{"id":4491,"date":"2017-09-04T09:00:16","date_gmt":"2017-09-04T09:00:16","guid":{"rendered":"https:\/\/endoscopiaterapeutica.net\/pt\/uncategorized\/cpre-em-bypass-gastrico\/"},"modified":"2023-03-13T16:56:35","modified_gmt":"2023-03-13T16:56:35","slug":"cpre-em-bypass-gastrico","status":"publish","type":"post","link":"https:\/\/endoscopiaterapeutica.net\/pt\/assuntosgerais\/cpre-em-bypass-gastrico\/","title":{"rendered":"CPRE em pacientes submetidos a Bypass G\u00e1strico"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-post\" data-elementor-id=\"4491\" class=\"elementor elementor-4491\">\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-392e877 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"392e877\" 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-4401d981\" data-id=\"4401d981\" 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-7c27ff73 elementor-widget elementor-widget-text-editor\" data-id=\"7c27ff73\" 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\t&nbsp;\n\n\u00c9 sabido que a obesidade \u00e9 um grave problema de sa\u00fade p\u00fablica e que a cirurgia bari\u00e1trica constitui arma poderosa no arsenal terap\u00eautico contra essa enfermidade. Sabe-se, tamb\u00e9m, que a r\u00e1pida perda de peso relacionada ao BYPASS G\u00c1STRICO EM Y DE ROUX (BGYR) \u00e9 fator de risco para colelit\u00edase e suas complica\u00e7\u00f5es como coledocolit\u00edase e pancreatite biliar. Sendo assim, a colecistectomia e a colangiopancreatografia retr\u00f3grada endosc\u00f3pica (CPRE) s\u00e3o frequentemente indicadas neste grupo de pacientes.\n\nEntretanto, o acesso \u00e0 via biliar ap\u00f3s BGYR constitui um desafio para o endoscopista, visto que este acesso somente \u00e9 obtido via enteroscopia ou via est\u00f4mago excluso, atrav\u00e9s de confec\u00e7\u00e3o de gastrotomia para introdu\u00e7\u00e3o do duodenosc\u00f3pio.\n\n&nbsp;\n<h5>T\u00e9cnicas endosc\u00f3picas para acesso \u00e0 papila:<\/h5>\n<strong>1. CPRE via enteroscopia:\u00a0<\/strong>\u00a0a CPRE por enteroscopia \u00e9\u00a0\u00a0bem descrita mas parece estar associada a resultados modestos. Entre as limita\u00e7\u00f5es, pode-se citar a dificuldade de canula\u00e7\u00e3o pela vis\u00e3o tangencial da papila, instabilidade do aparelho, aus\u00eancia de elevador, dificuldade de utiliza\u00e7\u00e3o dos acess\u00f3rios devido ao pequeno di\u00e2metro do canal de trabalho e o trajeto tortuoso que o aparelho pode fazer.\n\nKuga et al publicaram em 2008 uma s\u00e9rie de 6 casos de pacientes com anatomia em Y de Roux e submetidos a CPRE em que foi obtido um \u00edndice de sucesso em 83,3%<sup>1<\/sup>.\n\nA dificuldade de disponibilidade de materiais \u00e9 o grande limitante desta op\u00e7\u00e3o. Uma alternativa publicada pelo grupo do ICESP <sup>5<\/sup> consiste no uso da enteroscopia para acessar a papila; retirada do enterosc\u00f3pio; sec\u00e7\u00e3o do overtube (tomando-se cuidade de clampear o canal de ar com um <em>Kelly<\/em>) e inser\u00e7\u00e3o de um gastrosc\u00f3pio,\u00a0cujo canal de trabalho comporta a maioria dos acess\u00f3rios de CPRE.