{"id":3566,"date":"2017-06-26T09:00:05","date_gmt":"2017-06-26T09:00:05","guid":{"rendered":"https:\/\/endoscopiaterapeutica.net\/pt\/uncategorized\/papel-da-endoscopia-nas-lesoes-subepiteliais-do-trato-gastrointestinal\/"},"modified":"2022-06-10T12:54:08","modified_gmt":"2022-06-10T12:54:08","slug":"papel-da-endoscopia-nas-lesoes-subepiteliais-do-trato-gastrointestinal","status":"publish","type":"post","link":"https:\/\/endoscopiaterapeutica.net\/pt\/artigoscomentados\/papel-da-endoscopia-nas-lesoes-subepiteliais-do-trato-gastrointestinal\/","title":{"rendered":"Papel da endoscopia nas les\u00f5es subepiteliais do trato gastrointestinal"},"content":{"rendered":"<p><a href=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2017\/06\/lesoes-subepiteliais.png\" data-rel=\"penci-gallery-image-content\" ><img fetchpriority=\"high\" decoding=\"async\" class=\"aligncenter wp-image-7897 size-large\" src=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2021\/08\/lesoes-subepiteliais.png\" alt=\"\" width=\"670\" height=\"301\"><\/a><\/p>\n<p>No m\u00eas de junho de 2017 foi publicado na \u201cGastrointestinal Endoscopy\u201d a nova diretriz das les\u00f5es subepiteliais (LSEs) no trato gastrointestinal.<\/p>\n<p>Devido a frequ\u00eancia e ao potencial maligno destas les\u00f5es faremos aqui alguns coment\u00e1rios&nbsp; sobre esse Guideline.<\/p>\n<p>Antes de mais nada, o endoscopista deve estar familiarizado com os aspectos endosc\u00f3picos e ecoendosc\u00f3picos essas les\u00f5es.<\/p>\n<p>&nbsp;<\/p>\n<h5><\/h5>\n<h5><strong>Caracter\u00edsticas das les\u00f5es subepiteliais:<\/strong><\/h5>\n<p>&nbsp;<\/p>\n<p>Come\u00e7aremos discutindo as caracter\u00edsticas dos <strong>Tumores estromais (GISTs)<\/strong>. Essas les\u00f5es t\u00eam formato esf\u00e9rico ou fusiforme sendo mais comuns no est\u00f4mago (70%) e endurecidos \u00e0 palpa\u00e7\u00e3o com a pin\u00e7a.<\/p>\n<ul>\n<li>S\u00e3o da muscular pr\u00f3pria. Essa e outras revis\u00f5es colocam que podem ser da muscularis mucosa (mas fa\u00e7o uma ressalta aqui &#8211; desafio quem achar a refer\u00eancia original de um GIST da muscular da mucosa, PS n\u00e3o vale livro texto e revis\u00e3o!!!)<\/li>\n<li>Na Ecoendoscopia, s\u00e3o hipoec\u00f3icos e homog\u00eaneos.&nbsp;&nbsp; Alguns aspectos podem sugerir malignidade: tamanho &gt; 3 cm, heterogeneidade, cistos, \u00falceras e bordas irregulares.<\/li>\n<li>Pun\u00e7\u00e3o ecoguiada (FNA) pode ser realizada com obten\u00e7\u00e3o de material para imunohistoqu\u00edmica. Entretanto o \u00edndice mit\u00f3tico n\u00e3o pode ser avaliado pelo material da pun\u00e7\u00e3o (s\u00f3 da cirurgia).<\/li>\n<li>Noventa e cinco por cento dos casos s\u00e3o positivos para CD117. Portanto em cerca de 5% o CD117 \u00e9 negativo!! Para estes casos um novo marcador DOG1 (Discovered on GIST 1) \u00e9 \u00fatil.<\/li>\n<li>Todos os GISTs t\u00eam algum potencial maligno. Sendo os do delgado mais agressivos com at\u00e9 50% de malignidade!!! Indica\u00e7\u00f5es de cirurgia: sintomas, adenopatia regional, &gt; 2 cm e as de qualquer tamanho no delgado. Para les\u00f5es &lt; 2 cm mas com aspectos de alto risco na eco sugere-se ressec\u00e7\u00e3o tamb\u00e9m. Para aqueles pequenos e sem aspectos de alto riso, recomenda-se nova ECO em 6 a 12 meses.