{"id":19783,"date":"2025-03-11T07:30:00","date_gmt":"2025-03-11T07:30:00","guid":{"rendered":"https:\/\/endoscopiaterapeutica.net\/pt\/uncategorized\/disseccao-endoscopica-submucosa-esd-de-lesoes-colorretais-em-regime-ambulatorial-viabilidade-e-seguranca\/"},"modified":"2025-03-25T11:40:48","modified_gmt":"2025-03-25T11:40:48","slug":"disseccao-endoscopica-submucosa-esd-de-lesoes-colorretais-em-regime-ambulatorial-viabilidade-e-seguranca","status":"publish","type":"post","link":"https:\/\/endoscopiaterapeutica.net\/pt\/casosclinicos\/disseccao-endoscopica-submucosa-esd-de-lesoes-colorretais-em-regime-ambulatorial-viabilidade-e-seguranca\/","title":{"rendered":"Dissec\u00e7\u00e3o Endosc\u00f3pica Submucosa (ESD) de Les\u00f5es Colorretais em Regime Ambulatorial: Viabilidade e Seguran\u00e7a"},"content":{"rendered":"\n<h2 class=\"wp-block-heading\"><strong>Introdu\u00e7\u00e3o<\/strong><\/h2>\n\n\n\n<p>A\u00a0dissec\u00e7\u00e3o endosc\u00f3pica submucosa (ESD)\u00a0\u00e9 a t\u00e9cnica recomendada para ressec\u00e7\u00e3o em monobloco de\u00a0les\u00f5es colorretais maiores que 2 cm, sendo essencial para a adequada avalia\u00e7\u00e3o anatomopatol\u00f3gica de les\u00f5es com poss\u00edvel componente maligno. Embora a ESD ofere\u00e7a vantagens em rela\u00e7\u00e3o \u00e0 mucosectomia, apresenta uma taxa de complica\u00e7\u00e3o mais elevada, com a\u00a0perfura\u00e7\u00e3o\u00a0sendo a complica\u00e7\u00e3o mais temida (2-10,7% na ESD vs. 0,8% na mucosectomia) [1].<\/p>\n\n\n\n<p>Com o avan\u00e7o das indica\u00e7\u00f5es e maior expertise dos endoscopistas, a ESD tem se tornado mais comum. No entanto, os custos elevados da t\u00e9cnica motivaram a busca por alternativas, como a realiza\u00e7\u00e3o do procedimento em regime\u00a0ambulatorial, reduzindo custos e otimizando a ocupa\u00e7\u00e3o de leitos hospitalares. Este artigo revisa a literatura para avaliar a\u00a0viabilidade e seguran\u00e7a da ESD ambulatorial em les\u00f5es colorretais.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><strong>Revis\u00e3o da Literatura<\/strong><\/h2>\n\n\n\n<h3 class=\"wp-block-heading\"><strong>Maselli et al. (2018) [2]<\/strong><\/h3>\n\n\n\n<p>Um estudo de coorte com\u00a0122 pacientes\u00a0submetidos a ressec\u00e7\u00e3o comparou os resultados entre\u00a0ESD ambulatorial (68%) e interna\u00e7\u00e3o hospitalar (32%). Os crit\u00e9rios para interna\u00e7\u00e3o inclu\u00edram\u00a0idade \u2265 80 anos ou ASA \u2265 3. Os pacientes ambulatoriais foram observados por\u00a06 horas, com contato telef\u00f4nico em 24 e 48 horas.<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li><strong>Resultados:<\/strong>\n<ul class=\"wp-block-list\">\n<li>Taxa de\u00a0ressec\u00e7\u00e3o em monobloco\u00a0e\u00a0ressec\u00e7\u00e3o R0\u00a0semelhantes entre os grupos.<\/li>\n\n\n\n<li>Perfura\u00e7\u00e3o intra-procedimento\u00a0em 3 casos (1 no grupo ambulatorial e 2 no grupo interna\u00e7\u00e3o), tratados com clipes, sem necessidade de interna\u00e7\u00e3o.<\/li>\n\n\n\n<li>Pacientes do grupo interna\u00e7\u00e3o tiveram\u00a0custo de 941 euros superior\u00a0ao grupo ambulatorial.<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n\n\n\n<p class=\"has-text-align-center\"><strong>Conclus\u00e3o:<\/strong>\u00a0A\u00a0ESD ambulatorial para pacientes sem crit\u00e9rios de interna\u00e7\u00e3o \u00e9 vi\u00e1vel, segura e econ\u00f4mica.<\/p>\n\n\n\n<h3 class=\"wp-block-heading\"><strong>Tidehag et al. (2022) [3]<\/strong><\/h3>\n\n\n\n<p>An\u00e1lise retrospectiva de\u00a0660 pacientes, onde\u00a0612 (92,7%) realizaram ESD ambulatorial\u00a0e\u00a048 (7,3%) necessitaram interna\u00e7\u00e3o. Os crit\u00e9rios para interna\u00e7\u00e3o inclu\u00edram\u00a0idade avan\u00e7ada, comorbidades, tempo de procedimento >4 horas e resid\u00eancia a >100 km do hospital.