{"id":4832,"date":"2021-03-12T09:00:00","date_gmt":"2021-03-12T09:00:00","guid":{"rendered":"https:\/\/endoscopiaterapeutica.net\/pt\/uncategorized\/papilectomia-endoscopica-revisao-da-literatura\/"},"modified":"2023-08-07T20:19:13","modified_gmt":"2023-08-07T20:19:13","slug":"papilectomia-endoscopica-revisao-da-literatura-2","status":"publish","type":"post","link":"https:\/\/endoscopiaterapeutica.net\/pt\/assuntosgerais\/papilectomia-endoscopica-revisao-da-literatura-2\/","title":{"rendered":"Papilectomia endosc\u00f3pica \u2013 revis\u00e3o da literatura"},"content":{"rendered":"\n

Os tumores localizados na papila duodenal<\/a> maior (ou ampola de Vater) s\u00e3o um grupo de neoplasias pouco comum no trato gastrointestinal, no entanto, um estudo mostra um aumento da incid\u00eancia anual nos \u00faltimos 30 anos nos Estados Unidos, situando-se, atualmente, em torno de 3.000 casos\/anoi<\/sup>. Dentre os tipos histol\u00f3gicos, o adenocarcinoma e o adenoma representam mais de 95% dos casos. Embora o adenocarcinoma da papila duodenal maior seja usualmente a les\u00e3o de maior preval\u00eancia1<\/sup>, o surgimento de casos de adenomas incidentais nessa topografia (por ocasi\u00e3o de um exame endosc\u00f3pico gastroduodenal de rotina, por exemplo) tende a mudar essa estat\u00edsticaii<\/sup>. Em uma s\u00e9rie brasileira recente de pacientes submetidos \u00e0 papilectomia endosc\u00f3pica (PE), houve um aumento do n\u00famero de procedimentos nos \u00faltimos 5 anos, com predom\u00ednio de adenomas com displasia de alto grauiii<\/sup>.<\/p>\n\n\n\n

Os tumores dessa complexa regi\u00e3o anat\u00f4mica, onde confluem os ductos biliar e pancre\u00e1tico, podem ser classificados como benignos, pr\u00e9-neopl\u00e1sicos (por exemplo, adenomas) e malignos. O adenoma de papila duodenal maior \u00e9 considerado uma les\u00e3o pr\u00e9-neopl\u00e1sica, pois tende a seguir a sequ\u00eancia adenoma-adenocarcinoma de maneira semelhante ao c\u00e2ncer colorretal<\/a>, com taxas de transforma\u00e7\u00e3o para adenocarcinoma variando entre 25-85%iv<\/sup>. Os adenomas podem ser espor\u00e1dicos ou no contexto de s\u00edndromes gen\u00e9ticas, como o c\u00e2ncer colorretal heredit\u00e1rio n\u00e3o polip\u00f3ide e a polipose adenomatosa familiar (PAF), em que at\u00e9 80% dos pacientes desenvolver\u00e3o tal condi\u00e7\u00e3o durante a vidav<\/sup>. Os sintomas, quando presentes, s\u00e3o geralmente inespec\u00edficos, como dor abdominal, mal-estar, n\u00e1usea, v\u00f4mito e perda ponderalvi<\/sup>; a icter\u00edcia est\u00e1 mais frequentemente associada a les\u00f5es invasoras.<\/p>\n\n\n\n

Por serem, muitas vezes, diagnosticados incidentalmente e n\u00e3o apresentarem sintomas, os adenomas da papila duodenal maior representam hoje um dilema diagn\u00f3stico e terap\u00eautico. A abordagem terap\u00eautica desses tumores \u00e9 tradicionalmente cir\u00fargica e, embora permita a remo\u00e7\u00e3o completa da les\u00e3o, est\u00e1 associada a taxas consider\u00e1veis de morbidade e mortalidade (9-14% e 1-9%, respectivamente)vii<\/sup>. A excis\u00e3o local por via endosc\u00f3pica (PE) ou por ampulectomia cir\u00fargica pode ser empregada para les\u00f5es precoces, isto \u00e9, adenoma com acometimento neopl\u00e1sico superficial (displasia de alto grau) sem sinais de invas\u00e3o da muscular pr\u00f3pria (estadiamento oncol\u00f3gico cl\u00ednico pr\u00e9-operat\u00f3rio: T0\/T1aN0M0). A duodenopancreatectomia (procedimento de Whipple) tem sido reservada para tumores de papila com suspeita para invas\u00e3o para a muscular pr\u00f3pria, tendo como sinais macrosc\u00f3picos ulcera\u00e7\u00e3o, infiltra\u00e7\u00e3o, friabilidade e endurecimento \u00e0 endoscopia<\/a>.<\/p>\n\n\n\n

