Cryospray ablation using pressurized CO₂ for ablation of Barrett’s esophagus with early neoplasia: early termination of a prospective series

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.

Study aim: To determine the efficacy and safety of cryospray ablation using pressurized CO₂ gas in the treatment of BE with early neoplasia.

Methods: In this prospective single center case series, we aimed to include 30 patients with BE and early neoplasia. Nodular neoplastic lesions were treated with endoscopic mucosal resection (EMR). Residual BE mucosa was treated with cryospray ablation every 4 weeks until the complete BE segment was eliminated or up to seven treatment sessions. If no reduction of the BE segment was observed after two subsequent treatment sessions, cryoablation was terminated. Patients were contacted at days 1 and 4 post-treatment to evaluate the level of discomfort. Endoscopic and histologic follow-up evaluations were performed up to 24 months post-treatment.

Results: After the inclusion of 10 patients, insufficient effect of cryoablation was observed, resulting in early termination of the study. In total, seven patients with intramucosal carcinoma (IMC) and three with high grade dysplasia (HGD) were included. Prior EMR was performed in nine patients. A median of 2.5 (IQR 2.0 – 4.0) cryoablation sessions were performed. At 6 months of follow-up, complete eradication of intestinal metaplasia was observed in 11 % (1 /9; one patient died, not treatment or disease related) of the patients and complete eradication of dysplasia in 44 % (4 /9). In three patients, HGD or IMC was detected during follow-up, and was endoscopically treated. Apart from a gastric perforation as a result of gastric distension caused by CO₂ gas during the first treatment, cryospray treatments were well tolerated.

Conclusion: After a short learning curve, cryoablation using CO₂ gas was found to be 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 BE associated neoplasia.

• References

• 1 Guillem PG. How to make a Barrett esophagus: pathophysiology of columnar metaplasia of the esophagus. Dig Dis Sci 2005; 50: 415-424
• 2 Konda VJ, Waxman I. Endotherapy for Barrett’s esophagus. Am J Gastroenterol 2012; 107: 827-833
• 3 Tomizawa Y, Iyer PG, Wong Kee Song LM et al. Safety of endoscopic mucosal resection for Barrett’s esophagus. Am J Gastroenterol 2013; 108: 1440-1447
• 4 Manner H, Rabenstein T, Pech O et al. Ablation of residual Barrett’s epithelium after endoscopic resection: a randomized long-term follow-up study of argon plasma coagulation vs. surveillance (APE study). Endoscopy 2014; 46: 6-12
• 5 Orman ES, Li N, Shaheen NJ. Efficacy and durability of radiofrequency ablation for Barrett’s Esophagus: systematic review and meta-analysis. Clin Gastroenterol Hepatol 2013; 11: 1245-1255
• 6 Overholt BF, Wang KK, Burdick JS et al. Five-year efficacy and safety of photodynamic therapy with Photofrin in Barrett’s high-grade dysplasia. Gastrointest Endosc 2007; 66: 460-468
• 7 Gosain S, Mercer K, Twaddell WS et al. Liquid nitrogen spray cryotherapy in Barrett’s esophagus with high-grade dysplasia: long-term results. Gastrointest Endosc 2013; 78: 260-265
• 8 Shaheen NJ, Greenwald BD, Peery AF et al. Safety and efficacy of endoscopic spray cryotherapy for Barrett’s esophagus with high-grade dysplasia. Gastrointest Endosc 2010; 71: 680-685
• 9 Canto MI, Dunbar KB, Okolo P et al. Low flow CO₂-cryotherapy for high risk Barrett’s esophagus (BE) patients with high grade dysplasia and early adenocarcinoma: a pilot trial of feasibility and safety. Gastrointest Endosc 2008; 67: AB179-AB180
• 10 Canto MI, Gorospe EC, Shin EJ et al. Carbon dioxide (CO₂) cryotherapy is a safe and effective treatment of Barrett’s esophagus (BE) with HGD/intramucosal carcinoma. Gastrointest Endosc 2009; 69: AB341
• 11 Xue HB, Tan HH, Liu WZ et al. A pilot study of endoscopic spray cryotherapy by pressurized carbon dioxide gas for Barrett’s esophagus. Endoscopy 2011; 43: 379-385
• 12 Dumot JA, Vargo JJ, Falk GW et al. An open-label, prospective trial of cryospray ablation for Barrett’s esophagus high-grade dysplasia and early esophageal cancer in high-risk patients. Gastrointest Endosc 2009; 70: 635-644
• 13 Raju GS, Ahmed I, Xiao SY et al. Graded esophageal mucosal ablation with cryotherapy, and the protective effects of submucosal saline. Endoscopy 2005; 37: 523-526
• 14 Dumot JA, Greenwald BD. Argon plasma coagulation, bipolar cautery, and cryotherapy: ABC’s of ablative techniques. Endoscopy 2008; 40: 1026-1032
• 15 Dumot JA, Greenwald BD. Cryotherapy for Barrett’s esophagus: does the gas really matter?. Endoscopy 2011; 43: 432-433