{"id":18054,"date":"2023-12-12T07:00:00","date_gmt":"2023-12-12T07:00:00","guid":{"rendered":"https:\/\/endoscopiaterapeutica.net\/pt\/?p=18054"},"modified":"2023-12-12T01:39:52","modified_gmt":"2023-12-12T01:39:52","slug":"acesso-transgastrico-endoscopico-gate-edge-em-bypass-gastrico-o-passo-a-passo","status":"publish","type":"post","link":"https:\/\/endoscopiaterapeutica.net\/pt\/assuntosgerais\/acesso-transgastrico-endoscopico-gate-edge-em-bypass-gastrico-o-passo-a-passo\/","title":{"rendered":"Acesso Transg\u00e1strico Endosc\u00f3pico\u00a0GATE (EDGE) em Bypass G\u00e1strico: o passo a passo"},"content":{"rendered":"\n<p>Segundo o Minist\u00e9rio da Sa\u00fade, a obesidade atinge 6,7 milh\u00f5es de pessoas no Brasil. Devido ao crescimento das taxas de obesidade adjunto a efic\u00e1cia da cirurgia bari\u00e1trica, um levantamento da Sociedade Brasileira de Cirurgia Bari\u00e1trica e Metab\u00f3lica (SBCBM) contabilizou 315.720 mil cirurgias bari\u00e1tricas no per\u00edodo de 2017 a 2022. Com a crescente preval\u00eancia de pacientes com anatomia alterada principalmente pelo bypass g\u00e1strico com reconstru\u00e7\u00e3o em Y de Roux (BGYR), a necessidade de acesso no est\u00f4mago excluso para tratamento de coledocolit\u00edase, s\u00edndromes colest\u00e1ticas obstrutivas benignas e malignas nessa popula\u00e7\u00e3o s\u00e3o fatores que motivaram o desenvolvimento de t\u00e9cnicas para acesso transg\u00e1strico e viabilizar a abordagem endosc\u00f3pica.<\/p>\n\n\n\n<p>Atualmente, as abordagens mais tradicionais s\u00e3o:<\/p>\n\n\n\n<ul class=\"has-very-light-gray-to-cyan-bluish-gray-gradient-background has-background wp-block-list\">\n<li>acesso por enteroscopia<\/li>\n\n\n\n<li>acesso transg\u00e1strico intraoperat\u00f3rio: necessita equipe cir\u00fargica (assista ao v\u00eddeo &#8211; <strong><a href=\"https:\/\/endoscopiaterapeutica.net\/pt\/casosclinicos\/cpre-transgastrica-cirurgia-bariatrica\/\" target=\"_blank\" rel=\"noreferrer noopener\">clique aqui<\/a><\/strong>)<\/li>\n\n\n\n<li>gastric access temporary for endoscopy &#8211; GATE: realizado por ecoendoscopia. Essa t\u00e9cnica tamb\u00e9m pode ter a nomenclatura de Endoscopic ultrasound-Directed transGastric Endoscopic retrograde cholangiopancreatography \u2013 EDGE. <\/li>\n<\/ul>\n\n\n\n<p><em>saiba mais sobre esse assunto nesse outro artigo &#8211; <strong><a href=\"https:\/\/endoscopiaterapeutica.net\/pt\/assuntosgerais\/cpre-em-pacientes-com-y-de-roux\/\" target=\"_blank\" rel=\"noreferrer noopener\">clique aqui<\/a><\/strong> <\/em><\/p>\n\n\n\n<p>Dentre as tr\u00eas possibilidades, o GATE mostra-se mais promissor segundo uma metan\u00e1lise <em>head-to-head<\/em> de Deliwala et al., cujo trabalho demonstrou <\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>alta taxa de sucesso t\u00e9cnico quando comparado aos outros m\u00e9todos: GATE 100% vs. enteroscopia 66% e GATE 97% vs. intraoperatorio 98%)<\/li>\n\n\n\n<li>efeito adverso menor (GATE 9,6% vs. enteroscopia 16% e GATE 13% vs. intraop 17,6%), <\/li>\n\n\n\n<li>tempo de procedimento menor (GATE 61,26 min vs. entero 169,38 min e GATE 75,64 min vs. intraop 187,73 min)<\/li>\n\n\n\n<li>tempo de interna\u00e7\u00e3o menor (GATE 1,8 dias vs. entero 6,9 dias e GATE 2,2 dias vs. intraop 5,4 dias).