\n\n<strong>2. CPRE- transg\u00e1strica (CPRE-TG):<\/strong> realizada introduzindo-se o duodenosc\u00f3pio atrav\u00e9s de uma gastrotomia no est\u00f4mago excluso, tem se mostrado uma alternativa vi\u00e1vel e, aparentemente, com bons \u00edndices de sucesso. Existem duas possibilidades\u00a0t\u00e9cnicas para acesso ao est\u00f4mago excluso (ambas com aux\u00edlio da laparoscopia):\n<ol>\n \t<li>Realiza\u00e7\u00e3o de gastrotomia na parede anterior do est\u00f4mago excluso\u00a0e coloca\u00e7\u00e3o de um trocater de 15 a 18 mm no quadrante superior esquerdo, por onde passar\u00e1 o duodenosc\u00f3pio. Geralmente o trocater permanece no est\u00f4mago em dire\u00e7\u00e3o a grande curvatura o que permite direcionar o aparelho para o piloro. A convers\u00e3o para cirurgia aberta raramente \u00e9 realizada <sup>2\u00a0<\/sup>;<\/li>\n \t<li>Matura\u00e7\u00e3o tempor\u00e1ria\u00a0de um gastrostoma na pele, com acesso direto do duodenosc\u00f3pio (sem aux\u00edlo de trocarter);<\/li>\n<\/ol>\n<p style=\"text-align: center;\">.<\/p>\n<p style=\"text-align: center;\"><strong>Veja no v\u00eddeo a seguir\u00a0um exemplo de CPRE-TG para tratamento de coledocolit\u00edase:<\/strong><\/p>\n<div style=\"position:relative;padding-top:56.25%;\"><iframe id=\"panda-c0d879aa-33bb-4ff3-83f5-c361263ca514\" src=\"https:\/\/player-vz-a75e9d45-986.tv.pandavideo.com.br\/embed\/?v=c0d879aa-33bb-4ff3-83f5-c361263ca514\" 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\n\n<h5>Revis\u00e3o da literatura<\/h5>\nUma revis\u00e3o sistem\u00e1tica publicada em 2017 analisou 26 estudos, que compilaram 509 CPRE-TG, publicados entre 2007 e 2016 <sup>2<\/sup>;\n<ul>\n \t<li>6 estudos foram prospectivos e 20 foram retrospectivos. N\u00e3o houve estudo controlado e randomizado.<\/li>\n \t<li>Taxa de sucesso em CPRE-TG foi maior que 95%, o que \u00e9 comparado com CPRE em anatomia padr\u00e3o e superior aos 60-70% alcan\u00e7ados com CPRE via enteroscopia.<\/li>\n \t<li>Taxa de complica\u00e7\u00f5es de 14%, a maioria considerada leve e tratada de forma conservadora, como infec\u00e7\u00e3o e sangramento do s\u00edtio da gastrotomia, por\u00e9m houve complica\u00e7\u00f5es mais graves relacionadas \u00e0 pr\u00f3pria t\u00e9cnica como pneumot\u00f3rax hipertensivo, perfura\u00e7\u00f5es que necessitaram de tratamento cir\u00fargico e h\u00e9rnias incisionais. Com rela\u00e7\u00e3o a CPRE propriamente, a principal complica\u00e7\u00e3o \u00e9 pancreatite p\u00f3s-CPRE, seguida de perfura\u00e7\u00e3o e sangramento.<\/li>\n<\/ul>\n&nbsp;\n\nUm estudo retrospectivo, com 85 CPRE-TG realizadas entre 2004 e 2014, observou uma taxa de complica\u00e7\u00e3o de 19%, sendo 88% relacionados \u00e0 via de acesso e n\u00e3o \u00e0 CPRE propriamente, a maioria leve. N\u00e3o houve mortes ou pancreatite grave. Interven\u00e7\u00f5es adicionais, incluindo reparo por lacera\u00e7\u00e3o na parede posterior do est\u00f4mago e transfus\u00e3o sangu\u00ednea ocorreram em 4,7% dos casos. Outras complica\u00e7\u00f5es que necessitaram de abordagem cir\u00fargica foram perfura\u00e7\u00e3o duodenal e drenagem de abscesso de parede abdominal<sup>3<\/sup>.\n\nNo Brasil, Falc\u00e3o et al publicaram estudo com 20 pacientes submetidos a CPRE transg\u00e1strica laparosc\u00f3pica , com sucesso na papilotomia em todos os casos, sem intercorr\u00eancias maiores<sup>4<\/sup>.