{"id":19781,"date":"2025-02-18T07:30:00","date_gmt":"2025-02-18T07:30:00","guid":{"rendered":"https:\/\/endoscopiaterapeutica.net\/pt\/uncategorized\/impacto-do-metodo-suprapapilar-na-permeabilidade-da-obstrucao-biliar-maligna-distal-um-ensaio-clinico-randomizado-controlado-multicentrico\/"},"modified":"2025-04-03T19:06:29","modified_gmt":"2025-04-03T19:06:29","slug":"impacto-do-metodo-suprapapilar-na-permeabilidade-da-obstrucao-biliar-maligna-distal-um-ensaio-clinico-randomizado-controlado-multicentrico","status":"publish","type":"post","link":"https:\/\/endoscopiaterapeutica.net\/pt\/casosclinicos\/impacto-do-metodo-suprapapilar-na-permeabilidade-da-obstrucao-biliar-maligna-distal-um-ensaio-clinico-randomizado-controlado-multicentrico\/","title":{"rendered":"Impacto do m\u00e9todo suprapapilar na permeabilidade da obstru\u00e7\u00e3o biliar maligna distal: um ensaio cl\u00ednico randomizado controlado multic\u00eantrico"},"content":{"rendered":"\n<p>Estudo &#8220;<em>Impact of the suprapapillary method on patency in distal malignant biliary obstruction: a multicenter randomized controlled trial<\/em>&#8220;, publicado na Gastrointestinal Endoscopy em mar\u00e7o de 2024 (1).<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><strong>Introdu\u00e7\u00e3o<\/strong><\/h2>\n\n\n\n<p>As obstru\u00e7\u00f5es biliares malignas inoper\u00e1veis s\u00e3o habitualmente tratadas de modo paliativo com stents met\u00e1licos auto-expans\u00edveis (<em>self expandable metallic stents<\/em>&nbsp;&#8211; SEMS). Com o aumento sobrevida destes pacientes pelo avan\u00e7o da radio e quimioterapias, o endoscopista passa a lidar com a disfun\u00e7\u00e3o destes stents com maior frequ\u00eancia. Um dos mecanismos propostos para essa disfun\u00e7\u00e3o, \u00e9 o refluxo duodenobiliar (2). Para evitar este fator e aumentar o tempo de pat\u00eancia do stent, alguns autores propuseram o uso de stents suprapapilares em oposi\u00e7\u00e3o \u00e0 t\u00e9cnica transpapilar convencional, o que \u00e9 avaliado de modo prospectivo e randomizado por este trabalho (2-4).<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><strong>M\u00e9todos<\/strong><\/h2>\n\n\n\n<p>O trabalho foi realizado em 6 centros sul coreanos, incluindo apenas obstru\u00e7\u00f5es malignas distais irressec\u00e1veis, com ao menos 2 cm de col\u00e9doco preservado distalmente \u00e0 estenose e tamb\u00e9m em rela\u00e7\u00e3o ao hilo hep\u00e1tico.<\/p>\n\n\n\n<p>Os pacientes eram randomizados para a posi\u00e7\u00e3o distal do stent transpapilar (como habitual) ou intrapapilar, com acompanhamento fluorosc\u00f3pico. Em ambos os grupos, foi realizada papilotomia t\u00e1tica ou dilata\u00e7\u00e3o balonada da papila.<\/p>\n\n\n\n<p>Todos os stents utilizados foram totalmente recobertos e do fabricante Taewoong Medical. O seguimento foi feito em 1, 2, 6 e 12 meses.<\/p>\n\n\n\n<p>Desfecho prim\u00e1rio: pat\u00eancia do stent (tempo da inser\u00e7\u00e3o \u00e0 disfun\u00e7\u00e3o do stent &#8211; ao menos 2 dos 3 crit\u00e9rios: <\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>1) birrubina total (Bt) &gt; 2 mg\/dL (eleva\u00e7\u00e3o \u2265 1 mg\/dL); <\/li>\n\n\n\n<li>2) eleva\u00e7\u00e3o de FA ou GGT \u2265 2x VR (eleva\u00e7\u00e3o &gt; 30 U\/L); <\/li>\n\n\n\n<li>3) colangite (febre + leucocitose ou PCR &gt; 20 mg\/dL). Sua causa foi dividida entre:&nbsp;<em>ingrowth<\/em>, <em>overgrowth<\/em>&nbsp;e barro biliar associado a refluxo duodenobiliar. A migra\u00e7\u00e3o do stent foi avaliada \u00e0 parte.