<\/li>\n<\/ul>\n<div id=\"attachment_1129\" style=\"width: 310px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2015\/04\/GIST-G\u00c1STRICO-IVAN-2.jpg\" data-rel=\"penci-gallery-image-content\" ><img decoding=\"async\" aria-describedby=\"caption-attachment-1129\" class=\"size-medium wp-image-1129\" src=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2021\/08\/GIST-GC381STRICO-IVAN-2.jpg\" alt=\"\" width=\"300\" height=\"200\"><\/a><p id=\"caption-attachment-1129\" class=\"wp-caption-text\">Les\u00e3o subepitelial de parede posterior de corpo g\u00e1strico<\/p><\/div>\n<div id=\"attachment_1131\" style=\"width: 310px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2015\/04\/GIST-G\u00c1STRICO-IVAN-7.jpg\" data-rel=\"penci-gallery-image-content\" ><img decoding=\"async\" aria-describedby=\"caption-attachment-1131\" class=\"size-medium wp-image-1131\" src=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2021\/08\/GIST-GC381STRICO-IVAN-7.jpg\" alt=\"\" width=\"300\" height=\"200\"><\/a><p id=\"caption-attachment-1131\" class=\"wp-caption-text\">Les\u00e3o localizada na quarta camada<\/p><\/div>\n<p>&nbsp;<\/p>\n<p><strong>Leiomiomas<\/strong> s\u00e3o mais comuns no es\u00f4fago (especialmente ter\u00e7o distal). Na Eco s\u00e3o id\u00eanticos aos GISTs, sendo negativos para CD117 e positivos para desmina e actina. Cirurgia est\u00e1 somente indicada se sintom\u00e1ticos.<\/p>\n<p>&nbsp;<\/p>\n<p><strong>Lipomas<\/strong> s\u00e3o mais comuns no antro e c\u00f3lon. S\u00e3o amarelos e amolecidos (sinal do travesseiro). Hiperec\u00f3icos e da submucosa na ECO. Pun\u00e7\u00e3o, vigil\u00e2ncia e tratamento n\u00e3o s\u00e3o necess\u00e1rios.<\/p>\n<div id=\"attachment_1394\" style=\"width: 310px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2015\/05\/ECO-lipoma-de-duodeno-1.jpg\" data-rel=\"penci-gallery-image-content\" ><img loading=\"lazy\" decoding=\"async\" aria-describedby=\"caption-attachment-1394\" class=\"size-medium wp-image-1394\" src=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2021\/08\/ECO-lipoma-de-duodeno-1.jpg\" alt=\"\" width=\"300\" height=\"200\"><\/a><p id=\"caption-attachment-1394\" class=\"wp-caption-text\">Les\u00e3o subepitelial de bulbo duodenal<\/p><\/div>\n<div id=\"attachment_1397\" style=\"width: 310px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2015\/05\/ECO-lipoma-de-duodeno-4.jpg\" data-rel=\"penci-gallery-image-content\" ><img loading=\"lazy\" decoding=\"async\" aria-describedby=\"caption-attachment-1397\" class=\"wp-image-1397 size-medium\" src=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2021\/08\/ECO-lipoma-de-duodeno-4.jpg\" alt=\"\" width=\"300\" height=\"200\"><\/a><p id=\"caption-attachment-1397\" class=\"wp-caption-text\">Les\u00e3o hiperec\u00f3ica de submucosa sugestiva de lipoma<\/p><\/div>\n<p>&nbsp;<\/p>\n<p>&nbsp;<\/p>\n<p><strong>Tumores neuroend\u00f3crinos (carcin\u00f3ides)<\/strong> s\u00e3o les\u00f5es polip\u00f3ides podendo ter eros\u00e3o apical, sendo hipoec\u00f3icos e da submucosa ou mucosa profunda. Os g\u00e1stricos s\u00e3o divididos em tr\u00eas tipos<\/p>\n<ul>\n<li>I &#8211; associados a anemia perniciosa e gastrite atr\u00f3fica. Baixa malignidade<\/li>\n<li>II &#8211; associada \u00e0 Zollinger-Ellison. Risco intermedi\u00e1rio de malignidade<\/li>\n<li>III &#8211; Solit\u00e1rios. Alto risco de met\u00e1stases.