<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li><strong>Resultados:<\/strong>\n<ul class=\"wp-block-list\">\n<li>5,4%\u00a0dos pacientes ambulatoriais necessitaram interna\u00e7\u00e3o n\u00e3o programada, principalmente por perfura\u00e7\u00e3o intra-procedimento (16 casos).<\/li>\n\n\n\n<li>46 pacientes (7,5%) buscaram atendimento em 30 dias, principalmente por\u00a0sangramento tardio.<\/li>\n\n\n\n<li>Mediana do tempo da procura por atendimento: 4 dias, indicando que\u00a0seriam necess\u00e1rios 4 dias de interna\u00e7\u00e3o para que metade dos eventos adversos\u00a0ocorressem durante o per\u00edodo de interna\u00e7\u00e3o.<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n\n\n\n<p class=\"has-text-align-center\"><strong>Conclus\u00e3o:<\/strong>\u00a0A\u00a0ESD colorretal ambulatorial \u00e9 segura e vi\u00e1vel para a maioria dos pacientes.<\/p>\n\n\n\n<h3 class=\"wp-block-heading\"><strong>Wei e Friedland (2024)[4]<\/strong><\/h3>\n\n\n\n<p>An\u00e1lise de\u00a0105 pacientes\u00a0submetidos \u00e0 ESD ambulatorial no\u00a0Stanford Hospital, onde todos os pacientes eram tratados\u00a0ambulatorialmente independentemente da idade e comorbidades. Os pacientes eram observados por\u00a02-4 horas, com interna\u00e7\u00e3o apenas se houvesse sintomas persistentes.<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li><strong>Resultados:<\/strong>\n<ul class=\"wp-block-list\">\n<li>2 casos de perfura\u00e7\u00e3o intra-procedimento, tratados com clipes e alta ap\u00f3s 2 horas de observa\u00e7\u00e3o.<\/li>\n\n\n\n<li>1 paciente internado por dor abdominal persistente, com alta no dia seguinte.<\/li>\n\n\n\n<li>1 paciente reinternado por sangramento tardio, sem necessidade de transfus\u00e3o.<\/li>\n\n\n\n<li>Maior taxa de\u00a0sangramento em pacientes cujo leito de ressec\u00e7\u00e3o n\u00e3o foi fechado\u00a0(41,7% vs. 1%, p&lt;0,0001).<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n\n\n\n<p class=\"has-text-align-center\"><strong>Conclus\u00e3o:<\/strong>\u00a0Fechar o leito de ressec\u00e7\u00e3o reduz significativamente o risco de sangramento, aumentando a seguran\u00e7a da ESD ambulatorial.<\/p>\n\n\n\n<h3 class=\"wp-block-heading\"><strong>Diretriz Japonesa (JGES, 2022)[1]<\/strong><\/h3>\n\n\n\n<p>A\u00a0Japan Gastroenterological Endoscopy Society (JGES)\u00a0recomenda a\u00a0interna\u00e7\u00e3o para les\u00f5es > 2 cm, enquanto\u00a0les\u00f5es menores podem ser tratadas ambulatorialmente. Essa abordagem mais conservadora contrasta com a tend\u00eancia ocidental de ampliar os crit\u00e9rios para ESD ambulatorial.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><strong>Discuss\u00e3o<\/strong><\/h2>\n\n\n\n<p>O\u00a0Jap\u00e3o\u00a0adota uma abordagem mais conservadora, realizando ESD colorretal predominantemente com interna\u00e7\u00e3o hospitalar. Em contraste, os\u00a0pa\u00edses ocidentais\u00a0expandiram os crit\u00e9rios para ESD ambulatorial, priorizando\u00a0redu\u00e7\u00e3o de custos e otimiza\u00e7\u00e3o de recursos hospitalares.<\/p>\n\n\n\n<p>No\u00a0Brasil, onde a disponibilidade de leitos \u00e9 limitada, especialmente no\u00a0Sistema \u00danico de Sa\u00fade (SUS), a ESD ambulatorial pode ser uma solu\u00e7\u00e3o vi\u00e1vel. Para garantir seguran\u00e7a, os crit\u00e9rios de sele\u00e7\u00e3o devem considerar:<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Idade e comorbidades\u00a0do paciente.<\/li>\n\n\n\n<li>Tamanho da les\u00e3o\u00a0e tempo de procedimento.<\/li>\n\n\n\n<li>Intercorr\u00eancias intra-procedimento.<\/li>\n\n\n\n<li>Dist\u00e2ncia da resid\u00eancia ao hospital.<\/li>\n\n\n\n<li>Sintomas no p\u00f3s-operat\u00f3rio imediato.