<\/li>\n<\/ul>\n\n\n\n<p>Desfechos secund\u00e1rios: sucesso t\u00e9cnico, sucesso cl\u00ednico (redu\u00e7\u00e3o de ao menos 30% do valor de Bt), sobrevida, reinterven\u00e7\u00e3o.&nbsp;<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><strong>Resultados&nbsp;<\/strong><\/h2>\n\n\n\n<p>Entre 2021 e 2023, 84 pacientes foram inclu\u00eddos no estudo, sendo 42 em cada bra\u00e7o. Dentre as caracter\u00edsticas de base dos pacientes e dados do procedimento, a \u00fanica diferen\u00e7a entre os grupos, como era de se esperar, foi o comprimento do stent, maior no grupo transpapilar (p &lt; 0,01). Os resultados e eventos adversos imediatos est\u00e3o sumarizados na tabela 1.<\/p>\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\">\n<div class=\"wp-block-column is-layout-flow wp-block-column-is-layout-flow\" style=\"flex-basis:100%\">\n<figure class=\"wp-block-table\"><div class=\"pcrstb-wrap\"><table class=\"has-fixed-layout\"><tbody><tr><td><\/td><td class=\"has-text-align-center\" data-align=\"center\"><strong>Suprapapilar<\/strong><\/td><td class=\"has-text-align-center\" data-align=\"center\"><strong>Transpapilar<\/strong><\/td><td class=\"has-text-align-center\" data-align=\"center\"><strong>Total<\/strong><\/td><td class=\"has-text-align-center\" data-align=\"center\"><strong>P<\/strong><\/td><\/tr><tr><td><strong>Sucesso t\u00e9cnico<\/strong><\/td><td class=\"has-text-align-center\" data-align=\"center\">42 (100.0)<\/td><td class=\"has-text-align-center\" data-align=\"center\">42 (100.0)<\/td><td class=\"has-text-align-center\" data-align=\"center\">84 (100.0)<\/td><td class=\"has-text-align-center\" data-align=\"center\">&gt;.99<\/td><\/tr><tr><td><strong>Sucesso clinico<\/strong><\/td><td class=\"has-text-align-center\" data-align=\"center\">37 (88.1)<\/td><td class=\"has-text-align-center\" data-align=\"center\">34 (81.0)<\/td><td class=\"has-text-align-center\" data-align=\"center\">71 (84.5)<\/td><td class=\"has-text-align-center\" data-align=\"center\">.546<\/td><\/tr><tr><td><strong>Eventos Adversos<\/strong><\/td><td class=\"has-text-align-center\" data-align=\"center\">1 (2.4)<\/td><td class=\"has-text-align-center\" data-align=\"center\">5 (11.9)<\/td><td class=\"has-text-align-center\" data-align=\"center\">6 (7.1)<\/td><td class=\"has-text-align-center\" data-align=\"center\">.204<\/td><\/tr><tr><td><strong>Pancreatite Aguda<\/strong><\/td><td class=\"has-text-align-center\" data-align=\"center\">1 (2.4)<\/td><td class=\"has-text-align-center\" data-align=\"center\">4 (9.5)<\/td><td class=\"has-text-align-center\" data-align=\"center\">5 (6.0)<\/td><td class=\"has-text-align-center\" data-align=\"center\">&#8211;<\/td><\/tr><tr><td><strong>Colangite<\/strong><\/td><td class=\"has-text-align-center\" data-align=\"center\">0 (.0)<\/td><td class=\"has-text-align-center\" data-align=\"center\">1 (2.4)<\/td><td class=\"has-text-align-center\" data-align=\"center\">1 (1.2)<\/td><td class=\"has-text-align-center\" data-align=\"center\">&#8211;<\/td><\/tr><tr><td><strong>Colecistite<\/strong><\/td><td class=\"has-text-align-center\" data-align=\"center\">0<\/td><td class=\"has-text-align-center\" data-align=\"center\">0<\/td><td class=\"has-text-align-center\" data-align=\"center\">0<\/td><td class=\"has-text-align-center\" data-align=\"center\">&#8211;<\/td><\/tr><\/tbody><\/table><\/div><figcaption class=\"wp-element-caption\">Tabela 1: sucessos t\u00e9cnico e cl\u00ednico e eventos adversos imediatos comparativos entre os grupos.  