{"id":4698,"date":"2020-02-10T09:30:06","date_gmt":"2020-02-10T09:30:06","guid":{"rendered":"https:\/\/endoscopiaterapeutica.net\/pt\/uncategorized\/estenoses-benignas-do-colon\/"},"modified":"2023-12-03T22:50:33","modified_gmt":"2023-12-03T22:50:33","slug":"estenoses-benignas-do-colon","status":"publish","type":"post","link":"https:\/\/endoscopiaterapeutica.net\/pt\/assuntosgerais\/estenoses-benignas-do-colon\/","title":{"rendered":"Estenoses benignas do c\u00f3lon"},"content":{"rendered":"\n

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

Estenoses c\u00f3licas benignas n\u00e3o s\u00e3o t\u00e3o raras em nossa pr\u00e1tica cl\u00ednica. A maioria dos casos \u00e9 devido a anastomose colorretal, mas tamb\u00e9m pode ser secund\u00e1ria a doen\u00e7a de Crohn, doen\u00e7a diverticular, ou mesmo ap\u00f3s ressec\u00e7\u00f5es endosc\u00f3picas extensas.<\/p>\n\n\n\n

Etiologia<\/strong><\/h2>\n\n\n\n

Anastomose colorretal: <\/em><\/strong>principal causa de estenose benigna, podendo ocorrer em 3,6% a 22% dos casos1<\/sup> . Os fatores de risco mais comuns s\u00e3o obesidade, anastomoses baixas, diverticulite, infec\u00e7\u00e3o p\u00e9lvica, radioterapia p\u00f3s-operat\u00f3ria, anastomose mec\u00e2nica, inadequada mobiliza\u00e7\u00e3o da flexura espl\u00eanica e f\u00edstulas locais. 2; 3; 4.<\/sup><\/p>\n\n\n\n

Doen\u00e7a de Crohn:<\/strong> <\/em>estenoses sintom\u00e1ticas ocorrem em cerca de um ter\u00e7o dos paciente ap\u00f3s 10 anos de doen\u00e7a ativa5<\/sup>, sendo que nos pacientes p\u00f3s-operat\u00f3rios o local mais comum \u00e9 na anastomose \u00edleo-c\u00f3lica6<\/sup>. Apesar de a cirurgia ter sido o tratamento padr\u00e3o, a dilata\u00e7\u00e3o balonada pode evitar o tratamento cir\u00fargico em 1, 3 e 5 anos em cerca de 80%, 57% e 52% dos pacientes respectivamente7<\/sup>.<\/p>\n\n\n\n

Doen\u00e7a Diverticular:<\/em> <\/strong>secund\u00e1ria a repetidos epis\u00f3dios de inflama\u00e7\u00e3o, sendo o local mais comum o colon sigmoide. Importante lembrar que a presen\u00e7a de estenose n\u00e3o transpon\u00edvel ao colonosc\u00f3pio, por si s\u00f3, n\u00e3o \u00e9 uma indica\u00e7\u00e3o cir\u00fargica absoluta.8<\/sup>.<\/p>\n\n\n\n

Ressec\u00e7\u00e3o endosc\u00f3pica extensa:<\/strong> <\/em>evid\u00eancias demonstram que dissec\u00e7\u00f5es endosc\u00f3picas submucosas (ESD) acometendo mais de 90% da circunfer\u00eancia do reto s\u00e3o um importante fator de risco de estenose local. Essa complica\u00e7\u00e3o pode ocorrer em 11,1% nas ressec\u00e7\u00f5es  \u226590% e <100% , e em 50% das totalmente circunferenciais9<\/sup>.<\/p>\n\n\n\n

Endometriose:<\/strong> <\/em>apesar da preval\u00eancia cada vez maior dessa doen\u00e7a, a obstru\u00e7\u00e3o \u00e9 uma complica\u00e7\u00e3o muito rara (1,7% dos casos cir\u00fargicos) sendo que o tratamento cir\u00fargico deve ser a escolha10; 11<\/sup>.<\/p>\n\n\n\n

