Endoscopic applications of cryospray ablation therapy-from Barrett’s esophagus and beyond

Abstract

In the last decade, the treatment of dysplastic Barrett’s esophagus has evolved into primarily endoscopic therapy. Many techniques have become well-established to destroy or remove the mucosal lining of Barrett’s esophagus. One of the newest therapies, cryospray ablation, has become a modality to treat both dysplastic Barrett’s esophagus as well as esophageal carcinoma. In endoscopic applications, the cryogen used is either liquid nitrogen or carbon dioxide which causes tissue destruction through rapid freeze-thaw cycles. Unlike other endoscopic ablation techniques, its unique mechanism of action and depth of tissue injury allow cryoablation to be used effectively in flat or nodular disease. It can be combined with other modalities such as endoscopic mucosal resection or radiofrequency ablation. Its esophageal applications stem well-beyond Barrett’s into ablation of early carcinoma, palliative debulking of advanced carcinoma and reduction of tumor ingrowth into stents placed for dysphagia. Although there are fewer reported studies of endoscopic cryoablation in the literature compared to other endoscopic ablation methods, emerging research continues to demonstrate its efficacy as a durable ablation technology with a variety of applications. The aim of this review is to examine the pathophysiology of endoscopic cryospray ablation, describe its outcomes in Barrett’s with dysplasia and esophageal carcinoma, and examine its role in other gastrointestinal applications such as hemostasis in the stomach and rectum.

Keywords: Barrett’s esophagus; Dysplasia; Esophageal carcinoma; Endoscopic cryoablation; Cryotherapy

Core tip: The current standard of care in treatment of dysplastic Barrett’s esophagus is endoscopic ablation. Cryospray ablation, the newest modality can achieve complete eradication of dysplasia and intestinal metaplasia in over 90% of patients. Unlike other endoscopic methods, its unique mechanisms and depth of injury enable successful ablation of early esophageal carcinoma, palliative debulking of advanced carcinoma and reduction of tumor ingrowth into stents. The applications of cryospray ablation beyond the esophagus include control of bleeding from gastric antral vascular ectasia, portal hypertensive gastropathy, and radiation proctitis. This modality continues to evolve as an important tool of therapeutic endoscopy.