Abstract
Background: Endoscopic ablation of neoplastic tissue distal to the tubular esophagus presents a technical challenge with currently available modalities. Liquid nitrogen spray cryotherapy (LN2SC) is a catheter-based technique which has been used to treat Barrett's esophagus (BE), esophageal cancer and non-esophageal diseases. It does not require tissue contact for efficacy and treats flat and raised lesions. Recent technical improvements have permitted use of LN2SCwhile in retroflexion. There have been no published reports using this technique. We describe the feasibility and safety of treating lesions at the esophagogastric junction (EGJ) and gastric cardia with retroflexed LN2SC. Methods: We performed a retrospective study of subjects treated with LN2SC in retroflexion at 4 U.S. tertiary care centers. Eligible subjects were treated for dysplastic BE or adenocarcinoma with either curative or palliative intent. Cases were treated with LN2SC using the G2 or truFreeze catheter systems (CSA Medical, Lutherville MD). Dosimetry was at the discretion of the operator and varied with lesion size and morphology. De-identified data, including demographic and endoscopic details, were obtained using a standardized collection form. Results were aggregated for analysis. Results: In total, 13 patients underwent 18 retroflexed LN2SC administrations. While 9 patients had 1 retroflexed session, 4 had at least 2 sessions of retroflexed treatment. All but 1 patient was male, with a mean age of 74 years. Histologic grading of targeted lesions included 4 cases of invasive adenocarcinoma, 4 of intramucosal adenocarcinoma, 4 of BE with high grade dysplasia and 1 of BE with low grade dysplasia. Only 2 patients were treatment-Naive, while 8 had prior ablation with LN2SC, radiofrequency ablation or photodynamic therapy, and 8 had prior endoscopic mucosal resection. Lesions targeted for treatment included 3 EGJ nodules/masses, 3 cardia nodules/masses, 1 area of nodularity including the EGJ and cardia and 6 flat EGJ lesions. Retroflexed LN2SC was chosen either for lesions extending beyond the EGJ that were not fully visible en face or due to concerns for incomplete treatment with prior ablation. Four cases were performed using the older G2 catheter, which has greater stiffness and a limited bend radius compared to the truFreeze catheter used for the other cases. Only 1 adverse event was reported: hypoxemia leading to premature termination of the endoscopy. The event was not felt to be related to LN2SC or its retroflexed use. Conclusion: Experience to date demonstrates the feasibility and safety of LN2SC in retroflexion for treatment of lesions at the EGJ and cardia. The ability to use LN2SC in both en face and retroflexed positions expands the treatment options available for lesions in the upper gastrointestinal tract, especially those previously unreachable by other methods. Patients Treated With LN2SC In Retroflexion
Published Version
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