<\/li>\n<\/ul>\n\n\n\n<p>As principais <strong>complica\u00e7\u00f5es<\/strong> do GATE s\u00e3o: falha de fechamento da f\u00edstula confeccionada (chegando a 17%) e migra\u00e7\u00e3o do Stent (7% dos casos). Ambas as complica\u00e7\u00f5es s\u00e3o pass\u00edveis de corre\u00e7\u00e3o por endoscopia e a abordagem cir\u00fargica \u00e9 rara.<\/p>\n\n\n\n<p>A seguir, descreveremos o <strong>passo a passo para o GATE<\/strong>.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\" id=\"h-a-tecnica\"><strong>A t\u00e9cnica<\/strong> <\/h2>\n\n\n\n<p> Consiste na confec\u00e7\u00e3o de acesso transg\u00e1strico atrav\u00e9s de uma gastrogastroanastomose ou por jejunogastroanastomose atrav\u00e9s da al\u00e7a jejunal proximal do Y de Roux at\u00e9 o est\u00f4mago excluso, por meio de ecoendoscopia setorial e uso de pr\u00f3tese met\u00e1lica de aposi\u00e7\u00e3o de lumens \u2013 <a href=\"https:\/\/endoscopiaterapeutica.net\/pt\/assuntosgerais\/protese-metalica-de-aposicao-luminal-lams-2\/\" target=\"_blank\" rel=\"noreferrer noopener\">LAMS<\/a> (Figura 1);<\/p>\n\n\n<div class=\"wp-block-image\">\n<figure class=\"aligncenter size-full is-resized\"><a href=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2023\/12\/post-dr-angelo-1.jpg\" data-rel=\"penci-gallery-image-content\" ><img fetchpriority=\"high\" decoding=\"async\" width=\"818\" height=\"366\" src=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2023\/12\/post-dr-angelo-1.jpg?v=1702308681\" alt=\"\" class=\"wp-image-18069\" style=\"width:548px;height:auto\" srcset=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2023\/12\/post-dr-angelo-1.jpg?v=1702308681 818w, https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2023\/12\/post-dr-angelo-1-300x134.jpg?v=1702308681 300w, https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2023\/12\/post-dr-angelo-1-768x344.jpg?v=1702308681 768w, https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2023\/12\/post-dr-angelo-1-585x262.jpg?v=1702308681 585w\" sizes=\"(max-width: 818px) 100vw, 818px\" \/><\/a><figcaption class=\"wp-element-caption\"><strong>Figura 1: Hot Axios, pr\u00f3tese met\u00e1lica com aposi\u00e7\u00e3o de l\u00famens inserido em cat\u00e9ter diat\u00e9rmico que permite disparar sem necessidade de dilata\u00e7\u00e3o com cist\u00f3tomo.<\/strong><\/figcaption><\/figure>\n<\/div>\n\n\n<h2 class=\"wp-block-heading\" id=\"h-passo-1-avaliacao-ecoendoscopica\"><strong>Passo 1: Avalia\u00e7\u00e3o ecoendosc\u00f3pica<\/strong><\/h2>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Em transi\u00e7\u00e3o esofagog\u00e1strica, localizar a borda inferior do f\u00edgado e girar sentido hor\u00e1rio pela vis\u00e3o ecoendosc\u00f3pica at\u00e9 localizar a \u201cbolacha do mar\u201d, <em>sand dollar sign<\/em>, que seria o est\u00f4mago excluso em sua por\u00e7\u00e3o antral (Figura 2);<\/li>\n<\/ul>\n\n\n<div class=\"wp-block-image\">\n<figure class=\"aligncenter size-large is-resized\"><a href=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2023\/12\/post-dr-angelo-2.jpg\" data-rel=\"penci-gallery-image-content\" ><img decoding=\"async\" width=\"1024\" height=\"707\" src=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2023\/12\/post-dr-angelo-2-1024x707.jpg?v=1702305844\" alt=\"\" class=\"wp-image-18056\" style=\"width:528px;height:auto\" srcset=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2023\/12\/post-dr-angelo-2-1024x707.jpg?v=1702305844 1024w, https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2023\/12\/post-dr-angelo-2-300x207.jpg?v=1702305844 