{"id":18248,"date":"2024-01-23T20:42:00","date_gmt":"2024-01-23T20:42:00","guid":{"rendered":"https:\/\/endoscopiaterapeutica.net\/pt\/?p=18248"},"modified":"2024-06-18T15:47:28","modified_gmt":"2024-06-18T15:47:28","slug":"terapeuticas-endoscopicas-para-manejo-de-coledocolitiase-complexa","status":"publish","type":"post","link":"https:\/\/endoscopiaterapeutica.net\/pt\/assuntosgerais\/terapeuticas-endoscopicas-para-manejo-de-coledocolitiase-complexa\/","title":{"rendered":"Terap\u00eauticas endosc\u00f3picas para manejo de coledocolit\u00edase complexa"},"content":{"rendered":"\n<p>A coledocolit\u00edase \u00e9 uma complica\u00e7\u00e3o da doen\u00e7a calculosa da ves\u00edcula biliar que acomete 10 a 20% dessa popula\u00e7\u00e3o. A grande maioria dos casos (90%), possui resolu\u00e7\u00e3o com t\u00e9cnicas de tratamento endosc\u00f3pico convencional, entretanto, os 10% restantes comp\u00f5em um grupo populacional que possui uma condi\u00e7\u00e3o entitulada de coledocolit\u00edase complexa [1].<\/p>\n\n\n\n<h2 class=\"wp-block-heading\" id=\"h-definicao\"><strong>Defini\u00e7\u00e3o<\/strong><\/h2>\n\n\n\n<p>A <strong>coledocolit\u00edase complexa<\/strong>, tamb\u00e9m conhecida como \u201c<strong>c\u00e1lculo dif\u00edcil<\/strong>\u201d ou \u201c<strong>calculo de dif\u00edcil manejo<\/strong>\u201d, \u00e9 definida segundo alguns crit\u00e9rios que dependem das caracter\u00edsticas do c\u00e1lculo, localiza\u00e7\u00e3o do c\u00e1lculo, anatomia do paciente e fatores associados aos pacientes.<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li><strong>Quanto \u00e0s caracter\u00edsticas dos c\u00e1lculos:<\/strong> C\u00e1lculos de grande dimens\u00e3o (&gt;15mm), m\u00faltiplos c\u00e1lculos (&gt; 3 c\u00e1lculos maiores do que 10mm), c\u00e1lculos duros e aqueles com formato n\u00e3o-habitual (quadrado ou em barril) apresentam dificuldade de captura pelo basket e geralmente necessitam de litotripsia;<\/li>\n\n\n\n<li><strong>Quanto \u00e0 localiza\u00e7\u00e3o dos c\u00e1lculos: <\/strong>C\u00e1lculos intra-hep\u00e1ticos, acima de estenoses, impactados no ducto col\u00e9doco ou associado a s\u00edndrome de Mirizzi oferecem dificuldade no acesso;<\/li>\n\n\n\n<li><strong>Quanto \u00e0 situa\u00e7\u00e3o anat\u00f4mica: <\/strong>Altera\u00e7\u00e3o cong\u00eanita ou cir\u00fargica da via biliar (Billroth II\/ bypass g\u00e1strico com Y de roux) e divert\u00edculo duodenal com papila peri\/intradiverticular que dificultam o acesso e limita o endosc\u00f3pio e o manejo de acess\u00f3rios;<\/li>\n\n\n\n<li><strong>Quanto ao paciente:<\/strong> Idade avan\u00e7ada, condi\u00e7\u00f5es clinicas ruins, instabilidade hemodin\u00e2mica, tend\u00eancia a sangramento e respostas paradoxais que favorecem a ocorr\u00eancia de efeitos adversos;<\/li>\n<\/ul>\n\n\n\n<h2 class=\"wp-block-heading\" id=\"h-manejo\"><strong>Manejo<\/strong><\/h2>\n\n\n\n<p>A coledocolit\u00edase com c\u00e1lculos n\u00e3o complexos geralmente alcan\u00e7a altas taxas de sucesso terap\u00eautico com a t\u00e9cnica convencional de acesso e explora\u00e7\u00e3o da via biliar, geralmente com papilotomia e remo\u00e7\u00e3o com bal\u00e3o extrator. No caso de c\u00e1lculos complexos, s\u00e3o necess\u00e1rias t\u00e9cnicas adicionais para a completa resolu\u00e7\u00e3o do quadro, como dilata\u00e7\u00e3o da papila com bal\u00e3o, uso de basket com sistema de litotripsia mec\u00e2nica ou at\u00e9 mesmo uso de colangioscopia com litotripsia a laser.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\" id=\"h-dilatacao-da-papila-com-balao\"><strong>Dilata\u00e7\u00e3o da papila com bal\u00e3o<\/strong><\/h2>\n\n\n\n<p>A dilata\u00e7\u00e3o da papila com bal\u00e3o \u00e9 um m\u00e9todo que pode ser utilizado em associa\u00e7\u00e3o ou n\u00e3o \u00e0 papilotomia endosc\u00f3pica e que tem potencial em <strong>reduzir de 30 a 50% o uso de litotripsia mec\u00e2nica<\/strong> [2].