Doctors at the University of Maryland Medical Center are using a cryotherapy technique to treat cancerous and precancerous conditions of the esophagus. The Medical Center was one of the first sites in the world to offer the CryoSpray ablation and remains a leading center for the use of this procedure.
University of Maryland Medical Center gastroenterologist Bruce Greenwald, MD, who conducted one of the early studies of CryoSpray ablation, answers commonly asked questions about this new technique.
What is Cryotherapy Ablation?
Cryotherapy ablation destroys the abnormal lining of the esophagus by exposing cells to extreme cold using liquid nitrogen. It is a new technique which is done during an EGD (upper endoscopy).
While you are sedated, a small tube is placed through your mouth into your stomach. This prevents air build-up in your stomach. Next, an endoscope (lighted tube with camera) is passed through the mouth into the esophagus, and liquid nitrogen is sprayed on the esophagus through a device passed through the endoscope. By freezing the tissues using liquid nitrogen, we hope to remove the abnormal cells and allow regrowth of new, healthy cells in their place.
Who are candidates for cryotherapy ablation?
Patients who have:
Barrett's esophagus with high-grade dysplasia
Severe squamous dysplasia of the esophagus
Early stage esophageal cancer not amenable to standard therapies including surgery, chemotherapy, and radiation therapy
What is involved with cryotherapy ablation?
Before the Procedure
One week before treatment starts, you will take a high dose of a commonly-used medicine to decrease stomach acid. You may already take one of these medicines. They are Aciphex (rabeprazole), Nexium (esomeprazole), Prilosec (omeprazole), Prevacid (lansoprazole), or Protonix (pantoprazole). This will decrease acid flowing back into your swallowing tube (acid reflux). You will take this medicine throughout cryotherapy treatment.
You will have the cryotherapy ablation procedure every four to eight weeks. These will stop when no abnormal tissue is found.
You will answer questions before each procedure. This will record any side effects you had. The questions will take less than 15 minutes to answer.
Cryotherapy ablation is done during EGD (upper endoscopy). In this test, a flexible lighted tube (endoscope) is used. It is passed through your mouth and throat. It will examine the upper intestine (esophagus, stomach, duodenum). Before each procedure, an intravenous (IV) tube will be inserted into a vein. You will receive medicine through this IV to help you relax (sedation) during the procedure.
During EGD, the doctor will first evaluate the esophagus lining. Next, a tube will be placed through your nose or mouth into your stomach. This will prevent air build-up in your stomach. Next, the endoscope is reinserted, and liquid nitrogen is sprayed on the esophagus using the study device. Liquid nitrogen is very cold. It will freeze and destroy the tissue lining the swallowing tube.
After the Procedure
After EGD, you will remain in the recovery area until you wake up. You can not drive for eight hours after the EGD. A responsible adult must drive you home or ride a taxi or bus with you.
After each EGD, the nurse will call you by telephone and will ask if you had side effects from the procedure as well as any changes in your health.
If you are unable to tolerate treatment or your disease progresses, you can talk to your doctor about other treatment options.
Repeat cryotherapy is performed every four to six weeks until the entire abnormal lining is replaced by normal esophageal lining. On average, patients require three to four treatments for complete effect. The number of treatments you will need depends on the extent of the abnormal tissue in your esophagus and how well you respond to each treatment.
After cryotherapy ablation is complete, you will return to the medical center. This will occur every three to six months for three years, then every year. An EGD is done during these visits. During EGD, small samples of tissue (biopsies) are taken from the swallowing tube. These samples are examined under the microscope to see if treatment is successful. If abnormal tissue is found, repeat cryotherapy ablation treatment may be given.
What are the benefits of cryotherapy ablation?
The goal of treatment is complete elimination of abnormal tissue in the esophagus. Successful cryotherapy ablation will avoid the need for alternative treatments such as surgery. For some people with early esophageal cancer who aren't eligible for surgery or have failed to respond to chemotherapy and radiation, this new technique, which has minimal side effects, may be a good alternative.