300w, https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2023\/12\/post-dr-angelo-2-768x530.jpg?v=1702305844 768w, https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2023\/12\/post-dr-angelo-2-585x404.jpg?v=1702305844 585w, https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2023\/12\/post-dr-angelo-2.jpg?v=1702305844 1036w\" sizes=\"(max-width: 1024px) 100vw, 1024px\" \/><\/a><figcaption class=\"wp-element-caption\"><strong>Figura 2: Est\u00f4mago excluso visto em ecoendoscopia, visualizando o formato de \u201cbolacha do mar\u201d devido ao engruvinhamento das pregas g\u00e1stricas separadas em camadas ecogr\u00e1ficas.<\/strong><\/figcaption><\/figure>\n<\/div>\n\n\n<ul class=\"wp-block-list\">\n<li>Puncionar a por\u00e7\u00e3o distal do est\u00f4mago com agulha FNA de 19G at\u00e9 encostar na parede contralateral e retrair a agulha discretamente para centralizar no l\u00famen (Figura 3);<\/li>\n<\/ul>\n\n\n<div class=\"wp-block-image\">\n<figure class=\"aligncenter size-large is-resized\"><a href=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2023\/12\/post-dr-angelo-3.jpg\" data-rel=\"penci-gallery-image-content\" ><img decoding=\"async\" width=\"1024\" height=\"670\" src=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2023\/12\/post-dr-angelo-3-1024x670.jpg?v=1702306194\" alt=\"\" class=\"wp-image-18059\" style=\"width:510px;height:auto\" srcset=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2023\/12\/post-dr-angelo-3-1024x670.jpg?v=1702306194 1024w, https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2023\/12\/post-dr-angelo-3-300x196.jpg?v=1702306194 300w, https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2023\/12\/post-dr-angelo-3-768x503.jpg?v=1702306194 768w, https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2023\/12\/post-dr-angelo-3-585x383.jpg?v=1702306194 585w, https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2023\/12\/post-dr-angelo-3.jpg?v=1702306194 1030w\" sizes=\"(max-width: 1024px) 100vw, 1024px\" \/><\/a><figcaption class=\"wp-element-caption\"><strong>Figura 3: Vis\u00e3o ecogr\u00e1fica de pun\u00e7\u00e3o do est\u00f4mago excluso com agulha FNA 19G.<\/strong><\/figcaption><\/figure>\n<\/div>\n\n\n<ul class=\"wp-block-list\">\n<li>Administrar contraste iodado pela agulha (optar por seringas pequenas e contraste iodado (dilu\u00eddo em 50% com soro fisiol\u00f3gico), confirmando e dilatando o est\u00f4mago excluso por ecoendoscopia e fluoroscopia (Figura 4);<\/li>\n<\/ul>\n\n\n<div class=\"wp-block-image\">\n<figure class=\"aligncenter size-full is-resized\"><a href=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2023\/12\/post-dr-Angelo-4.jpg\" data-rel=\"penci-gallery-image-content\" ><img loading=\"lazy\" decoding=\"async\" width=\"618\" height=\"462\" src=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2023\/12\/post-dr-Angelo-4.jpg?v=1702306354\" alt=\"\" class=\"wp-image-18060\" style=\"width:496px;height:auto\" srcset=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2023\/12\/post-dr-Angelo-4.jpg?v=1702306354 618w, https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2023\/12\/post-dr-Angelo-4-300x224.jpg?v=1702306354 300w, https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2023\/12\/post-dr-Angelo-4-585x437.jpg?v=1702306354 585w\" sizes=\"(max-width: 618px) 100vw, 618px\" \/><\/a><figcaption class=\"wp-element-caption\"><strong>Figura 4: Inje\u00e7\u00e3o de contraste e soro fisiol\u00f3gico em est\u00f4mago excluso com a agulha FNA 19G.