<\/p>\n\n\n<div class=\"wp-block-image\">\n<figure class=\"aligncenter size-full\"><a href=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2016\/11\/dilatacao-balonada-papila.png\" data-rel=\"penci-gallery-image-content\" ><img fetchpriority=\"high\" decoding=\"async\" width=\"535\" height=\"521\" src=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2016\/11\/dilatacao-balonada-papila.png\" alt=\"\" class=\"wp-image-3910\" srcset=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2016\/11\/dilatacao-balonada-papila.png 535w, https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2016\/11\/dilatacao-balonada-papila-300x292.png 300w\" sizes=\"(max-width: 535px) 100vw, 535px\" \/><\/a><figcaption class=\"wp-element-caption\">Dilata\u00e7\u00e3o balonada de papila duodenal maior com bal\u00e3o hidrost\u00e1tico via CPRE.<\/figcaption><\/figure>\n<\/div>\n\n\n<p>A dilata\u00e7\u00e3o da papila pode auxiliar na resolu\u00e7\u00e3o de c\u00e1lculos de pacientes que tenham chances aumentadas de sangramento p\u00f3s-esfincterotomia e \u00e0queles que a papilotomia completa n\u00e3o \u00e9 tecnicamente poss\u00edvel (intradiverticular, papila com infund\u00edbulo pequeno). Sugere-se uma sele\u00e7\u00e3o criteriosa de pacientes, evitando-se procedimentos for\u00e7ados, dura\u00e7\u00e3o ideal da dilata\u00e7\u00e3o e convers\u00e3o imediata para procedimentos alternativos.<\/p>\n\n\n\n<blockquote class=\"wp-block-quote is-layout-flow wp-block-quote-is-layout-flow\">\n<p><a href=\"https:\/\/endoscopiaterapeutica.com.br\/video\/dilatacao-balonada-da-papila-duodenal\/\">Clique aqui<\/a> para mais informa\u00e7\u00f5es sobre dilata\u00e7\u00e3o da papila com bal\u00e3o.<\/p>\n<\/blockquote>\n\n\n\n<h2 class=\"wp-block-heading\" id=\"h-litotripsia-mecanica\"><strong>Litotripsia mec\u00e2nica<\/strong><\/h2>\n\n\n\n<p>A litotripsia mec\u00e2nica (LM) \u00e9 uma t\u00e9cnica geralmente utilizada ap\u00f3s a falha na tentativa de remo\u00e7\u00e3o c\u00e1lculo ap\u00f3s realiza\u00e7\u00e3o de esfincterotomia e dilata\u00e7\u00e3o da papila com bal\u00e3o, geralmente, ocasionada por despropor\u00e7\u00e3o do c\u00e1lculo em rela\u00e7\u00e3o \u00e0 via biliar distal. Possui taxa de sucesso relatado entre 79 a 96% e baixas taxas de mortalidade, bem como de efeitos adversos (3,5%) [3]. <\/p>\n\n\n\n<p>A cesta \u00e9 utilizada para captura de c\u00e1lculos e podem ser tamb\u00e9m instrumento para realiza\u00e7\u00e3o de quebra mec\u00e2nica do c\u00e1lculo de forma integrada ou com utiliza\u00e7\u00e3o de litotriptor de emerg\u00eancia.<\/p>\n\n\n\n<div style=\"position:relative;padding-top:100%;\"><iframe id=\"panda-18f29a61-fbdd-4675-932f-31296f13e393\" src=\"https:\/\/player-vz-a75e9d45-986.tv.pandavideo.com.br\/embed\/?v=18f29a61-fbdd-4675-932f-31296f13e393\" 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 class=\"wp-block-columns is-layout-flex wp-container-core-columns-is-layout-9d6595d7 wp-block-columns-is-layout-flex\"><\/div>\n\n\n\n<p><br>Apesar disso, a LM pode necessitar de m\u00faltiplas sess\u00f5es e ainda assim n\u00e3o ser eficaz na elimina\u00e7\u00e3o completa dos c\u00e1lculos, portanto, sendo necess\u00e1rio de procedimentos adicionais com utiliza\u00e7\u00e3o de acess\u00f3rios mais robustos como a colangioscopia com litotripsia eletro-hidr\u00e1ulica ou \u00e0 laser. <br>A taxa de sucesso \u00e9 inversamente proporcional ao di\u00e2metro do c\u00e1lculo, tendo 68% de chance de resolu\u00e7\u00e3o em c\u00e1lculos maiores que 28 mm e chegando a 90% em c\u00e1lculos inferiores a 10mm de di\u00e2metro [2]. Outro fator que reduz as chances de resolu\u00e7\u00e3o s\u00e3o a impacta\u00e7\u00e3o do c\u00e1lculo na via biliar, formato moldado pela via biliar e c\u00e1lculos endurecidos.