PRINCIPLES OF CRYOSURGERY
Cryosurgery (cryotherapy) is the application of extreme cold to destroy abnormal or diseased tissue.
The term comes from the Greek words cryo ("icy cold") and surgery meaning "hand work" or "handiwork".
Cryosurgery has been historically used to treat several diseases and disorders, especially variety of benign and malignant skin conditions.
Mechanism of cryosurgery
o The destructive effect of freezing tissue has been categorized into two major mechanisms-
Immediate cell destruction.
Delayed cell destruction.
Application techniques
Probe freezing: It is done by direct application of a probe tip to the lesion. The cryogen circulates through the probe tip and super cools it, when allowed to contact the target tissue. Probe freezing can be accomplished by one of the two mechanisms: contact freezing and penetration freezing.
In contact freezing, firm contact is made between the cryoprobe and the target tissue.
While in penetration freezing probe penetrates the target tissue, providing a large area of direct contact.
Spray freezing: It is done by direct application of the liquid nitrogen to the tissue and is the most destructive method. Liquid nitrogen is delivered to the target tissue at such a volume and velocity that it evaporates at the edge of the lesion. The spray orifice allows deeper and faster tissue penetration than the probe tip but the probe method is safer and more precise.
Benefits of Cryosurgery in Veterinary Medicine
Painless.
No Preparation.
No post op care.
No open wounds – No Bleeding.
No suturing.
No general anaesthesia – safe for older animals.
Rapid treatment time – only seconds.
Cost Effective.
Pressure to treat lesion.
Pinpoint Accuracy.
CryoProbe’s different micro applicators tips allow pinpoint accuracy to treat skin lesions from 1mm to 8mm in size.
Blue dot applicator Applications 1-3 mm.
White dot applicator Applications 2-4 mm.
Green dot applicator Applications 3-6 mm.
Yellow dot applicator Applications 4-10 mm.
Lesions
With the CryoProbe you will be able to treat (but not limited) to the following lesions successfully:
Perianal Adenomas.
Epuli.
Papilloma.
Lick Granulomas.
Warts.
Small Sarcoids.
Eye Lid Tumors.
You will be able to quickly and easily treat skin lesions that you could not treat before without undesired side effects.
Disadvantages of Cryosurgery
As with the advantages of cryosurgery, the disadvantages can also be categorized into those for the clinician and those for the patient.
Disadvantages for the clinician include the following:
Liquid nitrogen needs to be delivered and stored. A liquid nitrogen generator may be purchased. If that is not done, nitrous oxide tanks or other supplies will need to be replenished as needed.
PRINCIPLES OF CRYOSURGERY
Cryosurgery (cryotherapy) is the application of extreme cold to destroy abnormal or diseased tissue.
The term comes from the Greek words cryo ("icy cold") and surgery meaning "hand work" or "handiwork".
Cryosurgery has been historically used to treat several diseases and disorders, especially variety of benign and malignant skin conditions.
Mechanism of cryosurgery
o The destructive effect of freezing tissue has been categorized into two major mechanisms-
Immediate cell destruction.
Delayed cell destruction.
Application techniques
Probe freezing: It is done by direct application of a probe tip to the lesion. The cryogen circulates through the probe tip and super cools it, when allowed to contact the target tissue. Probe freezing can be accomplished by one of the two mechanisms: contact freezing and penetration freezing.
In contact freezing, firm contact is made between the cryoprobe and the target tissue.
While in penetration freezing probe penetrates the target tissue, providing a large area of direct contact.
Spray freezing: It is done by direct application of the liquid nitrogen to the tissue and is the most destructive method. Liquid nitrogen is delivered to the target tissue at such a volume and velocity that it evaporates at the edge of the lesion. The spray orifice allows deeper and faster tissue penetration than the probe tip but the probe method is safer and more precise.
Benefits of Cryosurgery in Veterinary Medicine
Painless.
No Preparation.
No post op care.
No open wounds – No Bleeding.
No suturing.
No general anaesthesia – safe for older animals.
Rapid treatment time – only seconds.
Cost Effective.
Pressure to treat lesion.
Pinpoint Accuracy.
CryoProbe’s different micro applicators tips allow pinpoint accuracy to treat skin lesions from 1mm to 8mm in size.
Blue dot applicator Applications 1-3 mm.
White dot applicator Applications 2-4 mm.
Green dot applicator Applications 3-6 mm.
Yellow dot applicator Applications 4-10 mm.