A PE, inicialmente proposta em 1993viii<\/sup> como uma alternativa de salvamento para pacientes sem condi\u00e7\u00e3o de cirurgia, vem destacando-se mundialmente e na Am\u00e9rica Latina como uma op\u00e7\u00e3o terap\u00eautica menos invasiva no tratamento de les\u00f5es precoces que acometem a papila duodenal maior3<\/sup> ix<\/sup>. Embora n\u00e3o exista consenso sobre quais adenomas devem ser acompanhados ou ressecados por via cir\u00fargica ou endosc\u00f3pica, recomenda-se a PE em adenomas tubulares, t\u00fabulo-vilosos ou vilosos na presen\u00e7a de displasia de alto grau (DAG) 7<\/sup>. Em duas revis\u00f5es sistem\u00e1ticas e meta-an\u00e1lise publicadas at\u00e9 o momento, avaliando-se o tratamento cir\u00fargico comparado ao endosc\u00f3pico, a ressec\u00e7\u00e3o cir\u00fargica local est\u00e1 associada a maiores taxas de ressec\u00e7\u00e3o completa e menor recidivax<\/sup> xi<\/sup>. Quando inclu\u00eddo o procedimento de duodenopancreatectomia<\/a> na avalia\u00e7\u00e3o, nota-se um maior n\u00famero de complica\u00e7\u00f5es 11<\/sup>. Em ambos estudos, \u00e9 not\u00f3ria aus\u00eancia de estudos prospectivos randomizados e elevada heterogeneidade. Na meta-an\u00e1lise mais recente (2020)11<\/sup>, a taxa de ressec\u00e7\u00e3o endosc\u00f3pica completa (ressec\u00e7\u00e3o oncol\u00f3gica R0) para PE foi 76.6% (IC 71.8\u201381.4%), a taxa de eventos adversos global 24.7% (IC 19.8\u201329.6%) e a taxa de recidiva 13.0% (IC 10.2\u201315.6%), esta para uma m\u00e9dia de 44 meses de seguimento. As complica\u00e7\u00f5es que necessitam alguma interven\u00e7\u00e3o associadas \u00e0 PE, em ordem de frequ\u00eancia, s\u00e3o sangramento (intra ou p\u00f3s-operat\u00f3rio), pancreatite e perfura\u00e7\u00e3o. Colangite e estenose de papila s\u00e3o outras complica\u00e7\u00f5es reportadas, de menor chance. A mortalidade \u00e9 rara, sendo reportada como menos de 1%4<\/sup>. Na maior s\u00e9rie comparativa (caso-controle) publicada at\u00e9 o momento, envolvendo 180 pacientes submetidos \u00e0 t\u00e9cnica endosc\u00f3pica (130 pacientes) versus cirurgia para excis\u00e3o local de adenomas da papila de Vaterxii<\/sup>, os resultados cl\u00ednicos foram semelhantes. A cirurgia apresentou maior n\u00famero de eventos adversos (EA), e a PE maior chance de recidiva quando nesta houve necessidade de mais de uma sess\u00e3o de tratamento endosc\u00f3pico. As les\u00f5es desfavor\u00e1veis para tratamento endosc\u00f3pico foram les\u00f5es maiores que 3.5 cm e com extens\u00e3o para o ducto biliar. A PE, portanto, \u00e9 recomendada como a principal op\u00e7\u00e3o de excis\u00e3o local para adenomas menores que 4 cm, profundidade de invas\u00e3o confinada \u00e0 mucosa e submucosa e com extens\u00e3o ductal menor que 1 cm 7<\/sup>.<\/p>\n\n\n\n