<\/li>\n<\/ul>\n<p>EMR pode ser considerada para os tipos I e II que forem &lt; 2 cm, com controle a cada 6-12 meses por tr\u00eas anos. As do Tipo III necessitam tratamento cir\u00fargico (exce\u00e7\u00e3o para as &lt; 1 cm e bem diferenciadas que podem ser ressecadas por via endosc\u00f3pica)<\/p>\n<p>Os neuroend\u00f3crinos retais &lt; 1 cm podem ser ressecados por via endosc\u00f3pica sem a necessidade de EUS pr\u00e9vio e se as margens forem negativas nem vigil\u00e2ncia \u00e9 necess\u00e1ria. Para les\u00f5es intermedi\u00e1rias (entre 1- 2 cm) fazer EUS antes e se aus\u00eancia de adenopatia e infiltra\u00e7\u00e3o profunda, a ressec\u00e7\u00e3o endosc\u00f3pica pode ser realizada. E posterior acompanhamento deve ser feito com EUS ou resson\u00e2ncia em 6 e 12 meses. Carcin\u00f3ides retais com mais de 2 cm dever ser tratados por cirurgia.<\/p>\n<p>N\u00e3o existem diretrizes para neuroend\u00f3crinos duodenais. Entretanto les\u00f5es pequenas (&lt; 1 cm) podem ser removidas por EMR.<\/p>\n<div id=\"attachment_1499\" style=\"width: 310px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2015\/05\/bi\u00f3psia-de-polipo1.png\" data-rel=\"penci-gallery-image-content\" ><img loading=\"lazy\" decoding=\"async\" aria-describedby=\"caption-attachment-1499\" class=\"wp-image-1499 size-medium\" src=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2021\/08\/biC3B3psia-de-polipo1.png\" alt=\"\" width=\"300\" height=\"242\"><\/a><p id=\"caption-attachment-1499\" class=\"wp-caption-text\">Tumor neuroend\u00f3crino de est\u00f4mago<\/p><\/div>\n<p>&nbsp;<\/p>\n<p><strong>P\u00e2ncreas ect\u00f3picos<\/strong> quando localizados na grande curvatura de antro e com umbilica\u00e7\u00e3o central nem precisam de EUS para confirma\u00e7\u00e3o diagn\u00f3stica.<\/p>\n<div id=\"attachment_7896\" style=\"width: 310px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2017\/06\/pancreas-ectopico.png\" data-rel=\"penci-gallery-image-content\" ><img loading=\"lazy\" decoding=\"async\" aria-describedby=\"caption-attachment-7896\" class=\"wp-image-7896 size-medium\" src=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2021\/08\/pancreas-ectopico.png\" alt=\"\" width=\"300\" height=\"90\"><\/a><p id=\"caption-attachment-7896\" class=\"wp-caption-text\">Les\u00f5es sugestivas de p\u00e2ncreas ect\u00f3pico<\/p><\/div>\n<p>&nbsp;<\/p>\n<p><strong>Tumores de c\u00e9lulas granulares<\/strong> podem ser diagnosticados com bi\u00f3psias simples (S-100 positivo). Ressec\u00e7\u00e3o pode ser considerada para evitar a necessidade de vigil\u00e2ncia.<\/p>\n<div id=\"attachment_1251\" style=\"width: 310px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2015\/04\/Captura-de-Tela-2015-04-21-\u00e0s-22.56.58.png\" data-rel=\"penci-gallery-image-content\" ><img loading=\"lazy\" decoding=\"async\" aria-describedby=\"caption-attachment-1251\" class=\"wp-image-1251 size-medium\" src=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2021\/08\/Captura-de-Tela-2015-04-21-C3A0s-22.56.58.png\" alt=\"\" width=\"300\" height=\"168\"><\/a><p id=\"caption-attachment-1251\" class=\"wp-caption-text\">Tumor de c\u00e9lulas granulares<\/p><\/div>\n<p>&nbsp;<\/p>\n<p><strong>Cistos de duplica\u00e7\u00e3o<\/strong> geralmente se apresentam com uma abaulamento na parede. Na eco podem ser anec\u00f3icos ou hipoec\u00f3icos (secund\u00e1rios a mucina produzida pelo cisto). Quando anec\u00f3icos, a pun\u00e7\u00e3o deve ser evitada e na d\u00favida fazer antibi\u00f3ticos na les\u00f5es hipoec\u00f3icas mediastinais. N\u00e3o existem dados que ap\u00f3iam a vigil\u00e2ncia nessas les\u00f5es e tratamento est\u00e1 indicado apenas se sintomas.