<\/strong><\/figcaption><\/figure>\n<\/div>\n\n\n<ul class=\"wp-block-list\">\n<li>Conectar a agulha com uma bomba de \u00e1gua adaptada com <em>luer lock<\/em> e preencher com soro fisiol\u00f3gico at\u00e9 distender o est\u00f4mago de forma segura (distender com ao menos o di\u00e2metro de uma coluna vertebral (estimado em 2,5 cm);<\/li>\n\n\n\n<li>Dica: utilizar o doppler para evitar vasos no trajeto de pun\u00e7\u00e3o e sangramento desnecess\u00e1rio \u00e9 essencial.<\/li>\n<\/ul>\n\n\n\n<h2 class=\"wp-block-heading\" id=\"h-passo-2-disparo-do-lams\"><strong>Passo 2: Disparo do LAMS<\/strong><\/h2>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Retrair a agulha e reposicionar o ecoendosc\u00f3pico at\u00e9 visualizar a parte proximal do corpo g\u00e1strico excluso, logo abaixo da transi\u00e7\u00e3o esogagog\u00e1strica, confirmando com ecoendoscopia, vis\u00e3o endosc\u00f3pica e fluoroscopia;<\/li>\n\n\n\n<li>Repuncionar com FNA 19G, em corpo proximal e distender o est\u00f4mago excluso novamente com soro fisiol\u00f3gico em bomba at\u00e9 ter uma janela de pun\u00e7\u00e3o com l\u00famen de ao menos 3 cm e visualizar o contraste em fundo (Figura 5);<\/li>\n<\/ul>\n\n\n<div class=\"wp-block-image\">\n<figure class=\"aligncenter size-full is-resized\"><a href=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2023\/12\/post-dr-angelo-5.jpg\" data-rel=\"penci-gallery-image-content\" ><img loading=\"lazy\" decoding=\"async\" width=\"572\" height=\"434\" src=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2023\/12\/post-dr-angelo-5.jpg?v=1702306517\" alt=\"\" class=\"wp-image-18061\" style=\"width:522px;height:auto\" srcset=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2023\/12\/post-dr-angelo-5.jpg?v=1702306517 572w, https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2023\/12\/post-dr-angelo-5-300x228.jpg?v=1702306517 300w\" sizes=\"(max-width: 572px) 100vw, 572px\" \/><\/a><figcaption class=\"wp-element-caption\"><strong>Figura 5: Dilata\u00e7\u00e3o do est\u00f4mago excluso atrav\u00e9s da inje\u00e7\u00e3o de soro fisiol\u00f3gico em nova pun\u00e7\u00e3o de corpo proximal.<\/strong><\/figcaption><\/figure>\n<\/div>\n\n\n<ul class=\"wp-block-list\">\n<li>Caso o LAMS n\u00e3o seja diat\u00e9rmico, ser\u00e1 necess\u00e1rio uso de cist\u00f3tomo para dilata\u00e7\u00e3o do trajeto guiada por fio-guia antes;<\/li>\n\n\n\n<li>Disparo do LAMS (preferencialmente de 20 mm de di\u00e2metro) em corpo proximal do est\u00f4mago excluso o mais distal \u00e0 transi\u00e7\u00e3o esofagog\u00e1strica e proximal \u00e0 anastomose gastrojejunal (Figura 6);<\/li>\n<\/ul>\n\n\n<div class=\"wp-block-image\">\n<figure class=\"aligncenter size-full is-resized\"><a href=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2023\/12\/post-dr-angelo-6.jpg\" data-rel=\"penci-gallery-image-content\" ><img loading=\"lazy\" decoding=\"async\" width=\"860\" height=\"713\" src=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2023\/12\/post-dr-angelo-6.jpg?v=1702306640\" alt=\"\" class=\"wp-image-18062\" style=\"width:504px;height:auto\" srcset=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2023\/12\/post-dr-angelo-6.jpg?v=1702306640 