title: Treatment of Barrett's esophagus with high-grade dysplasia or cancer: predictors of surgical versus endoscopic therapy.
abstract: OBJECTIVE
  Patients with Barrett's esophagus and high-grade dysplasia or intramucosal carcinoma are at risk of progression to invasive carcinoma. Both esophagectomy and endoscopic ablation are treatment options. The aim of this study was to identify predictors of surgical versus endoscopic therapy at a tertiary center.
  
  
  METHODS
  An institutional database identified patients with Barrett's esophagus between 2003 and 2007. Demographic data and International Classification of Diseases-9th revision codes for esophagectomy, endoscopic ablation, as well as selected medical comorbidities were retrieved. Individual endoscopy, surgical, and pathology reports were reviewed.
  
  
  RESULTS
  Among 2107 individuals with Barrett's esophagus, 79 underwent esophagectomy and 80 underwent endoscopic ablation. The mean age was 63.1 +/- 10.6 years in the surgical group and 69.7 +/- 9.4 years in the ablation group (P < .0001). Among high-grade dysplasia/intramucosal carcinoma patients, 9 of 76 (12%) first seen by a gastroenterologist underwent esophagectomy, whereas 18 of 21 (86%) first seen by a surgeon underwent esophagectomy. In a logistic regression model, factors associated independently with esophagectomy were as follows: patient age of 60 or younger (odds ratio [OR], 4.95; 95% confidence interval [CI], 1.65-14.9), cancer stage T1sm or greater (OR, 16.0; 95% CI, 5.60-45.6), and initial consultation performed by a surgeon (vs gastroenterologist) (OR, 35.1; 95% CI, 9.58-129).
  
  
  CONCLUSIONS
  Patient age and cancer stage predict treatment modality for Barrett's esophagus with neoplasia. Treatment choice is influenced further by whether the initial evaluation is performed by a gastroenterologist or a surgeon.
authors.affiliation: Gastrointestinal Unit, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts 02114, USA. pyachimski@partners.org
authors.forename: Patrick
authors.initials: P
authors.lastname: Yachimski
authors.forename: Norman S
authors.initials: NS
authors.lastname: Nishioka
authors.forename: Ethan
authors.initials: E
authors.lastname: Richards
authors.forename: Chin
authors.initials: C
authors.lastname: Hur
mesh_terms: D000367:Age Factors; D000368:Aged; D001471:Barrett Esophagus / Q000150:complications* / Q000601:surgery*; D004724:Endoscopy; D004938:Esophageal Neoplasms / Q000175:diagnosis / Q000517:prevention & control* / Q000601:surgery*; D016629:Esophagectomy; D004947:Esophagus / Q000473:pathology; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009369:Neoplasms / Q000175:diagnosis / Q000517:prevention & control* / Q000601:surgery*; D012720:Severity of Illness Index