{"id":21796,"date":"2026-08-18T07:00:00","date_gmt":"2026-08-18T07:00:00","guid":{"rendered":"https:\/\/endoscopiaterapeutica.net\/pt\/?p=21796"},"modified":"2026-08-17T21:54:33","modified_gmt":"2026-08-17T21:54:33","slug":"lerv-pancreatite-biliar-aguda","status":"publish","type":"post","link":"https:\/\/endoscopiaterapeutica.net\/pt\/casosclinicos\/lerv-pancreatite-biliar-aguda\/","title":{"rendered":"Laparoscopic-endoscopic rendez-vous (LERV) na pancreatite biliar aguda: relato de caso e revis\u00e3o da literatura"},"content":{"rendered":"\n<h2 id=\"h-introducao\" class=\"wp-block-heading\"><br><strong>Introdu\u00e7\u00e3o<\/strong><\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">A coledocolit\u00edase \u00e9 uma das principais complica\u00e7\u00f5es da colelit\u00edase e representa importante causa de <strong>pancreatite aguda biliar<\/strong>. Embora a maioria dos c\u00e1lculos migre espontaneamente para o duodeno, a persist\u00eancia da obstru\u00e7\u00e3o distal da via biliar pode perpetuar o processo inflamat\u00f3rio e justificar interven\u00e7\u00e3o precoce. <sup>1,2<\/sup><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Tradicionalmente, o tratamento consistia em duas etapas: colangiopancreatografia retr\u00f3grada endosc\u00f3pica (CPRE) seguida de colecistectomia videolaparosc\u00f3pica. Entretanto, tem-se adotado abordagem em <strong>tempo \u00fanico<\/strong>, por permitir o tratamento da coledocolit\u00edase e da colelit\u00edase no mesmo procedimento.<sup>2,3<\/sup><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Desse modo, entre as modalidades de tratamento em tempo \u00fanico, destaca-se a t\u00e9cnica de <em>laparoscopic-endoscopic rendez-vous (LERV)<\/em>, na qual o cirurgi\u00e3o realiza a passagem anter\u00f3grada de um fio-guia por meio do ducto c\u00edstico at\u00e9 o duodeno, permitindo ao endoscopista a canula\u00e7\u00e3o biliar guiada durante a CPRE. Essa estrat\u00e9gia pode facilitar o acesso seletivo \u00e0 via biliar e <strong>reduzir a manipula\u00e7\u00e3o da papila e do ducto pancre\u00e1tico<\/strong>, constituindo uma alternativa particularmente interessante em pacientes selecionados. <sup>3,5<\/sup><\/p>\n\n\n\n<h2 id=\"h-caso-clinico\" class=\"wp-block-heading\"><br><strong>Caso cl\u00ednico<\/strong><\/h2>\n\n\n\n<h3 id=\"h-apresentacao-e-avaliacao-inicial\" class=\"wp-block-heading\">Apresenta\u00e7\u00e3o e avalia\u00e7\u00e3o inicial<\/h3>\n\n\n\n<p class=\"wp-block-paragraph\">Paciente do sexo feminino, 33 anos, procurou atendimento no pronto-socorro com dor abdominal intensa em andar superior do abdome, associada a n\u00e1useas, v\u00f4mitos persistentes e distens\u00e3o abdominal.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Na admiss\u00e3o, os exames laboratoriais evidenciaram hiperbilirrubinemia e importante eleva\u00e7\u00e3o das transaminases, sem aumento das enzimas pancre\u00e1ticas. A ultrassonografia abdominal demonstrou ves\u00edcula hidr\u00f3pica contendo m\u00faltiplos microc\u00e1lculos. A tomografia computadorizada evidenciou discreta dilata\u00e7\u00e3o das vias biliares, sem identifica\u00e7\u00e3o de fator obstrutivo.