What are the possible risks, discomforts, and inconveniences?
In EGD, a flexible tube-like instrument is inserted down your throat and into your stomach. This is a common procedure performed in the hospital or doctor's office. You may experience mild discomfort due to gagging while the tube is passed down your throat.
You may receive medicine to numb your throat before the EGD. Rarely, the medicine causes an allergic reaction or irritation to your mouth or throat. You will receive medicine to help you relax during the EGD. An allergic reaction may also occur from this medicine. Severe allergic reactions could be life-threatening. This medicine can also cause other problems. These problems include excessive sleepiness, slowed breathing, or low blood pressure during the EGD.
Most patients have little or no difficulty swallowing the tube during the EGD. EGD rarely causes mild sore throat, chest pain or discomfort, or painful or difficult swallowing. Medicines may ease these problems.
Rare risks of EGD include aspiration, bleeding, or perforation. Aspiration is inhaling of fluid or stomach contents into the lungs. Bleeding can occur from EGD or from taking tissue samples. Perforation is a rare complication of EGD. Perforation is a tear in the intestine. If this happens, you may need emergency surgery. The surgery will repair the hole.
Other risks include pain, nausea, vomiting, fever, or irregular heartbeat.
With cryotherapy ablation, the swallowing tube rarely becomes narrowed (stricture). This could affect your ability to swallow food. If this happens, EGD is needed to stretch (dilate) the swallowing tube. Dilation increases the risk of a tear in the swallowing tube.
Other risks of cryotherapy ablation are similar to routine EGD. All of the EGD complications can occur with cryotherapy ablation. The complication rate may be higher with cryotherapy ablation than with routine EGD.
Cryotherapy ablation frequently takes multiple EGD sessions. The average is three to four sessions per patient, although some patients require eight or more treatment sessions. These treatment sessions are performed every four to eight weeks. Some patients find it difficult to undergo multiple treatment sessions.
Cryotherapy ablation may not be successful. Cancer can develop or progress during cryotherapy ablation treatment. No ablation technique is 100 percent successful in all patients, and some abnormal tissue may still be present at the end of treatment. If abnormal tissues persist, further cryotherapy ablation may be offered, or other treatments may be offered.
For Women: The risks of cryotherapy ablation for pregnant women or unborn babies are unknown. The risks of cryotherapy ablation for nursing mothers or babies are unknown. If you are pregnant or are breastfeeding, you will not be considered for treatment. You must use birth control to be sure that you do not become pregnant. If you become pregnant during the course of treatment, you should tell your doctor immediately.
What are alternatives to cryotherapy ablation?
Alternative treatments may include:
- Observation. With observation, you will have upper endoscopy at regular intervals (typically three to six months). If cancer develops, then treatment is given.
- Surgery. The surgery for these esophageal conditions is esophagectomy, surgical removal of the esophagus. The benefit of surgery is the high success rate of removing all the diseased tissue. The drawback of surgery is the long recovery time, alteration in eating habits, and risk of complications.
- Photodynamic therapy (PDT). This treatment uses a light-sensitizing drug and laser to destroy the abnormal tissue. The benefit of PDT is that more data is available on its success. The drawbacks of PDT include pain after the procedure, risk of stricture (esophageal scarring), and need to avoid direct sunlight for four to six weeks.
Why come to the University of Maryland Medical Center?
One of the first centers in the world to use this treatment, the University of Maryland Medical Center remains a pioneer in the use and development of the CryoSpray ablation procedure. It was one of the first sites in the world to conduct clinical research to determine its effectiveness.
Bruce D. Greenwald, M.D., a UMMC gastroenterologist who was the lead investigator on CryoSpray ablation at UMMC, has performed this procedure on over 35 patients since the start of the program in April 2006.
UMMC gastroenterologists have 15 years of experience in treating Barrett's esophagus and see a large volume of patients with this problem. They work together with a multidisciplinary team of physicians — including thoracic surgeons, medical and radiation oncologists, and pathologists — to treat complicated cases.