{"id":18264,"date":"2024-02-06T00:41:18","date_gmt":"2024-02-06T00:41:18","guid":{"rendered":"https:\/\/endoscopiaterapeutica.net\/pt\/?p=18264"},"modified":"2024-07-01T21:22:41","modified_gmt":"2024-07-01T21:22:41","slug":"perfuracao-na-colonoscopia-cuidados-e-manejo","status":"publish","type":"post","link":"https:\/\/endoscopiaterapeutica.net\/pt\/assuntosgerais\/perfuracao-na-colonoscopia-cuidados-e-manejo\/","title":{"rendered":"Perfura\u00e7\u00e3o na Colonoscopia: Cuidados e Manejo"},"content":{"rendered":"\n<h2 class=\"wp-block-heading\" id=\"h-introducao\"><strong>Introdu\u00e7\u00e3o<\/strong><\/h2>\n\n\n\n<p>O c\u00e2ncer colorretal (CCR) se trata de uma preocupa\u00e7\u00e3o global com incid\u00eancia ascendente com o decorrer dos anos, chegando a uma estimativa do n\u00famero atual de 1.960.000 chegar a 3.600.000 casos em 2050 segundo a Organiza\u00e7\u00e3o Mundial da Sa\u00fade (OMS) [1]. A colonoscopia tem um papel importante no diagn\u00f3stico do CCR e tamb\u00e9m para diminuir sua incid\u00eancia e mortalidade atrav\u00e9s do tratamento de afec\u00e7\u00f5es colorretais atrav\u00e9s de polipectomias e ressec\u00e7\u00f5es de les\u00f5es pr\u00e9-malignas [2, 3].&nbsp;<\/p>\n\n\n\n<p>Como em todo ato m\u00e9dico intervencionista, podem ocorrer eventos adversos inerentes a qualquer procedimento, e no caso das colonoscopias s\u00e3o: n\u00e1useas, v\u00f4mitos ou distens\u00e3o abdominal pelo preparo intestinal; hipotens\u00e3o arterial, bradicardia, depress\u00e3o respirat\u00f3ria e broncoaspira\u00e7\u00e3o pela seda\u00e7\u00e3o; dor abdominal, sangramento e perfura\u00e7\u00e3o pelo procedimento. <\/p>\n\n\n\n<p class=\"has-pale-ocean-gradient-background has-background\">Cada <strong>paciente<\/strong> \u00e9 um <strong>indiv\u00edduo particular<\/strong>, podendo ter anatomia variada cong\u00eanita ou por cirurgias pr\u00e9vias, sendo que os dispositivos de endoscopia e colonoscopia seguem um design para um biotipo padr\u00e3o. Como conseguinte, complica\u00e7\u00f5es como a perfura\u00e7\u00e3o podem ocorrer independente da t\u00e9cnica e expertise do endoscopista. As perfura\u00e7\u00f5es s\u00e3o efeitos adversos raros, inerentes a qualquer procedimento endosc\u00f3pico, potencialmente graves e sua incid\u00eancia estimada globalmente \u00e9 de <strong>0,016 a 0,8%<\/strong> para colonoscopias diagn\u00f3sticas e <strong>0,02 a 8%<\/strong> para colonoscopias terap\u00eauticas<sup> <\/sup>[4]. <\/p>\n\n\n\n<p>Os mecanismos associados \u00e0s perfura\u00e7\u00f5es de c\u00f3lon ap\u00f3s colonoscopia s\u00e3o:&nbsp;<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>trauma direto ocasionado pelo movimento progressivo do colonosc\u00f3pio;<\/li>\n\n\n\n<li>press\u00e3o lateral na parede do c\u00f3lon decorrente de al\u00e7as do aparelho;<\/li>\n\n\n\n<li>passagem do colonosc\u00f3pio por \u00e1reas doentes (estenoses, tumores ou divert\u00edculos);<\/li>\n\n\n\n<li>barotrauma por insufla\u00e7\u00e3o excessiva de ar;<\/li>\n\n\n\n<li>aplica\u00e7\u00e3o de corrente el\u00e9trica em ressec\u00e7\u00f5es endosc\u00f3picas.