S2074 Liquid Nitrogen Spray Cryotherapy Is a Safe and Effective Treatment Modality for Extensive Gastric Intestinal Metaplasia With Dysplasia

Abstract

INTRODUCTION: Gastric intestinal metaplasia with dysplasia (GIM-D) that is visible as a discrete limited lesion on endoscopy is readily treated using endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD). However, there are few options for more extensive and invisible dysplasia. Ablating a wide swath of tissue with argon plasma coagulation (APC) or radiofrequency ablation (RFA) can be challenging and carry risks, including post-procedure ulceration. Liquid Nitrogen Spray Cryotherapy (LSNC) is an established treatment for dysplasia in Barrett’s esophagus, but its use for GIM-D has not been previously reported. CASE DESCRIPTION/METHODS: Three patients with GIM-D underwent a total of ten sessions of LNSC. In all cases, LNSC was performed after passing an orogastric decompression tube in the stomach for active suctioning. Ablations were performed in cycles of 20-40 seconds, with at least 45 seconds in between cycles to allow for tissue thawing. Between two to seven ablations were performed during each procedure. Prior to each procedure, Sydney protocol biopsies were obtained. No patient reported any mild, moderate, or severe post-procedure complications. Patient 1: 73-year-old with a 15 mm intramucosal adenocarcinoma in the fundus, resected using band ligation EMR. Random biopsies in the fundus demonstrated low-grade GIM-D. The patient underwent 3 sessions of LNSC throughout the fundus. There was no evidence of GIM-D after 1 session, no evidence of GIM after 3 sessions, and no recurrence after 29 months of follow up (Table 1). Patient 2: 72-year-old with pre-pyloric intramucosal adenocarcinoma, with a positive margin after ESD, extensive surrounding high-grade dysplasia (HGD) in the antrum. He underwent 5 sessions of LSNC to this area and surrounding antrum (Figure 1). After 1 session, there was no adenocarcinoma. At 14 months, there is GIM but no GIM-D. Patient 3: 71-year-old with HGD of the gastric antrum and incisura, and persistent GIM-D despite EMR. He underwent 2 sessions of LSNC over 3 months. After 1 session, there was GIM but no GIM-D. DISCUSSION: Very few treatment modalities exist for extensive GIM-D. LNSC appears to be a safe, well tolerated, and effective treatment for extensive GIM-D. Our series provides a scientific rationale to pursue larger studies evaluating LNSC for GIM-D.Table 1.: Liquid nitrogen spray cryotherapy treatment detailsFigure 1.: A. Gastric intestinal metaplasia with high grade dysplasia throughout the antrum, and ulceration at the prior resection site (*) B. Liquid nitrogen spray cryotherapy, which allows for ablation of a wide swath of the antrum.