CRYOSURGERY Cryosurgery refers to destruction of tissue by controlled application of cold temperatures Indications : Anal sac diseases 1.

.Perianal adenoma 2.Perianal adenocarcinoma 3.Perianal fistula 4.Rectal polyps 5.Rectal adenocarcinoma Benign and malignant tumors of oral cavity and skin Aneurysmal bone cyst Insulinoma Gastrinoma Ophthalmic indications like eyelid tumors,recurrent herpetic corneal ulcers,breakdown of vitreo corneal adhesions,cataracts,glaucoma and pannus. Mechanism of cell death in cryosurgery: Ultimate goal of cryotherapeutics is to kill all cells in a diseased target area while causing minimal damage to the surrounding normal tissue . Mechanism of cellular death is accomplished by a combination of both direct cellular destruction and anoxia secondary to vascular stasis. Three major phases categorize the events at cellular level during cryonecrosis 1.Immediate phase 2.Delayed phase 3.Immunological phase Immediate phase: Occurs immediately during the freeze-thaw cycle. Destruction of cell occurs in four ways 1.Ice crystal formation 2.Dehydration and solute concentration 3.Protein denaturation 4.Thermal shock Ice crystal formation: Formation of either intracellular (or) extracellular ice crystals depends on the rate at which target tissue is frozen and thawed. Slow freezing produces large crystals outside the cells. Rapid freezing produces intracellular crystals. Maximum amount of cellular destruction results from a rapid freeze slow thaw cycle. Protein denaturation: Damage to lipoprotein complexes of cellular membrane.Loss of phospholipid renders the cell membrane permeable to ions and extracellular fluid leading to cell lysis. Thermal shock: Thermal shock refers to injury to the cell caused by a rapid change in temperature. Delayed phase: Occurs within a few hours of the final- freeze thaw cycle.Cellular destruction is caused primarily by effects of vascular stasis.Vascular stasis is limited to tissue area exposed to the cryogen.Vascular stasis causes thrombosis , ischemia,anoxia , pH changes and cell death. Immunological phase : Theoretical possibility of occurrence which is important in treatment of neoplasms. There will be tumor specific immunity and augmented cell mediated and humoral immunity.

Cryogen : A cryogen is a substance that has ability to remove heat from a given area. The most commonly used cryogens are 1.Liquid nitrogen 2.Nitrous oxide 3.Carbondioxide Liquid nitrogen : Widely used cryogen in veterinary practice Extremely low boiling point (-195.8C/320.4F) Colorless , odorless , non-inflammable , non-toxic and non-explosive Inert with respect to metallic and biologic surfaces Inexpensive Sprayed ,swabbed, poured(or) used in cryoprobe delivery systems Causes maximal tissue destruction in a short period of time Deepest penetration ability Close monitoring of freezing is essential Short storage life Carbondioxide : Used as cryogen as a solid and as gas Produce a temperature of -78C Pressurized pencils of dry ice are used in ophthalmic surgery for extraction of subluxated lenses When pressurized gas from a cylinder is released through a small orifice into an area of reduced pressure inside a cryoprobe , the gas expands and cool rapidly Poor tissue penetrating ability Nitrous oxide : Reaches a probe temperature of -89C through joule-thomson effect Readily available Easily applied through probe (or) spray Limited tissue penetration Factors affecting tissue susceptibility to cryonecrosis: 1.Tissue temperature Systemic body temperature and vascularity of affected area modify the rate and extent of local freezing.Cryonecrosis of highly vascular tissues is suboptimal.If blood can be limited (or) excluded from lesion to be frozen the resultant cryonecrosis is potentiated. 2.Tissue characteristics High water content in tissues facilitates freezing.Walls of large arteries are resistant to destructive effects of cryosurgery.Nerve sheath is cryoresistant. Preparation of surgical site: Excessive (or) matted hair around the lesion is clipped to allow adequate visualization of lesion for proper thermocouple placement and accurate cryogen delivery.Skin is gently cleansed and an antimicrobial agent is applied prior to freezing. Anesthesia: General anesthesia is not necessary.Tranquilization is needed.Local infiltration with lidocaine and epinephrine is done.

Insulators: Non conductive materials placed around target tissue to prevent freezing of underlying (or) adjacent tissues. White petroleum,furacin ointment,styrofoam cups,wood and x-ray film are used as insulators. Tissue temperature monitoring techniques: Decrease post operative complications resulting from inadequate (or) overzealous freezing. Two basic techniques for temperature determination 1.Direct method ( thermocouple devices) 2.Indirect method (visual palpation and inspection) Thermocouple devices: Accurate and function by indicating the current flow caused by temperature change sensed at non-insulated junctions of two dissimilar metallic leads. Indirect method: By visual inspection and palpation of ice ball as it spreads from edge of tumors. Frozen tissue has a white discoloration that is readily visualized.This method is confined to small,discrete, visible and palpable lesions. Application techniques: 1.Probe freezing Direct application of a probe tip to the lesion.Cryogen circulates through the probe tip and supercools it.Contact freezing and penetration freezing are two types of probe freezing.

Contact freezing: Firm contact is made between cryoprobe and target tissue. Saline applied to tumor surface, blood and serum from ulcerated surface acts as excellent media for cryoadhesion Penetration freezing: Performed in larger lesions.A core biopsy specimen is removed from center of tumor and cryoprobe is placed directly within the mass.

Spray freezing: Self pressurizing guns deliver a combination of vapor and droplets of liquid cryogen onto target tissues.Size of spray droplet is controlled by diameter of orifice used.Volume of cryogen released is regulated by finger pressure on trigger.

spray freezing

Post operative sequel: Swelling Bleeding Necrosis Depigmentation Odor Contraindications: Cutaneous mast cell tumors Osteosarcoma Nasal tumors Urinary bladder neoplasia Prostatic neoplasia