860w, https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2023\/12\/post-dr-angelo-6-300x249.jpg?v=1702306640 300w, https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2023\/12\/post-dr-angelo-6-768x637.jpg?v=1702306640 768w, https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2023\/12\/post-dr-angelo-6-585x485.jpg?v=1702306640 585w\" sizes=\"(max-width: 860px) 100vw, 860px\" \/><\/a><figcaption class=\"wp-element-caption\"><strong>Figura 6: Vis\u00e3o endosc\u00f3pica de parte proximal da LAMS disparada em est\u00f4mago remanescente.<\/strong><\/figcaption><\/figure>\n<\/div>\n\n\n<ul class=\"wp-block-list\">\n<li>Dicas: n\u00e3o distar mais de 1 cm da parede do est\u00f4mago remanescente com o excluso; molhar todo o cat\u00e9ter do LAMS antes de introduzir no aparelho; evitar puncionar em cima da linha de grampo afim de evitar perman\u00eancia de f\u00edstula e \u00e1rea de fibrose.<\/li>\n<\/ul>\n\n\n\n<h2 class=\"wp-block-heading\" id=\"h-passo-3-dilatacao-do-lams-e-procedimento\"><strong>Passo 3: Dilata\u00e7\u00e3o do LAMS e procedimento<\/strong><\/h2>\n\n\n\n<p>Nesta etapa h\u00e1 duas possibilidades:<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Em duas etapas: aguardar maturar a f\u00edstula em 1 a 2 semanas e seguir com procedimento ap\u00f3s esse per\u00edodo com a pr\u00f3tese met\u00e1lica j\u00e1 expandida ou dilata\u00e7\u00e3o do LAMS logo ap\u00f3s disparo;<\/li>\n\n\n\n<li>Etapa \u00fanica: realizar dilata\u00e7\u00e3o logo ap\u00f3s passagem da LAMS. H\u00e1 op\u00e7\u00e3o de fixa\u00e7\u00e3o da pr\u00f3tese com <em>over-ther-scope-clip <\/em>(Padlock e Ovesco) ou endossutura (Apollo) para minimizar a migra\u00e7\u00e3o;<\/li>\n<\/ul>\n\n\n\n<p>Dilata\u00e7\u00e3o da LAMS com bal\u00e3o hidrost\u00e1tico at\u00e9 20 mm de di\u00e2metro, com confirma\u00e7\u00e3o da dilata\u00e7\u00e3o por vis\u00e3o endosc\u00f3pica e fluorosc\u00f3pica (Figura 7 e 8);<\/p>\n\n\n<div class=\"wp-block-image\">\n<figure class=\"aligncenter size-full\"><img loading=\"lazy\" decoding=\"async\" width=\"490\" height=\"407\" src=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2023\/12\/post-dr-angelo-7.jpg?v=1702306999\" alt=\"\" class=\"wp-image-18063\" srcset=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2023\/12\/post-dr-angelo-7.jpg?v=1702306999 490w, https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2023\/12\/post-dr-angelo-7-300x249.jpg?v=1702306999 300w\" sizes=\"(max-width: 490px) 100vw, 490px\" \/><figcaption class=\"wp-element-caption\"><strong>Figura 7: Fluoroscopia de dilata\u00e7\u00e3o de LAMS com bal\u00e3o hidrost\u00e1tico.<\/strong><\/figcaption><\/figure>\n<\/div>\n\n<div class=\"wp-block-image\">\n<figure class=\"aligncenter size-full is-resized\"><a href=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2023\/12\/post-dr-angelo-8.jpg\" data-rel=\"penci-gallery-image-content\" ><img loading=\"lazy\" decoding=\"async\" width=\"732\" height=\"714\" src=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2023\/12\/post-dr-angelo-8.jpg?v=1702307092\" alt=\"\" class=\"wp-image-18064\" style=\"width:486px;height:auto\" srcset=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2023\/12\/post-dr-angelo-8.jpg?v=1702307092 732w, https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2023\/12\/post-dr-angelo-8-300x293.jpg?v=1702307092 300w, https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2023\/12\/post-dr-angelo-8-585x571.jpg?v=1702307092 585w\" sizes=\"(max-width: 732px) 100vw, 732px\" \/><\/a><figcaption class=\"wp-element-caption\"><strong>Figura 8: Vis\u00e3o endosc\u00f3pica da LAMS dilatada, podendo-se visualizar o est\u00f4mago excluso em parte distal da pr\u00f3tese.