<\/p>\n\n\n\n<h3 id=\"h-evolucao-clinica-e-indicacao-da-lerv\" class=\"wp-block-heading\">Evolu\u00e7\u00e3o cl\u00ednica e indica\u00e7\u00e3o da LERV<\/h3>\n\n\n\n<p class=\"wp-block-paragraph\">Ap\u00f3s aproximadamente 24 horas de interna\u00e7\u00e3o, observou-se piora cl\u00ednica associada \u00e0 progress\u00e3o do padr\u00e3o laboratorial de obstru\u00e7\u00e3o biliar, caracterizada por<strong> aumento da<\/strong> <strong>bilirrubina total (de 2,63 para 4,27 mg\/dL), eleva\u00e7\u00e3o da fra\u00e7\u00e3o direta e progress\u00e3o das enzimas hep\u00e1ticas e canaliculares.<\/strong> Concomitantemente, houve aumento expressivo das enzimas pancre\u00e1ticas, com amilase de 2.839 U\/L e lipase de 1.500 U\/L, confirmando o diagn\u00f3stico de pancreatite aguda biliar.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Realizou-se, ent\u00e3o, colangiorresson\u00e2ncia magn\u00e9tica (MRCP), que demonstrou dilata\u00e7\u00e3o da via biliar extra-hep\u00e1tica e c\u00e1lculo impactado na papila duodenal, caracterizando <strong>obstru\u00e7\u00e3o biliar persistente<\/strong>.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Diante da associa\u00e7\u00e3o entre colelit\u00edase, pancreatite biliar aguda e coledocolit\u00edase com c\u00e1lculo impactado na papila, indicou-se, portanto, tratamento por meio da LERV.<\/p>\n\n\n\n<h3 id=\"h-descricao-da-tecnica\" class=\"wp-block-heading\">Descri\u00e7\u00e3o da t\u00e9cnica<\/h3>\n\n\n\n<p class=\"wp-block-paragraph\">A equipe da cirurgia iniciou o procedimento com a dissec\u00e7\u00e3o do tri\u00e2ngulo hepatoc\u00edstico e identifica\u00e7\u00e3o do ducto c\u00edstico. Ap\u00f3s sua abertura, realizou-se a introdu\u00e7\u00e3o do cateter de colangiografia por acesso transparietal utilizando a t\u00e9cnica de Seldinger. Essa t\u00e9cnica consiste na pun\u00e7\u00e3o da parede abdominal com uma agulha, seguida da passagem de um fio-guia, retirada da agulha e progress\u00e3o do introdutor e do cateter sobre o fio-guia, permitindo sua introdu\u00e7\u00e3o no campo operat\u00f3rio de forma minimamente traum\u00e1tica e com posicionamento preciso no ducto c\u00edstico.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">A colangiografia intraoperat\u00f3ria evidenciou obstru\u00e7\u00e3o distal da via biliar.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Em seguida, avan\u00e7ou-se um fio-guia hidrof\u00edlico de forma anter\u00f3grada atrav\u00e9s do ducto c\u00edstico e do col\u00e9doco at\u00e9 o duodeno, permanecendo posicionado para a etapa endosc\u00f3pica (v\u00eddeo 1).<\/p>\n\n\n\n<div style=\"position:relative;padding-top:56.367924528301884%;\"><iframe id=\"panda-171d5c5e-f6e2-46fe-8d58-8f4302f11ee4\" src=\"https:\/\/player-vz-a75e9d45-986.tv.pandavideo.com.br\/embed\/?v=171d5c5e-f6e2-46fe-8d58-8f4302f11ee4\" 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<p class=\"wp-block-paragraph\"><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Na sequ\u00eancia, a equipe da endoscopia introduziu o duodenosc\u00f3pio at\u00e9 a segunda por\u00e7\u00e3o duodenal, onde o fio-guia foi identificado e exteriorizado pelo canal de trabalho do aparelho. Utilizando o fio-guia como refer\u00eancia, obteve-se acesso seletivo \u00e0 via biliar com m\u00ednima manipula\u00e7\u00e3o da papila.