{"id":4544,"date":"2018-04-09T09:00:00","date_gmt":"2018-04-09T09:00:00","guid":{"rendered":"https:\/\/endoscopiaterapeutica.net\/pt\/uncategorized\/estenose-biliar-transplante-hepatico\/"},"modified":"2022-06-17T14:26:28","modified_gmt":"2022-06-17T14:26:28","slug":"estenose-biliar-pos-transplante-hepatico","status":"publish","type":"post","link":"https:\/\/endoscopiaterapeutica.net\/pt\/assuntosgerais\/estenose-biliar-pos-transplante-hepatico\/","title":{"rendered":"Estenose biliar p\u00f3s transplante hep\u00e1tico"},"content":{"rendered":"

 <\/em><\/strong> <\/em><\/p>\n

As complica\u00e7\u00f5es biliares p\u00f3s-transplante hep\u00e1tico podem ocorrer em 6-40% dos pacientes, sendo mais frequentes ap\u00f3s o transplante intervivos.<\/p>\n

Elas podem ser precoces<\/strong>, ocorrendo nas primeiras 4 a 6 semanas (f\u00edstulas, biloma, estenoses  e deisc\u00eancia por necrose da anastomose biliar); ou tardias<\/strong> (f\u00edstulas, estenoses, colangite, coledocolit\u00edase, c\u00e1lculos, cast syndrome,<\/em> disfun\u00e7\u00e3o do esf\u00edncter de Oddi, mucocele, doen\u00e7a biliar recidivante).<\/p>\n

As estenoses biliares p\u00f3s-transplante hep\u00e1tico<\/strong> podem ainda ser classificadas em anastom\u00f3ticas<\/strong> (Figura 1<\/strong>) e n\u00e3o anastom\u00f3ticas<\/strong> (Figura 2<\/strong>). Suas caracter\u00edsticas est\u00e3o descritas na Tabela 1.<\/p>\n

\"\"<\/a>

Figura 1 – Aspecto colangiogr\u00e1fico de estenose anastom\u00f3tica ap\u00f3s transplante hep\u00e1tico de doador cad\u00e1ver.<\/p><\/div>\n

\"\"<\/a>

Figura 2 – Aspecto fluorosc\u00f3pico de estenose n\u00e3o anastom\u00f3tica (doador cad\u00e1ver), acometendo o hilo hep\u00e1tico, associada \u00e0 f\u00edstula biliar<\/p><\/div>\n

\"\"<\/a> \"\"<\/a><\/em><\/strong><\/p>\n

Tabela 1: <\/em><\/strong>Caracter\u00edsticas das estenoses biliares anastom\u00f3ticas e n\u00e3o anastom\u00f3ticas p\u00f3s transplante hep\u00e1tico.<\/em><\/p>\n

\n\n\n\n\n\n\n\n\n\n\n\n
<\/td>\nEstenoses anastom\u00f3ticas<\/em><\/strong><\/td>\nEstenoses n\u00e3o anastom\u00f3ticas <\/em><\/strong><\/td>\n<\/tr>\n
Incid\u00eancia<\/p>\n

 <\/td>\n

Doador cad\u00e1ver: 5 – 15%<\/p>\n

Intervivos (Figura 3<\/strong>): 19 – 40%<\/td>\n

5 -15%<\/td>\n<\/tr>\n
Caracter\u00edstica<\/td>\nIsoladas<\/p>\n

Curtas em extens\u00e3o<\/td>\n

M\u00faltiplas, longas<\/p>\n

Ductos intra-hep\u00e1ticos<\/p>\n

Ducto do doador<\/td>\n<\/tr>\n

Apresenta\u00e7\u00e3o<\/td>\n1o<\/sup> ano ap\u00f3s transplante<\/p>\n

(5 a 8 meses)<\/td>\n

Etiologia isqu\u00eamica: 3-6 meses<\/p>\n

Etiologia imunol\u00f3gica: > 1 ano<\/td>\n<\/tr>\n

Fatores de risco<\/td>\nQuest\u00f5es t\u00e9cnicas<\/p>\n

 <\/p>\n

F\u00edstula biliar<\/td>\n

Les\u00f5es isqu\u00eamicas: trombose da art\u00e9ria hep\u00e1tica, parada card\u00edaca, isquemia (quente ou fria), condi\u00e7\u00f5es de preserva\u00e7\u00e3o ou les\u00e3o de reperfus\u00e3o<\/p>\n

 <\/p>\n

Les\u00f5es imunol\u00f3gicas: rejei\u00e7\u00e3o ductop\u00eanica, incompatibilidade ABO, polimorfismo de genes, doen\u00e7as imunomediadas pr\u00e9-existentes no receptor<\/p>\n

