{"id":4081,"date":"2020-06-26T09:03:22","date_gmt":"2020-06-26T09:03:22","guid":{"rendered":"https:\/\/endoscopiaterapeutica.net\/pt\/uncategorized\/tratamento-do-diverticulo-de-zenker-por-z-poem\/"},"modified":"2022-02-02T18:45:39","modified_gmt":"2022-02-02T18:45:39","slug":"tratamento-do-diverticulo-de-zenker-por-z-poem","status":"publish","type":"post","link":"https:\/\/endoscopiaterapeutica.net\/pt\/casosclinicos\/tratamento-do-diverticulo-de-zenker-por-z-poem\/","title":{"rendered":"Tratamento do Divert\u00edculo de Zenker por Z-POEM"},"content":{"rendered":"<p>&nbsp;<\/p>\n<p><strong>Divert\u00edculo de Zenker (DZ)<\/strong> s\u00e3o protrus\u00f5es saculiformes da mucosa e submucosa esof\u00e1gica que ocorre na parede posterior da jun\u00e7\u00e3o faringoesof\u00e1gica, logo acima do m\u00fasculo cricofar\u00edngeo (MCF), com preval\u00eancia entre 0,01% e 0,1%.<\/p>\n<p>O tratamento endosc\u00f3pico ganhou espa\u00e7o nas \u00faltimas d\u00e9cadas sobre o tratamento cir\u00fargico, visto ser um tratamento minimamente invasivo, com menor morbidade e eficaz.<\/p>\n<p>V\u00e1rias t\u00e9cnicas endosc\u00f3picas foram descritas como a diverticulotomia (link), uso de ultracision, plasma de arg\u00f4nio, etc. Os resultados das t\u00e9cnicas endosc\u00f3picas est\u00e3o resumidos a seguir:<\/p>\n<ul>\n<li>Sucesso cl\u00ednico entre 56% e 100%<\/li>\n<li>Eventos adversos m\u00e9dia de 15%<\/li>\n<li>Recidiva cl\u00ednica 10,5%<\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<p>Essa recidiva relativamente alta \u00e9 atribu\u00edda a dificuldade em se identificar com precis\u00e3o o final do m\u00fasculo cricofar\u00edngeo, o que pode levar a septotomia incompleta. Por outro lado, a sec\u00e7\u00e3o al\u00e9m do limite do m\u00fasculo pode abrir comunica\u00e7\u00e3o com o mediastino e consequente risco infeccioso.<\/p>\n<p>Neste cen\u00e1rio surgiu a possibilidade de aplicar uma nova t\u00e9cnica endosc\u00f3pica, baseada na experi\u00eancia pr\u00e9via com o POEM (miotomia esof\u00e1gica perioral) utilizada para tratamento da acal\u00e1sia. Esse novo procedimento foi apelidado de <strong>Z-POEM<\/strong> ou <strong>D-POEM<\/strong>, ou seja, a miotomia do divert\u00edculo de Zenker com cria\u00e7\u00e3o de um t\u00fanel submucoso.<\/p>\n<p><strong>As vantagens te\u00f3ricas dessa t\u00e9cnica seriam:<\/strong><\/p>\n<ol>\n<li>Melhor identifica\u00e7\u00e3o e sec\u00e7\u00e3o completa do m\u00fasculo cricofar\u00edngeo<\/li>\n<li>Possibilidade de fechar a mucosa com clipes, trazendo menos dor, possibilitando cicatriza\u00e7\u00e3o mais r\u00e1pida e minimizando riscos infecciosos.<\/li>\n<\/ol>\n<p>&nbsp;<\/p>\n<h2>Indica\u00e7\u00e3o<\/h2>\n<ul>\n<li>Diverticulotomia do Zenker est\u00e1 indicada nos pacientes com DZ que apresentam disfagia, regurgita\u00e7\u00e3o, engasgos ou pneumonia de aspira\u00e7\u00e3o.<\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<h2>Avalia\u00e7\u00e3o pr\u00e9-procedimento<\/h2>\n<ul>\n<li>Deglutograma contrastado<\/li>\n<li><a href=\"https:\/\/endoscopiaterapeutica.net\/pt\/casos-clinicos\/cc-endoscopia-digestiva-alta\/\" target=\"_blank\" rel=\"noopener\">Endoscopia digestiva alta<\/a><\/li>\n<li>Pr\u00e9-operat\u00f3rio para anestesia geral (ECG, RX t\u00f3rax, exames laboratoriais com coagulograma)<\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<h2>Cuidados pr\u00e9-operat\u00f3rios:<\/h2>\n<ul>\n<li>Recomendamos dieta l\u00edquida na v\u00e9spera do procedimento e jejum de 12 horas para evitar presen\u00e7a de res\u00edduos alimentares no interior do divert\u00edculo<\/li>\n<li>Antibi\u00f3ticos de amplo espectro na indu\u00e7\u00e3o anest\u00e9sica.