Ablation of Dysplastic Barrettʼs Mucosa in Scleroderma-Type Esophagus: Cold Spray over RFA: 2016 ACG Presidential Poster Award

Abstract

Radiofrequency ablation (RFA) is currently the first line endoscopic therapy for eradication of dysplastic Barrett's esophagus (BE). In this modality, high frequency radio waves are applied to the esophageal mucosa by direct contact. Another option is spray cryotherapy, where liquid nitrogen is sprayed onto the mucosa, rapidly freezing the tissue as the liquid evaporates. RFA is not always successful at ablating the BE mucosa. We believe we have identified a subset of patients in whom RFA was not effective due to a dilated baggy esophagus.First described in patients with systemic sclerosis, the “scleroderma-type” esophagus is typified by a dilated, aperistaltic esophagus with an incompetent lower esophageal sphincter. Esophageal dysmotility of this kind was later described in patients with other conditions, and in those with no systemic disease at all. This population is prone to esophageal adenocarcinoma. We hypothesized that cryotherapy would be a useful adjunct in this patient population. As it does not require direct contact with the sagging esophagus, cryotherapy may succeed where RFA had failed due to difficulty in establishing tension with the baggy mucosa of scleroderma-type esophagus.We present a retrospective case series of 4 patients with endoscopic features of scleroderma-type esophagus who were treated for dysplastic BE with RFA followed by adjunctive cryotherapy. Two patients had features of systemic sclerosis (Table 1). Three patients had high-grade dysplasia (HGD), one had indefinite dysplasia (ID). The indications for adjunctive cryotherapy were persistent dysplasia and persistent metaplasia despite RFA.All patients had reduction of their BE segment length with adjunctive cryotherapy. All 3 dysplasia patients had reduction in their grade of dysplasia with cryotherapy and 2 achieved complete eradication of dysplasia (CE-D). One patient achieved complete eradication of intestinal metaplasia (CEIM). (Table 2).Table 1: Patient Demographics and Baseline CharacteristicsTable 2: Patient OutcomesIn our case series, cryotherapy was a useful complement to RFA, and achieved CE-D in most cases as well as improvement of dysplastic histology and reduction of BE length in all cases. We hypothesize that due to the non-contact nature of spray cryotherapy it may be better suited than contact RFA for treating the sagging scleroderma-type esophagus. Weaknesses of this study are its small sample size and retrospective nature. Future research may investigate cryotherapy as a first line treatment in this population.