Safety and efficacy of carbon dioxide cryotherapy for treatment of neoplastic Barrett's esophagus

Background and study aims: Endoscopic cryotherapy has been used successfully for the ablation of Barrett's esophagus but outcome data are limited. The aim of this study was to assess the long-term safety and efficacy of carbon dioxide (CO2) cryotherapy as primary or rescue treatment for Barrett's esophagus with high grade dysplasia (HGD) or neoplasia. Patients and methods: This was a retrospective, single-center, nonrandomized study carried out in an academic, tertiary care center and affiliated community hospital. A total of 78 patients with neoplastic Barrett's esophagus who had not undergone previous ablation (treatment-naive group) or who had persistent or recurrent neoplasia despite previous treatment (rescue treatment group) were enrolled. Visible Barrett's lesions, when present, were removed by endoscopic mucosal resection, which was followed by CO2 cryotherapy until neoplasia had been eradicated, or intervening therapy was necessary, or treatment was considered to have failed. Surveillance biopsies were obtained at standard intervals. Rates of complete response for cancer, HGD, and intestinal metaplasia were calculated. Treatment failure, recurrence, adverse events, progression, and mortality were also recorded. Results: Between 2006 and 2013, 64 evaluable patients (20 treatment naive, 44 rescue treatment) were treated and followed up (median time 4.2 years). At 1 year, the overall complete response rates were 77% for cancer (10/13), 89% for dysplasia 57/64), 94% for HGD (60/64; 100% for treatment naive, 91% for rescue treatment), and 55% for intestinal metaplasia (35/64). Long-term complete response for neoplasiawith rescue therapy was 87% (56/64). Disease-specific mortality was 1/68 (2 %). Treatment failed to eradicate neoplasia in four patients (6 %) (all in the rescue group). Recurrent or new intestinal metaplasia was detected in 20/64 (31 %) after two negative follow-up procedures. Serious adverse events were noted in two patients (3 %). Post-cryotherapy pain occurred in four patients (6 %; only two needed analgesics). No bleeding or new strictures were noted. Buried Barrett's was detected in 5/68 patients (7 %). Conclusions: CO2 cryotherapy was a safe and effective primary curative or rescue therapy for Barrett's neoplasia.