Treatment of Barrettʼs With Balloon Cryotherapy Is Feasible and Safe in Patients With Prior Magnetic Sphincter Augmentation Device (MSAD)

Abstract

Barrett's esophagus is a complication of severe gastro-esophageal reflux disease (GERD) and is a risk factor for developing esophageal adenocarcinoma. The MSAD is a flexible band of interlinked titanium beads with a magnetic core that is implanted around the lower esophageal sphincter. It is a new therapy for treating refractory GERD, but does not address pre-existing Barrett's esophagus. The endoscopic cryoballoon focal ablation system (CbFAS) is a novel technique for ablation of Barrett's esophagus. We present the first case of successful CbFAS for Barrett's esophagus in a patient with prior MSAD. This is a 65-year-old female with cough and heartburn for >30 years, improved on twice daily proton pump inhibitor (PPI). Her family history is significant for esophageal cancer in her father. A high resolution esophageal manometry revealed a 4-cm hiatal hernia, but was otherwise normal. Her 24-hour pH impedance test was positive for refractory GERD with a DeMeester score of 20.3, despite her use of a BID PPI. An endoscopy showed C0-M2 non-dysplastic Barrett's esophagus with a 5-cm hiatal hernia. Due to the hernia and uncontrolled reflux, she underwent a hiatal hernia repair with MSAD placement. This improved her reflux symptoms and her PPI was discontinued. The decision was made to treat her Barrett's esophagus given her family history. CbFAS was chosen, given her abnormal anatomy and surgical history. An ablation was attempted with a standard ovoid balloon, but due to the MSAD, positioning at the gastro-esophageal junction (GEJ) was unsuccessful. The pear-shaped balloon was then inflated in the stomach and pulled back into the GEJ, allowing for successful delivery of cryotherapy. Her Barrett's was visually eradicated without adverse effects on 2 separate endoscopies. On surveillance endoscopy using volumetric laser endomicroscopy (VLE), wide area transepithelial tissue sample with computer assisted 3D analysis (WATS 3D), and Seattle protocol forceps biopsies, she had complete remission of intestinal metaplasia. This case demonstrates that treating post-MSAD patients with balloon cryotherapy for Barrett's esophagus is feasible and safe. Utilizing a pear-shaped balloon alleviates the extrinsic compression applied by the MSAD, providing good visualization and position at the GEJ.1816_A Figure 1. From left to right: Pre-treatment, during treatment, and post-treatment endoscopic views. Yellow arrows point to laser markings for targeted biopsies.1816_B Figure 2. Volumetric laser endomicroscopy (VLE) post-ablation with visualization of MSAD device