Lesions
With the CryoProbe you will be able to treat (but not limited) to the following lesions successfully:
Perianal Adenomas.
Epuli.
Papilloma.
Lick Granulomas.
Warts.
Small Sarcoids.
Eye Lid Tumors.
You will be able to quickly and easily treat skin lesions that you could not treat before without undesired side effects.
Disadvantages of Cryosurgery
As with the advantages of cryosurgery, the disadvantages can also be categorized into those for the clinician and those for the patient.
Disadvantages for the clinician include the following:
Liquid nitrogen needs to be delivered and stored. A liquid nitrogen generator may be purchased. If that is not done, nitrous oxide tanks or other supplies will need to be replenished as needed.
Include infections of skin, subcutaneous tissue, fascia, and muscle, encompass a wide spectrum of clinical presentations, ranging from simple cellulitis to rapidly progressive necrotizing fasciitis.
Diagnosing the exact extent of the disease is critical for successful management of a patient of soft tissue infection
Include infections of skin, subcutaneous tissue, fascia, and muscle, encompass a wide spectrum of clinical presentations, ranging from simple cellulitis to rapidly progressive necrotizing fasciitis.
Diagnosing the exact extent of the disease is critical for successful management of a patient of soft tissue infection
Cryotherapy is a controlled and targeted destruction of diseased tissue by the application of cold temperature substance.
Used for treatment of diverse benign lesions and well corcumscribed pre malignant and malignant tumours
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The empire's roots lie in the city of Rome, founded, according to legend, by Romulus in 753 BCE. Over centuries, Rome evolved from a small settlement to a formidable republic, characterized by a complex political system with elected officials and checks on power. However, internal strife, class conflicts, and military ambitions paved the way for the end of the Republic. Julius Caesar’s dictatorship and subsequent assassination in 44 BCE created a power vacuum, leading to a civil war. Octavian, later Augustus, emerged victorious, heralding the Roman Empire’s birth.
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2. Introduction
• Cryotherapy is a controlled and targeted destruction of diseased tissue by the application of
cold temperature substance.
• It is used for the treatment of diverse benign lesions and well-circumscribed pre-malignant
and malignant tumors.
3. • It is a very safe, inexpensive, reproducible, repeatable and simple office
procedure.
• It requires a short preparation time, is a sutureless procedure with minimal risk of
infection and no anesthesia is usually required.
•
• It can be performed at any age, including in old patients with pacemakers in whom
electrocautery is contraindicated,
• And those on anticoagulants, patients allergic to anesthetic agents, patients with
transmissible conditions such as human immunodeficiency virus (HIV) and
hepatitis, during pregnancy.
4. • This effect induces tissue damage in 2 mechanisms.
1. The first mechanism is the induction of tissue ischemia by damaging
blood vessels and capillaries within the target area which leads to
ischemic necrosis of the tissue.
2. The second mechanism damages the cells more complexly by
forming ice crystals and inducing osmotic cell injury and cellular
membrane disruption.
5. • As the tissue is cooled, ice crystals form between cells which creates
an osmotic gradient rapidly drawing water out of the cells. As cooling
continues, crystals form within the cell which can lead to rupture of
the cell. The thawing process also damages cells. As the tissue thaws,
crystals outside the cells melt which creates a gradient that rapidly
draws water back into the cell which can cause cells to swell and burst.
6. • There is differential sensitivity of each cell or tissue to cryodamage, with
melanocytes and deeper epidermal cell layers being very sensitive and
dermal collagen being cryoresistant.
7. • Cryogen
• The commonly used cryogens include:
• Cryogens - Boiling point Liquid nitrogen (most commonly used)
-196°C
• Nitrous oxide : - 89°C
• Solidified CO 2 (dry ice, CO 2 snow) : -78°C
• Chlorodifluoromethane : -41°C
• Dimethyl ether and propane : -24°C, -42°C
8. • Cryosurgery equipment
1.Cryogun/cryogen spray canister
2.Cryospray nozzle, cryprobes, spray tips, neoprene or polystyrene cones.
3.Cryoprobes: they are available in various shapes and sizes and get attached to the
cryogen. They are cooled by the spray of the cryogen.
4.Cryogen storage device: they are metal cylinders/containers that store gaseous
cryogens as compressed gas and have an inbuilt internal pressure equalization
mechanism e.g., Dewar′s gas container. The cryogen is transferred to the cryogun
before the procedure by a siphon or by tilting the container to pour the cryogen into
the gun via a funnel. Insulated gloves must be worn while transferring the cryogen.
e.g., Brymill cryogenic system.
