{"id":15914,"date":"2023-05-16T06:30:11","date_gmt":"2023-05-16T06:30:11","guid":{"rendered":"https:\/\/endoscopiaterapeutica.net\/pt\/?p=15914"},"modified":"2023-12-03T21:57:42","modified_gmt":"2023-12-03T21:57:42","slug":"litotripsia-intraductal-na-colangiopancreatografia-retrograda-endoscopica","status":"publish","type":"post","link":"https:\/\/endoscopiaterapeutica.net\/pt\/assuntosgerais\/litotripsia-intraductal-na-colangiopancreatografia-retrograda-endoscopica\/","title":{"rendered":"Litotripsia Intraductal na Colangiopancreatografia Retr\u00f3grada Endosc\u00f3pica"},"content":{"rendered":"\n<p>Com o advento da colangioscopia digital de operador \u00fanico em 2015 (<a href=\"https:\/\/www.bostonscientific.com\/pt-BR\/produtos\/sistemas-de-visualizacao-direta\/spyglass-sistema-de-visualizacao-direta-ds.html\" target=\"_blank\" rel=\"noreferrer noopener\">SpyGlass\u2122<\/a>), superando a dificuldade t\u00e9cnica dos antigos aparelhos \u201cmother-baby\u201d que dependiam de dois operadores, diversas foram as utilidades desta nova tecnologia na colangiopancreatografia retr\u00f3grada endosc\u00f3pica (CPRE): avalia\u00e7\u00e3o intraductal de estenoses indeterminadas das vias biliares, direcionar a drenagem de segmentos acometidos por estenose, litotripsia intraductal de coledocolit\u00edase e hepatolit\u00edase. <\/p>\n\n\n\n<p>Os c\u00e1lculos complexos possuem preditores para falha de remo\u00e7\u00e3o das vias biliares pelo m\u00e9todo convencional, sendo:&nbsp;<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>c\u00e1lculos maiores que 1,5 cm;<\/li>\n\n\n\n<li>c\u00e1lculos m\u00faltiplos (mais de 10);&nbsp;<\/li>\n\n\n\n<li>c\u00e1lculos com formatos em barril e longo;<\/li>\n\n\n\n<li>c\u00e1lculos intrahep\u00e1ticos;&nbsp;<\/li>\n\n\n\n<li>anormalidades de col\u00e9doco distal (obl\u00edquos, estreitos, angulados);<\/li>\n\n\n\n<li>papila duodenal peridiverticular;<\/li>\n\n\n\n<li>despropor\u00e7\u00e3o de tamanho do c\u00e1lculo vs col\u00e9doco;&nbsp;<\/li>\n\n\n\n<li>associados a estenoses benignas e malignas;<\/li>\n\n\n\n<li>altera\u00e7\u00e3o p\u00f3s-cir\u00fargica do trato gastrointestinal alto<\/li>\n<\/ul>\n\n\n\n<p>Seguindo os <em>guidelines<\/em> europeu e americano da ESGE e ASGE, ap\u00f3s a falha de remo\u00e7\u00e3o convencional na CPRE, opta-se por <a href=\"https:\/\/endoscopiaterapeutica.net\/pt\/video\/dilatacao-balonada-da-papila-duodenal\/\" target=\"_blank\" rel=\"noreferrer noopener\">dilata\u00e7\u00e3o balonada de grandes propor\u00e7\u00f5es (DBGP) da papila<\/a>, que \u00e9 definida de 12 a 20 mm, limitando-se at\u00e9 o di\u00e2metro do col\u00e9doco distal, precedida de papilotomia pr\u00e9via ou t\u00e1tica (saiba mais nesse <strong><a href=\"https:\/\/endoscopiaterapeutica.net\/pt\/assuntosgerais\/dilatacao-da-papila-duodenal-maior-com-balao-para-remocao-de-calculos-dificeis\/\" target=\"_blank\" rel=\"noreferrer noopener\">post<\/a><\/strong>). Havendo a falha de extra\u00e7\u00e3o ap\u00f3s DBGP, os <em>guidelines<\/em> sugerem a <strong>litotripsia<\/strong>, que podem ser:<\/p>\n\n\n\n<ul class=\"has-very-light-gray-to-cyan-bluish-gray-gradient-background