<\/strong><\/figcaption><\/figure>\n<\/div>\n\n\n<ul class=\"wp-block-list\">\n<li>Prosseguir com o tratamento endosc\u00f3pico proposto: CPRE principalmente<\/li>\n\n\n\n<li>Dicas: em uso de duodenosc\u00f3pios ou ecoendosc\u00f3pios, entrar com aparelho em paralelo com a pr\u00f3tese; a pr\u00f3tese \u00e9 m\u00f3vel, ent\u00e3o a fluoroscopia ajuda no posicionamento e minimiza a fric\u00e7\u00e3o com a pr\u00f3tese, evitando migra\u00e7\u00e3o (Figura 9).<\/li>\n<\/ul>\n\n\n\n<p><\/p>\n\n\n<div class=\"wp-block-image\">\n<figure class=\"aligncenter size-full is-resized\"><a href=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2023\/12\/post-dr-angelo-9.jpg\" data-rel=\"penci-gallery-image-content\" ><img loading=\"lazy\" decoding=\"async\" width=\"814\" height=\"383\" src=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2023\/12\/post-dr-angelo-9.jpg?v=1702307210\" alt=\"\" class=\"wp-image-18065\" style=\"width:546px;height:auto\" srcset=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2023\/12\/post-dr-angelo-9.jpg?v=1702307210 814w, https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2023\/12\/post-dr-angelo-9-300x141.jpg?v=1702307210 300w, https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2023\/12\/post-dr-angelo-9-768x361.jpg?v=1702307210 768w, https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2023\/12\/post-dr-angelo-9-585x275.jpg?v=1702307210 585w\" sizes=\"(max-width: 814px) 100vw, 814px\" \/><\/a><figcaption class=\"wp-element-caption\"><strong>Figura 9: Passagem do aparelho com fluoroscopia e vis\u00e3o endosc\u00f3pica combinada, mantendo-se o eixo do aparelho paralelo \u00e0 LAMS.<\/strong><\/figcaption><\/figure>\n<\/div>\n\n\n<h2 class=\"wp-block-heading\" id=\"h-passo-4-fechamento-da-fistula\"><strong>Passo 4: Fechamento da f\u00edstula<\/strong><\/h2>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Devido ao risco de complica\u00e7\u00f5es p\u00f3s-procedimentos endosc\u00f3picos, como sangramento e perfura\u00e7\u00e3o p\u00f3s-CPRE, mant\u00e9m-se a LAMS por 1 a 2 semanas, possibilitando a reabordagem endosc\u00f3pica. Alguns autores, preconizam a retirada imediata seguida por coloca\u00e7\u00e3o de pr\u00f3tese pl\u00e1stica;<\/li>\n\n\n\n<li>Ap\u00f3s esse per\u00edodo, revisa-se por endoscopia digestiva alta (EDA), seguida de retirada do LAMS com pin\u00e7a de corpo estranho ou com al\u00e7a endosc\u00f3pica, tracionando-se preferencialmente pela falange proximal da pr\u00f3tese;<\/li>\n\n\n\n<li>Alguns autores preconizam troca por pr\u00f3tese pl\u00e1stica duplo <em>pigtail<\/em> de tamanho curto e outros por apenas retirar e deixar a f\u00edstula ocluir por cicatriza\u00e7\u00e3o em segunda inten\u00e7\u00e3o;<\/li>\n\n\n\n<li>O controle de fechamento da f\u00edstula com o est\u00f4mago excluso pode ser feita com EDA, radiografia contrastada (EED) ou tomografia computadorizada com contraste n\u00e3o-baritado por via oral ap\u00f3s 6 a 8 semanas da retirada da LAMS.