<\/li>\n<\/ul>\n\n\n\n<p>Aproximadamente 45-60% das perfura\u00e7\u00f5es s\u00e3o diagnosticadas durante o procedimento e o restante \u00e9 reconhecido ap\u00f3s o exame com base em sinais e sintomas cl\u00ednicos que se manifestam geralmente em at\u00e9 48h como dor abdominal importante com distens\u00e3o abdominal, sinais de peritonite, taquicardia, leucocitose e febre [4], ou identificados atrav\u00e9s de exames de imagem como radiografia simples ou tomografia computadorizada (TC) com sinais de pneumoperit\u00f4nio. Um dos pontos mais cr\u00edticos do manejo da perfura\u00e7\u00e3o tardia \u00e9 o tempo do diagn\u00f3stico, j\u00e1 que a mortalidade nessas condi\u00e7\u00f5es pode chegar a 5-25% [3,4].<\/p>\n\n\n\n<p><em><a href=\"https:\/\/endoscopiaterapeutica.com.br\/artigoscomentados\/artigo-comentado-perfuracoes-de-trato-gastrointestinal-alto-e-colonicas-medidas-praticas-de-prevencao-e-avaliacao\/\">Clique aqui<\/a> para mais informa\u00e7\u00f5es de perfura\u00e7\u00f5es de trato gastrointestinal alto.<\/em><\/p>\n\n\n\n<h2 class=\"wp-block-heading\" id=\"h-manejo\"><strong>Manejo<\/strong><\/h2>\n\n\n\n<p><\/p>\n\n\n\n<p>A depender de diferentes fatores, visando minimizar a morbimortalidade da perfura\u00e7\u00e3o por colonoscopia e se baseando na diretriz da <em>World Society of Emergency Surgery<\/em> [4], a conduta varia conforme diferentes cen\u00e1rios apresentados a seguir.<\/p>\n\n\n\n<h3 class=\"wp-block-heading\" id=\"h-suspeita-de-perfuracoes-nao-identificadas-durante-a-colonoscopia\"><strong><strong>Suspeita de perfura\u00e7\u00f5es n\u00e3o identificadas durante a colonoscopia<\/strong><\/strong><\/h3>\n\n\n\n<p>Ap\u00f3s colonoscopias diagn\u00f3sticas ou terap\u00eauticas recentes, devem ser orientados a procurar o pronto socorro e serem investigados para perfura\u00e7\u00e3o intestinal por exames laboratoriais e de imagem os pacientes que apresentem os seguintes sintomas:<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>dor abdominal persistente e refrat\u00e1ria a sintom\u00e1ticos;<\/li>\n\n\n\n<li>distens\u00e3o abdominal importante fora do habitual;<\/li>\n\n\n\n<li>febre e calafrios;<\/li>\n\n\n\n<li>sangramento retal.<\/li>\n<\/ul>\n\n\n\n<p>Os marcadores bioqu\u00edmicos solicitados no caso de suspeita de perfura\u00e7\u00e3o s\u00e3o essencialmente leucograma e prote\u00edna C reativa. A complica\u00e7\u00e3o pode ser confirmada com a demonstra\u00e7\u00e3o de ar livre intra-peritoneal ou extra-peritoneal. A TC possui maior sensibilidade do que as radiografias abdominais para detectar pneumoperit\u00f4nio.<\/p>\n\n\n\n<h3 class=\"wp-block-heading\" id=\"h-perfuracoes-identificadas-durante-a-colonoscopia\"><strong><strong>Perfura\u00e7\u00f5es identificadas durante a colonoscopia<\/strong><\/strong><\/h3>\n\n\n\n<p>Caso a perfura\u00e7\u00e3o seja detectada durante o procedimento pelo endoscopista, os seguintes detalhes das informa\u00e7\u00f5es ajudam na tomada de decis\u00e3o:<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Indica\u00e7\u00e3o de colonoscopia (ou seja, diagn\u00f3stica ou terap\u00eautica);<\/li>\n\n\n\n<li>Doen\u00e7a c\u00f3lica associada (por exemplo, estenoses, p\u00f3lipos, tumores);<\/li>\n\n\n\n<li>Estado geral do paciente e presen\u00e7a de comorbidades;<\/li>\n\n\n\n<li>Tipo de g\u00e1s usado para insufla\u00e7\u00e3o;<\/li>\n\n\n\n<li>Qualidade da prepara\u00e7\u00e3o do c\u00f3lon;<\/li>\n\n\n\n<li>Hora da ocorr\u00eancia da perfura\u00e7\u00e3o;<\/li>\n\n\n\n<li>Localiza\u00e7\u00e3o e tamanho da les\u00e3o;<\/li>\n\n\n\n<li>Se houve interven\u00e7\u00e3o endosc\u00f3pica pretendida ou sucedida.