 <\/p>\n

Outros: infec\u00e7\u00e3o CMV e recidiva viral (HBV ou HCV)<\/td>\n<\/tr>\n

Quadro cl\u00ednico<\/td>\nAssintom\u00e1ticos (altera\u00e7\u00f5es laboratoriais)<\/p>\n

 <\/p>\n

Sintomas inespec\u00edficos: prurido, anorexia, icter\u00edcia e febre<\/p>\n

 <\/p>\n

Dor ausente (imunossupress\u00e3o e denerva\u00e7\u00e3o hep\u00e1tica)<\/td>\n

Assintom\u00e1ticos (altera\u00e7\u00f5es laboratoriais)<\/p>\n

 <\/p>\n

Sintomas inespec\u00edficos: prurido, anorexia, icter\u00edcia e febre<\/p>\n

 <\/p>\n

Dor ausente<\/p>\n

 <\/p>\n

Maior ac\u00famulo de barro biliar: epis\u00f3dios recorrentes de colangite e forma\u00e7\u00e3o de casts*<\/em><\/td>\n<\/tr>\n

Diagn\u00f3stico<\/td>\nExames laboratoriais: AST, ALT, bilirrubinas, FAL e  \u03b4GT<\/td>\nExames laboratoriais: AST, ALT, bilirrubinas, FAL e  \u03b4GT<\/td>\n<\/tr>\n
<\/td>\nUSG abdominal com Doppler: exame inicial (sensibilidade 38 a 66%)<\/td>\nUSG abdominal com Doppler: exame inicial (sensibilidade 38 a 66%)<\/td>\n<\/tr>\n
<\/td>\nCPRM: acur\u00e1cia de 95%<\/td>\nCPRM: acur\u00e1cia de 95%<\/p>\n

Aspecto radiol\u00f3gico remete \u00e0 colangite esclerosante prim\u00e1ria devido \u00e0 presen\u00e7a de estenoses m\u00faltiplas e extensas<\/td>\n<\/tr>\n

Bi\u00f3psia hep\u00e1tica<\/td>\nExcluir rejei\u00e7\u00e3o se altera\u00e7\u00f5es dos exames de bioqu\u00edmica, sem dilata\u00e7\u00e3o comprovada da via biliar<\/td>\n<\/tr>\n<\/tbody>\n<\/table><\/div>\n

* casts: descama\u00e7\u00e3o epitelial em molde, CPRM: colangiopancreato resson\u00e2ncia magn\u00e9tica<\/em><\/p>\n

 <\/em><\/strong><\/p>\n

\"\"<\/a>

Figura 3 – Paciente transplantado hep\u00e1tico (doador vivo), com estenose complexa, anastom\u00f3tica e n\u00e3o anastom\u00f3tica, com les\u00f5es acometendo difusamente a via biliar intra-hep\u00e1tica.<\/p><\/div>\n

 <\/p>\n

A estenose biliar tamb\u00e9m \u00e9 descrita no doador vivo, com incid\u00eancia de 0,4% e 6%. \u00c9 mais frequente quando o lobo hep\u00e1tico direito \u00e9 utilizado. Os fatores de risco incluem a f\u00edstula biliar, idade avan\u00e7ada e o calibre do ducto biliar (< 4 mm). O quadro cl\u00ednico \u00e9 inespec\u00edfico, podendo haver colestase.<\/p>\n

 <\/p>\n

TRATAMENTO<\/em><\/strong><\/h5>\n

Na \u00faltima d\u00e9cada, medidas n\u00e3o operat\u00f3rias se tornaram a op\u00e7\u00e3o terap\u00eautica de primeira linha para as complica\u00e7\u00f5es biliares p\u00f3s transplante hep\u00e1tico. Nos pacientes com anastomose ducto-ducto a colangiografia retr\u00f3grada endosc\u00f3pica (CRE) \u00e9 a escolha inicial.<\/p>\n

O tratamento endosc\u00f3pico pode ser realizado por meio da dilata\u00e7\u00e3o com bal\u00e3o hidrost\u00e1tico ou dilatadores de passagem, seguida da coloca\u00e7\u00e3o de uma ou mais pr\u00f3teses pl\u00e1sticas, ou ainda, mais recentemente, da pr\u00f3tese met\u00e1lica autoexpans\u00edvel totalmente coberta (PMAEC). Na presen\u00e7a de les\u00f5es da art\u00e9ria hep\u00e1tica (insufici\u00eancia ou obstru\u00e7\u00e3o), estas devem ser abordadas durante o curso do tratamento.<\/p>\n