has-background wp-block-list\">\n<li>mec\u00e2nica atrav\u00e9s do basket refor\u00e7ado \u201cthrough the scope\u201d (convencional) ou \u201cout the scope\u201d (tamb\u00e9m conhecido como litotriptor de emerg\u00eancia);<\/li>\n\n\n\n<li>intraductal com <a href=\"https:\/\/endoscopiaterapeutica.net\/pt\/produto\/boston-scientific\/autolith\/\" target=\"_blank\" rel=\"noreferrer noopener\">pulso eletro-hidr\u00e1ulico<\/a> ou a laser atrav\u00e9s do uso de colangiosc\u00f3pio.<\/li>\n<\/ul>\n\n\n\n<h2 class=\"wp-block-heading\" id=\"h-caso-clinico\"><strong>Caso Cl\u00ednico<\/strong><\/h2>\n\n\n\n<p>No v\u00eddeo a seguir, temos o caso de uma mulher jovem com coledocolit\u00edase de 10 mm, com duas tentativas pr\u00e9vias de CPRE sem sucesso na remo\u00e7\u00e3o de c\u00e1lculo devido a despropor\u00e7\u00e3o c\u00e1lculo vs col\u00e9doco distal. Mesmo com papilotomia ampla pr\u00e9via e dilata\u00e7\u00e3o balonada CRE at\u00e9 18 mm, sem perda de cintura radiol\u00f3gica por fibrose de esf\u00edncter, houve falha na apreens\u00e3o do c\u00e1lculo com <em>basket trapezoid<\/em> devido a impacta\u00e7\u00e3o do c\u00e1lculo em via biliar. <\/p>\n\n\n\n<p>Neste caso, a abordagem cir\u00fargica seria dif\u00edcil especificamente devido ao col\u00e9doco pouco dilatado, sendo optado por interven\u00e7\u00e3o com colangioscopia (<a href=\"https:\/\/www.bostonscientific.com\/pt-BR\/produtos\/sistemas-de-visualizacao-direta\/spyglass-sistema-de-visualizacao-direta-ds.html\" target=\"_blank\" rel=\"noreferrer noopener\">Spyglass<\/a>) + litotripsia endosc\u00f3pica a laser intraductal. Como resultado, a paciente evoluiu com alta no primeiro p\u00f3s-operat\u00f3rio com resolu\u00e7\u00e3o da retirada do c\u00e1lculo, assintom\u00e1tica, podendo ser submetida a colecistectomia em seguida.<\/p>\n\n\n\n<div style=\"position:relative;padding-top:56.25%;\"><iframe id=\"panda-9a49165c-757a-49b9-9b57-a18822d42ff6\" src=\"https:\/\/player-vz-a75e9d45-986.tv.pandavideo.com.br\/embed\/?v=9a49165c-757a-49b9-9b57-a18822d42ff6\" style=\"border:none;position:absolute;top:0;left:0;\" allow=\"accelerometer;gyroscope;autoplay;encrypted-media;picture-in-picture\" allowfullscreen=true width=\"100%\" height=\"100%\" fetchpriority=\"high\"><\/iframe><\/div>\n\n\n\n<div style=\"height:49px\" aria-hidden=\"true\" class=\"wp-block-spacer\"><\/div>\n\n\n\n<h2 class=\"wp-block-heading\" id=\"h-discussao\"><strong>Discuss\u00e3o<\/strong><\/h2>\n\n\n\n<p>Um estudo multic\u00eantrico randomizado publicado na Endoscopy de Angsuwatcharakon et al. em 2019 comparou esses dois m\u00e9todos, que permitia o crossover entre a litotripsia mec\u00e2nica com basket de 30 mm (LithoCrush V, Olympus) e a litotripsia a laser (SpyGlass DS, Boston Scientific, com Dornier Medilas H Solvo, Wessling), chegando aos seguintes resultados:<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>476 pacientes p\u00f3s-CPRE, com 32 falhas p\u00f3s-DBGP, sendo randomizados 16 em cada grupo;<\/li>\n\n\n\n<li>M\u00e9dia do tamanho dos c\u00e1lculos: 19.5 mm (5.63) no grupo laser vs 17.6 mm (3.37) no grupo litotripsia