<\/li>\n<\/ul>\n\n\n\n<p>O tratamento endosc\u00f3pico pode ser considerado como uma abordagem inicial se for vi\u00e1vel dentro de 4 horas ap\u00f3s o procedimento, com paciente est\u00e1vel e pouca contamina\u00e7\u00e3o peritoneal, a depender:<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li><strong>Perfura\u00e7\u00f5es Menores que 2 cm<\/strong>: avaliar fechamento prim\u00e1rio por via endosc\u00f3pica com hemoclipes associado ou n\u00e3o a terapia a v\u00e1cuo endosc\u00f3pico, interna\u00e7\u00e3o, jejum, hidrata\u00e7\u00e3o endovenosa e antibioticoterapia por 3-5 dias com cobertura de Gram negativo e anaer\u00f3bio.<\/li>\n\n\n\n<li><strong>Perfura\u00e7\u00f5es Maiores que 2 cm<\/strong>: referir para a cirurgia. Pode-se de acordo com experi\u00eancia do endoscopista e os recursos locais, caracter\u00edsticas dos pacientes e localiza\u00e7\u00e3o da les\u00e3o avaliar a possibilidade de fechamento prim\u00e1rio por via endosc\u00f3pica e, seguir com mesmo processo das perfura\u00e7\u00f5es menores que 2 cm.<\/li>\n<\/ul>\n\n\n\n<p>O manejo n\u00e3o operat\u00f3rio, conservador, das perfura\u00e7\u00f5es pode ser apropriado em pacientes selecionados, incluindo pacientes que est\u00e3o hemodinamicamente est\u00e1veis, sem sepse, com dor localizada e sem l\u00edquido livre em exame de imagem. A TC abdominal \u00e9 sugerida para ajudar a descartar peritonite ou forma\u00e7\u00e3o precoce de abscesso. Um diagn\u00f3stico diferencial importante \u00e9 a s\u00edndrome p\u00f3s-coagula\u00e7\u00e3o.<\/p>\n\n\n\n<h3 class=\"wp-block-heading\" id=\"h-perfuracoes-tardias\"><strong>Perfura\u00e7\u00f5es tardias<\/strong><\/h3>\n\n\n\n<p>Em casos de perfura\u00e7\u00f5es confirmadas n\u00e3o identificadas durante a colonoscopia, deve-se avisar imediatamente a equipe de cirurgia e endoscopia, seguida de interna\u00e7\u00e3o hospitalar, em UTI a depender do estado e comorbidade do paciente, e avaliar necessidade de interven\u00e7\u00e3o cir\u00fargica.<\/p>\n\n\n\n<p>Pacientes com pequenas perfura\u00e7\u00f5es, aus\u00eancia de sinais de sepse e peritonite, preparo de c\u00f3lon adequado, assintom\u00e1tico ou com melhora dos sintomas:&nbsp;<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>interna\u00e7\u00e3o;<\/li>\n\n\n\n<li>jejum por 2-6 horas;<\/li>\n\n\n\n<li>hidrata\u00e7\u00e3o endovenosa;<\/li>\n\n\n\n<li>antibioticoterapia com cobertura de Gram negativo e anaer\u00f3bio por 3-5 dias.&nbsp;<\/li>\n<\/ul>\n\n\n\n<p>A <strong>cirurgia de emerg\u00eancia<\/strong> \u00e9 recomendada quando o paciente desenvolve sinais e sintomas de peritonite, em casos de deteriora\u00e7\u00e3o cl\u00ednica, suspeita de grande perfura\u00e7\u00e3o, falha no manejo conservador, preparo intestinal inadequado ou na presen\u00e7a de doen\u00e7a c\u00f3lica subjacente que requeira cirurgia.