{"id":4391,"date":"2016-09-26T09:00:58","date_gmt":"2016-09-26T09:00:58","guid":{"rendered":"https:\/\/endoscopiaterapeutica.net\/pt\/uncategorized\/comparacao-do-tratamento-endoscopico-vesus-ecoendoscopico-para-obliteracao-de-varizes-gastricas\/"},"modified":"2022-06-17T15:24:53","modified_gmt":"2022-06-17T15:24:53","slug":"comparacao-do-tratamento-endoscopico-vesus-ecoendoscopico-para-obliteracao-de-varizes-gastricas","status":"publish","type":"post","link":"https:\/\/endoscopiaterapeutica.net\/pt\/assuntosgerais\/comparacao-do-tratamento-endoscopico-vesus-ecoendoscopico-para-obliteracao-de-varizes-gastricas\/","title":{"rendered":"Compara\u00e7\u00e3o do tratamento endosc\u00f3pico versus ecoendosc\u00f3pico para oblitera\u00e7\u00e3o de varizes g\u00e1stricas"},"content":{"rendered":"

Varizes g\u00e1stricas secund\u00e1rias a hipertens\u00e3o portal s\u00e3o uma complica\u00e7\u00e3o da cirrose hep\u00e1tica. Apesar de menos comuns que as varizes esofagianas, apresentam maior gravidade em epis\u00f3dios de sangramento, com maiores taxas de mortalidade1<\/sup>.<\/p>\n

V\u00e1rias t\u00e9cnicas de tratamento j\u00e1 foram aplicadas para varizes g\u00e1stricas, como escleroterapia e ligadura el\u00e1stica, sendo a inje\u00e7\u00e3o da subst\u00e2ncia N-butil-2-cianoacrilato a t\u00e9cnica mais utilizada atualmente e mais recomendada pela literatura, contando com taxas de oblitera\u00e7\u00e3o dos vasos em torno de 70 a 90%, com ressangramento em torno de 7 a 65% a depender da literatura analisada2<\/sup>.<\/p>\n

A t\u00e9cnica consiste em utilizar uma agulha injetora para aplicar o cianoacrilato dentro da variz g\u00e1strica, promovendo o endurecimento da cola intra-vasal e consequentemente a oblitera\u00e7\u00e3o permanente do vaso.<\/p>\n

Algumas dificuldades t\u00e9cnicas s\u00e3o relatadas. Uma delas consiste inje\u00e7\u00e3o paravasal ou peritoneal da cola, pois o aparelho de endoscopia convencional n\u00e3o permite a localiza\u00e7\u00e3o precisa da variz, sendo a mesma identificada apenas pelo seu abaulamento na mucosa g\u00e1strica. A solidifica\u00e7\u00e3o r\u00e1pida da cola tamb\u00e9m \u00e9 uma possibilidade, dificultando a remo\u00e7\u00e3o da agulha ao final do procedimento. Segundo alguns estudos n\u00e3o randomizados, este evento pode ser minimizado com a utiliza\u00e7\u00e3o de uma emuls\u00e3o de ester de \u00e1cido graxo (Lipiodol R), ao final da inje\u00e7\u00e3o da cola. A outra grande dificuldade t\u00e9cnica deste m\u00e9todo \u00e9 a falta de adequado controle ap\u00f3s o tratamento. O cianoacrilato permanecer\u00e1 dentro da variz, muitas vezes perpetuando o abaulamento da mesma na mucosa g\u00e1strica, sendo dificil ao endoscopista em alguns casos diferenciar entre uma variz obliterada pela subst\u00e2ncia e uma variz ainda com fluxo sangu\u00edneo persistente3<\/sup>.<\/p>\n

O tratamento com o cianoacrilato tamb\u00e9m conta com suas complica\u00e7\u00f5es, como infec\u00e7\u00e3o, provocando febre, abscesso ou mesmo sepse, \u00falceras no local de aplica\u00e7\u00e3o da cola com ou sem extrus\u00e3o, e a emboliza\u00e7\u00e3o do cianoacrilato para a circula\u00e7\u00e3o, podendo promover tromboembolismo pulmonar.<\/p>\n

Apesar das complica\u00e7\u00f5es e dificuldades t\u00e9cnicas a inje\u00e7\u00e3o de cianoacrilato pela endoscopia convencional \u00e9 a t\u00e9cnica consagrada e mais utilizada hoje para tratamento de varizes g\u00e1stricas, mesmo em casos de profilaxia prim\u00e1ria, com taxas de sangramento de 13%, 28% e 45% em pacientes tratados com cianoacrilato, beta-bloqueador oral e sem tratamento respectivamente. Isso tamb\u00e9m impactou na sobrevida destes pacientes, segundo este mesmo estudo (72% sem tratamento vs 90% inje\u00e7\u00e3o de cianoacrilato)4<\/sup>.<\/p>\n

