Fadlallah Habr

Safety and efficacy of endoscopic spray cryotherapy for Barrett's dysplasia: results of the National Cryospray Registry

Retrospective series have shown the efficacy of endoscopic spray cryotherapy in eradicating high-grade dysplasia (HGD) in Barretts esophagus (BE); however, prospective data are lacking, and efficacy for low-grade dysplasia (LGD) is unclear. The aim of this study was to assess the efficacy and safety of spray cryotherapy in patients with LGD or HGD. A multicenter, prospective open-label registry enrolled patients with dysplastic BE. Spray cryotherapy was performed every 2-3 months until there was no endoscopic evidence of BE and no histological evidence of dysplasia, followed by surveillance endoscopies up to 2 years. Primary outcome measures were complete eradication of dysplasia (CE-D) and complete eradication of all intestinal metaplasia (CE-IM). Ninety-six subjects with Barretts dysplasia (67% HGD; 65% long-segment BE; mean length 4.5 cm) underwent 321 treatments (mean 3.3 per subject). Mean age was 67 years, 83% were male. Eighty patients (83%) completed treatment with follow-up endoscopy (mean duration 21 months). In patients with LGD, rate of CE-D was 91% (21/23) and rate of CE-IM was 61% (14/23). In HGD, CE-D rate was 81% (46/57) and CE-IM was 65% (37/57). In patients with short-segment BE (SSBE) with any dysplasia, CE-D was achieved in 97% (30/31) and CE-IM in 77% (24/31). There were no esophageal perforations or related deaths. One subject developed a stricture, which did not require dilation. One patient was hospitalized for bleeding in the setting of non-steroidal anti-inflammatory drug use. In the largest prospective cohort to date, data suggest endoscopic spray cryotherapy is a safe and effective modality for eradication of BE with LGD or HGD, particularly with SSBE.

Predictors of gastroesophageal reflux symptoms in pregnant women screened for sleep disordered breathing: A secondary analysis

BACKGROUND Gastroesophageal reflux disease (GERD) is common in pregnancy. The cause is multifactorial, including a decreased or transient lower esophageal sphincter relaxation, increased intra-abdominal pressure, and gastrointestinal motility disturbances. AIMS Evaluate the incidence of GERD in pregnancy and assess predictors and predisposing factors. METHOD This is a secondary analysis of a survey of postpartum women regarding symptoms of sleep disordered breathing (SDB) and GERD performed at a large tertiary care center. Patients rated heartburn frequency during pregnancy as either never, occasionally/sometimes, or frequently/always. Pregnancy outcomes and newborn information was collected. Categorical variables were compared by Fishers exact test and continuous variables were compared by Anova or Kruskal-Wallis test. Multinominal logistic regression was also performed. RESULTS Information regarding 1000 mothers and 1025 newborns was reviewed. The majority of mothers were Caucasian (68.8%) with mean age 29 ± 6.1 years. A total of 56.7% had GERD frequently/always; and 25.5% had none. GERD symptoms correlated with pre-pregnancy body mass index (BMI), BMI at delivery, maternal age, smoking and symptoms of SDB. There was no significant correlation between fetal weight and maternal weight gain with GERD symptoms. Symptoms were more frequent in white non-Hispanic women than in other racial groups. CONCLUSIONS This study suggests that GERD symptoms correlate with pre-pregnancy BMI and BMI at delivery, but not with the amount of weight gain during pregnancy. Maternal age, smoking, race, and SDB are also associated with GERD. Interestingly, fetal weight/uterine size did not seem predictive of developing GERD in pregnancy.

Review of Tracheostomy Usage: Complications and Decannulation Procedures. Part II

Althoughcreationofatracheostomydoesfacilitatesuctioningoftheairwayandoften simplifies usage of mechanical ventilation (as discussed in Part I), numerous complications can occur. Some occur immediately after tracheostomy placement (e.g., bleeding, laryngealnervedamage,andpneumomediastinum)andothersduringlong-term follow-up (e.g., tracheoesophageal fistula, tracheal stenosis, tracheomalacia, swallowingdysfunction,andaspiration).Therefore, ineachpatient inwhomthisprocedureis performed, the potential long-term risks and possible benefits must be carefully weighed. Insomepatients, tracheostomyusagewillbeneededonalife-longbasis. In others, once the primary process that led to the placement of the tracheostomy is reversed or when alternative noninvasive measures are thought to be adequate, decannulation should be contemplated. However, the procedure of decannulation andthetimingshouldbeindividualized.Someguidelinesareprovidedinthisarticle and are based, when possible, on objective data. For many of the issues regarding tracheostomy usage (e.g., timing of decannulation, best decannulation approach, and best approach to dealing with swallowing dysfunction induced by tracheostomy), additional studies are needed to objectively define the best therapeutic approaches.

