios for each strategy., Results: The results suggest that, at our baseline, annual cancer risk surveillance every 5 yr is the only viable strategy. More frequent surveillance costs more and yields a lower life expectancy. The incremental cost-utility ratio for surveillance every 5 yr is $98,000/quality-adjusted life year (QALY) gained, comparable to the incremental cost-effectiveness ratios of accepted practices (heart transplantation and screening for tuberculosis in selected populations, $160,000/LY gained and $216,000/LY gained, respectively)., Conclusions: Surveillance of Barrett's patients should extend life, with incremental cost-utility ratios that compare favorably with some accepted medical practices. Policy makers can compare the cost of surveillance to that of other accepted practices to determine their willingness to fund surveillance.

Objective: Endoscopic surveillance of Barrett's esophagus is commonly practiced to detect malignancy in an early and curable stage. However, the cost-effectiveness of this practice has been questioned. To clarify this issue, we undertook a cost analysis of endoscopic surveillance to detect adenocarcinoma in Barrett's esophagus compared with mammography used to detect occult carcinoma of the breast, a widely accepted cancer surveillance technique., Methods: The rate of esophageal adenocarcinoma detected by endoscopic surveillance was calculated for Duluth Clinic patients with Barrett's esophagus seen from 1980 to 1995 and compared with published rates. The rate of occult breast cancer detection was calculated for all women undergoing surveillance mammography at the Duluth Clinic for the year 1994 and compared with published rates. Costs for screening studies and therapy for cancer treatment for both cancers were calculated based on clinical results and assumptions regarding outcomes derived from published reports, and the costs were compared., Results: Endoscopic surveillance of 149 patients with benign Barrett's esophagus was performed for a total of 510 patient-yr, during which time seven patients developed adenocarcinoma, an incidence of one case per 73 patient-yr of follow-up. Occult breast cancer was detected in 50 of 12,537 mammograms, a detection rate of 0.4%. The incidences in both cases were comparable to published figures. The costs of detecting a case of adenocarcinoma in Barrett's esophagus and occult breast cancer were $37,928 and $54,513, respectively, and those for treatment resulting in cure were $83,340 and $83,292. Cost per life-yr saved was $4,151 for adenocarcinoma in Barrett's esophagus and $57,926 for breast cancer., Conclusion: Endoscopic surveillance of patients with Barrett's esophagus compares favorably with the common practice of surveillance mammography to detect early breast cancer, and should therefore be considered to be as cost-effective as surveillance mammography.

A review of endoscopic records at the Cleveland Clinic Foundation over a 7-yr period yielded 72 cases of Barrett's esophagus. Ten patients had adenocarcinoma at the time of diagnosis of Barrett's esophagus (14%). Sixty-two were followed for a mean of 31 months (range 2-154 months). During this follow-up period, cancer developed in one patient, an incidence of one cancer per 166 patient yr and an annual incidence of 0.6%. Males predominated in the group with both Barrett's esophagus (55 of 72) and adenocarcinoma (10 of 11). Symptoms were similar in those with simple Barrett's esophagus and those complicated by cancer. Our findings on incidence of cancer in Barrett's was applied to a model surveillance program. The cost of yearly endoscopic surveillance is estimated to be +62,000 and 78 lost work days to discover one cancer during the follow-up period. An endoscopic surveillance program requiring every-other-year studies appears justified and would cost only half as much, annually.