Cryoablation of Barrett Esophagus and Adenocarcinoma in Therapeutically Anticoagulated Patients

Abstract

Purpose: The risk of anticoagulation associated bleeding in the setting of cryoablation has not been defined. We present the first reported cases of successful cryoablation of dysplastic Barrett Esophagus (BE) and esophageal adenocarcinoma (EAC) successfully performed in patients who remained therapeutically anticoagulated on warfarin due to high risk comorbidities. Methods: All cases of cryoablation of BE and EAC performed at our institution were reviewed with respect to their anticoagulation status during successful cryoablation procedures. Patients were followed for a minimum of 1 month post procedure. Results: 3 patients were treated with cryoablation. 2 patients with dysplastic BE underwent 3 sessions of cryoablation. 1 Patient with persistent EAC following definitive chemoradiation (DRC) underwent 4 sessions of cryoablation. The 2 BE patients were anticoagulated with warfarin for Mitral valve prosthesis. The patient with EAC suffered a pulmonary embolism which necessitated therapeutic anticoagulation. The INR was at least 2.0 during all 7 treatment sessions. The initial Prague Classification for patient #1 was C1, M2. Biopsies showed both low and high grade dysplasia. 2 sessions of cryoablation were performed. During the 1st session, 20-second freeze cycles were performed twice at an INR of 2.4. During the 2nd session, 20-second freeze cycles were performed three times at an INR of 2.3. The initial Prague Classification for patient #2 was C2, M7. Biopsies showed low grade dysplasia. Two 20-second freeze intervals with intervening 2-3 minute thaw intervals were performed at an INR of 2.0 during a single treatment session. The initial tumor classification for the patient with EAC was T3N1. Surveillance EGD performed 5 months post completion of DCR and after initiation of warfarin revealed a 2 cm ulcerated lesion in the distal esophagus. The INR was 3.0. Three 15-second freeze intervals with intervening 2-3 minute thaw intervals were performed. Biopsies revealed moderately differentiated ACE. No significant bleeding was encountered. 3 additional cryoablation sessions were carried out with the patient anticoagulated. Final biopsies obtained were negative for malignancy and BE. All sessions of cryoablation were performed successfully and without bleeding problems. There were no acute or delayed complications. Conclusion: Our case series suggests that cryoablation of dysplastic BE and EAC does not provoke bleeding in the setting of therapeutic anticoagulation. The exact etiology of the absence of bleeding risk is unclear. Further investigation is warranted as the potential to maintain chronic anticoagulation significantly reduces overall cost and avoids the complexities of bridging therapy.