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\" id=\"h-fluxograma-do-manejo-da-perfuracao-na-colonoscopia\"><strong><strong><strong>Fluxograma do Manejo da Perfura\u00e7\u00e3o na Colonoscopia<\/strong><\/strong><\/strong><\/h2>\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\/2024\/07\/post-dr-angelo-fluxo.jpg\" data-rel=\"penci-gallery-image-content\" ><img fetchpriority=\"high\" decoding=\"async\" width=\"702\" height=\"732\" src=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2024\/07\/post-dr-angelo-fluxo.jpg?v=1719868799\" alt=\"\" class=\"wp-image-19157\" style=\"width:459px;height:auto\" srcset=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2024\/07\/post-dr-angelo-fluxo.jpg?v=1719868799 702w, https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2024\/07\/post-dr-angelo-fluxo-288x300.jpg?v=1719868799 288w, https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2024\/07\/post-dr-angelo-fluxo-585x610.jpg?v=1719868799 585w\" sizes=\"(max-width: 702px) 100vw, 702px\" \/><\/a><figcaption class=\"wp-element-caption\">Fluxograma para perfura\u00e7\u00e3o na colonoscopia (adaptado de <em>WSES guidelines for the management of iatrogenic colonoscopy perforation<\/em>)<\/figcaption><\/figure>\n<\/div>\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><em>Dados de Cancer Tomorrow da International Agency for Research on Cancer, da World Health Organization. https:\/\/gco.iarc.fr\/tomorrow\/en.<\/em><\/li>\n\n\n\n<li><em>Zauber AG, Winawer SJ, O&#8217;Brien MJ, et al. Colonoscopic polypectomy and long-term prevention of colorectal-cancer deaths. N Engl J Med. 2012 Feb 23;366(8):687-96. doi: 10.1056\/NEJMoa1100370. PMID: 22356322; PMCID: PMC3322371.<\/em><\/li>\n\n\n\n<li><em>Lee J, Lee YJ, Seo JW, et al. Incidence of colonoscopy-related perforation and risk factors for poor outcomes: 3-year results from a prospective, multicenter registry (with videos). Surg Endosc 37, 5865\u20135874 (2023). https:\/\/doi.org\/10.1007\/s00464-023-10046-5.<\/em><\/li>\n\n\n\n<li><em>de&#8217;Angelis N, Di Saverio S, Chiara O, et al. 2017 WSES guidelines for the management of iatrogenic colonoscopy perforation. World J Emerg Surg. 2018 Jan 24;13:5. doi: 10.1186\/s13017-018-0162-9. PMID: 29416554; PMCID: PMC5784542.<\/em><\/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\">Santos JB, Vilela Filho TF, Furuya J\u00fanior CK, Kuga R, Kum AST. Perfura\u00e7\u00e3o na Colonoscopia: Cuidados e Manejo. Endoscopia Terapeutica 2024, Vol I. Dispon\u00edvel em: <a href=\"https:\/\/endoscopiaterapeutica.com.br\/assuntosgerais\/perfuracao-na-colonoscopia-cuidados-e-manejo\/\">https:\/\/endoscopiaterapeutica.com.br\/assuntosgerais\/perfuracao-na-colonoscopia-cuidados-e-manejo\/<\/a><\/p>\n","protected":false},"excerpt":{"rendered":"<p>Introdu\u00e7\u00e3o O c\u00e2ncer colorretal (CCR) se trata de uma preocupa\u00e7\u00e3o global com incid\u00eancia ascendente&hellip;<\/p>\n","protected":false},"author":5762,"featured_media":18265,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_lmt_disableupdate":"","_lmt_disable":"","footnotes":""},"categories":[151],"tags":[],"ano":[742],"tipo":[156],"volume":[263],"class_list":["post-18264","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-assuntosgerais","ano-742","tipo-colonoscopia","volume-volume-i"],"yoast_head":"<!-- This site is optimized with the Yoast SEO Premium plugin v27.2 (Yoast 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