9. • Methodology of Cryosurgery
I. Counseling and consent; explaining the procedure, the achievable
results, recurrence rate and various complications.
II. History taking and examination:History of sensitivity to cold, cold
urticaria, Raynaud′s phenomenon or vascular insufficiency .
III. Lesional characteristics such as size, margin, location, depth, biological
behavior and approximation to superficial nerves and previous treatment
sites should be undertaken.
10. • Different methods of applying the cryogen to the skin lesion include:
• Timed spot freeze technique:The cryogen is directly sprayed onto the lesion
through an appropriate sized nozzle, which is chosen according to the size of
the lesion.
11. • Spot freeze can be carried out in two ways:
1.Open spray technique - it is used for large lesions or when light superficial
freeze is desired. There are two methods for open spray:
1. Paint brush method - the lesion is treated by spraying from one side of the lesion and
moving up and down across the lesion.
2. Spiral method - the cryogen is sprayed initially in the center of the lesion and is then
moved outward in concentric circles.
2.Confined-spray technique - it is preferred for round, small, discrete lesions or
those close to vital structures. In this, the range of spray is limited to a discrete
area by the use of neoprene or polystyrene cones.
12. • Indications
• This procedure has been used to treat a wide variety of skin conditions;
1.Vascular lesions
2.Benign tumors
3.Acne
4.Pigmented lesions
5.Viral infections
6.Inflammatory dermatoses
7.Infectious dermatoses
8.Pre-malignant and malignant tumors
13. The following conditions are recommended as specific indications for
cryosurgery:
• Genital warts in HIV-positive patients or during pregnancy.
• Hemangiomas/vascular malformations - macular, flat-topped, superficial
lesions, exophytic lesions or those with a subcutaneous component (deep or
mixed hemangiomas and malformations).
• Well-defined, superficial non-melanoma skin cancers (basal and squamous
cell carcinoma), especially located on the trunk.
• As combination therapy for lesions located on covered sites. E.g., plantar
warts in combination with keratolytics, keloids in combination with I/L steroids.
14. • In other dermatoses, it may be used as alternate therapy, especially under the
following circumstances:
• In old patients with pacemakers in whom electrocautery is contraindicated
• In patients on anticoagulants
• In subjects allergic to anesthetic agents
• Patients with transmissible conditions such as HIV and hepatitis
• For genital lesions during pregnancy
• If other ablative modalities are not available
15. • Complications:
• Acute complications
• Local pain - more in the periungual area, temple, plantar areas, eyelids, lips,
mucous membranes. Tingling and numbness, especially on the fingers.
• Edema, especially on the eyelids, lips, labia and prepuce, more in infants and
the elderly.
• Cryoblister formation.
• Syncope (vasovagal reaction) in anxious patients.
• Headache (migraine type) after the treatment of the head and neck area.
16. • Subacute complications
• Hemorrhagic necrosis.
• Wound infection due to the use of infected cryoprobes or redipping cotton
swabs into the cryogen.
• Delayed wound healing after treatment over the extremities.
• Temporary scar hypertrophy.
• Subcutaneous emphysema due to insufflation of the underlying tissue on
spraying over broken skin.
17. Contraindications;
• Absolute
• Blood dyscrasias of unknown origin.
• Cold intolerance.
• Raynaud′s disease.
• Cold urticaria.
• Cryoglobulinemia.
• Lesions in which tissue pathology is required.
• Lesions in areas of compromised circulation.
• Sclerosing basal cell carcinoma (BCC) or recurrent BCC or squamous cell
carcinoma (SCC ) located in high-risk areas like the temple or nasolabial
folds.
18. Relative
• Keloidal tendency.
• Collagen vascular diseases.
• Dark-skinned individuals due to the high risk of developing cosmetically
inacceptable protracted hypopigmentation.
• Lesions over the nasolabial fold, eyelid margins, ala nasi and hair-bearing
areas (high risk of developing alopecia, especially cicatricial alopecia).
• Patients with sensory loss at lesional sites.
• Pyoderma gangrenosum.
19. Conclusion
• Cryotherapy is a simple, safe and inexpensive office procedure for the treatment of
various benign, pre-malignant and well-circumscribed malignant tumors.
• It provides satisfactory cosmetic results with minimal complications if patient
selection is proper and if it is undertaken by a trained and experienced
dermatologist.