RFA and Cyrotherapy for Esophageal Disease

Transcription

1 RFA and Cyrotherapy for Esophageal Disease Daniel L. Miller MD Chief, General Thoracic Surgery WellStar Healthcare System/ Mayo Clinic Care Network Clinical Professor of Surgery Medical College of Georgia/ Georgia Regents University

2 Barrett s Esophagus is Caused by Chronic GERD Endoscopic Image of a Normal Esophagus Chronic Injury Cancer risk fold increase Barrett s Esophagus % risk of cancer per year

3 Barrett s Ideal Treatment Endoscopic approach Remove all intestinal metaplasia; circumferential Uniform, reproducible, treatment depth Target depth muscularis mucosae No injury to submucosa or deeper structures Very low risk of complications No buried glands Quick and efficient; Re-treatment if required Prevent Cancer development

4 Techniques for Mucosal Ablation Thermal Argon plasma coagulation Lasers: Argon, Nd: YAG, KTP-YAG Radiofrequency Ablation (HALO 360) Chemical Photodynamic Therapy New Technology CSA CryoSpray Ablation

5 Ablation Technical Challenges Hand-held Point and Shoot Technically demanding Non-uniform ablation Uncontrolled power delivery Visual endpoint for completion Anatomy of distal esophagus not considered, its not round Repeat therapy is the rule

6 Human Esophagus Ablation Target Muscularis mucosae (Ablation Target Depth) HGD T1a T1b RFA Depth Submucosa with esophageal Submucosa glands with esophageal glands Muscularis laris propria propria EMR Depth CryoSpray Depth Surgical Depth

7 How Ablation with the HALO 360 System Works HALO 360 Ablation Catheter Balloon Based Bipolar Design Allows for 360 Degree Ablation of Targeted Tissue creating an even target W (10 to 12 J/S 2 ) 300 msec Eliminates Point and Shoot ; Energy Density and Ablation Depth Control of less than 1000 um - prevent strictures or perforations

8 Radiofrequency Ablation

9 Complete Response after HALO360

10 Efficacy and Durability of RFA for BE: Systematic Review and Meta-analysis Orman ES, Nan L, Shaheen NJ Clinic Gastroeneterol Hepatol 2013:25;1-11

11 Results 18 studies of 3802 patients reporting efficacy 6 studies of 540 patients reporting durability Compete eradication after RFA Intestinal metaplasia 78% (70-86%) of patients Dysplasia 91% (87-95%) of patients After eradication Intestinal metaplasia recurred 13% (9-18%) Progression to cancer 0.2% of patients during treatment 0.7% of patients after CE-IM Esophageal stricture 5% (3-7%) of patients Pain 3% (0-31%); Bleeding 1% (1-2%)

12 The Spray Cryotherapy Liquid Nitrogen (LN2) System

13 Spray Cryotherapy: The CSA System Energy Transfer Extreme Cold (-196 C) Liquid Nitrogen contacts tissue prior to phase shift Rapid transfer of Thermal Energy 25W of energy delivered to treatment site Cryogen - LN2 Continuous cryogen flow Broad and focal coverage Low pressure spray (< 5 psi at treatment site) of non-toxic cryogen No risk of fire Tissue Effect Treats over and through stents, mesh and other appliances Histological studies confirm preservation of stromal components

14 Spray Cryotherapy: Procedure Endoscope is introduced and treatment area is mapped out with team Placement of the Cryo Decompression Tube (CDT)

15 Spray Cryotherapy: Procedure Insert and advance catheter through the biopsy channel of the endoscope

16 Spray Cryotherapy: Catheters

17 Spray Cryotherapy: Procedure Initiation

18 The Spray Cryotherapy Liquid Nitrogen (LN2) System

19 Spray Cryotherapy: Procedure Courtesy Dr. Fukami from the University of Colorado

20 LN2 Spray Cryotherapy Depth of Injury Controlled by Three Variables: Length of tissue freeze time Number of freeze thaw cycles Amount of tissue targeted

21 Spray Cryotherapy for Barrett s Dysplasia: National CryoSpray Registry 96 patients (83% male); Two year follow-up (83%) HGD 67%, Long Segment BE 65% 321 treatments (mean 3.3 per patient); q 2-3 mos till No BE LGD CE-D 91%; CE-IM 61% HGD CE-D 81%; CE-IM 65% SSBE CE-D 97%; CE-IM 77% No perforations or deaths Stricture 1% Safe and effective modality for eradication of BE with LGD and HGD, particularly SSBE Ghorbani et al. Dis Esophagus 2015

22 Spray Cryotherapy for Esophageal Cancer 10 Sites - Retrospective case series for Esophageal Cancer N = 79 patients - All patients refused, failed, or were ineligible for conventional therapies. Previous Tx: EMR-27, PDT-11, XRT-7, Chemo/XRT-9, Chemo/XRT/Surgery-2, Concurrent XRT-12, Chemo-1, Stent-1, RFA-1, Concurrent EMR-9 Mean age of 76 years; 72% men Mean tumor length 3.7cm (T1= 60, T2 =16, T3 = 2, T4 =1) ~11 month average follow up Median of 3 Cryo Tx sessions Treatment complete for 44 patients CR- CA = 70.5%; CR-HGD = 68.2%, CR-D = 59.1% Before Adenocarcinoma 82 year-old T1sm After Before During 1 Year After Squamous Carcinoma BD Greenwald et al.: DDW 2009 (10 Centers)

23 Current Management of BE/HGD/CA RFA/CryoSpray Summary Individualize pt? Endoscopic Tx First line Multidisciplinary approach - Cost/Time/QOL GI Medicine Surgery Pathology Preventive Medicine Work-up EGD, EUS, Motility study, 24 hr ph study, Path review Patient education Long-term Follow-up GERD control; EGD surveillance; Risk factors for cancer