<\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<h2>Seda\u00e7\u00e3o e posicionamento sugerido<\/h2>\n<ul>\n<li>Anestesia geral<\/li>\n<li>Nossa prefer\u00eancia \u00e9 pelo DLE, embora alguns autores realizem o procedimento na posi\u00e7\u00e3o supina<\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<h2>Materiais necess\u00e1rios<\/h2>\n<ul>\n<li>Agulha de esclerose<\/li>\n<li>Cap, de prefer\u00eancia o cap c\u00f4nico.<\/li>\n<li>Faca de dissec\u00e7\u00e3o submucosa (<strong><em><a href=\"https:\/\/www.tamussino.com.br\/pt\/hybridknife\">Hybrid-knife Erbe<\/a><\/em><\/strong>)<\/li>\n<li>Bisturi el\u00e9trico <strong>Erbe<\/strong> com fun\u00e7\u00e3o endocut<\/li>\n<li>Pin\u00e7a hemost\u00e1tica (coagrasper ou <strong><a href=\"https:\/\/www.bostonscientific.com\/content\/gwc\/pt-BR\/products\/forceps\/single-use-radial-jaw-4-biopsy-forceps.html\"><em>hot-biopsy Boston<\/em><\/a><\/strong>)<\/li>\n<li>Insuflador de CO2 (imprescind\u00edvel). Recomendado baixo fluxo para evitar enfisema subcut\u00e2neo<\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<h2>Passos t\u00e9cnicos do procedimento<\/h2>\n<ul>\n<li>Inje\u00e7\u00e3o e sec\u00e7\u00e3o da mucosa 2 cm acima do septo do DZ<\/li>\n<li>Cria\u00e7\u00e3o do t\u00fanel submucoso<\/li>\n<li>Identifica\u00e7\u00e3o do septo (MCF)<\/li>\n<li>Dissec\u00e7\u00e3o meticulosa do septo na sua face anterior e posterior.<\/li>\n<li>Sec\u00e7\u00e3o do septo<\/li>\n<li>Revis\u00e3o da hemostasia<\/li>\n<li>Fechamento da mucosa com clips<\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<h2>Cuidados p\u00f3s-operat\u00f3rios<\/h2>\n<ul>\n<li>Antibi\u00f3ticos. EV s\u00e3o mantidos por 24horas ap\u00f3s o procedimento e na alta s\u00e3o substitu\u00eddos por ATB via oral por 5-7 dias (solu\u00e7\u00e3o l\u00edquida de amoxicilina ou amoxicilina + clavulanato).<\/li>\n<li>Agu\u00e1 e ch\u00e1 frio podem ser iniciados 6 horas ap\u00f3s o procedimento.<\/li>\n<li>Dieta l\u00edquida no primeiro PO, com progress\u00e3o gradual para dieta pastosa e dieta leve conforme aus\u00eancia de dor e boa aceita\u00e7\u00e3o via oral.<\/li>\n<li>IBP por 4 semanas.<\/li>\n<li>Controle endosc\u00f3pico em 3 meses<\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<h2>Video do Procedimento<\/h2>\n<p>&nbsp;<\/p>\n<div  id=\"_ytid_88837\"  width=\"600\" height=\"300\"  data-origwidth=\"600\" data-origheight=\"300\" data-facadesrc=\"https:\/\/www.youtube.com\/embed\/YjoWkodh3BQ?enablejsapi=1&#038;autoplay=0&#038;cc_load_policy=0&#038;cc_lang_pref=&#038;iv_load_policy=1&#038;loop=0&#038;rel=1&#038;fs=1&#038;playsinline=0&#038;autohide=2&#038;theme=dark&#038;color=red&#038;controls=1&#038;disablekb=0&#038;\" class=\"__youtube_prefs__ epyt-facade epyt-is-override  no-lazyload\" data-epautoplay=\"1\" ><img decoding=\"async\" data-spai-excluded=\"true\" class=\"epyt-facade-poster skip-lazy\" loading=\"lazy\"  alt=\"YouTube player\"  src=\"https:\/\/i.ytimg.com\/vi\/YjoWkodh3BQ\/maxresdefault.jpg\"  \/><button class=\"epyt-facade-play\" aria-label=\"Play\"><svg data-no-lazy=\"1\" height=\"100%\" version=\"1.1\" viewBox=\"0 0 68 48\" width=\"100%\"><path class=\"ytp-large-play-button-bg\" d=\"M66.52,7.74c-0.78-2.93-2.49-5.41-5.42-6.19C55.79,.13,34,0,34,0S12.21,.13,6.9,1.55 C3.97,2.33,2.27,4.81,1.48,7.74C0.06,13.05,0,24,0,24s0.06,10.95,1.48,16.26c0.78,2.93,2.49,5.41,5.42,6.19 C12.21,47.87,34,48,34,48s21.79-0.13,27.1-1.55c2.93-0.78,4.64-3.26,5.42-6.19C67.94,34.95,68,24,68,24S67.94,13.05,66.52,7.74z\" fill=\"#f00\"><\/path><path d=\"M 45,24 27,14 27,34\" fill=\"#fff\"><\/path><\/svg><\/button><\/div>\n<p style=\"text-align: center;\"><em>Procedimento realizado por Dr. Nelson Miyajima + Dr. Bruno Martins<\/em><\/p>\n<p>&nbsp;<\/p>\n<h2>Resultados<\/h2>\n<p>O