Procedures

Cryotherapy Treatment for Barrett’s Esophagus

Cryotherapy is an FDA-approved endoscopic technique used by specialists at the Massachusetts General Hospital Barrett’s Esophagus Treatment Center to treat Barrett’s esophagus.

Cryotherapy is an FDA-approved endoscopic technique in which diseased tissue is exposed to extremely cold temperatures and destroyed. Specialists at the Massachusetts General Hospital Barrett's Esophagus Treatment Center offer cryotherapy to treat Barrett's esophagus.

Cryotherapy was first used to treat Barrett's esophagus in 1991, and first reported in a group of Barrett's patients in 2005. Since then, several studies have shown the safety and efficacy of cryotherapy for Barrett’s esophagus with dysplasia, a precancerous stage. These studies have demonstrated successful destruction of dysplasia in more than 90% of patients undergoing therapy.

Gastroenterologists at the Mass General Barrett's Esophagus Treatment Center have been performing cryotherapy since 2007 and have performed hundreds of successful cryotherapy procedures.

How Does Cryotherapy Work?Cryotherapy for Barrett’s esophagus is performed on an outpatient basis by a gastroenterologist. Under the care of an anesthesiologist, the patient will receive either deep sedation or general anesthesia. During cryotherapy a thin, flexible tube (endoscope) is inserted through the mouth and into the esophagus, the tube that connects the mouth to the stomach. The tip of the flexible scope has a lens and a light source, which allow images to be sent to a monitor for close inspection of the lining of the upper gastrointestinal tract.

The most common cryotherapy technique uses an endoscope to spray the diseased tissue, with liquid nitrogen, similar to how dermatologists “freeze off” skin warts. Liquid nitrogen is a clear, colorless liquid with a temperature of −196 °C (−321 °F). When exposed to these temperatures, the abnormal tissue is ablated.

Because liquid nitrogen rapidly evaporates into a gas when it reaches body temperature, a small suction tube is placed into the stomach to remove this gas and prevent the stomach from over-expanding. This tube is removed at the end of the procedure.

Cryotherapy is performed at Mass General in Boston. The procedure typically takes 25 to 35 minutes.

What Preparation is Required Before Cryotherapy?

Cryotherapy

Endoscopic image demonstrating Barrett’s esophagus being treated with cryotherapy. Note the cryotherapy catheter (right) and the decompression tube (left) placed into the stomach to vent the gas produced by cryotherapy

Patients with high-grade dysplasia or intramucosal carcinoma (the earliest stage of esophageal cancer) often undergo an endoscopic ultrasound exam before undergoing resection to ensure there is no deeper tissue involvement.
 
The patient will be asked not to eat or drink anything after midnight the night before the procedure. If the patient takes daily medication in the form of a pill, he/she may take it with sips of water the morning of cryotherapy.What is the Recovery Time and Follow-up?Patients are discharged from the Mass General endoscopy unit with prescriptions for oral pain medications and an oral numbing solution they may use for five to seven days.

A modified diet is recommended for the first three days after the procedure to allow time for healing. Patients may return to work the day after the procedure.

All patients with Barrett’s esophagus will also be treated with high-dose antacids (typically in the proton pump inhibitor family) indefinitely. A low-acid environment helps the body replace the removed tissue with normal tissue (squamous mucosa). Patients will remain in a surveillance program indefinitely to ensure that the Barrett’s mucosa, or diseased tissue, does not recur.

For most patients, one to five cryotherapy treatment sessions are required to remove all of the Barrett’s mucosa.
 
Patients who are treated with cryotherapy return for a follow-up endoscopy in two to three months to ensure they are healing properly and to determine if additional treatment is required.

How Safe is the Procedure?

Cryotherapy

Endoscopic image showing an area just treated with cryotherapy. The white area is frozen Barrett's mucosa

Cryotherapy is a safe and well-tolerated procedure. However, about 10% of patients may have chest pain following the procedure.

About 5% of patients may develop narrowing of the esophagus (known as a stricture) as a result of cryotherapy and may require one or more procedures to stretch the esophagus (known as dilations) to treat this. Strictures are more common in patients who have had previously undergone endoscopic mucosal resection (EMR).

Major complications are very uncommon (occur in less than 1% of patients), but may include bleeding or perforation of the esophagus or stomach.
What other Ablation Procedures are Available? The Mass General Barrett’s Esophagus Treatment Center also performs radiofrequency ablation (RFA), an FDA-approved ablation procedure that uses heat energy to destroy diseased tissue.

Presently, there are no studies comparing the efficacy of cryotherapy with RFA to treat dysplasia due to Barrett's esophagus. A number of factors go into deciding which form of ablation is recommended for an individual patient. These include anatomic factors, co-existing medical conditions and patient preference. Some patients who are treated with one form of therapy may be transitioned to the other form of ablation based upon tolerance, side effects and effectiveness of the treatment.

 

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