Harris Spencer, Fasullo Matt, Smallfield George, Shah Tilak
Department of Internal Medicine, Virginia Commonwealth University Health System, Richmond, Virginia.
Department of Internal Medicine, Division of Gastroenterology, Hepatology, and Nutrition, Virginia Commonwealth University Health System, Richmond, Virginia.
VideoGIE. 2021 Mar 4;6(5):239-242. doi: 10.1016/j.vgie.2021.01.002. eCollection 2021 May.
Gastric intestinal metaplasia with dysplasia (GIM-D) that is visible as a discrete limited lesion on endoscopy is readily treated using endoscopic mucosal resection or endoscopic submucosal dissection. However, there are few options for more extensive and invisible dysplasia. Ablating a wide swath of tissue with argon plasma coagulation or radiofrequency ablation can be challenging and carries risks, including postprocedure ulceration. Liquid nitrogen spray cryotherapy is an established treatment for dysplasia in Barrett's esophagus, but its use for GIM-D has not been previously reported.
Three patients with intramucosal adenocarcinoma and GIM-D underwent a total of 10 sessions of spray cryotherapy. In all cases, spray cryotherapy was performed after passing an orogastric decompression tube into the stomach for active suctioning. Ablations were performed in cycles of 20 to 40 seconds, with at least 45 seconds between cycles to allow for tissue thawing. Between 2 and 7 ablations were performed during each procedure. Before each procedure, Sydney protocol biopsy specimens were obtained. No patient reported any postprocedure adverse events.
The first patient underwent 3 sessions of spray cryotherapy; there was no evidence of GIM-D after 1 session, no evidence of gastric intestinal metaplasia after 3 sessions, and no recurrence after 29 months. The second patient underwent 5 sessions of spray cryotherapy; after 1 session there was no adenocarcinoma, and at 14 months there was only GIM-D. The third patient underwent 2 spray cryotherapy sessions, and after 1 session there was gastric intestinal metaplasia but no GIM-D.
Very few treatment modalities exist for extensive GIM-D. We present 3 cases in which off-label spray cryotherapy was used to treat extensive high-grade dysplasia with good treatment effect and patient tolerance. This adds to the body of literature supporting spray cryotherapy as a safe, well-tolerated, and effective treatment for extensive GIM-D.
在内镜检查中表现为离散局限性病变的伴有发育异常的胃肠化生（GIM-D），可通过内镜黏膜切除术或内镜黏膜下剥离术轻松治疗。然而，对于范围更广且不可见的发育异常，治疗选择很少。用氩离子凝固术或射频消融术大面积消融组织具有挑战性且存在风险，包括术后溃疡。液氮喷雾冷冻疗法是治疗巴雷特食管发育异常的既定方法，但此前尚未报道其用于GIM-D的情况。
3例黏膜内腺癌合并GIM-D患者共接受了10次喷雾冷冻治疗。在所有病例中，在将鼻胃减压管插入胃内进行主动抽吸后进行喷雾冷冻治疗。消融以20至40秒为一个周期进行，周期之间至少间隔45秒以使组织解冻。每次治疗期间进行2至7次消融。在每次治疗前，获取悉尼系统活检标本。没有患者报告任何术后不良事件。
首例患者接受了3次喷雾冷冻治疗；第1次治疗后没有GIM-D的证据，第3次治疗后没有胃肠化生的证据，29个月后无复发。第2例患者接受了5次喷雾冷冻治疗；第1次治疗后没有腺癌，14个月时仅有GIM-D。第3例患者接受了2次喷雾冷冻治疗，第1次治疗后有胃肠化生但没有GIM-D。
对于广泛的GIM-D，治疗方式非常有限。我们报告了3例使用超适应证喷雾冷冻疗法治疗广泛高级别发育异常的病例，治疗效果良好且患者耐受性良好。这增加了支持喷雾冷冻疗法作为一种安全、耐受性好且有效的广泛GIM-D治疗方法的文献资料。