maior estudo at\u00e9 ent\u00e3o foi publicado este ano na GIE. [2]<\/p>\n<ul>\n<li>Estudo internacional multic\u00eantrico envolvendo 10 institui\u00e7\u00f5es<\/li>\n<li>75 pacientes, m\u00e9dia idade 73 anos<\/li>\n<li>Sucesso t\u00e9cnico 97% (73\/75)<\/li>\n<li>Eventos adversos em 6,7% (5\/75)\n<ul>\n<li>1 sangramento leve tratado de forma conservadora<\/li>\n<li>4 perfura\u00e7\u00f5es (1 grave e 3 moderadas)<\/li>\n<\/ul>\n<\/li>\n<li>Tempo m\u00e9dio do procedimento 52 minutos<\/li>\n<li>M\u00e9dia de estadia hospitalar 1,8 dias<\/li>\n<li>Sucesso cl\u00ednico 92% (69\/75)<\/li>\n<li>M\u00e9dia de follow-up 291 dias<\/li>\n<li>Com 12 meses de follow-up, um paciente referiu recidiva dos sintomas<\/li>\n<\/ul>\n<p>&nbsp;<\/p>\n<h2><strong>Conclus\u00f5es:\u00a0<\/strong><\/h2>\n<p>O tratamento endosc\u00f3pico do divert\u00edculo de Zenker utilizando a t\u00e9cnica do Z-POEM \u00e9 promissora, eficaz e apresenta bons resultados.<\/p>\n<p>Imagina-se que essa t\u00e9cnica possa oferecer uma resposta mais duradoura a longo prazo, visto possibilitar a sec\u00e7\u00e3o completa do m\u00fasculo cricofar\u00edngeo com seguran\u00e7a, j\u00e1 que a mucosa pode ser fechada com clipes ao t\u00e9rmino do procedimento.<\/p>\n<p>No entanto, estudos com follow-up a longo prazo ainda s\u00e3o necess\u00e1rio para nos certificarmos da resposta duradoura do procedimento.<\/p>\n<p>Tampouco existem estudos comparando o Z-POEM com a t\u00e9cnica tradicional, embora existam estudos em andamento. Os resultados desses estudo s\u00e3o aguardados ansiosamente.<\/p>\n<p>&nbsp;<\/p>\n<h2>Refer\u00eancias:<\/h2>\n<p>&nbsp;<\/p>\n<ol>\n<li>Li QL, Chen WF, Zhang XC, et al. Submucosal Tunneling Endoscopic Septum Division: A Novel Technique for Treating Zenker&#8217;s Diverticulum.\u00a0<em>Gastroenterology<\/em>. 2016;151(6):1071\u20101074. doi:10.1053\/j.gastro.2016.08.064<\/li>\n<li>Yang J, Novak S, Ujiki M, et al. An international study on the use of peroral endoscopic myotomy in the management of Zenker&#8217;s diverticulum.\u00a0<em>Gastrointest Endosc<\/em>. 2020;91(1):163\u2010168. doi:10.1016\/j.gie.2019.04.249<\/li>\n<li>Maydeo A, Patil GK, Dalal A. Operative technical tricks and 12-month outcomes of diverticular peroral endoscopic myotomy (D-POEM) in patients with symptomatic esophageal diverticula.\u00a0<em>Endoscopy<\/em>. 2019;51(12):1136\u20101140. doi:10.1055\/a-1015-0214<\/li>\n<\/ol>\n<p>&nbsp;<\/p>\n<p>&#8230;&#8230;&#8230;&#8230;&#8230;&#8230;&#8230;&#8230;&#8230;&#8230;&#8230;&#8230;&#8230;&#8230;&#8230;&#8230;&#8230;&#8230;&#8230;&#8230;&#8230;&#8230;&#8230;&#8230;&#8230;&#8230;&#8230;&#8230;&#8230;&#8230;&#8230;&#8230;&#8230;&#8230;&#8230;&#8230;&#8230;&#8230;.<\/p>\n<h2><strong>Como citar esse artigo:<\/strong><\/h2>\n<p><em>Martins, BC. Tratamento do Divert\u00edculo de Zenker por Z-POEM. Endoscopia Terap\u00eautica; 2020. Dispon\u00edvel em:\u00a0https:\/\/endoscopiaterapeutica.net\/pt\/casosclinicos\/tratamento-do-diverticulo-de-zenker-por-z-poem\/<\/em><\/p>\n<p>&nbsp;<\/p>\n","protected":false},"excerpt":{"rendered":"<p>&nbsp; Divert\u00edculo de Zenker (DZ) s\u00e3o protrus\u00f5es saculiformes da mucosa e submucosa esof\u00e1gica que&hellip;<\/p>\n","protected":false},"author":712,"featured_media":4082,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_lmt_disableupdate":"","_lmt_disable":"","footnotes":""},"categories":[150],"tags":[],"ano":[146],"tipo":[153],"volume":[263],"class_list":["post-4081","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-casosclinicos","ano-146","tipo-endoscopia-digestiva-alta","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\/ 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