{"id":4272,"date":"2015-08-26T10:00:46","date_gmt":"2015-08-26T10:00:46","guid":{"rendered":"https:\/\/endoscopiaterapeutica.net\/pt\/uncategorized\/underwater-emr-mucosectomia-de-lesoes-colonicas-sem-injecao-submucosa\/"},"modified":"2021-09-22T12:59:53","modified_gmt":"2021-09-22T12:59:53","slug":"underwater-emr-mucosectomia-de-lesoes-colonicas-sem-injecao-submucosa","status":"publish","type":"post","link":"https:\/\/endoscopiaterapeutica.net\/pt\/assuntosgerais\/underwater-emr-mucosectomia-de-lesoes-colonicas-sem-injecao-submucosa\/","title":{"rendered":"Underwater EMR &#8211; mucosectomia de les\u00f5es col\u00f4nicas sem inje\u00e7\u00e3o submucosa"},"content":{"rendered":"<p>A mucosectomia \u00e9 um m\u00e9todo muito bem estabelecido para a ressec\u00e7\u00e3o de les\u00f5es benignas do c\u00f3lon. A \u00a0inje\u00e7\u00e3o submucosa \u00e9 considerada como parte fundamental durante a aplica\u00e7\u00e3o desta t\u00e9cnica, fazendo a eleva\u00e7\u00e3o da les\u00e3o e afastando a submucosa da muscular pr\u00f3pria, teoricamente reduzindo o risco de perfura\u00e7\u00e3o e les\u00e3o t\u00e9rmica das camadas mais profundas. Apesar disso, \u00a0a inje\u00e7\u00e3o submucosa pode, em alguns casos, dificultar ou at\u00e9 inviabilizar a captura de les\u00f5es planas, fazendo com que a al\u00e7a deslize sobre elas. Outra preocupa\u00e7\u00e3o \u00e9 a possibilidade da inje\u00e7\u00e3o levar c\u00e9lulas para camadas profundas quando a pun\u00e7\u00e3o \u00e9 feita atrav\u00e9s do p\u00f3lipo <sup>(1)<\/sup>.<\/p>\n<p>Em 2012, Binmoeller et al.\u00a0publicaram a primeira s\u00e9rie de casos de uma nova op\u00e7\u00e3o para realizar mucosectomias sem a necessidade de inje\u00e7\u00e3o submucosa. Nessas ressec\u00e7\u00f5es foi \u00a0utilizada \u00a0a imers\u00e3o completa da les\u00e3o em \u00e1gua e ressec\u00e7\u00e3o com al\u00e7a diat\u00e9rmica &#8220;<em>underwater<\/em>&#8220;. \u00a0Este procedimento foi desenvolvido a partir da observa\u00e7\u00e3o de que durante a imers\u00e3o em \u00e1gua para fazer ecoendoscopia de les\u00f5es precoces no c\u00f3lon a mucosa e a submucosa ficavam &#8220;boiando&#8221; enquanto a muscular pr\u00f3pria se mantinha distendida (figura 1).<\/p>\n<p><a href=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2015\/08\/Underwater-EMR1.png\" data-rel=\"penci-gallery-image-content\" ><img fetchpriority=\"high\" decoding=\"async\" class=\"alignnone size-medium wp-image-2655\" src=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2021\/08\/Underwater-EMR1.png\" alt=\"Underwater EMR\" width=\"300\" height=\"274\" \/><\/a><\/p>\n<p>Figura 1 &#8211; Imagem de ecoendoscopia radial demonstrando a mucosa e submucosa &#8220;boiando&#8221; na \u00e1gua enquanto a muscular pr\u00f3pria se mant\u00e9m distendida (clique para aumentar)<\/p>\n<p>&nbsp;<\/p>\n<p>Para realiza\u00e7\u00e3o da mucosectomia, ap\u00f3s a identifica\u00e7\u00e3o da les\u00e3o, todo o ar do c\u00f3lon era aspirado e realizada a infus\u00e3o de \u00e1gua em temperatura ambiente.\u00a0 Todas as ressec\u00e7\u00f5es foram realizadas com \u00a0al\u00e7a tipo <em>duckbill de 15 mm (figura 2)<\/em>. \u00a0Em nenhum paciente a mucosa foi aproximada ap\u00f3s a ressec\u00e7\u00e3o.