{"id":4293,"date":"2015-10-07T10:00:03","date_gmt":"2015-10-07T10:00:03","guid":{"rendered":"https:\/\/endoscopiaterapeutica.net\/pt\/uncategorized\/poem-miotomia-endoscopica-peroral-no-tratamento-da-acalasia\/"},"modified":"2022-06-10T12:38:09","modified_gmt":"2022-06-10T12:38:09","slug":"poem-miotomia-endoscopica-peroral-no-tratamento-da-acalasia","status":"publish","type":"post","link":"https:\/\/endoscopiaterapeutica.net\/pt\/assuntosgerais\/poem-miotomia-endoscopica-peroral-no-tratamento-da-acalasia\/","title":{"rendered":"POEM – Miotomia Endosc\u00f3pica Peroral no tratamento da acal\u00e1sia"},"content":{"rendered":"

\"poem<\/a><\/p>\n

Introdu\u00e7\u00e3o<\/strong><\/h2>\n

A acalasia \u00e9 um dist\u00farbio de motilidade esof\u00e1gica caracterizado pelo relaxamento incompleto do esf\u00edncter esof\u00e1gico inferior (EEI), aumento do t\u00f4nus do EEI ou perda da peristalse do es\u00f4fago devido \u00e0 degenera\u00e7\u00e3o dos neur\u00f4nios mioent\u00e9ricos da parede esof\u00e1gica.<\/p>\n

A incid\u00eancia desta patologia varia 0,03 a 1,63\/100.000 pessoas e sua preval\u00eacia  \u00e9 de quase 10\/100.000, n\u00e3o havendo diferen\u00e7a entre os sexos1<\/sup>.<\/p>\n

A acalasia pode ser classificada em prim\u00e1ria ou idiop\u00e1tica, e secund\u00e1ria \u00e0 infec\u00e7\u00e3o pelo protozo\u00e1rio Trypanossoma cruzi, <\/em>agente etiol\u00f3gico da doen\u00e7a de Chagas.<\/em><\/p>\n

Os principais sintomas do megaes\u00f4fago consistem: disfagia de longa dura\u00e7\u00e3o, odinofagia, regurgita\u00e7\u00e3o, azia, dor retroesternal e perda ponderal2<\/sup>.<\/p>\n

O tratamento da patologia \u00e9 funcional, consistindo em m\u00e9todos que visam \u00e0 diminui\u00e7\u00e3o da press\u00e3o de repouso do EEI, sejam eles endosc\u00f3picos, medicamentosos ou cir\u00fargico3<\/sup>.<\/p>\n

O tratamento de melhor resultado \u00e9 baseado no rompimento da musculatura do EEI, tanto atrav\u00e9s da dilata\u00e7\u00e3o com bal\u00e3o pneum\u00e1tico quanto atrav\u00e9s da miotomia laparosc\u00f3pica de Heller.<\/p>\n

A efic\u00e1cia de ambos os procedimentos aparentemente \u00e9 semelhante, por\u00e9m estima-se que o al\u00edvio dos sintomas conseguido atrav\u00e9s da cirurgia seja mais duradouro e definitivo, sem a necessidade de repetidas dilata\u00e7\u00f5es endosc\u00f3pica e os riscos que delas decorrem4,5<\/sup>.<\/p>\n

 <\/p>\n

POEM (MIOTOMIA ENDOSC\u00d3PICA PERORAL)<\/strong><\/h2>\n

Em 1980, Ortega et al.<\/em>6<\/sup> descreveu a t\u00e9cnica da miotomia endosc\u00f3pica em 17 pacientes com acalasia atrav\u00e9s do corte da mucosa seguido da sec\u00e7\u00e3o da musculatura circular do es\u00f4fago distal, obtendo melhora dos sintomas e queda da press\u00e3o do esf\u00edncter esof\u00e1gico inferior \u00e0 manometria, com baixos \u00edndices de complica\u00e7\u00e3o. Em 2007, Pasricha et al<\/em>.7<\/sup> desenvolveu a t\u00e9cnica de sec\u00e7\u00e3o da musculatura circular do EEI associado ao t\u00fanel submucoso em modelo experimental.<\/p>\n

Em 2010, Inoue et al.<\/em>8<\/sup> descreveu pela primeira vez a miotomia endosc\u00f3pica peroral (POEM) em 17 pacientes consecutivos com megaes\u00f4fago. Em todos os casos, o POEM reduziu significativamente o escore dos sintomas de disfagia e foi respons\u00e1vel pela queda de press\u00e3o de repouso do EEI da m\u00e9dia de 52,4 mmHg para 19,9 mmHg. N\u00e3o foram relatadas complica\u00e7\u00f5es graves relacionadas ao POEM nesses pacientes.<\/p>\n