Adaptado de Ko SW et al. Gastrointest Endosc. 2024 (1).<\/figcaption><\/figure>\n<\/div>\n<\/div>\n\n\n\n<p>Os desfechos a longo prazo est\u00e3o expostos na tabela 2. A m\u00e9dia de seguimento foi de 343 dias (IQR, 168-480) no grupo suprapapilar e 243 dias (IQR, 90-504) no transpapilar (p = 0,357). A pat\u00eancia do stent foi significativamente maior no grupo suprapapilar (m\u00e9dia, 369 dias [IQR, 289-497] vs 154 dias [IQR, 78-361]; P &lt; 0,01).<\/p>\n\n\n\n<p>No grupo suprapapilar, 25 pacientes (59,5%) apresentaram disfun\u00e7\u00e3o do stent x 33 (78.6%) no transpapilar. A etiologia da disfun\u00e7\u00e3o tamb\u00e9m foi diferente entre os grupos, com maior incid\u00eancia de refluxo duodenobiliar e obstru\u00e7\u00e3o por barro no grupo transpapilar (9,4% vs 40,8%, p &lt; 0,01). O m\u00e9todo de reinterven\u00e7\u00e3o diferiu entre os bra\u00e7os do estudo, sendo o principal (28.6%) no grupo suprapapilar, a adi\u00e7\u00e3o de um stent, e troca de stent no grupo transpapilar (61,9%, P = 0,025).&nbsp;<\/p>\n\n\n\n<p>N\u00e3o houve diferen\u00e7a na sobrevida (p = 0,692).<\/p>\n\n\n\n<p>Na an\u00e1lise multivariada, os dois fatores com rela\u00e7\u00e3o com maior tempo de pat\u00eancia do stent foram a posi\u00e7\u00e3o suprapapilar (HR, 0,40; 95% IC, 0,17-0,98; P = 0,045) e o calibre do stent \u2265 8 mm (HR, 0,29; 95% IC, 0,12-0,73; P = 0,008).<\/p>\n\n\n\n<figure class=\"wp-block-table\"><div class=\"pcrstb-wrap\"><table class=\"has-fixed-layout\"><tbody><tr><td><\/td><td class=\"has-text-align-center\" data-align=\"center\"><strong>Suprapapilar<\/strong><br><strong>(n = 42)<\/strong><\/td><td class=\"has-text-align-center\" data-align=\"center\"><strong>Transpapilar<\/strong><br><strong>(n = 42)<\/strong><\/td><td class=\"has-text-align-center\" data-align=\"center\"><strong>Total<\/strong><br><strong>(n = 84)<\/strong><\/td><td class=\"has-text-align-center\" data-align=\"center\"><strong>P<\/strong><\/td><\/tr><tr><td><strong>Seguimento (dias)<\/strong><\/td><td class=\"has-text-align-center\" data-align=\"center\">343 (168-480)<\/td><td class=\"has-text-align-center\" data-align=\"center\">243.5 (90-504)&nbsp;<\/td><td class=\"has-text-align-center\" data-align=\"center\">300.5 (155.2-503.2)<\/td><td class=\"has-text-align-center\" data-align=\"center\">.357<\/td><\/tr><tr><td><strong>Pat\u00eancia (dias)<\/strong><\/td><td class=\"has-text-align-center\" data-align=\"center\">369 (289-497)<\/td><td class=\"has-text-align-center\" data-align=\"center\">154 (78-361)<\/td><td class=\"has-text-align-center\" data-align=\"center\">289 (177-398)<\/td><td class=\"has-text-align-center\" data-align=\"center\">.0012<\/td><\/tr><tr><td><strong>Disfun\u00e7\u00e3o do stent<\/strong><\/td><td class=\"has-text-align-center\" data-align=\"center\">25 (59.5)<\/td><td class=\"has-text-align-center\" data-align=\"center\">33 (78.6)<\/td><td class=\"has-text-align-center\" data-align=\"center\">58 (69.0)<\/td><td class=\"has-text-align-center\" data-align=\"center\">.098<\/td><\/tr><tr><td><strong>Causas de disfun\u00e7\u00e3o do stent<\/strong><\/td><td