<\/p>\n<p>&nbsp;<\/p>\n<p><a href=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2015\/08\/AcuSnare\u00ae-Duck-Bill_jfq3_esc_asdb.png\" data-rel=\"penci-gallery-image-content\" ><img decoding=\"async\" class=\"alignnone size-medium wp-image-2656\" src=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2021\/08\/AcuSnareC2AE-Duck-Bill_jfq3_esc_asdb.png\" alt=\"AcuSnare\u00ae Duck Bill_jfq3_esc_asdb\" width=\"300\" height=\"225\" \/><\/a><\/p>\n<p>Figura 2 &#8211; Al\u00e7a tipo <em>duckbill<\/em> de 15 mm (clique para aumentar).<\/p>\n<p>&nbsp;<\/p>\n<p>Nesta primeira s\u00e9rie, foram apresentados dados de 62 les\u00f5es s\u00e9sseis ressecadas com a t\u00e9cnica de mucosectomia <em>underwater<\/em>. O tamanho m\u00e9dio das les\u00f5es era de 34 mm. Todas as les\u00f5es foram ressecadas com sucesso.\u00a0 N\u00e3o houve nenhuma perfura\u00e7\u00e3o. Tr\u00eas pacientes apresentaram sangramento tardio, e todos foram tratados conservadoramente. O seguimento m\u00e9dio foi de 20,4 semanas e apenas 1 paciente apresentou les\u00e3o residual de 5 mm que foi ressecada endoscopicamente <sup>(1)<\/sup>.<\/p>\n<p>&nbsp;<\/p>\n<div style=\"width: 854px;\" class=\"wp-video\"><video class=\"wp-video-shortcode\" id=\"video-4272-1\" width=\"854\" height=\"480\" preload=\"metadata\" controls=\"controls\"><source type=\"video\/mp4\" src=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2015\/08\/UEMR-com-legendas.mp4?_=1\" \/><a href=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2015\/08\/UEMR-com-legendas.mp4\">https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2015\/08\/UEMR-com-legendas.mp4<\/a><\/video><\/div>\n<p><em>Underwater<\/em> EMR de les\u00e3o de reto.<\/p>\n<p>&nbsp;<\/p>\n<p>Outra s\u00e9rie publicada na Surgical Endoscopy em 2014 <sup>(2)<\/sup> relatou 21 pacientes com 43 les\u00f5es ressecadas utilizando a t\u00e9cnica de mucosectomia <em>underwater<\/em>. O tamanho m\u00e9dio das les\u00f5es era de 30 mm (8-50 mm).\u00a0 Dezesseis les\u00f5es eram localizadas no c\u00f3lon direito, 5 no transverso, 19 no c\u00f3lon esquerdo e 3 no reto. Em rela\u00e7\u00e3o \u00e0 patologia, 34 eram adenomas, 3 neoplasias intraepiteliais de alto grau, 3 adenomas serrados e 3 inflamat\u00f3rios.\u00a0 A ressec\u00e7\u00e3o completa foi poss\u00edvel em 97,7% dos p\u00f3lipos. Em rela\u00e7\u00e3o \u00e0s complica\u00e7\u00f5es apenas 1 paciente apresentou sangramento tardio.<\/p>\n<p>Em maio deste ano (2015), \u00a0Curcio et al. <sup>(3)<\/sup> publicaram uma s\u00e9rie de 72 pacientes submetidos \u00e0 81 ressec\u00e7\u00f5es de p\u00f3lipos com a t\u00e9cnica de mucosectomia <em>underwater<\/em> utilizando al\u00e7a de polipectomia padr\u00e3o<em>. <\/em>O tamanho m\u00e9dio das les\u00f5es era de 18,7 mm (10-50 mm).\u00a0 Cinquenta e cinco p\u00f3lipos (68%) foram ressecados <em>en bloc<\/em> e o restante em <em>piecemeal.<\/em> \u00a0A histopatologia demonstrou 30,9 % de adenomas sem displasia, 42 % de adenomas com displasia de alto grau, 4,9% de p\u00f3lipos serrados e 13,6% de carcinoma <em>in situ<\/em>. Em dois casos ocorreu sangramento imediato ap\u00f3s a mucosectomia.