 <\/p>\n

Indica\u00e7\u00f5es<\/strong><\/h2>\n

Inicialmente Inoue et al<\/em>.8<\/sup> realizou o POEM nos pacientes com acalasia e megaes\u00f4fago Grau I e II. Posteriormente, as indica\u00e7\u00f5es foram expandidas para megaes\u00f4fago com tortuosidade. Entretanto,  existem maiores dificuldades t\u00e9cnicas na realiza\u00e7\u00e3o do POEM nos pacientes apresentando um alongamento sigmoide do es\u00f4fago.<\/p>\n

O POEM tamb\u00e9m pode ser realizado em casos de espasmo esofageano difuso e es\u00f4fago em quebranozes. Shiwaku et al<\/em>.9<\/sup> relatou um caso submetido ao POEM com sucesso em paciente com espasmo esofageano difuso sendo realizada uma miotomia extensa. Minami et al<\/em>.10<\/sup> obteve a mesma efetividade  do POEM em espasmo esofageano difuso.<\/p>\n

Terap\u00eauticas endosc\u00f3picas pr\u00e9vias como a inje\u00e7\u00e3o de toxina botul\u00ednica e a dilata\u00e7\u00e3o balonada causam uma fibrose e distor\u00e7\u00e3o da anatomia tornando o POEM tecnicamente desafiador, particularmente em pacientes com tortuosidade do es\u00f4fago. Sharata et al.<\/em>11<\/sup> publicou os resultados de 40 pacientes submetidos ao POEM. Nesta s\u00e9rie estavam inclu\u00eddos 10 pacientes com tratamento endosc\u00f3pico pr\u00e9vio  e evolu\u00edram com queda do escore de Eckardt ap\u00f3s o POEM.<\/p>\n

Onimaru et al.<\/em>12<\/sup> e Vigneswaran et al<\/em>.13<\/sup> relataram excelentes resultados do POEM em pacientes com falha no tratamento cir\u00fargico da acalasia pela t\u00e9cnica de Heller com v\u00e1vula antirefluxo. Entretato, o POEM \u00e9 tecnicamente mais dif\u00edcil devido \u00e0 fibrose nesses casos de cirurgia pr\u00e9via.<\/p>\n

 <\/p>\n

T\u00e9cnica<\/strong><\/h2>\n

                        <\/strong>A miotomia endosc\u00f3pica da acalasia do es\u00f4fago consiste na cria\u00e7\u00e3o de t\u00fanel submucoso, dissec\u00e7\u00e3o do m\u00fasculo do EEI e fechamento da mucosa.<\/p>\n

 <\/p>\n

1 – Cria\u00e7\u00e3o do t\u00fanel submucoso<\/strong><\/h3>\n

                        <\/strong>Inicialmente, realiza-se a inje\u00e7\u00e3o submucosa com solu\u00e7\u00e3o de soro fisiol\u00f3gico e \u00edndigo carmim no es\u00f4fago, 10 cm proximal \u00e0 transi\u00e7\u00e3o esofagog\u00e1strica (TEG) (Figura 1). Em seguida, efetua-se incis\u00e3o de 2 cm na mucosa, longitudinalmente, criando-se um espa\u00e7o na submucosa. Uma vez no espa\u00e7o da submucosa, cria-se um t\u00fanel usando a coagula\u00e7\u00e3o no modo spray, ultrapassando-se a TEG em cerca de 2 cm, correspondendo ao est\u00f4mago proximal (Figura A,B).<\/p>\n

 <\/p>\n

2 – Dissec\u00e7\u00e3o do m\u00fasculo do EEI<\/strong><\/h3>\n

                        <\/strong>D\u00e1-se in\u00edcio \u00e0 dissec\u00e7\u00e3o do feixe muscular circular 2 cm distalmente \u00e0 entrada da mucosa e cerca de 6 cm acima da TEG.<\/p>\n

\u00c9 importante a identifica\u00e7\u00e3o da camada longitudinal, que \u00e9 geralmente muito mais fina. A miotomia prossegue distalmente at\u00e9 que se atinja a submucosa g\u00e1strica, extendendo-se at\u00e9 cerca de 2 ou 3 cm distalmente \u00e0 TEG (Figura C).<\/p>\n

 <\/p>\n

3 – Fechamento do t\u00fanel submucoso<\/strong><\/h3>\n

A abertura do t\u00fanel submucoso geralmente com 2 cm de comprimento \u00e9 fechada atrav\u00e9s da coloca\u00e7\u00e3o de clipes hemost\u00e1ticos (Figura D).<\/p>\n