class=\"has-text-align-center\" data-align=\"center\"><\/td><td class=\"has-text-align-center\" data-align=\"center\"><\/td><td class=\"has-text-align-center\" data-align=\"center\"><\/td><td class=\"has-text-align-center\" data-align=\"center\"><\/td><\/tr><tr><td><em><strong>Ingrowth<\/strong><\/em><\/td><td class=\"has-text-align-center\" data-align=\"center\">16 (38.1)<\/td><td class=\"has-text-align-center\" data-align=\"center\">11 (26.2)<\/td><td class=\"has-text-align-center\" data-align=\"center\">27 (32.1)<\/td><td class=\"has-text-align-center\" data-align=\"center\">.238<\/td><\/tr><tr><td><em><strong>Overgrowth<\/strong><\/em><\/td><td class=\"has-text-align-center\" data-align=\"center\">5 (11.9)<\/td><td class=\"has-text-align-center\" data-align=\"center\">10 (11.9)<\/td><td class=\"has-text-align-center\" data-align=\"center\">10 (11.9)<\/td><td class=\"has-text-align-center\" data-align=\"center\">&gt;.99<\/td><\/tr><tr><td><strong><em>Barro\/refluxo duodenobiliar<\/em><\/strong><\/td><td class=\"has-text-align-center\" data-align=\"center\">4 (9.4)<\/td><td class=\"has-text-align-center\" data-align=\"center\">17 (40.8)<\/td><td class=\"has-text-align-center\" data-align=\"center\">21 (25.0)<\/td><td class=\"has-text-align-center\" data-align=\"center\">.002<\/td><\/tr><tr><td><strong>Migra\u00e7\u00e3o do stent<\/strong><\/td><td class=\"has-text-align-center\" data-align=\"center\">&nbsp;2 (4.8)<\/td><td class=\"has-text-align-center\" data-align=\"center\">4 (9.5)<\/td><td class=\"has-text-align-center\" data-align=\"center\">6 (7.1)<\/td><td class=\"has-text-align-center\" data-align=\"center\">.672<\/td><\/tr><tr><td><strong>Reinterven\u00e7\u00e3o<\/strong><\/td><td class=\"has-text-align-center\" data-align=\"center\"><\/td><td class=\"has-text-align-center\" data-align=\"center\"><\/td><td class=\"has-text-align-center\" data-align=\"center\"><\/td><td class=\"has-text-align-center\" data-align=\"center\"><\/td><\/tr><tr><td><strong>Troca de stent<\/strong><\/td><td class=\"has-text-align-center\" data-align=\"center\">10 (23.8)<\/td><td class=\"has-text-align-center\" data-align=\"center\">26 (61.9)<\/td><td class=\"has-text-align-center\" data-align=\"center\">37 (44.0)<\/td><td class=\"has-text-align-center\" data-align=\"center\">&lt;.001<\/td><\/tr><tr><td><strong>Adi\u00e7\u00e3o de stent<\/strong><\/td><td class=\"has-text-align-center\" data-align=\"center\">&nbsp;12 (28.6)<\/td><td class=\"has-text-align-center\" data-align=\"center\">4 (9.4)<\/td><td class=\"has-text-align-center\" data-align=\"center\">16 (38.1)<\/td><td class=\"has-text-align-center\" data-align=\"center\">.051<\/td><\/tr><tr><td><strong>Hepatogastrostomia ecoguiada<\/strong><\/td><td class=\"has-text-align-center\" data-align=\"center\">&nbsp;1 (2.4)<\/td><td class=\"has-text-align-center\" data-align=\"center\">1 (2.4)<\/td><td class=\"has-text-align-center\" data-align=\"center\">2 (4.8)<\/td><td class=\"has-text-align-center\" data-align=\"center\">&nbsp;&gt;.99<\/td><\/tr><tr><td><strong>Drenagem percut\u00e2nea<\/strong><\/td><td class=\"has-text-align-center\" data-align=\"center\">2 (4.8)<\/td><td class=\"has-text-align-center\" data-align=\"center\">1 (2.4)<\/td><td class=\"has-text-align-center\" data-align=\"center\">3 (3.6)<\/td><td class=\"has-text-align-center\" data-align=\"center\">&gt;.99<\/td><\/tr><tr><td><strong>Sobrevida (dias)<\/strong><\/td><td class=\"has-text-align-center\" data-align=\"center\">373 (269-581)<\/td><td class=\"has-text-align-center\" data-align=\"center\">461 (170-NA)<\/td><td class=\"has-text-align-center\" data-align=\"center\">410 (253-515)<\/td><td class=\"has-text-align-center\" data-align=\"center\">.692<\/td><\/tr><\/tbody><\/table><\/div><figcaption class=\"wp-element-caption\">Tabela 2: desfechos cl\u00ednicos a longo termo. Adaptado de Ko SW et al. Gastrointest Endosc. 