Radioterapia:<\/strong> <\/em>as estenoses s\u00e3o mais comuns na jun\u00e7\u00e3o anorretal e o tratamento ci\u00fargico deve ser evitado, tendo em vista a dificuldade t\u00e9cnica e alta incid\u00eancia de complica\u00e7\u00f5es12; 13<\/sup>.<\/p>\n\n\n\n

Isquemia:<\/strong> <\/em>os pacientes oligo ou assintom\u00e1ticos devem ser apenas observados, pois a maioria apresentar\u00e1 melhora em 12 a 24 meses. Nos casos sintom\u00e1ticos a dilata\u00e7\u00e3o balonada deve ser ser considerada e nos refrat\u00e1rios a terapia cir\u00fargica14<\/sup>.<\/p>\n\n\n\n

Preparo de c\u00f3lon<\/strong><\/h2>\n\n\n\n

Como a maioria desses paciente s\u00e3o assintom\u00e1ticos o preparo tradicional pode ser realizado sem intercorr\u00eancias. Entretanto, no caso de pacientes sintom\u00e1ticos, com hist\u00f3ria de v\u00f4mitos ou distens\u00e3o abdominal, o preparo anter\u00f3grado n\u00e3o dever\u00e1 ser realizado, sendo que, dois enemas devem ser suficientes15<\/sup>. Nos pacientes oligossintom\u00e1ticos o preparo fracionado pode ser considerado.<\/p>\n\n\n\n

Tratamento endosc\u00f3pico<\/strong><\/h2>\n\n\n\n

Dilata\u00e7\u00e3o digital ou instrumental:<\/strong> <\/em>apesar dos bons resultados nos casos distais e simples16<\/sup>, a dilata\u00e7\u00e3o endosc\u00f3pica deve ser a escolha nas estenoses acima de 4 cm da borda anal.<\/p>\n\n\n\n

Dilata\u00e7\u00e3o Balonada:<\/strong>  <\/em>principal t\u00e9cnica de tratamento endosc\u00f3pico com resultados satisfat\u00f3rios em cerca de tr\u00eas quartos dos casos17; 18<\/sup>. Deve-se sempre transpor a estenose com um fio-guia para o correto posicionamento do bal\u00e3o e no caso de estenoses longas e tortuosas a fluoroscopia poder\u00e1 ser necess\u00e1ria19<\/sup>.  Idealmente, o objetivo \u00e9 alcan\u00e7ar um di\u00e2metro de 18 a 20 mm, preferencialmente atrav\u00e9s de sess\u00f5es semanais com aumento gradual.<\/p>\n\n\n\n

Dilata\u00e7\u00e3o balonada e inje\u00e7\u00e3o local de corticoide:<\/strong>  <\/em>apesar da evid\u00eancia bem documentada do uso local de triancinolona nos casos de estenose de es\u00f4fago, os resultados em colon s\u00e3o conflitantes20 <\/sup>. Por\u00e9m, apesar do baixo n\u00edvel de evid\u00eancia, esta t\u00e9cnica pode ser considerada antes de uma abordagem cir\u00fargica agressiva.<\/p>\n\n\n\n

Incis\u00e3o endosc\u00f3pica:<\/strong>  <\/em>inclu\u00edda nessa t\u00e9cnica est\u00e3o a estenotomia, que consiste em incis\u00f5es radiais (preferencialmente seguido da dilata\u00e7\u00e3o balonada), e a estenectomia, que configura a ressec\u00e7\u00e3o em arco ou mesmo anelar da \u00e1rea de fibrose (sem a necessidade de dilata\u00e7\u00e3o). Apesar dos bons resultados dessa t\u00e9cnica, com taxas de sucesso de at\u00e9 98,4%23<\/sup>, ela deve ser limitada a estenoses curtas (<1 cm)24; 25; 26<\/sup>.<\/p>\n\n\n\n