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\" id=\"h-stent-biliar-endoscopico\"><strong>Stent biliar endosc\u00f3pico<\/strong><\/h2>\n\n\n\n<p>A inser\u00e7\u00e3o de stent biliar \u00e9 op\u00e7\u00e3o terap\u00eautica para pacientes com insucesso na remo\u00e7\u00e3o dos c\u00e1lculos e necessidade de drenagem da via biliar, evitando-se assim a colangite. O atrito do stent sobre os c\u00e1lculos promove sua fragmenta\u00e7\u00e3o e aumentam as chances de resolu\u00e7\u00e3o em uma abordagem posterior. <br>Os stents met\u00e1licos autoexpans\u00edveis totalmente recobertos tamb\u00e9m podem ser utilizados para drenar a via biliar ap\u00f3s uma remo\u00e7\u00e3o malsucedida de c\u00e1lculos, entretanto, com custo-efetividade ainda question\u00e1vel.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\" id=\"h-litotripsia-guiada-por-colangioscopia\"><strong>Litotripsia guiada por colangioscopia<\/strong><\/h2>\n\n\n\n<p>A colangioscopia \u00e9 um procedimento que permite a visualiza\u00e7\u00e3o do interior da via biliar e \u00e9 realizado atrav\u00e9s do uso do colangiosc\u00f3pio, instrumento que \u00e9 inserido atrav\u00e9s do canal do duodenosc\u00f3pio para que seja introduzido na via biliar visualizando seus ductos e paredes. Esse \u00e9 um procedimento idealmente realizado por endoscopistas experientes e equipe treinada para o manejo do acess\u00f3rio, chegando a alcan\u00e7ar <strong>taxas de sucesso superiores a 90%<\/strong> no clareamento da via biliar [1]. <br>A litotripsia guiada por colangioscopia pode ser realizada atrav\u00e9s de duas modalidades: \u00e0 laser (LL) ou eletro-hidr\u00e1ulica (LEH). <\/p>\n\n\n\n<blockquote class=\"wp-block-quote is-layout-flow wp-block-quote-is-layout-flow\">\n<p><a href=\"https:\/\/endoscopiaterapeutica.com.br\/assuntosgerais\/litotripsia-intraductal-na-colangiopancreatografia-retrograda-endoscopica\/\">Clique aqui<\/a> para mais informa\u00e7\u00f5es sobre litotripsia por colangioscopia.<\/p>\n<\/blockquote>\n\n\n\n<p>Uma importante metan\u00e1lise, comparou a taxa de sucesso da litotripsia extracorp\u00f3rea (LECO), LL e LEH no clareamento da via biliar, sendo 84,5%, 95,1% e 88,4%, respectivamente, bem como taxas de complica\u00e7\u00e3o mais altas nos procedimentos de LEH (13,8%), seguidos de LL (9,6%) e LECO (8,4%) [4]. Entretanto, outra metanalise mais recente, compara LL vs. LEH mostrando superioridade de sucesso nessa \u00faltima com taxas de sucesso terap\u00eautico de 88,6% e 91,4%, respectivamente [5]. <\/p>\n\n\n\n<p>Recomenda-se que tal procedimento deve ser reservado para uso em casos selecionados de insucesso com CPRE convencional, preferencialmente sendo realizada em centro de refer\u00eancia, devido a sua complexidade, custo e eventos adversos, apesar de alguns autores j\u00e1 deferem sua indica\u00e7\u00e3o como terapia de primeira linha para pacientes com coledocolitiase complexa a fim de redu\u00e7\u00e3o de numero de interven\u00e7\u00f5es e eleva\u00e7\u00e3o de custo-efetividade.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\" id=\"h-conclusao\"><strong>Conclus\u00e3o<\/strong><\/h2>\n\n\n\n<p class=\"has-pale-ocean-gradient-background has-background\">A <strong>CPRE<\/strong> \u00e9 procedimento terap\u00eautico destinado a manejo de doen\u00e7as das vias biliopancre\u00e1ticas, incluindo o manejo dos c\u00e1lculos nas vias biliares. A <strong>coledocolitiase complexa<\/strong>, apesar de pouco frequente, ainda \u00e9 uma afec\u00e7\u00e3o que exige n\u00e3o apenas expertise na sua condu\u00e7\u00e3o como tamb\u00e9m de conhecimento e habilidade dos endoscopistas. Hoje, temos um vasto arsenal para resolu\u00e7\u00e3o desses casos, como uso de bal\u00e3o dilatador para corre\u00e7\u00e3o da despropor\u00e7\u00e3o c\u00e1lculo-papila e instrumentos de litotripsia (mec\u00e2nica, extracorp\u00f3rea e guiada por colangioscopia, seja a laser ou eletrohidr\u00e1ulica) e \u00e9 de fundamental import\u00e2ncia o treinamento de equipes para sua correta utiliza\u00e7\u00e3o em tais situa\u00e7\u00f5es.