2024 (1).<\/figcaption><\/figure>\n\n\n\n<h2 class=\"wp-block-heading\"><strong>Discuss\u00e3o<\/strong><\/h2>\n\n\n\n<p>Trata-se do primeiro estudo multic\u00eantrico randomizado sobre o assunto, refor\u00e7ando que o mecanismo de refluxo duodenobiliar e forma\u00e7\u00e3o de barro biliar possui grande relev\u00e2ncia na pat\u00eancia dos stents met\u00e1licos. Al\u00e9m da maior incid\u00eancia de disfun\u00e7\u00e3o do stent no grupo transpapilar (9,4% x 40,8% de obstru\u00e7\u00e3o por barro biliar), o tempo para obstru\u00e7\u00e3o por esta etiologia foi menor no mesmo grupo (8\/17 = 47,1% em at\u00e9 3 meses x todos casos &gt; 5 meses no grupo suprapapilar).<\/p>\n\n\n\n<p>Apesar de n\u00e3o haver relev\u00e2ncia estat\u00edstica, chama a aten\u00e7\u00e3o a maior incid\u00eancia de pancreatite no grupo transpapilar (1\/42 = 2.4% vs 4\/42 = 9.5%, p = 0,356). Uma vez que n\u00e3o foram realizadas papilotomias amplas, stents transpapilares podem ocluir o ducto pancre\u00e1tico principal com maior frequ\u00eancia, causando pancreatite. Para evitar isso, uma solu\u00e7\u00e3o adequada no dia a dia \u00e9 aumentar a incis\u00e3o (papilotomia ampla) para stents transpapilares. Por outro lado, para evitar o refluxo duodenobiliar nos casos suprapapilares, \u00e9 interessante manter o m\u00e1ximo poss\u00edvel a integridade do esf\u00edncter de Oddi, sendo recomendada a papilotomia t\u00e1tica, com incis\u00e3o suficiente apenas para a passagem do stent.<\/p>\n\n\n\n<p>A reinterven\u00e7\u00e3o nos casos de disfun\u00e7\u00e3o do stent tamb\u00e9m \u00e9 alvo de debate. No grupo suprapapilar, pode haver maior dificuldade, uma vez que a papilotomia \u00e9 limitada (t\u00e1tica) e o stent visualizado apenas por radioscopia. Al\u00e9m disso, uma causa de obstru\u00e7\u00e3o \u00e9 o crescimento tumoral atrav\u00e9s da malha do stent (<em>ingrowth<\/em>) ou por sua extremidade (<em>overgrowth<\/em>). Nestes casos, h\u00e1 maior dificuldade de remover o stent, e a principal forma de abordagem foi a adi\u00e7\u00e3o de outro stent. O desenvolvimento de stents com uma al\u00e7a\/la\u00e7o male\u00e1vel posicionado no duodeno pode auxiliar diante deste tipo de situa\u00e7\u00e3o (5). No bra\u00e7o transpapilar, a troca do stent foi bem sucedida na maioria dos casos.<\/p>\n\n\n\n<p>Outro ponto importante a ser considerado, \u00e9 que, em muitos casos de obstru\u00e7\u00e3o maligna biliar, n\u00e3o h\u00e1 2 cm de col\u00e9doco preservado entre o tumor e a papila, limitando a t\u00e9cnica suprapapilar. Um estudo demonstrou maior tempo de pat\u00eancia no grupo transpapilar para obstru\u00e7\u00f5es sem esta dist\u00e2ncia m\u00ednima de col\u00e9doco distal normal (6). Sendo o c\u00e2ncer de p\u00e2ncreas a etiologia mais frequente, o envolvimento do col\u00e9doco pr\u00f3ximo \u00e0 papila e a invas\u00e3o duodenal (n\u00e3o raros nestes casos), tornam o m\u00e9todo suprapapilar inadequado.