\u00a0 O autor relata que o tratamento <em>underwater<\/em>\u00a0permitiu uma melhor identifica\u00e7\u00e3o do ponto de sangramento, facilitando a realiza\u00e7\u00e3o da hemostasia. Nenhum paciente apresentou sangramento \u00a0tardio ou perfura\u00e7\u00e3o. A endoscopia de controle foi realizada 3 meses ap\u00f3s, sem nenhuma recidiva.<\/p>\n<p>Kim et al.<sup>(4) <\/sup>publicou uma s\u00e9rie na Gastrointestinal Endoscopy demonstrando que esta t\u00e9cnica tamb\u00e9m pode ser aplicada para recorr\u00eancias de les\u00f5es ressecadas previamente.\u00a0 Neste estudo foi comparado a ressec\u00e7\u00e3o de les\u00f5es recidivadas utilizando a mucosectomia tradicional (n= 44) com a t\u00e9cnica <em>underwater <\/em>(n=36). O tamanho m\u00e9dio das les\u00f5es era semelhante \u00a0entre os 2 grupos (9,3 mm vs 9,4 mm). A taxa de ressec\u00e7\u00e3o <em>en bloc<\/em> foi maior no grupo <em>underwater <\/em>(47,2% vs 15,9%) e a necessidade de uso de APC para les\u00f5es\u00a0 residuais durante a ressec\u00e7\u00e3o da recidiva foi menor no grupo <em>underwater<\/em> (11,1% vs 65,9%). \u00a0Na colonoscopia de seguimento a recorr\u00eancia tamb\u00e9m foi menor no grupo tratado com a t\u00e9cnica <em>underwater <\/em>(10% vs 39,4%).<\/p>\n<p>&nbsp;<\/p>\n<div style=\"width: 854px;\" class=\"wp-video\"><video class=\"wp-video-shortcode\" id=\"video-4272-2\" width=\"854\" height=\"480\" preload=\"metadata\" controls=\"controls\"><source type=\"video\/mp4\" src=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2015\/05\/Les\u00e3o-residual-UEMR-site.mp4?_=2\" \/><a href=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2015\/05\/Les\u00e3o-residual-UEMR-site.mp4\">https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2015\/05\/Les\u00e3o-residual-UEMR-site.mp4<\/a><\/video><\/div>\n<p><em>Underwater<\/em> EMR de les\u00e3o recidivada.<\/p>\n<p>&nbsp;<\/p>\n<p><strong>Conclus\u00e3o<\/strong><\/p>\n<p>A t\u00e9cnica de mucosectomia <em>underwater<\/em> parece apresentar benef\u00edcios significativos em rela\u00e7\u00e3o \u00e0 mucosectomia convencional. As s\u00e9ries iniciais demonstram que a t\u00e9cnica \u00e9 facilmente aprendida e executada por profissionais com experi\u00eancia em mucosectomia tradicional, al\u00e9m de apresentar\u00a0um baixo \u00edndice de complica\u00e7\u00f5es. \u00a0Nas les\u00f5es residuais aparentemente facilita o tratamento, tem um maior \u00edndice de ressec\u00e7\u00e3o completa e menor recidiva. Por\u00e9m ainda \u00e9 cedo para tirar conclus\u00f5es definitivas. Novas s\u00e9ries com grande n\u00famero de casos e trabalhos prospectivos e controlados ainda s\u00e3o necess\u00e1rios para confirmar estes achados iniciais.<\/p>\n<p>&nbsp;<\/p>\n<p><strong>Refer\u00eancias<\/strong><\/p>\n<p>1\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Binmoeller KF, Weilert F, Shah J, Bhat Y, Kane S. &#8220;Underwater&#8221;\u00a0EMR without submucosal injection for large sessile colorectal polyps. Gastrointest Endosc. 2012;75(5):1086-91.