Neil Sengupta, MD, from the Department of Medicine and Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, in Boston, Massachusetts, USA describes this Original Article, “Salvage cryotherapy after failed radiofrequency ablation for Barrett’s esophagus–related dysplasia is safe and effective.”
Radiofrequency ablation (RFA) is an effective and durable treatment option for patients with Barrett’s esophagus (BE) dysplasia. Liquid nitrogen spray cryotherapy has also been shown to be effective as a primary treatment option for patients with BE dysplasia. However, there is limited data on endoscopic therapies for the subgroup of patients who are refractory to RFA. Our aims were to report the results of RFA in our cohort of patients with BE dysplasia, and to demonstrate the safety and efficacy of salvage cryotherapy in BE dysplasia that was refractory to RFA.
Although RFA is a valuable technique to eliminate BE dysplasia, a subgroup of patients are treatment-refractory. Although surgical therapy is an option, many patients either decline surgical intervention or are not appropriate surgical candidates. There is limited data on the success of cryotherapy as a salvage therapy for patients failing RFA. We felt it was important to describe the success as well as the rate of adverse events associated with salvage cryotherapy in this higher risk population.
Of the 121 patients undergoing RFA for BE dysplasia (55% with high-grade dysplasia), 75% had complete eradication of dysplasia (CE-D). Sixteen patients (14 who had persistent dysplasia after RFA and 2 with recurrent dysplasia after RFA) were offered cryotherapy and had appropriate endoscopic follow up. After cryotherapy, 75% of patients had CE-D, although the rate of eradication of intestinal metaplasia (IM) was only 31%. Three patients developed strictures that were responsive to dilation.
This is the first report of cryotherapy as a salvage treatment option for patients who are not responsive to RFA. We demonstrate that cryotherapy is feasible and safe in eradication of dysplasia in this high risk population who fail RFA. However, further research is needed to demonstrate the efficacy of cryotherapy versus other endoscopic modalities such as endoscopic mucosal resection in eradication of both dysplasia and IM for patients who fail RFA. In addition, long term endoscopic follow-up is needed to describe the recurrence rate of both IM and dysplasia following salvage cryotherapy.
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