A ultrassonografia endosc\u00f3pica ou ecoendoscopia (EUS) \u00e9 um m\u00e9todo diagn\u00f3stico e terap\u00eautico inovador, que combina as t\u00e9cnicas de endoscopia e ultrassonografia em um \u00fanico aparelho, permitindo com grande acur\u00e1cia a avalia\u00e7\u00e3o de estruturas da parede do tubo g\u00e1strico e mesmo de \u00f3rg\u00e3os vizinhos. V\u00e1rios estudos descrevem a utiliza\u00e7\u00e3o do EUS para investiga\u00e7\u00e3o da hipertens\u00e3o portal, permitindo a adequada avalia\u00e7\u00e3o das varizes esof\u00e1gicas e g\u00e1stricas, identifica\u00e7\u00e3o dos vasos paraesof\u00e1gicas e parag\u00e1stricos, bem como a pat\u00eancia do fluxo dos mesmos atrav\u00e9s do estudo doppler3<\/sup> (fig 1 e 2).<\/p>\n

\"Figura<\/a>

Figura 1: Varizes de fundo g\u00e1strico a ecoendoscopia – UNIFESP 2015<\/p><\/div>\n

\"Figura<\/a>

Figura 2: Varizes de fundo g\u00e1strico a ecoendoscopia com doppler \u2013 UNIFESP 2015<\/p><\/div>\n

Al\u00e9m de melhor avalia\u00e7\u00e3o das varizes esofago-g\u00e1stricas, o EUS surge com uma proposta de melhorar a terap\u00eautica destas les\u00f5es, podendo ser utilizado como ferramenta guia para inje\u00e7\u00e3o de cianoacrilato, permitindo a inje\u00e7\u00e3o intravasal precisa da subst\u00e2ncia, bem como o controle da oblitera\u00e7\u00e3o do vaso ap\u00f3s a terapia3<\/sup>.<\/p>\n

O uso de outras t\u00e9cnicas tamb\u00e9m se tornaram poss\u00edveis com a implementa\u00e7\u00e3o do EUS no tratamento de varizes g\u00e1stricas, e uma delas foi a aplica\u00e7\u00e3o de molas (coils) intravasais, que fariam o mesmo papel do cianoacrilato, promovendo a trombose e oblitera\u00e7\u00e3o da variz, podendo ser aplicada isoladamente ou em combina\u00e7\u00e3o com a cola, diminuindo teoricamente assim o seu risco de embolia5<\/sup>.<\/p>\n

Em 2000, um estudo publicado comparando a inje\u00e7\u00e3o de cianoacrilato por endoscopia convencional \u201csob-demanda\u201d (no sangramento) em compara\u00e7\u00e3o com a inje\u00e7\u00e3o pela mesma t\u00e9cnica mas com controle do tratamento por EUS at\u00e9 oblitera\u00e7\u00e3o completa da variz mostrou menores taxas de ressangramento no grupo controlado por EUS6<\/sup>.<\/p>\n

De 2007 a 2015 v\u00e1rias s\u00e9ries de casos foram publicadas na literatura internacional, utilizando o EUS como m\u00e9todo de tratamento para varizes g\u00e1stricas, e como terap\u00eautica o cianoacrilato, a mola ou a combina\u00e7\u00e3o destes m\u00e9todos. Todos estes estudos mostram baixas taxas de ressangramento e complica\u00e7\u00f5es6-12<\/sup>, sendo a maior s\u00e9rie publicada por Bhat et al em 2016, com 152 casos tratados por EUS e inje\u00e7\u00e3o de cola + mola, obtendo uma taxa de oblitera\u00e7\u00e3o de 93%, com ressangramento em 16%, apresentando 7 casos de complica\u00e7\u00f5es, sendo apenas 1 de embolia12<\/sup>.<\/span><\/p>\n

Apesar de bons resultados em series de casos, a utiliza\u00e7\u00e3o do EUS como terapia na oblitera\u00e7\u00e3o de varizes g\u00e1stricas carece de estudos randomizados, que possam comparar a efic\u00e1cia deste m\u00e9todo em compara\u00e7\u00e3o com a terap\u00eautica endosc\u00f3pica convencional, pois apesar dos seus benef\u00edcios atualmente apresentados, o m\u00e9todo aumenta consideravelmente os custos do procedimento. <\/span><\/p>\n

Assim, ap\u00f3s an\u00e1lise da literatura atual, concluimos que o tratamento de varizes g\u00e1stricas de fundo guiado por EUS pode ser uma op\u00e7\u00e3o na falha terap\u00eautica do tratamento convencional, apresentando efic\u00e1cia semelhante e menores taxas de complica\u00e7\u00f5es de acordo com a literatura dispon\u00edvel (grau de evid\u00eancia C).<\/span><\/p>\n