 <\/p>\n

\"POEM<\/a><\/p>\n

Figura – A) Inje\u00e7\u00e3o submucosa para incis\u00e3o da entrada do t\u00fanel. B) Disse\u00e7c\u00e3o da submucosa e forma\u00e7\u00e3o do t\u00fanel. C) Miotomia. D) Fechamento do orif\u00edcio mucoso com clipes. (Clique para ampliar).<\/p>\n

 <\/p>\n

P\u00f3s-operat\u00f3rio<\/strong><\/h2>\n

Imediatamente ap\u00f3s o procedimento, o paciente deve ser submetido a RX de t\u00f3rax para avalia\u00e7\u00e3o de eventual pneumot\u00f3rax ou pneumomediastino. De acordo com Ponsky et al.,14<\/sup> \u00e9 poss\u00edvel a dissec\u00e7\u00e3o de CO2 para abd\u00f4men, t\u00f3rax e mediatino em at\u00e9 20% dos pacientes.<\/p>\n

Deve-se manter o paciente em jejum por 24h e esofagograma com contraste hidrossol\u00favel para descartar f\u00edstula e avaliar a passagem do l\u00edquido para o est\u00f4mago. O paciente deve manter dieta l\u00edquida por 7 dias, quando ent\u00e3o se progride a dieta para pastosa e subsequentemente, s\u00f3lida. Os pacientes recebem alta 1 dia ap\u00f3s o procedimento, com uso de inibidor de bomba de pr\u00f3tons por 30 dias.<\/p>\n

 <\/p>\n

Resultados<\/strong><\/h2>\n

O POEM \u00e9 considerado bem sucedido quando os pacientes passam a apresentar escore de Eckardt \u2264 3.<\/p>\n

Nos estudos recentes, nota-se melhora importante tanto dos sintomas quando das medidas de press\u00e3o de repouso do esf\u00edncter inferior do es\u00f4fago. Costamagna et al.<\/em>3 <\/sup>completou o  POEM em 10 dos 11 pacientes. Num paciente que foi previamente submetido \u00e0 radioterapia do mediastino para o c\u00e2ncer de mama, a cria\u00e7\u00e3o do t\u00fanel submucoso foi impossibilitada devido \u00e0 altera\u00e7\u00f5es fibr\u00f3ticas na submucosa . O sucesso cl\u00ednico foi obtido em todos os pacientes tratados em tr\u00eas meses de seguimento (m\u00e9dia do escore de Eckardt pr\u00e9-tratamento versus p\u00f3s- tratamento (7,1 vs 1,1) e a m\u00e9dia da press\u00e3o do esf\u00edncter esof\u00e1gico inferior diminuiu de 45,1 para 16.9mmHg . Nenhum paciente desenvolveu sintomas de refluxo gastroesof\u00e1gico ap\u00f3s o tratamento.<\/p>\n

Von Renteln et al.<\/em>15<\/sup> realizou o POEM em 16 pacientes. O sucesso do tratamento foi alcan\u00e7ada em 94% dos casos ap\u00f3s 3 meses de seguimento (pontua\u00e7\u00e3o m\u00e9dia de Eckardt diminui de 8,8 para 1,4), e a m\u00e9dia da press\u00e3o do esf\u00edncter esof\u00e1gico inferior foi de 27.2mmHg (pr\u00e9-tratamento) para 11.8mmHg (p\u00f3s-tratamento). Nenhum paciente desenvolveu sintomas de refluxo gastroesof\u00e1gico ap\u00f3s o tratamento, mas um paciente apresentou uma eros\u00e3o no es\u00f4fago distal (grau A de Los Angeles) na endoscopia digestiva alta de seguimento.<\/p>\n