Safety and efficacy of endoscopic spray cryotherapy for esophageal cancer

Although surgery is traditionally the standard of care for esophageal cancer, esophagectomy carries significant morbidity. Alternative endoscopic therapies are needed for patients who are not candidates for conventional treatment. The objective of this study is to assess the safety, efficacy, and tolerability of spray cryotherapy of esophageal adenocarcinoma. This study includes patients with esophageal adenocarcinoma who had failed or were not candidates for conventional therapy enrolled retrospectively and prospectively in an open-label registry and patients in a retrospective cohort from 11 academic and community practices. Endoscopic spray cryotherapy was performed until biopsy proven local tumor eradication or until treatment was halted due to progression of disease, patient withdrawal or comorbidities. Eighty-eight patients with esophageal adenocarcinoma (median age 76, 80.7% male, mean length 5.1 cm) underwent 359 treatments (mean 4.4 per patient). Tumor stages included 39 with T1a, 25 with T1b, 9 with unspecified T1, and 15 with T2. Eighty-six patients completed treatment with complete response of intraluminal disease in 55.8%, including complete response in 76.3% for T1a, 45.8% for T1b, 66.2% for all T1, and 6.7% for T2. Mean follow-up was 18.4 months. There were no deaths or perforations related to spray cryotherapy. Strictures developed in 12 of 88 patients (13.6%) but were present before spray cryotherapy in 3 of 12. This study suggests that endoscopic spray cryotherapy is a safe, well-tolerated, and effective treatment option for early esophageal adenocarcinoma.

Current state of endoscopic therapies in Barrett's esophagus and esophageal cancer.

Abstract Barretts esophagus (BE) is a premalignant condition that predisposes patients to esophageal adenocarcinoma. This risk increases with increasing dysplasia, especially in patients with BE and high-grade dysplasia. Radical esophagectomy had long been the only option for these patients; however, it has been associated with significant morbidity and mortality. Endoscopic therapies have been increasingly used as an alternative to radical esophagectomy given the minimally invasive nature and tolerability of the procedure relative to surgery. Currently, the most widely used endoscopic therapies include endoscopic mucosal resection, photodynamic therapy, CryoSpray ablation, and radiofrequency ablation. Retrospective and prospective studies on the use of each of these modalities in patients with nondysplastic BE, dysplastic BE, and early esophageal cancer have demonstrated their effectiveness in eradication of dysplasia with or without reversion of Barretts epithelium to normal squamous epithelium of the esophagus. These modalities are well tolerated, safe, and have few side effects. Ultimately, more research is needed regarding their ability to fully displace surgical intervention as the gold standard, although at this point their role in poor operative candidates or patients seeking conservative approaches remains promising.

Review of Tracheostomy Usage: Types and Indications. Part I

The use of tracheostomy tubes has become common practice in the last few decades. Early in the twentieth century, tracheostomy tubes were being placed almost exclusively for acute or impending upper airway obstruction. Indications for their placement have now become much broader and include, but are not limited to, mechanical ventilation, both in the setting of prolonged translaryngeal intubation and chronic progressive respiratory insufficiency, as occurs in neuromuscular diseases, excessive pulmonary secretions and airway suctioning, and sleep apnea. There are various types of tracheostomy methods described. Percutaneous dilational tracheostomy can now be performed at the bedside with or without bronchoscopic guidance, with a low complication rate in experienced hands. Minitracheostomy has been used in postoperative situations where airway secretions are excessive. Cricothyrotomy is the procedure of choice in emergency situations. Alternative, less-invasive measures to tracheostomy are widely available. These are used in different clinical settings and include: (1) the use of noninvasive ventilation in weaning after acute respiratory failure, (2) noninvasive ventilation in chronic respiratory failure with a special emphasis on neuromuscular weakness, and (3) noninvasive cough assistance devices in patients with excessive airway secretions.