Pr\u00f3tese met\u00e1lica:  <\/em><\/strong>apesar de ainda n\u00e3o ser poss\u00edvel a indica\u00e7\u00e3o rotineira desse tratamento, tendo em vista taxas de migra\u00e7\u00e3o de at\u00e9 70%27<\/sup>, nos casos de estenose refrat\u00e1ria e especialmente associado a f\u00edstula, sem \u00e1reas de inflama\u00e7\u00e3o ou trajeto complexo, esta pode ser uma op\u00e7\u00e3o. A literatura ainda mostra relatos como ponte cir\u00fargica na diverticulite com estenose 28; 29; 30<\/sup> e uso de stents de aposi\u00e7\u00e3o luminal para estenoses severas, baixas (distais) e refrat\u00e1rias31; 32<\/sup>. Deve-se sempre manter uma margem distal de 2 cm acima do canal anal para evitar sintomas como tenesmo, dor anal e incontin\u00eancia15<\/sup>.<\/p>\n\n\n\n

Conclus\u00e3o<\/strong><\/h2>\n\n\n\n

A dilata\u00e7\u00e3o endosc\u00f3pica balonada continua sendo uma modalidade segura e eficaz para o tratamento de estenoses benignas do c\u00f3lon em pacientes selecionados. Para uma estenose fibrosten\u00f3tica intestinal isolada com comprimento igual ou inferior a 5 cm, sem fistuliza\u00e7\u00e3o ou perfura\u00e7\u00e3o adjacente, a dilata\u00e7\u00e3o balonada deve ser considerada como terapia de primeira linha.<\/p>\n\n\n\n

Em casos selecionados, outras terapias, como inje\u00e7\u00e3o intramural de cortic\u00f3ide, incis\u00e3o endosc\u00f3pica e coloca\u00e7\u00e3o de pr\u00f3teses podem ser realizadas antes de se optar pela abordagem cir\u00fargica.<\/p>\n\n\n\n

Para saber mais sobre este tema e outros relacionados, acesse o site Gastropedia clicando aqui!<\/a><\/h3>\n\n\n\n

Refer\u00eancias<\/strong><\/h2>\n\n\n\n
    \n
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  32. AXELRAD, J. E.; LICHTIGER, S.; SETHI, A. Treatment of Crohn’s Disease Anastomotic Stricture With a Lumen-apposing Metal Stent. Clin Gastroenterol Hepatol, <\/strong>v. 16, n. 3, p. A25-A26, 03 2018. ISSN 1542-7714. Dispon\u00edvel em: < https:\/\/www.ncbi.nlm.nih.gov\/pubmed\/28529163<\/a> >.<\/li>\n<\/ol>\n","protected":false},"excerpt":{"rendered":"

    Introdu\u00e7\u00e3o Estenoses c\u00f3licas benignas n\u00e3o s\u00e3o t\u00e3o raras em nossa pr\u00e1tica cl\u00ednica. A maioria…<\/p>\n","protected":false},"author":2592,"featured_media":5337,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_lmt_disableupdate":"","_lmt_disable":"","footnotes":""},"categories":[151],"tags":[],"ano":[146],"tipo":[156],"volume":[263],"class_list":["post-4698","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-assuntosgerais","ano-146","tipo-colonoscopia","volume-volume-i"],"yoast_head":"\nEstenoses benignas do c\u00f3lon • 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\/estenoses-benignas-do-colon\/\" \/>\n<meta property=\"og:locale\" content=\"pt_BR\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Estenoses benignas do c\u00f3lon\" \/>\n<meta property=\"og:description\" content=\"Introdu\u00e7\u00e3o Estenoses c\u00f3licas benignas n\u00e3o s\u00e3o t\u00e3o raras em nossa pr\u00e1tica cl\u00ednica. 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