{"id":4370,"date":"2016-07-04T10:00:50","date_gmt":"2016-07-04T10:00:50","guid":{"rendered":"https:\/\/endoscopiaterapeutica.net\/pt\/uncategorized\/tratamento-endoscopico-dos-calculos-biliares-dificeis\/"},"modified":"2023-03-13T17:35:46","modified_gmt":"2023-03-13T17:35:46","slug":"tratamento-endoscopico-dos-calculos-biliares-dificeis","status":"publish","type":"post","link":"https:\/\/endoscopiaterapeutica.net\/pt\/assuntosgerais\/tratamento-endoscopico-dos-calculos-biliares-dificeis\/","title":{"rendered":"Tratamento endosc\u00f3pico dos c\u00e1lculos biliares dif\u00edceis"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-post\" data-elementor-id=\"4370\" class=\"elementor elementor-4370\">\n\t\t\t\t\t\t<section class=\"penci-section penci-disSticky penci-structure-10 elementor-section elementor-top-section elementor-element elementor-element-202f5d97 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"202f5d97\" data-element_type=\"section\" data-e-type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"penci-ercol-100 penci-ercol-order-1 penci-sticky-ct    elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-2b3cd394\" data-id=\"2b3cd394\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-22058930 elementor-widget elementor-widget-text-editor\" data-id=\"22058930\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\tO tratamento da coledocolit\u00edase evoluiu muitos nas ultimas 4 d\u00e9cadas gra\u00e7as ao avan\u00e7o das t\u00e9cnicas endosc\u00f3picas. Hoje sabemos que entre 85 e 90 % dos casos de coledocolit\u00edase s\u00e3o bem resolvidos pelas t\u00e9cnicas\u00a0 habituais da Colangiopancreatografia Retr\u00f3grada Endosc\u00f3pica (CPRE) : papiloesfincterotomia e extra\u00e7\u00e3o com basket ou bal\u00e3o.\n\nAlguns fatores de risco devem ser considerados como preditores de dificuldades na extra\u00e7\u00e3o destes c\u00e1lculos, sendo eles:\n<ul>\n \t<li>\u00a0 \u00a0 \u00a0 \u00a0 Idade &gt; 65 anos<\/li>\n \t<li>\u00a0 \u00a0 \u00a0 \u00a0 C\u00e1lculo &gt; 15 mm de di\u00e2metro<\/li>\n \t<li>\u00a0 \u00a0 \u00a0 \u00a0 C\u00e1lculo em posi\u00e7\u00e3o peri-ampular ( &lt;36 mm da papila)<\/li>\n \t<li>\u00a0 \u00a0 \u00a0 \u00a0 M\u00faltiplos c\u00e1lculos (&gt;10)<\/li>\n \t<li>\u00a0 \u00a0 \u00a0 \u00a0 C\u00e1lculos em forma de barril ou muito longos<\/li>\n \t<li>\u00a0 \u00a0 \u00a0 \u00a0 C\u00e1lculos intra-hep\u00e1ticos<\/li>\n \t<li>\u00a0 \u00a0 \u00a0 \u00a0 Vias viliares muito dilatadas<\/li>\n \t<li>\u00a0 \u00a0 \u00a0 \u00a0 Angula\u00e7\u00e3o das vias biliares &lt; 135\u00b0<\/li>\n \t<li>\u00a0 \u00a0 \u00a0 \u00a0 Estenose biliar distal<\/li>\n<\/ul>\nAs op\u00e7\u00f5es t\u00e9cnicas nestes casos s\u00e3o muitas, dependendo do arsenal de acess\u00f3rios, bem como da experi\u00eancia e prefer\u00eancia do endoscopista.\n\n<a href=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2016\/07\/coledocolitiase-multiplos-calculos-1.jpg\" data-rel=\"penci-gallery-image-content\" ><img fetchpriority=\"high\" decoding=\"async\" class=\"size-medium wp-image-6115 aligncenter\" src=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2021\/08\/coledocolitiase-multiplos-calculos-1.jpg\" alt=\"coledocolitiase multiplos calculos\" width=\"300\" height=\"254\" \/><\/a>\n<p style=\"padding-left: 90px;\"><em>Clique na imagem para ampliar. A)Paciente com m\u00faltiplos c\u00e1lculos. B)Remo\u00e7\u00e3o iniciada pelos c\u00e1lculos distais para evitar impacta\u00e7\u00e3o. C) Remo\u00e7\u00e3o dos c\u00e1lculos proximais. D) Colangiografia controle confirmando aus\u00eancia de c\u00e1lculos residuais.