<\/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 class=\"has-small-font-size\">Trikudanathan G, Navaneethan U, Parsi MA. Endoscopic management of difficult common bile duct stones. World J Gastroenterol. 2013 Jan 14;19(2):165-73. doi: 10.3748\/wjg.v19.i2.165. PMID: 23345939; PMCID: PMC3547556.<\/li>\n\n\n\n<li class=\"has-small-font-size\">Tringali A, Costa D, Fugazza A, Colombo M, Khalaf K, Repici A, Anderloni A. Endoscopic management of difficult common bile duct stones: Where are we now? A comprehensive review. World J Gastroenterol. 2021 Nov 28;27(44):7597-7611. doi: 10.3748\/wjg.v27.i44.7597. PMID: 34908801; PMCID: PMC8641054.<\/li>\n\n\n\n<li class=\"has-small-font-size\">Thomas M, Howell DA, Carr-Locke D, Mel Wilcox C, Chak A, Raijman I, Watkins JL, Schmalz MJ, Geenen JE, Catalano MF. Mechanical lithotripsy of pancreatic and biliary stones: complications and available treatment options collected from expert centers. Am J Gastroenterol. 2007 Sep;102(9):1896-902. doi: 10.1111\/j.1572-0241.2007.01350.x. Epub 2007 Jun 15. PMID: 17573790.<\/li>\n\n\n\n<li class=\"has-small-font-size\">Veld JV, van Huijgevoort NCM, Boermeester MA, Besselink MG, van Delden OM, Fockens P, van Hooft JE. A systematic review of advanced endoscopy-assisted lithotripsy for retained biliary tract stones: laser, electrohydraulic or extracorporeal shock wave. Endoscopy. 2018 Sep;50(9):896-909. doi: 10.1055\/a-0637-8806. Epub 2018 Jul 10. PMID: 29991072.<\/li>\n\n\n\n<li class=\"has-small-font-size\">Galetti F, Moura DTH, Ribeiro IB, Funari MP, Coronel M, Sachde AH, Brunaldi VO, Franzini TP, Bernardo WM, Moura EGH. Cholangioscopy-guided lithotripsy vs. conventional therapy for complex bile duct stones: a systematic review and meta-analysis. Arq Bras Cir Dig. 2020 Jun 26;33(1):e1491. doi: 10.1590\/0102-672020190001e1491. PMID: 32609255; PMCID: PMC7325696.<\/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\">Martins S. Terapeuticas endoscopicas para manejo de coledocolit\u00edase complexa. Endoscopia Terapeutica, 2024, vol 1. Disponivel em: https:\/\/endoscopiaterapeutica.com.br\/assuntosgerais\/terapeuticas-endoscopicas-para-manejo-de-coledocolitiase-complexa\/<\/p>\n","protected":false},"excerpt":{"rendered":"<p>A coledocolit\u00edase \u00e9 uma complica\u00e7\u00e3o da doen\u00e7a calculosa da ves\u00edcula biliar que acomete 10&hellip;<\/p>\n","protected":false},"author":5616,"featured_media":18249,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_lmt_disableupdate":"","_lmt_disable":"","footnotes":""},"categories":[151],"tags":[],"ano":[742],"tipo":[155],"volume":[263],"class_list":["post-18248","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-assuntosgerais","ano-742","tipo-cpre","volume-volume-i"],"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>Terap\u00eauticas endosc\u00f3picas para manejo de coledocolit\u00edase complexa &#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\/terapeuticas-endoscopicas-para-manejo-de-coledocolitiase-complexa\/\" \/>\n<meta property=\"og:locale\" content=\"pt_BR\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Terap\u00eauticas endosc\u00f3picas para manejo de coledocolit\u00edase complexa\" \/>\n<meta property=\"og:description\" content=\"A coledocolit\u00edase \u00e9 uma complica\u00e7\u00e3o da doen\u00e7a calculosa da ves\u00edcula biliar que acomete 10 a 20% dessa popula\u00e7\u00e3o. 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