Tu1579 Cryospray Ablation Using Pressurized Carbon Dioxide Gas for the Ablation of Barrett's Esophagus With Early Neoplasia

Abstract

higher Charlson Comorbidity Score (5.0 vs 3.6, p 0.001). EMR was associated with a higher rate of any complication (36% vs 25%, p 0.05) due entirely to the development of stricture formation (36% vs 6%, p 0.0001). All strictures in the EMR group were successfully treated with a median of 1 endoscopic dilation. In the surgery group, 10 patients (4%) required re-operation, and 24 (10%) developed an anastomotic leak. 3 surgery patients (1%) died during hospitalization vs. 0 procedural deaths in the EMR group. Excluding those without at least HGD on final pathology, EMR patients were marginally more likely to have cancer found during follow-up than surgery patients (7% vs. 3%, p 0.25). In the EMR group, all recurrent HGD or cancer occurred within the first 18 months of follow-up (Figure 1). 6 EMR patients (8%) crossed over to surgery, and 13 (17%) ultimately also received radiofrequency ablation. There were 0 cancer deaths in the EMR group and 2 (1%) in the surgery group. Excluding patients without at least HGD, EMR was marginally associated with better survival than surgery (Hazard Ratio 0.80, 95% confidence interval 0.16, 3.9), adjusting for age and comorbidities (Figure 2). Conclusion: At a center with expertise in both procedures, we did not find that EMR was associated with worse survival or recurrence rates than esophagectomy for HGD or IMC. Although EMR had more complications, these were all treated endoscopically and there were no procedure related deaths. To our knowledge, this is the largest comparison of EMR to surgery, yet the analysis is still limited by sample size. EMR is a viable option for treatment of Barrett’s esophagus with HGD or IMC if patients receive close surveillance for 2 years following completion of therapy. Tu1579 Cryospray Ablation Using Pressurized Carbon Dioxide Gas for the Ablation of Barrett’s Esophagus With Early Neoplasia Romy E. Verbeek*, Frank P. Vleggaar, Fiebo J. Ten Kate, Jantine W. Van Baal, Peter D. Siersema Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, Netherlands; Pathology, University Medical Center Utrecht, Utrecht, Netherlands Background: Cryotherapy is a relatively novel ablation modality for the endoscopic ablation of Barrett’s esophagus (BE). Data on the use of pressurized carbon dioxide (CO2) gas for cryoablation are scarce.AIM: To determine efficacy and safety of cryospray ablation using pressurized CO2 gas (Polar wand, GI supply) in the treatment of BE with early neoplasia. Methods: In this prospective single center study, we aimed to include 30 patients with BE and early neoplasia. Visible neoplastic lesions were treated with endoscopic mucosal resection (EMR). Residual BE mucosa was treated with cryospray ablation which was performed every 4 weeks until the complete BE segment was eliminated or up to 7 treatment sessions. If no reduction of the BE segment was observed after 2 subsequent treatment sessions, cryoablation was terminated. Cryospray treatments consisted of 6 applications with a CO2 catheter on 2-3 cm hemi circumferential BE during 20 seconds, with active suctioning of the stomach between applications. Biopsies of BE and neo-squamous epithelium were obtained in 4-quadrants every 1-2 cm prior to the 1st, 4th and 7th treatment and at 3 and 6 months post-treatment using a large capacity forceps. Patients were contacted at day 1 and 4 post-treatment to evaluate the level of discomfort. Interim analysis was scheduled after the inclusion of 10 patients for insufficient clinical effect, defined as complete eradication of intestinal metaplasia at 3 months follow-up in less than 50% of patients. Results: Interim analysis showed insufficient effect of cryoablation, which resulted in termination of the study. In total, 7 patients with intramucosal carcinoma (IMC) and 3 with high-grade dysplasia (HGD) were included. Prior EMR was performed in 9 patients. Precryoablation diagnoses were intestinal metaplasia (IM; n 4), low-grade dysplasia (LGD; n 5) and high-grade dysplasia (HGD; n 1).,A median of 3.0 (IQR1.8-4.8) cryoablation sessions were performed. At 6 months follow-up, complete eradication of dysplasia was observed in 50% (3/6) of the patients and complete eradication of IM in 20% (2/10). One patient progressed to IMC. A nonsignificant reduction of the BE length was observed (5.0 (IQR1.8-7.3) vs. 2.5 (IQR0.9-6.3) cm, p 0.08). No buried BE glands were detected in the ablated segments. In 1 patient, gastric perforation occurred after the first treatment as a result of gastric distention caused by CO2 gas. No further cryoablation was applied in this patient. Apart from a superficial esophageal laceration in another patient, cryospray treatments were well tolerated. Conclusion: After a short learning curve, cryoablation using CO2 gas is a safe and well tolerated treatment modality. However, in our experience, the efficacy of CO2 cryoablation combined with EMR for nodular lesions is disappointing for the treatment of residual BE and BE associated dysplasia.