<\/p>\n<div id=\"attachment_6854\" style=\"width: 310px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2016\/09\/Picture1.png\" data-rel=\"penci-gallery-image-content\" ><img loading=\"lazy\" decoding=\"async\" aria-describedby=\"caption-attachment-6854\" class=\"wp-image-6854 size-medium\" src=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2016\/10\/Picture1.png\" alt=\"\" width=\"300\" height=\"267\"><\/a><p id=\"caption-attachment-6854\" class=\"wp-caption-text\">Les\u00e3o subepitelial da transi\u00e7\u00e3o es\u00f4fago g\u00e1strica<\/p><\/div>\n<div id=\"attachment_6855\" style=\"width: 310px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2016\/09\/Picture2.png\" data-rel=\"penci-gallery-image-content\" ><img loading=\"lazy\" decoding=\"async\" aria-describedby=\"caption-attachment-6855\" class=\"wp-image-6855 size-medium\" src=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2021\/08\/Picture2.png\" alt=\"\" width=\"300\" height=\"223\"><\/a><p id=\"caption-attachment-6855\" class=\"wp-caption-text\">Imagem ecoendosc\u00f3pica compat\u00edvel com cisto de duplica\u00e7\u00e3o<\/p><\/div>\n<p>&nbsp;<\/p>\n<p><strong>Met\u00e1stases de melanoma e mama<\/strong> principalmente, podem se apresentar como les\u00f5es subepiteliais. S\u00e3o hipoec\u00f3icas e heterog\u00eaneas. A hist\u00f3ria cl\u00ednica ajuda bastante nesse diagn\u00f3stico. Assim com a hist\u00f3ria de hipertens\u00e3o portal levanta a probabilidade de varizes (estruturas anec\u00f3icas na eco).<\/p>\n<h5><\/h5>\n<p>&nbsp;<\/p>\n<h5><strong>Diagn\u00f3stico:<\/strong><\/h5>\n<p>Para algumas les\u00f5es, como lipomas, cistos de duplica\u00e7\u00e3o e p\u00e2ncreas ect\u00f3picos, aspectos endosc\u00f3picos e ecoendosc\u00f3picos s\u00e3o suficientes para o diagn\u00f3stico.<\/p>\n<p>Les\u00f5es hipoec\u00f3icas e heterog\u00eaneas da submucosa e da muscular pr\u00f3pria necessitam de an\u00e1lise tecidual para diagn\u00f3stico diferencial e para avalia\u00e7\u00e3o de potencial de malignidade. Imunohistoqu\u00edmica \u00e9 mandat\u00f3ria para caracterizar esses casos.<\/p>\n<p>Bi\u00f3psias simples raramente d\u00e3o diagn\u00f3stico. Mesmo bi\u00f3psias sobre bi\u00f3psias tem baixa sensibilidade (30-40%).&nbsp; Bi\u00f3psias com pin\u00e7a JUMBO, destelhamento (unroofing) e incis\u00f5es com estiletes (single-incision needle-knife \u2013 SINK) tem um potencial diagn\u00f3stico maior, entretanto tamb\u00e9m est\u00e3o associadas com risco de sangramento e podem causar fibrose que inviabiliza uma subsequente ressec\u00e7\u00e3o endosc\u00f3pica se necess\u00e1ria.<\/p>\n<p>Em rela\u00e7\u00e3o a pun\u00e7\u00e3o ecoguiada (FNA) n\u00e3o existem dados robustos ou diferen\u00e7as estat\u00edsticas entre o calibre da agulha, usar ou n\u00e3o estilete, suc\u00e7\u00e3o ou t\u00e9cnica de leque (fanning)<\/p>\n<h5><\/h5>\n<p>&nbsp;<\/p>\n<h5><strong>Ressec\u00e7\u00f5es endosc\u00f3picas de les\u00f5es subepiteliais:<\/strong><\/h5>\n<p>Mucosectomias com Cap ou com ligadura el\u00e1stica podem ser realizadas para les\u00f5es pequenas (&lt; 20 mm no est\u00f4mago e &lt; 10 mm no duodeno) e limitadas a mucosa ou sbmucosa.