<\/li>\n<\/ul>\n\n\n\n<p>Dado que a maioria das complica\u00e7\u00f5es tardias ocorrem em at\u00e9\u00a010 dias ap\u00f3s o procedimento, \u00e9 fundamental garantir\u00a0contato imediato com a equipe m\u00e9dica e acesso f\u00e1cil ao hospital\u00a0para pacientes que apresentem sinais de complica\u00e7\u00f5es.<\/p>\n\n\n\n<h2 class=\"wp-block-heading has-pale-ocean-gradient-background has-background\"><strong>Conclus\u00e3o<\/strong><\/h2>\n\n\n\n<p class=\"has-pale-ocean-gradient-background has-background\">O\u00a0ESD colorretal ambulatorial \u00e9 vi\u00e1vel e seguro em pacientes selecionados, proporcionando redu\u00e7\u00e3o de custos e melhor aloca\u00e7\u00e3o dos recursos hospitalares. A sele\u00e7\u00e3o dos pacientes deve considerar fatores como\u00a0idade, comorbidades, tamanho da les\u00e3o e intercorr\u00eancias intra-procedimento. O\u00a0contato com a equipe m\u00e9dica e\u00a0acesso ao hospital\u00a0\u00e9 essencial para manejo adequado de eventuais complica\u00e7\u00f5es tardias.<\/p>\n\n\n\n<p>Clique aqui para mais informa\u00e7\u00f5es de <a href=\"https:\/\/endoscopiaterapeutica.net\/assuntosgerais\/esd-de-colon-dicas-e-truques\/\">ESD de C\u00f3lon &#8211; Dicas e Truques<\/a>.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\"><strong>Refer\u00eancias<\/strong><\/h2>\n\n\n\n<ol start=\"1\" class=\"wp-block-list\">\n<li>Tanaka S, Kashida H, Saito Y, et al. Japan Gastroenterological Endoscopy Society guidelines for colorectal endoscopic submucosal dissection\/endoscopic mucosal resection.&nbsp;<em>Dig Endosc<\/em>. 2020;32(2):219-239. doi:10.1111\/den.13545<\/li>\n\n\n\n<li>Maselli R, Galtieri PA, Di Leo M, et al.&nbsp;Cost analysis and outcome of endoscopic submucosal dissection for colorectal lesions in an outpatient setting.&nbsp;<em>Dig Liver Dis<\/em>. 2019;51(3):391-396. doi:10.1016\/j.dld.2018.09.023<\/li>\n\n\n\n<li>Tidehag, V., T\u00f6rnqvist, B., Pekkari, K., &amp; Marsk, R. (2022). Endoscopic submucosal dissection for removal of large colorectal neoplasias in an outpatient setting: a single-center series of 660 procedures in Sweden.\u00a0Gastrointestinal endoscopy, 96(1), 101\u2013107.\u00a0https:\/\/doi.org\/10.1016\/j.gie.2022.02.017<\/li>\n\n\n\n<li>Wei M, Friedland S. EVALUATION OF THE SAFETY AND FEASIBILITY OF OUTPATIENT COLORECTAL ENDOSCOPIC SUBMUCOSAL DISSECTION. Gastrointest Endosc [Internet]. 2024 Jun 1;99(6):AB505\u20136. Available from: https:\/\/doi.org\/10.1016\/j.gie.2024.04.1519<\/li>\n<\/ol>\n\n\n\n<h2 class=\"wp-block-heading\">Como citar este artigo<\/h2>\n\n\n\n<p class=\"has-very-light-gray-to-cyan-bluish-gray-gradient-background has-background\">Proen\u00e7a IM. Dissec\u00e7\u00e3o Endosc\u00f3pica Submucosa (ESD) de Les\u00f5es Colorretais em Regime Ambulatorial: Viabilidade e Seguran\u00e7a. Endoscopia Terapeutica. Ano 2025. Vol. I. Dispon\u00edvel em:  https:\/\/endoscopiaterapeutica.net\/uncategorized\/rascunho-automatico\/ <\/p>\n","protected":false},"excerpt":{"rendered":"<p>Introdu\u00e7\u00e3o A\u00a0dissec\u00e7\u00e3o endosc\u00f3pica submucosa (ESD)\u00a0\u00e9 a t\u00e9cnica recomendada para ressec\u00e7\u00e3o em monobloco de\u00a0les\u00f5es colorretais&hellip;<\/p>\n","protected":false},"author":2381,"featured_media":4499,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_lmt_disableupdate":"","_lmt_disable":"","footnotes":""},"categories":[150],"tags":[325],"ano":[783],"tipo":[788],"volume":[263],"class_list":["post-19783","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-casosclinicos","tag-esd","ano-783","tipo-assuntos-gerais","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>Dissec\u00e7\u00e3o Endosc\u00f3pica Submucosa (ESD) de Les\u00f5es Colorretais em Regime Ambulatorial: Viabilidade e Seguran\u00e7a &#8226; 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