 <\/p>\n

Refer\u00eancias bibliogr\u00e1ficas<\/strong><\/h2>\n

 <\/strong><\/p>\n

    \n
  1. Fei L, Rossetti G, Moccia F, Cimmino M, et al. Definition, incidence and etiology: what\u2019s new in the 21st century?. Ann Ital Chir 489-94, 2013.<\/span><\/li>\n
  2. Ferrari Jr AP, Siqueira ES, Brant CQ. Treatment of achalasia in Chagas’ disease with botulinum toxin (letter). N Engl J Med 332:24, 1995.<\/span><\/li>\n
  3. Costamagna G, Marchese M, Familiari P, et al. Peroral endoscopic myotomy (POEM) for oesophageal achalasia: preliminary results in humans.<\/a> Dig Liver Dis.; 44:827-832, 2012.<\/span><\/li>\n
  4. Muehldorfer SM, Schneider TH, Hochberger J, et al. Esophageal achalasia: intrasphincteric injection of botulinum toxin A versus balloon dilation. Endoscopy 1999; 31:517.<\/a><\/span><\/li>\n
  5. Vaezi MF, Richter JE, Wilcox CM, et al. Botulinum toxin versus pneumatic dilatation in the treatment of achalasia: a randomised trial. Gut 1999; 44:231.<\/span><\/li>\n
  6. Ortega JA<\/a>, Madureri V<\/a>, Perez L<\/a>. Endoscopic myotomy in the treatment of achalasia. Gastrointest Endosc 1980: 26:8-10.<\/span><\/li>\n
  7. Inoue H, Minami H, Kobayashi Y, et al.<\/em> Peroral endoscopic myotomy (POEM) \u2028for esophageal achalasia. 42:265\u2013271, 2010.<\/span><\/li>\n
  8. Pashricha PJ, Hawari R, Ahmed I, et al.<\/em> Submucosal endoscopic esophageal \u2028myotomy: a novel experimental approach for the treatment of achalasia. 2007;39:761\u2013764.<\/span><\/li>\n
  9. Shiwaku H, Inoue H, Beppu R, et al. <\/em>Succesful treatment of diffuse esophageal spasm by peroral endoscopic myotomy. Gastrointest Endosc. 2013; 77: 149-150.<\/span><\/li>\n
  10. Minami H, Isomoto H, Yamaguchi N, et al<\/em>. Peroral endoscopic myotomy (POEM) for diffuse esophageal spasm. Endoscopy 2014; 46 (Suppl 1 UCTN): E79-80.<\/span><\/li>\n
  11. Sharata A, Kurian AA, Dunst CM, Bhayani NH, Reavis KM, Swanstr\u00f6m LL. Peroral endoscopic myotomy (POEM) is safe and effective in the setting of prior endoscopic intervention.<\/a> <\/span><\/span>J Gastrointest Surg. 2013; 17: 1188-92.<\/span><\/li>\n
  12. Onimaru M, Inoue H, Ikeda H, et al.<\/em> Peroral endoscopic myotomy is a viable option for failed surgical esophagocardiomyotomy instead of redo surgical Heller myotomy: a single center prospective study.<\/a> J Am Coll Surg. 2013;217: 598-605.<\/span><\/li>\n
  13. Vigneswaran Y, Yetasook AK, Zhao JC, Denham W, Linn JG, Ujiki MB. Peroral endoscopic myotomy (POEM): feasible as reoperation following Heller myotomy.<\/a> J Gastrointest Surg. 2014; 18: 1071-6.<\/span><\/li>\n
  14. Ponsky JL, Marks JM, Pauli EM. How i do it: per-oral endoscopic myotomy (POEM).<\/a> J Gastrointest Surg 2012; 16:1251\u20131255.<\/span><\/li>\n
  15. Von Rentelm D, Inoue H, Minami H, et al. <\/em>Peroral endoscopic myotomy for the treatment of achalasia: a prospective study. Am J Gastroenterol. 2012; 107: 411-417.<\/span><\/li>\n<\/ol>\n

     <\/p>\n

    Assuntos relacionados<\/strong><\/p>\n

    \n

    Imagens – Megaes\u00f4fago chag\u00e1sico<\/a><\/p>\n

    \n

    Caso cl\u00ednico – Estenose benigna de es\u00f4fago<\/a><\/p>\n

    \n

    Fundoplicatura g\u00e1strica – como avaliar?<\/a><\/p>\n

    \n

    Caso cl\u00ednico – Ruptura de anel de bari\u00e1trica com bal\u00e3o de acal\u00e1sia<\/a><\/p>\n

    \n

    Caso cl\u00ednico – Tratamento endosc\u00f3pico do divert\u00edculo de Zenker<\/a><\/p>\n

    \n

     <\/p>\n

    O autor<\/strong><\/p>\n

    \"capa<\/a><\/p>\n","protected":false},"excerpt":{"rendered":"

    Introdu\u00e7\u00e3o A acalasia \u00e9 um dist\u00farbio de motilidade esof\u00e1gica caracterizado pelo relaxamento incompleto do…<\/p>\n","protected":false},"author":5709,"featured_media":4292,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_lmt_disableupdate":"","_lmt_disable":"","footnotes":""},"categories":[151],"tags":[],"ano":[282],"tipo":[153],"volume":[147],"class_list":["post-4293","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-assuntosgerais","ano-282","tipo-endoscopia-digestiva-alta","volume-volume-ii"],"yoast_head":"\nPOEM - Miotomia Endosc\u00f3pica Peroral no tratamento da acal\u00e1sia • 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\" 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