A terap\u00eautica com pr\u00f3teses pl\u00e1sticas m\u00faltiplas<\/strong> consiste na dilata\u00e7\u00e3o hidrost\u00e1tica da estenose seguida da coloca\u00e7\u00e3o do maior n\u00famero de pr\u00f3teses pl\u00e1sticas poss\u00edvel. Os pacientes devem ser submetidos \u00e0 sess\u00f5es repetidas, no prazo m\u00e9dio de tr\u00eas meses, para preven\u00e7\u00e3o da oclus\u00e3o, colangite e forma\u00e7\u00e3o de c\u00e1lculos. Todas as pr\u00f3teses devem ser retiradas, a estenose deve ser dilatada e um n\u00famero progressivamente maior de pr\u00f3teses (Figura 4A e B<\/strong>) deve ser utilizado a cada troca, com objetivo de alcan\u00e7ar o maior di\u00e2metro poss\u00edvel. O tratamento \u00e9 completado em um ano e a maioria dos pacientes deve precisar de quatro a cinco procedimentos nesse per\u00edodo.<\/p>\n

A terapia com pr\u00f3tese met\u00e1lica totalmente coberta<\/strong> consiste na coloca\u00e7\u00e3o de uma \u00fanica PMAEC (Figura 5<\/strong>) ap\u00f3s esfincterotomia biliar, sem necessidade de dilata\u00e7\u00e3o na maioria das vezes. O tempo de perman\u00eancia ideal da pr\u00f3tese met\u00e1lica ainda n\u00e3o est\u00e1 completamente definido. Os resultados do tratamento s\u00e3o favor\u00e1veis quando ela \u00e9 mantida por per\u00edodo superior \u00e0 3 meses, n\u00e3o havendo comprova\u00e7\u00e3o \u00e0 respeito do benef\u00edcio da sua perman\u00eancia por mais de 6 meses.<\/p>\n

\"\"<\/a>

Figura 4 – Aspecto radiol\u00f3gico (A) e endosc\u00f3pico (B) da estenose anastom\u00f3tica (doador cad\u00e1ver) tratada com dilata\u00e7\u00e3o hidrost\u00e1tica e coloca\u00e7\u00e3o de pr\u00f3teses pl\u00e1sticas m\u00faltiplas.<\/p><\/div>\n

\"\"<\/a>

Figura 5 – Aspecto colangiogr\u00e1fico da PMAE totalmente coberta liberada evidenciando discreta compress\u00e3o (seta), que corresponde ao ponto da estenose anastom\u00f3tica.<\/p><\/div>\n

 <\/p>\n

Tabela 2:<\/em><\/strong> Compara\u00e7\u00e3o do tratamento com pr\u00f3teses pl\u00e1sticas m\u00faltiplas e pr\u00f3tese met\u00e1lica auto-expans\u00edvel totalmente coberta no tratamento das estenoses biliares p\u00f3s transplante hep\u00e1tico.<\/em><\/p>\n

\n\n\n\n\n\n\n\n\n\n\n
 <\/strong><\/td>\nPr\u00f3teses pl\u00e1sticas m\u00faltiplas <\/em><\/strong><\/td>\nPMAEC<\/em><\/strong><\/td>\n<\/tr>\n
Tempo de tratamento<\/td>\n12 meses<\/td>\n\u00b1 6 meses<\/td>\n<\/tr>\n
N\u00famero de procedimentos<\/td>\n4 a 5<\/td>\n2<\/td>\n<\/tr>\n
Taxa de sucesso<\/p>\n

Estenose anastom\u00f3tica<\/em><\/p>\n

 <\/p>\n

 <\/td>\n

Doador cad\u00e1ver: 82 a 98%<\/p>\n

 <\/p>\n

Doador vivo: 60 a 75%<\/p>\n

 <\/td>\n

87,5 a 100%<\/td>\n<\/tr>\n
Taxa de sucesso<\/p>\n

Estenose n\u00e3o anastom\u00f3tica<\/em><\/p>\n

 <\/td>\n

Doador cad\u00e1ver: 50 a 75%<\/p>\n

 <\/p>\n

Doador vivo: 25 a 33%<\/p>\n

 <\/td>\n

N\u00e3o est\u00e1 indicada.<\/td>\n<\/tr>\n
Taxa de complica\u00e7\u00f5es<\/td>\n4 a 16%<\/td>\n14,5 a 18%<\/td>\n<\/tr>\n
Migra\u00e7\u00e3o<\/td>\n5 a 33,3%<\/td>\n4 a 46,7%<\/td>\n<\/tr>\n
Recidiva<\/td>\n0 a 34%<\/td>\n4,5 47,4%<\/td>\n<\/tr>\n
Custo (6)<\/sup><\/td>\nUS$ 16.095<\/td>\nUS$ 6.903<\/td>\n<\/tr>\n<\/tbody>\n<\/table><\/div>\n