<\/em><\/p>\n\n<h2><strong>Stents Biliares<\/strong><\/h2>\nMuito utilizados quando ocorre falha na retirada completa dos c\u00e1lculos. O uso de stents, tanto pl\u00e1sticos como met\u00e1licos, s\u00e3o\u00a0grandes aliados nestas situa\u00e7\u00f5es. Para os stents pl\u00e1sticos, os modelos em pigtail apresentam menor risco de migra\u00e7\u00e3o. Apesar do maior custo em nosso meio, os stents met\u00e1licos totalmente recobertos tamb\u00e9m podem ser usados e alguns estudos mostram melhores resultados, com menores complica\u00e7\u00f5es a longo prazo, provavelmente devido a maior for\u00e7a radial e por promoverem maior dilata\u00e7\u00e3o papilar.\n<h3><strong>Vantagens<\/strong>:<\/h3>\n<ul>\n \t<li>\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 Permite ampla drenagem biliar at\u00e9 a solu\u00e7\u00e3o definitiva<\/li>\n \t<li>\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 Sucesso de implanta\u00e7\u00e3o em quase 100% dos casos<\/li>\n \t<li>\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 Promove redu\u00e7\u00e3o progressiva do tamanho dos c\u00e1lculos<\/li>\n \t<li>\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 Passagem espont\u00e2nea dos c\u00e1lculos em alguns casos<\/li>\n \t<li>\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 Aumenta a taxa de extra\u00e7\u00e3o em at\u00e9 92 % na segunda tentativa<\/li>\n<\/ul>\n<h3><strong>Desvantagens:<\/strong><\/h3>\n<ul>\n \t<li>\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 Risco de oclus\u00e3o e\u00a0 colangite em at\u00e9 40% dos casos<\/li>\n \t<li>\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 Risco de migra\u00e7\u00e3o<\/li>\n \t<li>\u00a0 \u00a0 \u00a0 \u00a0 \u00a0 Troca necess\u00e1ria a cada 3 meses<\/li>\n<\/ul>\n<a href=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2016\/07\/coledocolitiase-colangite-protese.jpg\" data-rel=\"penci-gallery-image-content\" ><img decoding=\"async\" class=\"size-medium wp-image-6118 aligncenter\" src=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2021\/08\/coledocolitiase-colangite-protese.jpg\" alt=\"coledocolitiase colangite protese\" width=\"300\" height=\"253\" \/><\/a>\n<p style=\"padding-left: 90px;\"><em>Clique na imagem para ampliar. Paciente de 78 anos, m\u00faltiplas comorbidades e com quadro de sepse e colangite. A) Colangiografia mostrando m\u00faltiplos c\u00e1lculos de col\u00e9doco\u00a0e estenose na via biliar distal. B) Detalhe da redu\u00e7\u00e3o de calibre no col\u00e9doco distal. C) Tentativa de remo\u00e7\u00e3o dos c\u00e1lculos com papilotomia e bal\u00e3o extrator sem sucesso. D) Devido \u00e0s condi\u00e7\u00f5es cl\u00ednicas ruins da paciente foi optado por passar uma pr\u00f3tese pl\u00e1stica e tratar a colangite com reabordagem endosc\u00f3pica a ser programada ap\u00f3s compensa\u00e7\u00e3o cl\u00ednica da paciente.<\/em><\/p>\n\n<h2><strong>Dilata\u00e7\u00e3o Papilar com Bal\u00e3o de Grande Calibre<\/strong><\/h2>\nO uso de bal\u00f5es de grande calibre ( 12 a 20 mm) tem se mostrado efetivo em v\u00e1rias publica\u00e7\u00f5es. Esta t\u00e9cnica \u00e9 indicada para a abordagem de c\u00e1lculos maiores do que 13 ou 14 mm, diminuindo nestes casos a necessidade de litotripsia mec\u00e2nica, bem como em casos de S\u00edndrome de Mirizzi e impacta\u00e7\u00e3o de basket. Outras\u00a0 indica\u00e7\u00f5es incluem anatomia alterada, como gastrectomia B II, \u00a0by-pass g\u00e1strico e divert\u00edculo peri-ampular, sem aumento do risco de complica\u00e7\u00f5es. O uso do bal\u00e3o hidrost\u00e1tico, associado ao bal\u00e3o extrator ou basket, se torna mais econ\u00f4mico em nosso meio quando comparado ao uso das diversas op\u00e7\u00f5es de litotripsia.