This ASG video tip is sponsored by Braintree, maker of the newly approved Soufflave and Soutab. Hi, I'm Tofi Kishami, I'm the chief of medicine and director of gastroenterology at City of Hope in Phoenix, Arizona. Hello, I'm Joe Solomon, assistant professor and gastroenterologist at City of Hope in Phoenix. Thank you for joining us for this video. This video will discuss liquid spray nitrogen cryotherapy applied endoscopically in cases of esophageal cancer. With over 500 procedures under our belt in our institution, we hope to share some pearls of experience and tips and tricks. In this effective multi-center study, endoscopic spray cryotherapy with concurrent chemotherapy were associated with improvement in dysphagia and quality of life symptoms that are specifically related to inoperable esophageal cancer. Here's our approach to performing endoscopic spray cryotherapy in these cases. We begin by assessing the location and topography of the lesion. We note the length and the distance of the lesion from the incisors. We map out and prioritize treating the most obstructive aspects of the tumor. We take every opportunity to suction and clear the field of liquid. Here we confirm the tightest or most obstructive part of the tumor. We continue to suction the stomach of fluid and the stent of carbon dioxide. Retroflexion identifies no target distal to the G-junction. Continuous suction in the field is important to avoid inadvertent freezing of fluid once it is time to apply cryotherapy. The G-junction location is again confirmed as this will affect the placement and adequate function of the ventilation tube. A flexible tip guide wire is placed. The assistant helps in withdrawing the scope while the endoscopist keeps the guide wire in stable position. Once the scope is extracorporeal, the guide wire is visible and held by the assistant to ensure its stable position. The endoscopist takes over withdrawing the scope from the guide wire. The endoscopist suctions 70% alcohol for a few seconds to further help dehydrate the instrument channel. Next, the venting tube is advanced over the guide wire for placement. Note that the guide wire continues to be stabilized, and it will remain within the venting tube until the final position. An introducer is placed into the scoped instrument channel to allow for smooth insertion of the spray catheter. The catheter is advanced along the length of the scope, but retracted into the tip of the scope so as to keep it protected upon scope insertion. Often because of tumor stenosis, adjusting the position of the venting tube independent of the scope can be challenging. A solution is to maneuver both the scope shaft and the venting tube as a single human. Here the endoscopist is gently torquing both the scope and the venting tube to advance beyond the most stenosed area. Once the venting tube is in the appropriate position, the scope can be withdrawn with gentle back and forth torquing, while the assistant stabilizes the venting tube. Because liquid spray nitrogen rapidly expands upon application, our goal is to ensure that the stomach is adequately decompressed by suction through the venting tube. This is accomplished by ensuring that the marks on the venting tube are at or slightly beyond the GE junction. Once everything is in position, the guide wire is removed and continuous decompression via suction is turned on. The spray catheter tip is advanced 2 to 3 millimeters into view and cryotherapy is applied by a continuous step on the pedal. We target treatment of no more than 2 centimeters at a time, with special attention on the areas with the most obstruction. We apply constant low to medium flow CO2 to help maintain visibility and minimize the chance of the lens freezing. Once the target treatment area, in this case the bottom left half of the field, is frozen, we continue treatment for 30 seconds. The scope is gently and carefully rotated back and forth to allow for an adequate treatment field. This also helps minimize the risk of the catheter contacting and potentially adhering to the tissue. As cryotherapy is applied, we avoid using the scope buttons to suction through the scope or clean the lens. As mentioned, we prefer a constant flow of CO2 to help maintain endoscopic visibility. After 30 seconds of freezing, we stop the application of liquid spray nitrogen to allow the tissue to thaw. With constant CO2 and sufflation, this takes about 1 to 2 minutes, depending on the quality of the freeze. Rather than stick to an absolute time frame, we prefer to observe a complete thaw, as this optimizes the immediate effects of cryotherapy via fluid shifts that potentiate the disruption of the cell membranes. As soon as the tissue thaws, we immediately start the next cycle of cryotherapy, as will be shown in the on-medical segment. At this juncture, we would like to share our approach to dealing with endoscopic visibility issues. Not uncommonly, despite all the precautions described, the lens may get frozen during cryotherapy application. This can interfere with endoscopic visualization, but