<\/p>\n\n\n\n<p>O estudo apresenta limita\u00e7\u00f5es como tempo de follow-up relativamente curto, principalmente para compreender melhor o impacto da forma de manejo at\u00e9 o \u00f3bito do paciente, uma vez que estamos tratando de tratamento paliativo. Al\u00e9m disso, o n\u00famero total de pacientes \u00e9 pequeno para avaliar migra\u00e7\u00e3o do stent e eventos adversos como pancreatite. O trabalho incluiu muitos casos com CPRE pr\u00e9via, com poss\u00edvel altera\u00e7\u00e3o funcional \u201cde base\u201d do esf\u00edncter de Oddi. Outra limita\u00e7\u00e3o \u00e9 a ampla gama de tamanhos de stents dispon\u00edveis no estudo, o que \u00e9 necess\u00e1rio em muitos casos suprapapilares, mas n\u00e3o \u00e9 a realidade na maioria dos centros brasileiros (foram empregados stents, de 4, 5, 6, 7, 8, 9 e 10 cm de comprimento).&nbsp;<\/p>\n\n\n\n<p class=\"has-pale-ocean-gradient-background has-background\">Conclui-se que o m\u00e9todo suprapapilar \u00e9 fact\u00edvel para evitar um dos principais mecanismos de disfun\u00e7\u00e3o de stent que \u00e9 o refluxo duodenobiliar e forma\u00e7\u00e3o de barro biliar, considerando uma papilotomia t\u00e1tica e uma dist\u00e2ncia \u2265 2 cm da papila maior. O tratamento da disfun\u00e7\u00e3o do stent nestes pacientes pode ser um pouco mais trabalhoso, mas foi obtido em todos os pacientes do estudo. Outro fator importante \u00e9 o calibre do stent: recomenda-se o m\u00ednimo de 8 mm com base nos dados do estudo.<\/p>\n\n\n<div class=\"wp-block-image\">\n<figure data-wp-context=\"{&quot;imageId&quot;:&quot;69d697f6d31d8&quot;}\" data-wp-interactive=\"core\/image\" data-wp-key=\"69d697f6d31d8\" class=\"aligncenter size-full is-resized wp-lightbox-container\"><img fetchpriority=\"high\" decoding=\"async\" width=\"304\" height=\"304\" data-wp-class--hide=\"state.isContentHidden\" data-wp-class--show=\"state.isContentVisible\" data-wp-init=\"callbacks.setButtonStyles\" data-wp-on--click=\"actions.showLightbox\" data-wp-on--load=\"callbacks.setButtonStyles\" data-wp-on-window--resize=\"callbacks.setButtonStyles\" src=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2025\/02\/mateus1.jpg\" alt=\"\" class=\"wp-image-19829\" style=\"width:410px;height:auto\" srcset=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2025\/02\/mateus1.jpg 304w, https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2025\/02\/mateus1-300x300.jpg 300w, https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2025\/02\/mateus1-150x150.jpg 150w, https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2025\/02\/mateus1-70x70.jpg 70w\" sizes=\"(max-width: 304px) 100vw, 304px\" \/><button\n\t\t\tclass=\"lightbox-trigger\"\n\t\t\ttype=\"button\"\n\t\t\taria-haspopup=\"dialog\"\n\t\t\taria-label=\"Ampliar\"\n\t\t\tdata-wp-init=\"callbacks.initTriggerButton\"\n\t\t\tdata-wp-on--click=\"actions.showLightbox\"\n\t\t\tdata-wp-style--right=\"state.imageButtonRight\"\n\t\t\tdata-wp-style--top=\"state.imageButtonTop\"\n\t\t>\n\t\t\t<svg xmlns=\"http:\/\/www.w3.org\/2000\/svg\" width=\"12\" height=\"12\" fill=\"none\" viewBox=\"0 0 12 12\">\n\t\t\t\t<path fill=\"#fff\" d=\"M2 0a2 2 0 0 0-2 2v2h1.5V2a.5.5 0 0 1 .5-.5h2V0H2Zm2 10.5H2a.5.5 0 0 1-.5-.5V8H0v2a2 2 0 0 0 2 2h2v-1.5ZM8 12v-1.5h2a.5.5 0 0 0 .5-.5V8H12v2a2 2 0 0 1-2 2H8Zm2-12a2 2 0 0 1 2 2v2h-1.5V2a.5.5 0 0 0-.5-.5H8V0h2Z\" \/>\n\t\t\t<\/svg>\n\t\t<\/button><figcaption class=\"wp-element-caption\">Imagem fluorosc\u00f3pica de estenose maligna de col\u00e9doco distal.