\n\n<strong>Detalhes t\u00e9cnicos:<\/strong>\n<ul>\n \t<li>Realizar papilotomia entre 1\/3 e \u00bd da dist\u00e2ncia at\u00e9 a primeira prega duodenal<\/li>\n \t<li>Nos casos com papilotomia pr\u00e9via a amplia\u00e7\u00e3o de papilotomia pode aumentar risco de sangramento<\/li>\n \t<li>Acesso por infundibulotomia n\u00e3o aumenta risco de complica\u00e7\u00f5es<\/li>\n \t<li>Dilatar <span style=\"text-decoration: underline;\">at\u00e9 no m\u00e1ximo o calibre da via biliar<\/span>, lenta e progressivamente, abaixo dos c\u00e1lculos<\/li>\n \t<li>Inflar o bal\u00e3o com \u00e1gua e contraste hidrossol\u00favel, sob controle fluorosc\u00f3pico<\/li>\n \t<li>Cinturas persistentes podem significar estenoses ocultas, com maior risco de perfura\u00e7\u00e3o<\/li>\n<\/ul>\n<a href=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2016\/07\/Coledocolitiase-dilatacao-balao-grande-calibre-1.jpg\" data-rel=\"penci-gallery-image-content\" ><img decoding=\"async\" class=\"size-medium wp-image-6117 aligncenter\" src=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2021\/08\/Coledocolitiase-dilatacao-balao-grande-calibre-1.jpg\" alt=\"Coledocolitiase dilatacao balao grande calibre\" width=\"300\" height=\"169\" \/><\/a>\n<p style=\"padding-left: 120px;\"><em>Clique na imagem para ampliar. A) Grande c\u00e1lculo na via biliar com despropor\u00e7\u00e3o entre o seu tamanho e a via biliar distal. B) Vis\u00e3o fluorosc\u00f3pica da dilata\u00e7\u00e3o com bal\u00e3o &#8211; bal\u00e3o insuflado com contraste e soro para melhor visualiza\u00e7\u00e3o. C) Colangiografia ap\u00f3s a remo\u00e7\u00e3o do c\u00e1lculo. D) Vis\u00e3o endosc\u00f3pica da dilata\u00e7\u00e3o com bal\u00e3o. E) Grande c\u00e1lculo na luz duodenal. F) Optado por remo\u00e7\u00e3o endosc\u00f3pica do c\u00e1lculo devido ao risco de \u00edleo biliar.<\/em><\/p>\n\n<h2><strong>Litotripsia Mec\u00e2nica<\/strong><\/h2>\nTem como princ\u00edpio fundamental a fratura do c\u00e1lculo, atrav\u00e9s de sua apreens\u00e3o por um basket e a press\u00e3o deste sobre uma bainha met\u00e1lica, exercendo for\u00e7a suficiente para a fragmenta\u00e7\u00e3o do c\u00e1lculo. Apresenta taxas de sucesso de at\u00e9 90% e baixo \u00edndice de complica\u00e7\u00f5es, sendo as mais comuns a fratura do sistema com reten\u00e7\u00e3o do c\u00e1lculo e basket, pancreatite e sangramento.\n<h2><strong>Litotripsia Intraductal<\/strong><\/h2>\nConsiste na fragmenta\u00e7\u00e3o dos c\u00e1lculos atrav\u00e9s de contato direto com uma sonda, sob controle endosc\u00f3pico ( colangiosc\u00f3pico), utilizando-se o sistema Eletrohidr\u00e1ulico ou o sistema a Laser. Ambos apresentam taxas de sucesso em torno de 90%, com complica\u00e7\u00f5es entre 10 e 18%, sendo a colangite e sangramento as mais comuns. Devido ao alto custo destes equipamentos, n\u00e3o apresentam grande disponibilidade em nosso meio.\n<h2><strong>Litotripsia Extra-Corp\u00f3rea<\/strong><\/h2>\nRealizada atrav\u00e9s da emiss\u00e3o de ondas de choque, por um gerador externo. Necessita de localiza\u00e7\u00e3o radiol\u00f3gica ou ultrassonogr\u00e1fica dos c\u00e1lculos, normalmente atrav\u00e9s de um dreno nasobiliar ou biliar externo. Ap\u00f3s a fragmenta\u00e7\u00e3o dos c\u00e1lculos necessita\u00a0de CPRE para limpeza das vias biliares e tem taxas de sucesso entre 70 e 90%. Complica\u00e7\u00f5es ocorrem entre 30 a 40% dos casos, mais frequentemente c\u00f3lica biliar, <a href=\"https:\/\/endoscopiaterapeutica.net\/pt\/casosclinicos\/varizes-de-coledoco-uma-causa-rara-de-hemobilia\/\">hemobilia<\/a>, colangite, hematoma perinefr\u00e9tico e hemat\u00faria.\n\nEm recente revis\u00e3o, foi proposto um algoritmo para estes casos dif\u00edceis.\n\n<a href=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2016\/07\/algoritmo-calculos-dificeis.jpg\" data-rel=\"penci-gallery-image-content\" ><img loading=\"lazy\" decoding=\"async\" class=\"size-medium wp-image-6113 aligncenter\" src=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2021\/08\/algoritmo-calculos-dificeis.jpg\" alt=\"algoritmo calculos dificeis\" width=\"300\" height=\"217\" \/><\/a>\n<p style=\"padding-left: 90px;\">Clique para ampliar. Adaptado de Esler JJ et al. Gastrointest Endosc Clin N Am. 2015;25(4):657-75.