The Spray Cryotherapy Esophageal Consortium has developed a set of expert and evidence-based consensus recommendations guiding the use of liquid nitrogen spray cryotherapy in Barrett's esophagus and esophageal cancer. The recommendations, decided upon through a modified Delphi process, were published in The American Journal of Gastroenterology.
“Our goal is to ensure the safe and effective application of this cryotherapy technique,” said principal investigator Tilak Shah, MD, Medical Director in the Department of Gastroenterology, Hepatology, and Nutrition, Ellen Leifer Shulman & Steven Shulman Digestive Disease Center, Cleveland Clinic Weston Hospital.
“We felt the best way to answer some [persisting] questions [about the use of this technique] was to gather a group of experts and use a modified Delphi consensus process to draw on everyone's collective experience,” Dr. Shah explained. “The subsequent recommendations will support the use of spray cryotherapy in clinical practice and promote the future trials needed to deliver high-level evidence on which to base national guidelines.”
Background and Study Methods
Although liquid nitrogen spray cryotherapy has been used in clinical practice for almost 20 years, there are many remaining questions about how the technique should be used to treat patients with Barrett's esophagus and esophageal cancer. Many of these questions were asked during the 2024 Digestive Disease Week meeting, which led to the formation of the Spray Cryotherapy Esophageal Consortium.
A systematic literature review was conducted to introduce statements for members of the Consortium to review and decide upon. A multidisciplinary panel of 19 experts from the Consortium participated in anonymous surveys for the modified Delphi process. The panel grouped statements into categories and two investigators assessed the strength of the evidence for each statement. They then tried to reach consensus on the statements whereby any statement with agreement of over 80% was edited slightly until the panel could reach unanimous agreement. If the agreement was under 80%, the statement was largely modified and re-introduced in the next round of Delphi surveys. If no consensus was reached after three rounds of feedback, the statement was rejected.
Recommendation Statements
After three rounds of the Delphi process, 41 out of 42 statements were accepted either as originally submitted (n = 11) or after modifications (n = 30). The resulting consensus statements included 8 statements on indications, 3 on trainings, 6 on pre-procedure considerations, 15 on intraprocedure recommendations, 3 on postprocedure recommendations, 2 on frequency and timing, and 4 on discontinuation and contraindications for liquid nitrogen spray cryotherapy use in Barrett's esophagus and esophageal cancer.
An area where panelists unanimously agreed quickly was regarding the frequency of cryotherapy. The statements note that liquid nitrogen spray cryotherapy should be repeated every 2 to 3 months for Barrett's esophagus, and at least two sessions should be considered within a 3-week period as initial intensive therapy for bulky esophageal cancers.
One topic that the panel could not come to a consensus on, however, was whether biopsies could be performed in the same session as cryotherapy. “Some of the survey participants expressed concerns about the risk of complications, such as nitrogen gas dissecting through biopsy sites,” Dr. Shah said.
Dr. Shah is currently planning for a proposed phase II trial examining the addition of cryotherapy to standard chemotherapy in patients with newly diagnosed, locally advanced esophageal cancer, and he noted that grants and plans for the trial have been made easier with the set of published consensus statements on the use of liquid nitrogen spray cryotherapy.
DISCLOSURE: For full disclosures of the study authors, visit journals.lww.com.
