The National Institute for Health and Care Excellence (NICE) has issued full guidance to the NHS in England, Wales, Scotland and Northern Ireland on endoscopic radiofrequency ablation for Barrett’s oesophagus with low-grade dysplasia or no dysplasia in July 2014.

Description

Barrett’s oesophagus is a precancerous condition characterised by abnormal replacement of the squamous epithelium of the lower oesophagus by a type of columnar epithelium resembling that in the stomach and intestine.

In some patients, Barrett’s oesophagus may progress through a series of stages to oesophageal adenocarcinoma – a cancer with a poor prognosis. These intermediate stages are graded into low-grade and high-grade dysplasia according to the degree of abnormal cellular architecture.

The risk of progression to oesophageal adenocarcinoma for any individual with Barrett’s oesophagus is difficult to predict accurately. In general, the risk of cancer is highest for patients with high-grade dysplasia, lower for patients with low-grade dysplasia, and lowest for patients with no dysplasia (also referred to as intestinal metaplasia – a change from epithelium that is normal for this site but with no evidence of dysplasia). Accurate classification of Barrett’s oesophagus into these distinct histopathological types is difficult; there is the possibility of diagnostic misclassification because of biopsy sampling error and subjective biopsy interpretation. Strategies for addressing this include multiple biopsy sampling, diagnosis on at least 2 occasions, confirmation by 2 specialist histopathological experts and confirmation by an independent pathologist external to the original institution each time – all in the context of a multidisciplinary team.

The main risk factor for developing Barrett’s oesophagus is a history of reflux of acid and bile into the oesophagus. Reflux commonly produces symptoms of heartburn but it can be asymptomatic.

The management of Barrett’s oesophagus is determined by the type of dysplasia present. In Barrett’s oesophagus with no dysplasia or low-grade dysplasia, periodic endoscopic surveillance and repeat biopsies may be considered, with the aim of early detection of progression to high-grade dysplasia or cancer. If high-grade dysplasia or early cancer (carcinoma in situ) is detected, then treatment is recommended. If the disease is superficial (confined to the mucosa), treatment can usually be done endoscopically.

Endoscopic treatments for Barrett’s oesophagus aim to destroy the Barrett’s epithelium, leaving a surface that is subsequently replaced with a normal squamous epithelium. If the disease is flat, then it is generally ablated using one of several possible modalities, such as photodynamic therapy, argon plasma coagulation, laser ablation, cryotherapy or multipolar electrocoagulation. If there are visible abnormalities, such as nodules or ulcers, then those areas are usually removed by endoscopic resection.

Coding recommendations

G14.5 Fibreoptic endoscopic destruction of lesion of oesophagus NEC

Y13.4 Radiofrequency controlled thermal destruction of lesion of organ NOC

Includes: Radiofrequency ablation of lesion of organ NOC

When the examination is not limited to the oesophagus, the following OPCS-4 codes are assigned:

G43.5 Fibreoptic endoscopic destruction of lesion of upper gastrointestinal tract NEC

Y13.4 Radiofrequency controlled thermal destruction of lesion of organ NOC

Includes: Radiofrequency ablation of lesion of organ NOC

Z27.1 Oesophagus

The Clinical Classifications Service has advised NICE that currently these are the most suitable OPCS-4 codes to describe this procedure. The OPCS-4 classification is designed to categorise procedures for analysis and it is not always possible to identify a procedure uniquely

Your responsibility

This guidance represents the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take this guidance fully into account. However, the guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.

Commissioners and/or providers have a responsibility to implement the guidance, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

  • National Institute for Health and Care Excellence (NICE)