<\/li>\n<\/ul>\n\n\n\n<p class=\"has-very-light-gray-to-cyan-bluish-gray-gradient-background has-background\">Em suma, o GATE mostra-se como um procedimento seguro e eficaz com taxa de sucesso t\u00e9cnico e cl\u00ednico compar\u00e1vel a abordagem transg\u00e1strica intraoperat\u00f3ria, sem necessidade de combinar duas especialidades m\u00e9dicas, com menor taxa de efeitos adversos, menor tempo de procedimento e interna\u00e7\u00e3o. A realiza\u00e7\u00e3o do procedimento ap\u00f3s GATE em tempo \u00fanico, com dilata\u00e7\u00e3o sem fixa\u00e7\u00e3o do LAMS est\u00e1 cada vez mais se mostrando seguro e eficaz com o avan\u00e7o das t\u00e9cnicas endosc\u00f3picas.<\/p>\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>Sociedade Brasileira de Cirurgia Bari\u00e1trica e Metab\u00f3lica (SBCBM).&nbsp;SBCBM, 2023. Dispon\u00edvel em: https:\/\/www.sbcbm.org.br\/obesidade-atinge-mais-de-67-milhoes-de-pessoas-no-brasil-em-2022\/. Acesso em: 16, novembro, 2023.<\/li>\n\n\n\n<li>Deliwala SS, Mohan BP, Yarra P, Khan SR, Chandan S, Ramai D, et al. Efficacy &amp; safety of EUS-directed transgastric endoscopic retrograde cholangiopancreatography (EDGE) in Roux-en-Y gastric bypass anatomy: a systematic review &amp; meta-analysis. Surg Endosc. 2023 Jun;37(6):4144\u201358.<\/li>\n\n\n\n<li>Wang TJ, Thompson CC, Ryou M. Gastric access temporary for endoscopy (GATE): a proposed algorithm for EUS-directed transgastric ERCP in gastric bypass patients. Surg Endosc. 2019 Jun;33(6):2024\u201333.<\/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-very-light-gray-to-cyan-bluish-gray-gradient-background has-background\">Kum AST, Nunes CM, Rocha SPR. Acesso Transg\u00e1strico Endosc\u00f3pico\u00a0GATE (EDGE) em Bypass G\u00e1strico: o passo a passo. Endoscopia Terapeutica 2023, Vol II. Dispon\u00edvel em: <a href=\"https:\/\/endoscopiaterapeutica.net\/pt\/?p=18054\" target=\"_blank\" rel=\"noreferrer noopener\">https:\/\/endoscopiaterapeutica.net\/pt\/uncategorized\/acesso-transgastrico-endoscopico-gate-edge-em-bypass-gastrico-com-y-de-roux-o-passo-a-passo\/<\/a><\/p>\n","protected":false},"excerpt":{"rendered":"<p>Segundo o Minist\u00e9rio da Sa\u00fade, a obesidade atinge 6,7 milh\u00f5es de pessoas no Brasil.&hellip;<\/p>\n","protected":false},"author":5611,"featured_media":18067,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_lmt_disableupdate":"","_lmt_disable":"","footnotes":""},"categories":[151],"tags":[740,738],"ano":[555],"tipo":[155],"volume":[147],"class_list":["post-18054","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-assuntosgerais","tag-bypass","tag-gate","ano-555","tipo-cpre","volume-volume-ii"],"yoast_head":"<!-- This site is optimized with the Yoast SEO Premium plugin v27.2 (Yoast SEO v27.2) - https:\/\/yoast.com\/product\/yoast-seo-premium-wordpress\/ -->\n<title>Acesso Transg\u00e1strico Endosc\u00f3pico\u00a0GATE (EDGE) em Bypass G\u00e1strico: o passo a passo &#8226; Endoscopia Terapeutica<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/endoscopiaterapeutica.net\/pt\/assuntosgerais\/acesso-transgastrico-endoscopico-gate-edge-em-bypass-gastrico-o-passo-a-passo\/\" \/>\n<meta property=\"og:locale\" content=\"pt_BR\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Acesso Transg\u00e1strico Endosc\u00f3pico\u00a0GATE (EDGE) em Bypass G\u00e1strico: o passo a passo\" \/>\n<meta property=\"og:description\" content=\"Segundo o Minist\u00e9rio da Sa\u00fade, a obesidade atinge 6,7 milh\u00f5es de pessoas no Brasil. 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