<\/figcaption><\/figure>\n<\/div>\n\n\n<p>Clique para outros artigos nesse tema: <a href=\"https:\/\/endoscopiaterapeutica.net\/artigoscomentados\/a-papilotomia-antes-da-passagem-de-protese-para-drenagem-biliar-e-eficaz-em-prevenir-pancreatite-pos-cpre\/\">A papilotomia antes da passagem de pr\u00f3tese para drenagem biliar \u00e9 eficaz em prevenir pancreatite p\u00f3s-CPRE?<\/a><\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><strong>Refer\u00eancias<\/strong><\/h2>\n\n\n\n<ol class=\"wp-block-list\">\n<li>Ko SW, Joo HD, Song TJ, et al. Impact of the suprapapillary method on patency in distal malignant biliary obstruction: a multicenter randomized controlled trial. Gastrointest Endosc. 2024;100(4):679-687.e1. doi:10.1016\/j.gie.2024.03.024.<\/li>\n\n\n\n<li>Misra SP, Dwivedi M. Reflux of duodenal contents and cholangitis in patients undergoing self-expanding metal stent placement. Gastrointest Endosc. 2009;70(2):317-321. doi:10.1016\/j.gie.2008.12.054.<\/li>\n\n\n\n<li>Kov\u00e1cs N, P\u00e9csi D, Sipos Z, et al.&nbsp;Suprapapillary Biliary Stents Have Longer Patency Times than Transpapillary Stents-A Systematic Review and Meta-Analysis. J Clin Med. 2023;12(3):898. Published 2023 Jan 23. doi:10.3390\/jcm12030898.<\/li>\n\n\n\n<li>Huang X, Shen L, Jin Y, et al. Comparison of uncovered stent placement across versus above the main duodenal papilla for malignant biliary obstruction. J Vasc Interv Radiol. 2015;26(3):432-437. doi:10.1016\/j.jvir.2014.11.008.<\/li>\n\n\n\n<li>Kwon CI, Ko KH, Hahm KB, Kang DH. Functional self-expandable metal stents in biliary obstruction.&nbsp;Clin Endosc. 2013;46(5):515-521. doi:10.5946\/ce.2013.46.5.515.<\/li>\n\n\n\n<li>Han SY, Lee TH, Jang SI, et al. Efficacy Analysis of Suprapapillary versus Transpapillary Self-Expandable Metal Stents According to the Level of Obstruction in Malignant Extrahepatic Biliary Obstruction. Gut Liver. 2023;17(5):806-813. doi:10.5009\/gnl220437.<\/li>\n<\/ol>\n\n\n\n<h2 class=\"wp-block-heading\"><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\">Funari MP. Caso cl\u00ednico: Impact of the suprapapillary method on patency in distal malignant biliary obstruction: a multicenter randomized controlled trial. Endoscopia Terapeutica 2025 vol 1. Dispon\u00edvel: https:\/\/endoscopiaterapeutica.net\/uncategorized\/impact-of-the-suprapapillary-method-on-patency-in-distal-malignant-biliary-obstruction-a-multicenter-randomized-controlled-trial\/ <\/p>\n\n\n\n<p><br><\/p>\n","protected":false},"excerpt":{"rendered":"<p>Estudo &#8220;Impact of the suprapapillary method on patency in distal malignant biliary obstruction: a&hellip;<\/p>\n","protected":false},"author":3493,"featured_media":19829,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_lmt_disableupdate":"","_lmt_disable":"","footnotes":""},"categories":[150],"tags":[294,789,790],"ano":[783],"tipo":[791],"volume":[263],"class_list":["post-19781","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-casosclinicos","tag-cpre","tag-protese-metalica","tag-tumor-de-vias-biliares","ano-783","tipo-artigos-comentados","volume-volume-i"],"yoast_head":"<!-- This site is optimized with the Yoast 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