<\/p>\n<p>2\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Wang AY,\u00a0Flynn MM,\u00a0Patrie JT,\u00a0Cox DG,\u00a0Mann JA,\u00a0Sauer BG,\u00a0Shami VM. \u00a0Underwater\u00a0endoscopic mucosal resection of colorectal neoplasia is easily learned, efficacious, and safe. \u00a0Surg Endosc.\u00a02014;28(4):1348-54.<\/p>\n<p>3\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Curcio G, Granata A, Ligresti D, Tarantino I, Barresi L, Liotta R, Traina M.<strong> \u00a0<\/strong>Underwater\u00a0colorectal\u00a0EMR: remodeling endoscopic mucosal resection. Gastrointest Endosc. 2015;81(5):1238-42.<\/p>\n<p>4\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 Kim HG, Thosani N, Banerjee S, Chen A, Friedland S. Underwater\u00a0endoscopic mucosal resection for recurrences after previous piecemeal resection of colorectal polyps. Gastrointest Endosc. 2014;80(6):1094-102.<\/p>\n<p>&nbsp;<\/p>\n<p><strong>Assuntos relacionados<\/strong><\/p>\n<hr \/>\n<p><a title=\"Neoplasia precoce de reto \u2013 ESD\" href=\"https:\/\/endoscopiaterapeutica.net\/pt\/neoplasia-precoce-de-reto-esd\/\">Imagens &#8211; LST de reto<\/a><\/p>\n<hr \/>\n<p><a title=\"Quiz! \u2013 Qual sua hip\u00f3tese e conduta para este caso?\" href=\"https:\/\/endoscopiaterapeutica.net\/pt\/quiz-qual-sua-hipotese-e-conduta-para-este-caso\/\">Quiz &#8211; \u00a0Les\u00e3o no c\u00f3lon &#8211; Qual a hip\u00f3tese e conduta para este caso?<\/a><\/p>\n<hr \/>\n<p><a title=\"V\u00eddeo - Mucosectomia de LST de sigm\u00f3ide\" href=\"https:\/\/endoscopiaterapeutica.net\/pt\/mucosectomia-de-lst-de-sigmoide\/\">V\u00eddeo &#8211; Mucosectomia de LST de sigm\u00f3ide<\/a><\/p>\n<hr \/>\n<p>&nbsp;<\/p>\n<h3><em>Assista os v\u00eddeos do site em nosso canal no Youtube: <a href=\"https:\/\/www.youtube.com\/user\/therapeuticendoscopy\" target=\"_blank\" rel=\"noopener\"><strong>Clique aqui!<\/strong><\/a><\/em><\/h3>\n","protected":false},"excerpt":{"rendered":"<p>A mucosectomia \u00e9 um m\u00e9todo muito bem estabelecido para a ressec\u00e7\u00e3o de les\u00f5es benignas&hellip;<\/p>\n","protected":false},"author":2464,"featured_media":3699,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_lmt_disableupdate":"","_lmt_disable":"","footnotes":""},"categories":[151],"tags":[],"ano":[282],"tipo":[156],"volume":[147],"class_list":["post-4272","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-assuntosgerais","ano-282","tipo-colonoscopia","volume-volume-ii"],"yoast_head":"<!-- This site is optimized with the Yoast SEO Premium plugin v27.2 (Yoast SEO v27.4) - https:\/\/yoast.com\/product\/yoast-seo-premium-wordpress\/ -->\n<title>Underwater EMR - mucosectomia de les\u00f5es col\u00f4nicas sem inje\u00e7\u00e3o submucosa &#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\/assuntosgerais\/underwater-emr-mucosectomia-de-lesoes-colonicas-sem-injecao-submucosa\/\" \/>\n<meta property=\"og:locale\" content=\"pt_BR\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Underwater EMR - mucosectomia de les\u00f5es col\u00f4nicas sem inje\u00e7\u00e3o submucosa\" \/>\n<meta property=\"og:description\" content=\"A mucosectomia \u00e9 um m\u00e9todo muito bem estabelecido para a ressec\u00e7\u00e3o de les\u00f5es benignas do c\u00f3lon. 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