Spray Cryotherapy for Management of an Anastomotic Esophagojejunal Stricture

{"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"","caption":"","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_76493li1"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} CASE REPORT Spray cryotherapy uses liquid nitrogen to freeze and destroy tissue and is used for esophageal cancer and Barrett esophagus.1–3 Its use for benign strictures is mostly only reported in small case reports or series.4,5 Because liquid nitrogen expands up to 700 times as it evaporates, a venting tube must be placed to remove gas to prevent excessive intraluminal pressure.3 Limited data exist in its safety and efficacy in patients without a stomach to accommodate gaseous distension. We present a unique case of a successful spray cryotherapy-assisted dilation for refractory esophagojejunal stricture. A 70-year-old woman with total gastrectomy and esophagojejunal anastomosis presented with severe dysphagia from an anastomotic stricture (Figure 1) requiring nasojejunal tube feeds. An adult gastroscope was never able to traverse through despite 5 prior dilations with steroids. An ultrathin gastroscope traversed stricture to place a ventilation tube in jejunum. Liquid nitrogen cryogen was then applied for 20 seconds with frosting effect for 2 cycles (Figure 2). The stricture was dilated gradually in a stepwise fashion to 15 mm (Figure 3), with tissue disruption and improved luminal patency (Figure 4). Throughout the procedure, the patient's abdomen was closely monitored for distension. The patient tolerated the procedure well and was able to remove feeding tube. She underwent multiple cryodilation sessions safely and is now tolerating a regular diet.Figure 1.: Severe esophagojejunal stricture, initially with moderate resistance with passage of an adult gastroscope.Figure 2.: Frosting effect of the spray cryotherapy on the target area.Figure 3.: Through-the-scope balloon dilation.Figure 4.: Moderate mucosal disruption after spray cryotherapy with dilation.To our knowledge, this is the first to report spray cryotherapy for management of esophagojejunal anastomotic stricture in a patient with gastrectomy. In patients with an intact stomach, the stomach serves as a large, compliant reservoir capable of accommodating abrupt increases in intraluminal pressure and volume as the liquid nitrogen evaporates into gas. Without a stomach to assist with this rapid volume expansion, spray cryotherapy could be potentially more challenging. Thus, this case emphasizes the importance of continuous abdominal assessment during the spray cryotherapy procedure. Furthermore, this case illustrates that spray cryotherapy is safe and effective in patients with altered anatomy that may limit gastrointestinal luminal compliance. DISCLOSURES Author contributions: GE Kim literature review, performed the procedure, drafted abstract. UD Siddiqui revised and finalized the abstract and is the article guarantor. Financial disclosure: GE Kim—none. UD Siddiqui—consultant, speaker, research support: Olympus, Boston Scientific; consultant, speaker: Cook, ConMed, Medtronic. Informed consent was obtained for this case report.