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">A CPRE foi ent\u00e3o realizada. Ap\u00f3s papilotomia, procedeu-se \u00e0 extra\u00e7\u00e3o completa do c\u00e1lculo com bal\u00e3o extrator, seguida de varredura da via biliar, sem evid\u00eancia de c\u00e1lculos residuais \u00e0 colangiografia de controle (v\u00eddeo 2).<\/p>\n\n\n\n<div style=\"position:relative;padding-top:56.367924528301884%;\"><iframe id=\"panda-b0a4fe19-07af-4529-9373-51fdbd4d6056\" src=\"https:\/\/player-vz-a75e9d45-986.tv.pandavideo.com.br\/embed\/?v=b0a4fe19-07af-4529-9373-51fdbd4d6056\" 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<p class=\"wp-block-paragraph\"><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Conclu\u00edda a etapa endosc\u00f3pica, procedeu-se, ent\u00e3o, com o clampeamento do ducto c\u00edstico e a finaliza\u00e7\u00e3o da colecistectomia videolaparosc\u00f3pica.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Por fim, a paciente apresentou <strong>evolu\u00e7\u00e3o cl\u00ednica satisfat\u00f3ria<\/strong>, com melhora progressiva da dor abdominal, regress\u00e3o da icter\u00edcia e normaliza\u00e7\u00e3o gradual dos n\u00edveis s\u00e9ricos de bilirrubina, amilase e lipase, recebendo alta hospitalar sem intercorr\u00eancias.<\/p>\n\n\n\n<h2 id=\"h-discussao\" class=\"wp-block-heading\"><br><strong>Discuss\u00e3o<\/strong><\/h2>\n\n\n\n<h3 id=\"h-indicacao-de-cpre-na-pancreatite-biliar-aguda\" class=\"wp-block-heading\">Indica\u00e7\u00e3o de CPRE na pancreatite biliar aguda<\/h3>\n\n\n\n<p class=\"wp-block-paragraph\">A pancreatite aguda biliar resulta, na maioria dos casos, da migra\u00e7\u00e3o de c\u00e1lculos ou microc\u00e1lculos atrav\u00e9s da papila duodenal. Quando ocorre obstru\u00e7\u00e3o transit\u00f3ria, a evolu\u00e7\u00e3o costuma ser favor\u00e1vel apenas com tratamento cl\u00ednico. Entretanto, a persist\u00eancia da obstru\u00e7\u00e3o da via biliar modifica a estrat\u00e9gia terap\u00eautica, pois mant\u00e9m o est\u00edmulo inflamat\u00f3rio e aumenta o risco de complica\u00e7\u00f5es.<sup>1<\/sup><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Segundo a diretriz da <a href=\"https:\/\/www.thieme-connect.com\/products\/ejournals\/abstract\/10.1055\/a-0588-5365\">European Society of Gastrointestinal Endoscopy (ESGE) sobre pancreatite aguda<\/a>, a realiza\u00e7\u00e3o rotineira de CPRE precoce n\u00e3o \u00e9 recomendada em pacientes com pancreatite biliar na aus\u00eancia de colangite ou evid\u00eancias de obstru\u00e7\u00e3o biliar persistente. Nos pacientes com sinais persistentes de obstru\u00e7\u00e3o biliar, como eleva\u00e7\u00e3o progressiva da bilirrubina, dilata\u00e7\u00e3o das vias biliares ou demonstra\u00e7\u00e3o de c\u00e1lculo impactado, a CPRE est\u00e1 indicada e deve ser realizada precocemente.<sup> 1<\/sup><\/p>\n\n\n\n<h3 id=\"h-a-escolha-da-tecnica\" class=\"wp-block-heading\">A escolha da t\u00e9cnica<\/h3>\n\n\n\n<p class=\"wp-block-paragraph\">O presente caso enquadra-se precisamente nesse cen\u00e1rio, uma vez que a paciente apresentou piora cl\u00ednica e laboratorial durante a interna\u00e7\u00e3o, associada \u00e0 documenta\u00e7\u00e3o por MRCP de c\u00e1lculo impactado na papila e dilata\u00e7\u00e3o da via biliar, configurando obstru\u00e7\u00e3o persistente e justificando a interven\u00e7\u00e3o endosc\u00f3pica.