often the peripheral visual field is preserved and can offer clues and reassurance that the catheter and scope are not stuck on the tissue while treatment is ongoing. The constant insufflation with the relatively warm CO2 helps preserve the peripheral visual field and restore endoscopic visibility. So in a treatment session, each site is treated with three freeze-thaw cycles in succession. To avoid disrupting a treatment cycle, we take the opportunity to clean our devices in between treatment sessions. Sometimes, the scope may get stuck on the tissue due to a frozen layer of liquid between the scope and esophageal tissue. This typically melts as the tissue thaws. If, however, after a complete thaw the scope is still stuck, defrosting the catheter helps melt that layer to free the scope. Since the tissue has thawed, this should not affect the efficacy of freeze-thaw cycles of the treated site. Defrosting also helps free the catheter from the channel and allows it to be gently advanced and withdrawn to mechanically clear debris in the channel. We use an alcohol pad to both clean and dehydrate the scope lens and catheter. When done methodically, this process takes about two minutes in total and doesn't compromise procedure efficiency or efficacy. Further treatment can be set and undertaken as necessary. At the completion of a treatment session, the catheter can be removed from the scope and the venting tube can be withdrawn from the patient. Examining the treated sites may show minimal improvement in stenosis, but we'll often see hyperemia in treated areas, which reflects vasodilation and return of microcirculation reversing the vasoconstriction that would have occurred with cryotherapy. This reversal contributes to the immediate and delayed effects of cryotherapy on tissue ablation. Next, we would like to present a real patient's case, who we followed for several months, undertaking cryotherapy and chemotherapy. This should give you an idea of what to expect when you're using this technology in associated cancer patients. A 58-year-old female presented with dysphagia for two months. On initial endoscopy, she was found to have a tumor involving the GE junction and ranged from 29 to 40 centimeters from the incisors. Biopsy showed adenocarcinoma. Her esophagus was nearly obstructed in one area. You see the appearance now on retroflexion. On PET scan, she had a cervical lymph node that lit up, and biopsy was positive. In terms of symptom assessment, on a score from 0 to 4, where 0 indicates no dysphagia and 4 is severe difficulty swallowing, she scored at 4. One quality of life assessment score that is used is the European Organization for Research and Treatment of Cancer score, EORTC. The esophageal-specific questionnaire has 18 questions with a total score ranging from 18 to 72, with higher indicating worse quality of life. The patient initial score was 44. A multidisciplinary decision was made to pursue systemic treatment with FALFOX and concurrent cryotherapy for palliation. There were three major areas that were narrowed, and these were the areas that we focused on during our treatment. This is the appearance of her esophagus immediately after the first cryo-treatment with the typical red changes. This is the appearance again, typically seen after treatment, after the second session. And after the third session, you can see significant improvement in the appearance of her esophagus and the cardiac. In two months, and a total of four treatments in addition to systemic therapy, her quality of life score almost normalized and her dysphagia completely resolved. And you see the progression on these images from left to right. She had a stable disease initially until around a year when she had disease progression on imaging and mild worsening in her symptoms, both in terms of quality of life and dysphagia score went up to 1. Her chemotherapy was switched to a new regimen and the patient requested repeat cryotherapy. This is the appearance of her esophagus before cryotherapy at that time. You can see that the pattern of progression is different, especially in the area where she received cryotherapy. Eventually the patient has further progression with multiple liver mets and ascites and she elected hospice. She didn't request to have one more cryo-treatment before she went to hospice. In summary, this patient survived 20 months after her diagnosis. She received a total of six cryotherapy treatments in addition to her systemic therapy. Throughout her treatment, she sustained an improvement in her dysphagia with a score ranging from 0 to 1. She also was able to avoid esophageal stenting and feeding tube placement. After we've shared with you our tips and tricks for performing cryotherapy successfully for esophageal cancer, we're going to show you unedited videos so you know exactly how it's done. This video was made with the help of Dr. Marco Paret Free course on www.mesmerism.info Learn more on our channel!

endoscopic spray cryotherapy

esophageal cancer

chemotherapy

dysphagia improvement

quality of life