Refer\u00eancias.<\/p>\n

    \n
  1. Sarin SK, Lahoti D, Saxena SP, et al. Prevalence, classification and natural history of gastric varices: long term follow-up studyin 568 patients with portal hypertension. Hepatology 1992; 16:1343-9.<\/li>\n
  2. Ashwani K, Narayan D, Arun JS. Endoscopic diagnosis and therapy in gastro-esophageal variceal bleeding. Gastrointest Endosc Clin N Am 2015; 25(3): 491-507.<\/li>\n
  3. Girotra M, Raghavapuram S, Abraham S, et al. Management of gastric varicela bleeding: Role of endoscopy and endoscopic ultrasound. World J Hepatol 2014; 6(3): 130-136.<\/li>\n
  4. Mishra SR,Sharma BC, Kumar A, et al. Primary prophylaxis of gastric variceal bleeding comparing cyanoacrylate injection and beta-blockers: a randomized controlled trial. J Hepatol. 2011 Jun;54(6):1161-7.<\/li>\n
  5. Romero-Castro R,Pellicer-Bautista F, Giovannini M, et al. Endoscopic ultrasound (EUS)-guided coil embolization therapy in gastric varices.  2010;42 Suppl 2:E35-6.<\/li>\n
  6. Lee YT,Chan FK, Ng EK,et al EUS-guided injection of cyanoacrylate for bleeding gastric varices. Gastrointest Endosc. 2000 Aug;52(2):168-74.<\/li>\n
  7. Romero-Castro R, Pellicer-Bautista FJ, Jimenez-Saenz M et al. EUS-guided injection of cyanoacrylate in perforating feeding veins in gastric varices: Results in 5 cases. Endosc. 2007; 66: 402\u20137.<\/li>\n
  8. Romero-Castro R, Pellicer-Bautista F, Giovannini M et al. Endoscopic ultrasound (EUS)-guided coil embolization therapy in gastric varices. Endoscopy 2010; 42: E35\u20136.<\/li>\n
  9. Binmoeller KF, Weilert F, Shah JN, et al. EUS-guided transesophageal treatment of gastric fundal varices with combined coiling and cyanoacrylate glue injection. Gastrointest. Endosc. 2011; 74: 1019\u201325.<\/li>\n
  10. Romero-Castro R, Ellrichmann M, Ortiz-Maoyano C et al. EUS-guided coil versus cyanoacrylate therapy for the treatment of gastric varices: A multicenter study. Gastrointest. Endosc. 2013; 78: 711\u201321.<\/li>\n
  11. Sanchez-Yague A, Shah JN, Nguyen-Tag T et al. EUS-guided coil embolization of gastric varices after unsuccessful endoscopic glue injection. Gastrointest. Endosc. 2009; 69: A\u20136.<\/li>\n
  12. Bhat YM, Weilert F, Fredrick RT, et al. <\/sup>EUS-guided treatment of gastric fundal varices with combined injection of coils and cyanoacrylate glue: a large U.S. experience over 6 years. Gastrointest Endosc. 2016 Jun;83(6):1164-72.<\/li>\n<\/ol>\n

     <\/p>\n

    Postado por: <\/strong><\/p>\n

    Frank Shigueo Nakao<\/strong><\/p>\n

    Mestrado pela UNIFESP\/EPM.<\/p>\n

    M\u00e9dico endoscopista do Hospital Universit\u00e1rio da UNIFESP\/EPM, e do Fleury Medicina e Sa\u00fade.<\/p>\n

    Daniel de Alencar Macedo Dutra<\/strong><\/p>\n

    Membro titular da FBG e da SOBED<\/p>\n

    M\u00e9dico endoscopista do Hospital Universit\u00e1rio da UFPI.<\/p>\n

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

    Varizes g\u00e1stricas secund\u00e1rias a hipertens\u00e3o portal s\u00e3o uma complica\u00e7\u00e3o da cirrose hep\u00e1tica. Apesar de…<\/p>\n","protected":false},"author":5709,"featured_media":5136,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_lmt_disableupdate":"","_lmt_disable":"","footnotes":""},"categories":[151],"tags":[],"ano":[281],"tipo":[154,153],"volume":[147],"class_list":["post-4391","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-assuntosgerais","ano-281","tipo-ecoendoscopia","tipo-endoscopia-digestiva-alta","volume-volume-ii"],"yoast_head":"\nCompara\u00e7\u00e3o do tratamento endosc\u00f3pico versus ecoendosc\u00f3pico para oblitera\u00e7\u00e3o de varizes g\u00e1stricas • 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\/comparacao-do-tratamento-endoscopico-vesus-ecoendoscopico-para-obliteracao-de-varizes-gastricas\/\" \/>\n<meta property=\"og:locale\" content=\"pt_BR\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Compara\u00e7\u00e3o do tratamento endosc\u00f3pico versus ecoendosc\u00f3pico para oblitera\u00e7\u00e3o de varizes g\u00e1stricas\" \/>\n<meta property=\"og:description\" content=\"Varizes g\u00e1stricas secund\u00e1rias a hipertens\u00e3o portal s\u00e3o uma complica\u00e7\u00e3o da cirrose hep\u00e1tica. 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