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Entretanto, outro aspecto influenciou a estrat\u00e9gia terap\u00eautica adotada. A paciente j\u00e1 apresentava pancreatite aguda estabelecida, situa\u00e7\u00e3o em que qualquer manipula\u00e7\u00e3o adicional da papila ou do ducto pancre\u00e1tico poderia contribuir para maior agress\u00e3o local.<sup>1,2<\/sup><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">O trauma mec\u00e2nico repetido da papila, a canula\u00e7\u00e3o inadvertida do ducto pancre\u00e1tico com fio-guia e a inje\u00e7\u00e3o de contraste no ducto pancre\u00e1tico s\u00e3o fatores reconhecidamente associados \u00e0 inflama\u00e7\u00e3o pancre\u00e1tica durante a CPRE. Desse modo, em pacientes com pancreatite aguda biliar, a minimiza\u00e7\u00e3o dessas manobras \u00e9 desej\u00e1vel para evitar insulto pancre\u00e1tico adicional.<sup>3,5<\/sup><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Nesse sentido, a escolha pela t\u00e9cnica do LERV teve como principal objetivo facilitar a canula\u00e7\u00e3o seletiva da via biliar e minimizar a necessidade de m\u00faltiplas tentativas de acesso papilar, reduzindo a manipula\u00e7\u00e3o da papila e do ducto pancre\u00e1tico durante a CPRE.<sup>3,5<\/sup><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Estudos recentes demonstram que a t\u00e9cnica de <strong>laparoscopic-endoscopic rendez-vous<\/strong> apresenta taxas de sucesso para depura\u00e7\u00e3o da via biliar compar\u00e1veis \u00e0s da estrat\u00e9gia convencional em dois tempos, estando associada a altas taxas de canula\u00e7\u00e3o seletiva, menor incid\u00eancia de pancreatite p\u00f3s-CPRE e redu\u00e7\u00e3o do tempo de interna\u00e7\u00e3o hospitalar. Esses benef\u00edcios decorrem da canula\u00e7\u00e3o guiada por fio-guia introduzido de forma anter\u00f3grada, reduzindo a manipula\u00e7\u00e3o da papila e do ducto pancre\u00e1tico, refor\u00e7ando a LERV como uma <strong>alternativa segura e eficaz<\/strong> em pacientes selecionados com coledocolit\u00edase associada \u00e0 pancreatite biliar aguda.<sup>3,4,5<\/sup><\/p>\n\n\n\n<h2 id=\"h-referencias\" class=\"wp-block-heading\"><br><strong>Refer\u00eancias<\/strong><\/h2>\n\n\n\n<ol class=\"wp-block-list\">\n<li>ARVANITAKIS, M.; DUMONCEAU, J. M.; ALBERT, J. et al. <strong>Endoscopic management of acute necrotizing pancreatitis: European Society of Gastrointestinal Endoscopy (ESGE) Evidence-based multidisciplinary guidelines. <\/strong>Endoscopy, Stuttgart, v. 50, n. 5, p. 524-546, 2018. DOI: 10.1055\/a-0588-5365<\/li>\n\n\n\n<li>MANES, G.; PASPATIS, G. A.; AABAKKEN, L. et al. <strong>Endoscopic management of common bile duct stones (CBDS): European Society of Gastrointestinal Endoscopy (ESGE) Guideline<\/strong>. <em>Endoscopy<\/em>, Stuttgart, v. 51, n. 5, p. 472-491, 2019. DOI: 10.1055\/a-0862-0346.