<\/p>\n<p>ESD pode ser empregada para les\u00f5es maiores (at\u00e9 5 cm) e at\u00e9 mesmo para les\u00f5es que acometem a muscular pr\u00f3pria. Entretanto ESD \u00e9 tecnicamente dif\u00edcil, demorada e com risco n\u00e3o insignificante de complica\u00e7\u00f5es (perfura\u00e7\u00e3o, sangramento e dissemina\u00e7\u00e3o tumoral, pela ruptura da c\u00e1psula)<\/p>\n<p>A tuneliza\u00e7\u00e3o submucosa permite a enuclea\u00e7\u00e3o da les\u00e3o utilizando os mesmos princ\u00edpios da ESD, entretanto faz-se um t\u00fanel submucoso e depois que o tumor \u00e9 completamente retirado, a incis\u00e3o da mucosa \u00e9 fechada. Quando se mant\u00e9m a integridade da mucosa reduz-se o risco de peritonite e mediastinite. A aplica\u00e7\u00e3o dessa t\u00e9cnica, entretanto requer expertise e centros especializados.<\/p>\n<p>Por \u00faltimo foi criada uma t\u00e9cnica de ressec\u00e7\u00e3o endosc\u00f3pica completa da parede, necessitando assim de um fechamento confi\u00e1vel da parede, seja este procedimento com clipes convencionais, clipes over-the-scope, dispositivos de sutura ou endoloops. A efetividade deste fechamento permanece o maior desafio desta t\u00e9cnica.<\/p>\n<p>&nbsp;<\/p>\n<p>&nbsp;<\/p>\n<h4><strong>Considera\u00e7\u00f5es finais:<\/strong><\/h4>\n<p>Lembrando que les\u00f5es assintom\u00e1ticas e benignas (lipomas, cistos, p\u00e2ncreas ect\u00f3pico e leiomiomas) n\u00e3o necessitam qualquer interven\u00e7\u00e3o ou seguimento.&nbsp; Les\u00f5es potencialmente malignas podem ser ressecadas por via endosc\u00f3pica ou cir\u00fargica dependendo da prefer\u00eancia do paciente, caracter\u00edsticas da les\u00e3o (tipo, tamanho e localiza\u00e7\u00e3o) e expertise do centro. E que a ressec\u00e7\u00e3o laparosc\u00f3pica continua sendo a t\u00e9cnica de escolha para les\u00f5es sabidamente malignas.<\/p>\n<h5><strong>Refer\u00eancia<\/strong><\/h5>\n<p>Gastrointest Endosc. 2017 Jun;85(6):1117-1132. doi: 10.1016\/j.gie.2017.02.022. Epub 2017 Apr 3. <em>The role of endoscopy in subepithelial lesions of the GI tract<\/em>.<\/p>\n","protected":false},"excerpt":{"rendered":"<p>No m\u00eas de junho de 2017 foi publicado na \u201cGastrointestinal Endoscopy\u201d a nova diretriz&hellip;<\/p>\n","protected":false},"author":3257,"featured_media":3557,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_lmt_disableupdate":"","_lmt_disable":"","footnotes":""},"categories":[142],"tags":[],"ano":[276],"tipo":[154],"volume":[263],"class_list":["post-3566","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-artigoscomentados","ano-276","tipo-ecoendoscopia","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>Papel da endoscopia nas les\u00f5es subepiteliais do trato gastrointestinal &#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\/artigoscomentados\/papel-da-endoscopia-nas-lesoes-subepiteliais-do-trato-gastrointestinal\/\" \/>\n<meta property=\"og:locale\" content=\"pt_BR\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Papel da endoscopia nas les\u00f5es subepiteliais do trato gastrointestinal\" \/>\n<meta property=\"og:description\" content=\"No m\u00eas de junho de 2017 foi publicado na \u201cGastrointestinal Endoscopy\u201d a nova diretriz das les\u00f5es subepiteliais (LSEs) no trato gastrointestinal. 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