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ENDOSCOPIC MUCOSAL RESECTION VERSUS ENDOSCOPIC SUBMUCOSAL DISSECTION FOR BARRETT’S NEOPLASIA: A COST-EFFECTIVENESS ANALYSIS

Sneh Sonaiya 1, Jay Maturi 2, Suchapa Arayakarnkul 1, Linda Zhang 3, Kevin Frick 4, Saowanee Ngamruengphong 5

Affiliations

1 Johns Hopkins Medicine, Baltimore, United States

2 Johns Hopkins University School of Medicine, Baltimore, United States

3 University of New South Wales, Sydney, New Zealand

4 Johns Hopkins Carey Business School, Baltimore, United States

5 Johns Hopkins University, Baltimore, United States

Summary

AI Generated

A cost-effectiveness analysis of 5677 patients found that endoscopic submucosal dissection is more cost-effective than endoscopic mucosal resection for Barrett's esophagus neoplasia lesions 10mm or larger, but not for smaller lesions.

For lesions 10-20mm and greater than 20mm, ESD was more cost-effective than EMR and yielded higher quality of life, while EMR was more cost-effective for lesions smaller than 10mm.
ESD achieved higher R0 resection rates compared to EMR (74.5% vs 40.82%, p=0.001) and significantly lower overall local recurrence (2.92% vs 11.27%, p=0.01).
ESD prevented an additional 71.21 per 1000 cases of repeat endoscopic resection and approximately 12 additional esophagectomies per 1000 patients at an incremental cost per surgery avoided of $5362.
ESD had higher rates of periprocedural adverse events including bleeding (2.79% vs 1.13%, p=0.01) and perforation (0.46% vs 0.04%, p=0.01) compared to EMR.
The analysis included 1267 ESD and 4410 EMR patients with median follow-up of 31 months and may be most relevant for clinicians managing high-grade dysplasia or T1a esophageal adenocarcinoma in Barrett's esophagus.

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Abstract

Introduction

Endoscopic submucosal dissection (ESD) and endoscopic mucosal resection (EMR) are minimally invasive procedures to remove the dysplastic Barrett’s esophagus (BE) lesion. The optimal resection technique for dysplastic BE lesions remains unclear as while EMR is safe, effective and easy to perform, recurrence rates are lower with ESD. We aim to compare the cost-effectiveness of EMR and ESD for resection of BE neoplasia at different lesion size cutoffs.

Aims & Methods

An incremental cost-effectiveness analysis was performed using a Markov decision tree model including parameters available from the literature review (including 1267 patients who underwent ESD and 4410 who underwent EMR) for BE neoplasia. Monte Carlo simulations were conducted for randomly sampled values for each model estimate to predict the probability of cost-effectiveness at various willingness-to-pay (WTP) thresholds. The base case was a patient with high-risk BE lesions (high-grade dysplasia (HGD) or T1a esophageal adenocarcinoma (EAC)). Outcomes data for BE patients with HGD or T1a esophageal adenocarcinoma were analyzed. The median follow-up period was 31 months (18 months to 5 years). The average lesion size before intervention was higher for ESD compared to EMR (22.7mm vs 13.6mm). We divided the BE HGD lesions into three categories: <10mm, 10-20mm, and >20mm to compare the cost effectiveness of EMR and ESD at different lesion sizes. The probability of overall post-resection recurrence was analyzed, and the incremental cost of the ESD was compared to that of EMR. Effectiveness was defined as the number of esophagectomies or repeat endoscopic procedures avoided per 1000 cases in the simulation. The costs of EMR and esophagectomy were derived through CPT codes and the existing literature, and the cost of ESD was derived through the billing department of our institution. The probabilistic sensitivity analysis reflects the effect of uncertainties of the model variables on the final model outcomes. All our analysis was conducted using TreeAge Pro Software (2021 R1 Healthcare, Win 64-bit).

Results

ESD resulted in higher rates of R0 resection (74.5% vs 40.82%, p=0.001) but higher rates of periprocedural adverse events such as bleeding (2.79% vs 1.13%, p=0.01) and perforation (0.46% vs 0.04%, p=0.01) compared to EMR. ESD yielded a significantly lower overall local recurrence compared EMR (2.92% vs 11.27%, p=0.01). The proportion of recurrence requiring repeat endoscopic treatment following ESD or EMR was 1.84% and 8.96%, respectively. ESD prevented an additional 71.21 per 1000 cases of repeat endoscopic resection compared to EMR. ESD would prevent approximately 12 additional esophagectomies compared to EMR for every 1000 patients undergoing the procedure at an incremental cost per surgery avoided of $5362. Based on our analysis, ESD was more cost effective than EMR and yielded higher Quality of Life (QoL) for lesion size >20mm and for lesion size 10-20mm. For lesion size <10mm, EMR was more cost effective than ESD and yielded higher QoL for lesion size <10mm. Limitations of the study include: (a) Utility data is based on the literature review and may not reflect individual patient preferences. (b) It is assumed in the model that all patients with T1a EAC are eligible for both EMR and ESD at baseline.

Conclusion

ESD is associated with higher upfront costs for the patient, but is more cost-effective in the long term by lower overall recurrence and lower probability of repeat endoscopic or surgical treatment for lesion size 10-20mm and >20mm.

Conference

UEG Week Copenhagen 2023

Topics

Oesophagus

Submission format

Abstract

Session

Diagnosis and resection of upper GI neoplasia (Posters)

Citation

United European Gastroenterology Journal 2023; 11 (Supplement 8)

Published

2023

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1 University of Nottingham, Nottingham, United Kingdom

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Abstract

Event

UEG Week Barcelona 2026

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Neurogastroenterology & Motility Paediatrics

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What’s new in… Rome V?

Citation

2026: United European Gastroenterology Journal 2026; 14 (S1)

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Eosinophilic GI disorders: Pathophysiology and beyond – are drugs for eosinophilia enough?

Antonio Di Sabatino 1, Albert J. Bredenoord 2

Affiliations

1 University of Pavia, Pavia, Italy

2 Amsterdam University Medical Center, Amsterdam, Netherlands

Summary

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Abstract

Event

UEG Week Barcelona 2026

Session

Eosinophilic gastrointestinal diseases: From basic to clinical practice

Citation

2026: United European Gastroenterology Journal 2026; 14 (S1)

Published

2026

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What are the diagnostic options?

Ariadna Aguilar 1

Affiliations

1 Hospital Universitari Vall d'Hebrón, Barcelona, Spain

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Abstract

Event

UEG Week Barcelona 2026

Topics

Endoscopy Primary Care Neurogastroenterology & Motility

Session

Non-achalasia dysphagia: From symptoms to solution

Citation

2026: United European Gastroenterology Journal 2026; 14 (S1)

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Giovanni Barbara 1

Affiliations

1 University of Bologna, Bologna, Italy

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Abstract

Event

UEG Week Barcelona 2026

Topics

Neurogastroenterology & Motility Primary Care

Session

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Citation

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1 Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom

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UEG Week Barcelona 2026

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Neurogastroenterology & Motility Primary Care

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1 Hospital General de Tomelloso, Madrid, Spain

2 University Childrens Hospital Cologne, Cologne, Germany

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Abstract

Event

UEG Week Barcelona 2026

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