<\/li>\n\n\n\n<li>LIN, Y.; SU, Y.; YAN, J.; LI, X. <strong>Laparoendoscopic rendezvous versus ERCP followed by laparoscopic cholecystectomy in the management of cholecystocholedocholithiasis: a systematic review and meta-analysis<\/strong>. <em>Surgical Endoscopy<\/em>, New York, v. 34, n. 9, p. 4214-4224, 2020. DOI: 10.1007\/s00464-020-07698-y.<\/li>\n\n\n\n<li>LA BARBA, G.; GARDINI, A.; CAVARGINI, E. et al. <strong>Laparoendoscopic rendezvous in the treatment of cholecystocholedocholithiasis: a single series of 200 patients<\/strong>. <em>Surgical Endoscopy<\/em>, New York, v. 32, n. 9, p. 3868-3873, 2018. DOI: 10.1007\/s00464-018-6125-0.<\/li>\n\n\n\n<li>TSIOPOULOS, F.; KAPSORITAKIS, A.; PSYCHOS, A. et al. <strong>Laparoendoscopic rendezvous may be an effective alternative to a failed preoperative endoscopic retrograde cholangiopancreatography in patients with cholecystocholedocholithiasis<\/strong>. <em>Annals of Gastroenterology<\/em>, Athens, v. 31, n. 1, p. 102-108, 2018. DOI: 10.20524\/aog.2017.0210.<\/li>\n<\/ol>\n\n\n\n<h2 id=\"h-como-citar-este-artigo\" 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 wp-block-paragraph\">Botelho PFR, Neto HJM. Laparoscopic-endoscopic rendez-vous (LERV) na pancreatite biliar aguda: relato de caso e revis\u00e3o da literatura. Endoscopia Terapeutica 2026 Vol II. Dispon\u00edvel em: <a href=\"https:\/\/endoscopiaterapeutica.net\/pt\/?p=21796\" target=\"_blank\" rel=\"noreferrer noopener\">https:\/\/endoscopiaterapeutica.net\/pt\/assuntosgerais\/laparoscopic-endoscopic-rendez-vous-lerv-na-pancreatite-biliar-aguda-relato-de-caso-e-revisao-da-literatura\/<\/a><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><\/p>\n","protected":false},"excerpt":{"rendered":"<p>Introdu\u00e7\u00e3o A coledocolit\u00edase \u00e9 uma das principais complica\u00e7\u00f5es da colelit\u00edase e representa importante causa&hellip;<\/p>\n","protected":false},"author":4014,"featured_media":21801,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_lmt_disableupdate":"","_lmt_disable":"","footnotes":""},"categories":[150],"tags":[294,883,460,884],"ano":[847],"tipo":[155],"volume":[147],"class_list":["post-21796","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-casosclinicos","tag-cpre","tag-lerv","tag-pancreatite","tag-rendez-vous","ano-847","tipo-cpre","volume-volume-ii"],"yoast_head":"<!-- This site is optimized with the Yoast SEO Premium plugin v27.2 (Yoast SEO v28.2) - https:\/\/yoast.com\/product\/yoast-seo-premium-wordpress\/ -->\n<title>Rendez-Vous Laparoendosc\u00f3pico (LERV) na Pancreatite Biliar<\/title>\n<meta name=\"description\" content=\"Conhe\u00e7a a t\u00e9cnica LERV para o tratamento em tempo \u00fanico da coledocolit\u00edase no contexto da pancreatite biliar aguda.\" \/>\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\/casosclinicos\/lerv-pancreatite-biliar-aguda\/\" \/>\n<meta property=\"og:locale\" content=\"pt_BR\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Laparoscopic-endoscopic rendez-vous (LERV) na pancreatite biliar aguda: relato de caso e revis\u00e3o da literatura\" \/>\n<meta property=\"og:description\" content=\"Introdu\u00e7\u00e3o A coledocolit\u00edase \u00e9 uma das principais complica\u00e7\u00f5es da colelit\u00edase e representa importante causa de pancreatite aguda biliar. 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