mec\u00e2nica;<\/li>\n\n\n\n<li>Remo\u00e7\u00e3o completa na primeira tentativa foi maior na litotripsia laser vs mec\u00e2nica (100% vs 63%, p &lt; 0,01);<\/li>\n\n\n\n<li>Tempo de procedimento total foi menor no laser vs mec\u00e2nica (83 vs. 66 min; P = 0.23);<\/li>\n\n\n\n<li>Tempo de remo\u00e7\u00e3o foi menor no laser vs mec\u00e2nica (53 vs. 39 min; P = 0.26);<\/li>\n\n\n\n<li>Tempo de fluoroscopia e radia\u00e7\u00e3o menor no laser vs mec\u00e2nica (21 vs. 11 minutes; P &lt; 0.01 e (40 745 vs. 20989 mGycm2; P = 0.04);<\/li>\n\n\n\n<li>Efeitos adversos e tempo de interna\u00e7\u00e3o foram semelhantes entre os grupos.<\/li>\n<\/ul>\n\n\n\n<p>As limita\u00e7\u00f5es do estudo est\u00e3o na amostra relativamente baixa, que tange \u00e0s indica\u00e7\u00f5es restritas da litotripsia ap\u00f3s falha da CPRE e DBGP, bem como na avalia\u00e7\u00e3o de apenas a metodologia a laser, sem comparar a eletro-hidr\u00e1ulica, apesar da equival\u00eancia de efetividade dos dois m\u00e9todos. <\/p>\n\n\n\n<p>Embora os limites impostos pelo alto custo do dispositivo, com necessidade de expertise do uso de colangioscopia, e baixa disponibilidade desta tecnologia nos centros de endoscopia, Deprez et al. avaliou maior economia e menor custo no grupo da litotripsia intraductal devido a maior taxa de sucesso e menor n\u00famero de CPREs no tratamento da coledocolit\u00edase complexa. Salvo limita\u00e7\u00f5es do custo de sa\u00fade, pa\u00eds e moeda diferente do estudo, as justificativas de menor custo-efetividade s\u00e3o v\u00e1lidos. <\/p>\n\n\n\n<p>Ademais, com o desenvolvimento de outras marcas de colangiosc\u00f3pios e a maior abrang\u00eancia desta tecnologia, espera-se que esse m\u00e9todo diagn\u00f3stico e terap\u00eautico se popularize e se torne um novo arsenal ao endoscopista.<\/p>\n\n\n\n<figure class=\"wp-block-embed is-type-wp-embed is-provider-endoscopia-terapeutica wp-block-embed-endoscopia-terapeutica\"><div class=\"wp-block-embed__wrapper\">\n<blockquote class=\"wp-embedded-content\" data-secret=\"0RcwfD1CVF\"><a href=\"https:\/\/endoscopiaterapeutica.net\/pt\/assuntosgerais\/tratamento-endoscopico-dos-calculos-biliares-dificeis\/\">Tratamento endosc\u00f3pico dos c\u00e1lculos biliares dif\u00edceis<\/a><\/blockquote><iframe class=\"wp-embedded-content\" sandbox=\"allow-scripts\" security=\"restricted\" style=\"position: absolute; visibility: hidden;\" title=\"&#8220;Tratamento endosc\u00f3pico dos c\u00e1lculos biliares dif\u00edceis&#8221; &#8212; Endoscopia Terapeutica\" src=\"https:\/\/endoscopiaterapeutica.net\/pt\/assuntosgerais\/tratamento-endoscopico-dos-calculos-biliares-dificeis\/embed\/#?secret=8Yhcc3q3LQ#?secret=0RcwfD1CVF\" data-secret=\"0RcwfD1CVF\" width=\"600\" height=\"338\" frameborder=\"0\" marginwidth=\"0\" marginheight=\"0\" scrolling=\"no\"><\/iframe>\n<\/div><\/figure>\n\n\n\n<figure class=\"wp-block-embed is-type-wp-embed is-provider-endoscopia-terapeutica wp-block-embed-endoscopia-terapeutica\"><div class=\"wp-block-embed__wrapper\">\n<blockquote class=\"wp-embedded-content\" data-secret=\"EdNwZVC3Wm\"><a