PMAEC: pr\u00f3tese met\u00e1lica auto-expans\u00edvel totalmente coberta<\/em><\/p>\n

 <\/p>\n

Nos pacientes com estenose grave da anastomose direta ducto-ducto e falha no acesso profundo retr\u00f3grado \u00e0 via biliar \u00e9 poss\u00edvel a realiza\u00e7\u00e3o do procedimento combinado, com pun\u00e7\u00e3o biliar percut\u00e2nea ou guiada por EUS, seguida da terapia endosc\u00f3pica rendez-vous<\/em>. A colangioscopia direta tamb\u00e9m \u00e9 uma ferramenta dispon\u00edvel para a transposi\u00e7\u00e3o da estenose em caso de insucesso, com custo inferior ao das duas op\u00e7\u00f5es citadas anteriormente (Figura 6<\/strong>).<\/p>\n

O tratamento cir\u00fargico fica reservado para os casos de insucesso da interven\u00e7\u00e3o endosc\u00f3pica ou radiol\u00f3gica e consiste na convers\u00e3o da reconstru\u00e7\u00e3o para deriva\u00e7\u00e3o biliar ou em casos extremos, o re-transplante.<\/p>\n

\"\"<\/a>

Figura 6 – Aspecto colangiosc\u00f3pico da passagem do fio guia pelo orif\u00edcio da estenose da anastomose biliar.<\/p><\/div>\n

 <\/p>\n

Refer\u00eancias Bibliogr\u00e1ficas<\/strong><\/p>\n

    \n
  1. Costamagna G, Tringali A, Mutignani M, Perri V, Spada C, Pandolfi M et al. Endotherapy of postoperative biliary strictures with multiple stents: results after more than 10 years of follow-up. Gastrointest Endosc. 2010;72:551-557.10.1016\/j.gie.2010.04.052.20630514.<\/li>\n
  2. Akamatsu N, Sugawara Y, Hashimoto D. Biliary reconstruction, its complications and management of biliary complications after adult liver transplantation: a systematic review of the incidence, risk factors and outcome. Transpl Int. 2011;24:379-392.10.1111\/j.1432-2277.2010.01202.x.21143651.<\/li>\n
  3. Chaput U, Vienne A, Audureau E, Bauret P, Bichard P, Coumaros D et al. Temporary placement of fully covered self-expandable metal stents for the treatment of benign biliary strictures. United European Gastroenterol J. 2016;4:403-412.10.1177\/2050640615606550.27403307.<\/li>\n
  4. Cot\u00e9 GA, Slivka A, Tarnasky P, Mullady DK, Elmunzer BJ, Elta G et al. Effect of Covered Metallic Stents Compared With Plastic Stents on Benign Biliary Stricture Resolution: A Randomized Clinical Trial. JAMA. 2016;315:1250-1257.10.1001\/jama.2016.2619.27002446.<\/li>\n
  5. Martins FP, Ferrari AP. Cholangioscopy-assisted guidewire placement in post-liver transplant anastomotic biliary stricture. Endoscopy 2018;49:E283-E284. 10.1055\/s-0043-117940<\/li>\n
  6. Martins FP, De Paulo GA, Contini MLC, Ferrari AP. Metal versus plastic stents for anastomotic biliary strictures after liver transplantation: a randomized controlled trial. Gastrointest Endosc. 2018;87:131e1-131e13. 10.1016\/j.gie.2017.04.013.<\/li>\n<\/ol>\n
    …………………………………………………………………………………………………………..<\/h6>\n
    Como citar esse artigo:<\/strong><\/h6>\n

    Martins FP. Estenose biliar p\u00f3s transplante hep\u00e1tico. Endoscopia Terap\u00eautica; 2018. Dispon\u00edvel em: https:\/\/endoscopiaterapeutica.net\/pt\/assuntosgerais\/estenose-biliar-transplante-hepatico<\/span>\/<\/span> \u200e<\/em><\/p>\n

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

       As complica\u00e7\u00f5es biliares p\u00f3s-transplante hep\u00e1tico podem ocorrer em 6-40% dos pacientes, sendo mais…<\/p>\n","protected":false},"author":1805,"featured_media":5215,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_lmt_disableupdate":"","_lmt_disable":"","footnotes":""},"categories":[151],"tags":[],"ano":[270],"tipo":[155],"volume":[263],"class_list":["post-4544","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-assuntosgerais","ano-270","tipo-cpre","volume-volume-i"],"yoast_head":"\nEstenose biliar p\u00f3s transplante hep\u00e1tico • 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\/estenose-biliar-pos-transplante-hepatico\/\" \/>\n<meta property=\"og:locale\" content=\"pt_BR\" 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