Intermittent Esophageal Dysphagia: An Intriguing Diagnosis

Gastroen Question: A 68-yearold man presented with intermittent dysphagia to solids of 5 years’ duration. He denied any associated weight loss, melena, or chest pain. Physical examination was within normal limits with no pallor or lymphadenopathy. Laboratory studies, including a chemistry panel, complete blood count and liver functions were unremarkable. He underwent a barium swallow which is shown below (Figure A). On upper endoscopy, there was a bulge in the mid-esophageal region (Figure B, arrow), suggestive of an extrinsic compression with normal looking gastric and esophageal mucosa. After this, computed tomography (CT) of the chest with intravenous contrast was performed. What is the likely diagnosis? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.

Now You See It, Endo You Don't: Case of the Disappearing Knife

Question: A 32-year-old woman with a psychiatric history of compulsive foreign body ingestions resulting in multiple upper endoscopies and retrievals, presented to the emergency room after swallowing a butter knife approximately 10 hours earlier. Chief symptoms included an inability to rotate her neck, odynophagia, and chest pain. Vital signs revealed an afebrile normotensive patient with a heart rate of 140 bpm. Physical examination of her oropharynx evealed no gross lesions or signs of trauma, crepitus, or palpable mass in the neck. Abdominal examination was unrevealing for epigastric enderness, rebound, or guarding. Laboratory data was unremarkable. Radiographic imaging performed in the ED suggested a knife that was ocated in the hypopharynx and esophagus (Figure A). An upper endoscopy was unable to locate the foreign body in esophagus or identify any igns of trauma or perforation (Figure B). Furthermore, both the stomach and duodenum were within normal limits. Bronchoscopy performed lso was unable to reveal the location of the knife. What should be the next step taken to confirm the diagnosis? See the GASTROENTEROLOGY web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.

Spray Cryotherapy for Palliation of Locally Advanced Adenocarcinoma in Barrett's Esophagus

152 Background: Up to 60% of patients with esophageal cancer are deemed inoperable at the time of diagnosis due to either advanced stage or significant co-morbidities. Currently, endoscopic palliative measures include stenting and photodynamic therapy. Although spray cryotherapy has been successfully used in ablating Barretts esophagus, and different grades of dysplasia, there has been only one published case describing complete remission of squamous cell carcinoma following cryoablation. We present the first case of the use of the CryoSpray Ablation System (CSA Medical, Baltimore, MD) for palliative treatment of an esophageal T3 adenocarcinoma in an elderly woman with dysphagia and weight loss. METHODS An upper endoscopy was performed with standard monitored anesthesia. A special dual lumen Cryo decompression tube is introduced over an endoscopically placed savary guidewire in the gastric antrum and connected to suction. This tube is used to decompress the stomach when the liquid nitrogen is sprayed. Cryoablation is performed using the CryoSpray Ablation System that uses liquid nitrogen is delivered via a 7 Fr catheter at low pressures (2-3 PSI) at -196°C.The lesion was treated with four freeze cycles of 10-20 seconds each with 60 second interim thaws. Freezing and thawing techniques were monitored by direct visualization. The procedure is repeated every 4-6 weeks. The patient received a total of 7 treatments over 10 months. RESULTS The patient did not experience any adverse effects after treatment. After 3 treatments (week 20), complete endoscopic resolution of the lesion was noted, with regression of the Barretts mucosa and major improvement of her dysphagia. At week 28, a recurrent mass was seen on EGD in the mid-esophagus. This was treated with 3 sessions of spray cryotherapy at 4 week intervals with improvement of dysphagia after each application. 11 months after her initial cryotherapy, the patient opted to have an esophageal stent due to tumor progression. CONCLUSIONS Spray cryotherapy is a safe and effective endoscopic modality for the ablation of Barretts esophagus and superficial esophageal cancer, it is a promising new modality for the palliation of advanced esophageal cancer. No significant financial relationships to disclose.