Endoscopic Cryoablation of Barrett's with High Grade Dysplasia: A Single Center Case Series

Abstract

Background: Endoscopic ablation of Barrett's esophagus (BE) with high grade dysplasia (HGD) is a potential alternative to surgery in poor surgical candidates. Currently, there are multiple ablative modalities demonstrating various levels of safety and efficacy. Spray cryotherapy is considered a safe, and well tolerated procedure. Given its potential to treat both flat and nodular lesions, cryotherapy is emerging as an attractive endoscopic ablation option. Aim: Review the efficacy and safety of spray cryoablation in patients with BE with HGD at a tertiary care center. Methods: A retrospective review of records of patients undergoing spray cryotherapy for HGD in BE was done. All procedures were performed by the authors. Spray cryotherapy with low pressure liquid nitrogen was performed using the CryoSpray Ablation System (CSA Medical, Baltimore, MD). A dual lumen CryoDecompression tube was placed in the gastric antrum to evacuate the nitrogen gas when suction was activated during the procedure. The abdomen was monitored by a nurse for any signs of gastric distention. Freezing and thawing techniques were monitored by direct visualization. Dosimetry used was 10 or 20 seconds for 4 or 3 cycles respectively, followed by 60 seconds interim thaws. Results: Five male patients were treated. The BE appeared flat, ranging from 25- 100% circumferential. Two patients had short segment HGD (1cm). One patient had failed radiofrequency ablation and photodynamic therapy (PDT) with resultant post PDT stricture. Complete reversal of the intestinal metaplasia (CR-IM) and dysplasia (CR-D) was seen in all patients after an average of 1.5 treatments. Follow-up duration is 10 months and 1.5 months respectively. The other 3 patients had longer segments Barrett's with HGD (3-6 cm), one had failed radiofrequency ablation. Although still in treatment, 30-50% reduction was observed endoscopically in all patients after 2 treatment sessions (Table 1). There were no adverse events or complications including perforations, strictures, bleeding, or chest pain. Conclusions: Our early experience with endoscopic spray cryotherapy indicates that it is a safe and well-tolerated procedure. These results suggest that this technology may be an attractive alternative to other endoscopic ablative modalities.