\n\n<div id=\"attachment_8246\" style=\"width: 650px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2021\/08\/CPRE-por-enteroscopia.jpg\" data-rel=\"penci-gallery-image-content\" ><img fetchpriority=\"high\" decoding=\"async\" aria-describedby=\"caption-attachment-8246\" class=\"wp-image-8246 size-full\" src=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2021\/08\/CPRE-por-enteroscopia.jpg\" alt=\"\" width=\"640\" height=\"546\" \/><\/a><p id=\"caption-attachment-8246\" class=\"wp-caption-text\">CPRE por enteroscopia: A) identifica\u00e7\u00e3o da papila duodenal maior (seta); B) radioscopia; C) dilata\u00e7\u00e3o abalonada da papila; D) retirada do c\u00e1lculo<\/p><\/div>\n\n<div id=\"attachment_8247\" style=\"width: 650px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2021\/08\/CPRE-TG-trocarter.png\" data-rel=\"penci-gallery-image-content\" ><img decoding=\"async\" aria-describedby=\"caption-attachment-8247\" class=\"wp-image-8247 size-full\" src=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2021\/08\/CPRE-TG-trocarter.png\" alt=\"\" width=\"640\" height=\"183\" \/><\/a><p id=\"caption-attachment-8247\" class=\"wp-caption-text\">CPRE-TG assistida por trocarter<\/p><\/div>\n<h5>Conclus\u00e3o<\/h5>\nPortanto, a CPRE-TG parece ser um m\u00e9todo seguro e altamente efetivo na abordagem dos pacientes com BGYR, sendo imprescind\u00edvel uma \u00f3tima intera\u00e7\u00e3o entre as equipes cir\u00fargica e endosc\u00f3pica.\n\nA CPRE via enteroscopia, embora com resultados mais modestos, pode ser favorecida quando uma interven\u00e7\u00e3o de urg\u00eancia \u00e9 indicada (em al\u00e7as n\u00e3o t\u00e3o longas).\n\n&nbsp;\n<h6><strong>Refer\u00eancias:<\/strong><\/h6>\n<ol>\n \t<li>Kuga R., Furuya Jr. C.K., Hondo F.Y., Ide E., Ishioka S., Sakai P. ERCP Using Double-Balloon Enteroscopy in Patients with Roux-en-Y Anatomy. Dig Dis 2008; 26(4): 330-5.<\/li>\n \t<li>Banerjee N., Parepally M., Byrne T.K., PullatT R.C., Cot\u00e9 G.A., Elmunzer B.J. Systematic review of transgastric ERCP in Roux-en-Y Bypass Transgastric patients. Surg Oes Relat Dis 2017; 13(7): 1236-1242.<\/li>\n \t<li>Grimes K.L, Maciel V.H, Mata W., Arevalo G., Singh K., Arregui M.E. Complications of Laparoscopic Transgastric ERCP in patients with Roux-en-Y Gastric Bypass. Surg Endosc 2015; 29 (7): 1743-9.<\/li>\n \t<li>Falcao M., Campos J.M., Galvao-Neto M., Ramos A., Secchi T., Alves E., Franca E., Maluf-Filho, Ferraz A. Transgastric Endoscopic Retrograde Cholangiopancreatography for the Management of Biliary Tract Disease after Roux-en-Y Gastric Bypass Treatment of Obesity. Obes Surg 2012; 22 (6): 872-876.<\/li>\n \t<li>Franco MC, Safatle-Ribeiro AV, Gusmon CC, Ribeiro MS, Maluf-Filho F. ERCP with balloon-overtube-assisted enteroscopy in postsurgical anatomy. Gastrointest Endosc. 2016 Feb;83(2):462-3.<\/li>\n<\/ol>\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>&nbsp; \u00c9 sabido que a obesidade \u00e9 um grave problema de sa\u00fade p\u00fablica e&hellip;<\/p>\n","protected":false},"author":3179,"featured_media":8434,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_lmt_disableupdate":"","_lmt_disable":"","footnotes":""},"categories":[151],"tags":[],"ano":[276],"tipo":[155,157],"volume":[147],"class_list":["post-4491","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-assuntosgerais","ano-276","tipo-cpre","tipo-intestino-delgado","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\/ 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