<\/p>\nNestes \u00faltimos anos tenho usado com muito mais frequ\u00eancia a dilata\u00e7\u00e3o com bal\u00e3o, seja de calibre normal ( 10 a12 mm), ou mesmo os de grande calibre, quando nestas situa\u00e7\u00f5es de c\u00e1lculos dif\u00edceis como descritas aqui, e muito raramente tenho necessitado de stents ou mesmo litotripsia mec\u00e2nica. O uso destes bal\u00f5es \u00e9 f\u00e1cil, mais barato que a litotripsia, e muito seguro, quando respeitados os detalhes t\u00e9cnicos aqui discutidos.\n\nPara finalizar, um \u00faltimo cuidado quando se trata de c\u00e1lculos volumosos, \u00e9 a fragmenta\u00e7\u00e3o dos mesmos no duodeno, ou retirada per-oral, para se evitar o \u00edleo biliar ou mesmo a S\u00edndrome de Bouveret (obstru\u00e7\u00e3o duodenal pelo c\u00e1lculo).\n\n<div style=\"position:relative;padding-top:56.20608899297424%;\"><iframe id=\"panda-7929a2d5-7c84-440f-9791-2c7838989a06\" src=\"https:\/\/player-vz-a75e9d45-986.tv.pandavideo.com.br\/embed\/?v=7929a2d5-7c84-440f-9791-2c7838989a06\" 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<p style=\"padding-left: 90px; text-align: center;\"><em>Clique para assistir o video. \u00a0Paciente com via biliar bastante dilatada e c\u00e1lculo\u00a0gigante. Ap\u00f3s a remo\u00e7\u00e3o do c\u00e1lculo foi realizada a fragmenta\u00e7\u00e3o do mesmo no duodeno para prevenir o \u00edleo biliar.<\/em><\/p>\n\n<h2>Refer\u00eancias<\/h2>\nEasler JJ et al. Endoscopic Retrograde Cholangiopancreatography for the management of common bile duct stones and gallstone pancreatitis.Gastrointest Endosc Clin N Am. 2015;25(4):657-75.\n\nYang J et al. Endoscopic biliary stenting for irretrievable common buli duct stones: Indications, advantages, disadvantages and follow up results. The sugeon. 2012;10:211-217.\n\nPark JS et al. Endoscopic balloon dilation lithotripsy for difficult bile duct stones. Dig Dis Sci. 2014;59:1898-1901.\n\nKim JH et al. Endoscopic papillary large balloon dilation for the removal of bile duct stones. World J Gastroenterol. 2013;19(46).\n\nMangiavillano B et al. Outcome of stenting in biliary and pancreatic benign and malignant diseases. World J Gastroenterol 2015;21(30).\n\nOrso I. Tratamento endosc\u00f3pico da coledocolit\u00edase. in: Paulo Sakai. Tratado de endoscopia digestiva &#8211; Vias biliares e p\u00e2ncreas. 2015; Volume 3, Segunda edi\u00e7\u00e3o.\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>O tratamento da coledocolit\u00edase evoluiu muitos nas ultimas 4 d\u00e9cadas gra\u00e7as ao avan\u00e7o das&hellip;<\/p>\n","protected":false},"author":811,"featured_media":9392,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_lmt_disableupdate":"","_lmt_disable":"","footnotes":""},"categories":[151],"tags":[],"ano":[281],"tipo":[155],"volume":[147],"class_list":["post-4370","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-assuntosgerais","ano-281","tipo-cpre","volume-volume-ii"],"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>Tratamento endosc\u00f3pico dos c\u00e1lculos biliares dif\u00edceis &#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\/tratamento-endoscopico-dos-calculos-biliares-dificeis\/\" \/>\n<meta property=\"og:locale\" content=\"pt_BR\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Tratamento endosc\u00f3pico dos c\u00e1lculos biliares dif\u00edceis\" \/>\n<meta property=\"og:description\" content=\"O tratamento da coledocolit\u00edase evoluiu muitos nas ultimas 4 d\u00e9cadas gra\u00e7as ao avan\u00e7o das t\u00e9cnicas endosc\u00f3picas. 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