href=\"https:\/\/endoscopiaterapeutica.net\/pt\/produto\/boston-scientific\/autolith\/\">Autolith<\/a><\/blockquote><iframe class=\"wp-embedded-content\" sandbox=\"allow-scripts\" security=\"restricted\" style=\"position: absolute; visibility: hidden;\" title=\"&#8220;Autolith&#8221; &#8212; Endoscopia Terapeutica\" src=\"https:\/\/endoscopiaterapeutica.net\/pt\/produto\/boston-scientific\/autolith\/embed\/#?secret=lTsC15ownZ#?secret=EdNwZVC3Wm\" data-secret=\"EdNwZVC3Wm\" width=\"600\" height=\"338\" frameborder=\"0\" marginwidth=\"0\" marginheight=\"0\" scrolling=\"no\"><\/iframe>\n<\/div><\/figure>\n\n\n\n<h2 class=\"wp-block-heading\" id=\"h-referencias\"><strong>Refer\u00eancias<\/strong><\/h2>\n\n\n\n<ol class=\"wp-block-list\">\n<li>Angsuwatcharakon P, Kulpatcharapong S, Ridtitid W, et al. Digital cholangioscopy-guided laser versus mechanical lithotripsy for large bile duct stone removal after failed papillary large-balloon dilation: a randomized study. Endoscopy. 2019 Nov;51(11):1066-1073. doi: 10.1055\/a-0848-8373. Epub 2019 Feb 20. PMID: 30786315.<\/li>\n\n\n\n<li>ASGE Standards of Practice Committee; Buxbaum JL, Abbas Fehmi SM, Sultan S, et al. ASGE guideline on the role of endoscopy in the evaluation and management of choledocholithiasis. Gastrointest Endosc. 2019 Jun;89(6):1075-1105.e15. doi: 10.1016\/j.gie.2018.10.001. Epub 2019 Apr 9. PMID: 30979521; PMCID: PMC8594622.<\/li>\n\n\n\n<li>Manes G, Paspatis G, Aabakken L, et al. Endoscopic management of common bile duct stones: European Society of Gastrointestinal Endoscopy (ESGE) guideline. Endoscopy. 2019 May;51(5):472-491. doi: 10.1055\/a-0862-0346. Epub 2019 Apr 3. PMID: 30943551.<\/li>\n\n\n\n<li>Deprez PH, Garces Duran R, Moreels T, et al. The economic impact of using single-operator cholangioscopy for the treatment of difficult bile duct stones and diagnosis of indeterminate bile duct strictures. Endoscopy 2018;50:109-18.<\/li>\n<\/ol>\n\n\n\n<h2 class=\"wp-block-heading\" id=\"h-como-citar-este-artigo\"><strong>Como citar este artigo<\/strong><\/h2>\n\n\n\n<p class=\"has-background\" style=\"background-color:#e0e2e9\">Kum AST, Ide E, Nunes BCM. Litotripsia Intraductal na Colangiopancreatografia Retr\u00f3grada Endosc\u00f3pica. Dispon\u00edvel em Endoscopia Terapeutica 2023, vol. 1. <a href=\"https:\/\/endoscopiaterapeutica.net\/pt\/?p=15914\" target=\"_blank\" rel=\"noreferrer noopener\">https:\/\/endoscopiaterapeutica.net\/pt\/litotripsia-intraductal-na-colangiopancreatografia-retrograda-endoscopica\/<\/a><\/p>\n","protected":false},"excerpt":{"rendered":"<p>Com o advento da colangioscopia digital de operador \u00fanico em 2015 (SpyGlass\u2122), superando a&hellip;<\/p>\n","protected":false},"author":5611,"featured_media":15916,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_lmt_disableupdate":"","_lmt_disable":"","footnotes":""},"categories":[151,150],"tags":[],"ano":[555],"tipo":[155],"volume":[263],"class_list":["post-15914","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-assuntosgerais","category-casosclinicos","ano-555","tipo-cpre","volume-volume-i"],"yoast_head":"<!-- This site is optimized with the 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