A bi\u00f3psia de papila duodenal maior permanece o padr\u00e3o-ouro para decis\u00e3o terap\u00eautica, em que recomenda-se a obten\u00e7\u00e3o de, ao menos, 6 esp\u00e9cimes e\/ou coleta de fragmentos ap\u00f3s 10 dias de uma esfincterotomia p\u00f3s-drenagem biliar de tumor ampular obstrutivo7<\/sup>, bem como avalia\u00e7\u00e3o por patologista experiente em doen\u00e7as biliopancre\u00e1ticas. Entretanto, a bi\u00f3psia, isoladamente, oferece baixa sensibilidade para diagn\u00f3stico de adenoma e de carcinoma, em que se pode subestimar a les\u00e3o em at\u00e9 23% dos casosxiii<\/sup>, e que, na suspeita de neoplasia, recomenda-se a ressec\u00e7\u00e3o completa da les\u00e3o. Inversamente, as m\u00faltiplas varia\u00e7\u00f5es morfol\u00f3gicas endosc\u00f3picas histopatol\u00f3gicas de uma papila duodenal maior normal podem ser erroneamente interpretadas como adenomas. Esses dilemas diagn\u00f3sticos s\u00e3o evidenciados quando se estuda a popula\u00e7\u00e3o de pacientes submetidos \u00e0 PE, em que, atualmente, apenas cerca de 13 a 36% deles apresentam correla\u00e7\u00e3o histopatol\u00f3gica com o esp\u00e9cime cir\u00fargico ressecadoxiv<\/sup> xv<\/sup>. Nesse contexto, pode haver tecido adenomatoso sem displasia (podendo ser interpretado como falso positivo para DAG ou elimina\u00e7\u00e3o do foco de displasia por ocasi\u00e3o da bi\u00f3psia) e neoplasia invasora (falso negativo para adenocarcinoma) no esp\u00e9cime cir\u00fargico. Em uma s\u00e9rie nacional recente, houve baixa correla\u00e7\u00e3o entre o diagn\u00f3stico pr\u00e9 e p\u00f3s-PE para adenocarcinoma invasor e presen\u00e7a de DAG3<\/sup>. Com o aumento da experi\u00eancia na abordagem dessas les\u00f5es, espera-se que essa correla\u00e7\u00e3o venha a ser equilibrada. Em complementa\u00e7\u00e3o ao diagn\u00f3stico, houve um aprimoramento das t\u00e9cnicas endosc\u00f3picas de estadiamento, como o ultrassom endosc\u00f3pico (USE), cromoscopia e magnifica\u00e7\u00e3o endosc\u00f3pica4<\/sup>. De fato, a utiliza\u00e7\u00e3o do USE parece ser um m\u00e9todo \u00fatil no estadiamento de les\u00f5es precoces, com taxa de detec\u00e7\u00e3o de malignidade para les\u00f5es suspeitas de 82%xvi<\/sup>.<\/p>\n\n\n\n

Com rela\u00e7\u00e3o ao aspecto t\u00e9cnico, a PE prop\u00f5e a ressec\u00e7\u00e3o da mucosa e submucosa duodenal na topografia dos anexos anat\u00f4micos da papila duodenal maior, incluindo o aparato esfincteriano e tecido ao redor do ducto biliar e os orif\u00edcios do ducto pancre\u00e1tico. A principal vantagem desse procedimento comparado \u00e0 ampulectomia cir\u00fargica \u00e9 evitar o acesso abdominal com duodenotomia e manipula\u00e7\u00e3o da regi\u00e3o periampular, com ressec\u00e7\u00e3o de tecido pancre\u00e1tico e reinser\u00e7\u00e3o separada do ducto biliar comum e do ducto pancre\u00e1tico principal na parede duodenalxvii<\/sup>. Atualmente, tem sido descrito a ressec\u00e7\u00e3o endosc\u00f3pica completa de tumores ampulares de at\u00e9 4-5 cm de extens\u00e3o lateral, desde que restritos \u00e0 submucosa e com infiltra\u00e7\u00e3o intraductal menor que 1 cm, mantendo taxas de sucesso elevadas e morbidade inferior \u00e0s s\u00e9ries cir\u00fargicas.A t\u00e9cnica de PE tem como objetivo remover a les\u00e3o em bloco utilizando uma al\u00e7a diat\u00e9rmica, semelhante a um procedimento de mucosectomia endosc\u00f3pica para adenomas col\u00f4nicos. Com rela\u00e7\u00e3o \u00e0s t\u00e9cnicas utilizadas, as principais controv\u00e9rsias s\u00e3o o uso de inje\u00e7\u00e3o submucosa antecedendo a ressec\u00e7\u00e3o com al\u00e7a diat\u00e9rmica e o uso de pr\u00f3tese pancre\u00e1tica profil\u00e1tica ap\u00f3s a ressec\u00e7\u00e3o da les\u00e3o. Os argumentos para o uso de inje\u00e7\u00e3o submucosa s\u00e3o a redu\u00e7\u00e3o no risco de sangramento quando associado \u00e0 adrenalina e a cria\u00e7\u00e3o de um coxim com separa\u00e7\u00e3o das camadas superficial e profunda. Entretanto, essa etapa tem sido abolida por muitos centros por aumentar a dificuldade de apreens\u00e3o da al\u00e7a na les\u00e3o e o risco de pancreatitexviii<\/sup>. O benef\u00edcio do uso de pr\u00f3tese pancre\u00e1tica como profilaxia para pancreatite, atualmente recomendado nesse contexto para pacientes de alto risco para pancreatite7 xix xx<\/sup>, vem sendo questionado em s\u00e9ries mais recentesxxi<\/sup>xxii<\/sup>. O uso de pr\u00f3teses biliares n\u00e3o \u00e9 incentivado de rotina7<\/sup>, podendo ser \u00fatil em caso de perfura\u00e7\u00e3o e sangramento com o intuito de compress\u00e3o local e desvio da secre\u00e7\u00e3o biliar. Outras t\u00e9cnicas descritas, alternativamente, consistem na utiliza\u00e7\u00e3o de um fio guia transpapilarxxiii<\/sup> ou dissec\u00e7\u00e3o submucosa da margem lateralxxiv<\/sup>, empregados previamente \u00e0 preens\u00e3o e ressec\u00e7\u00e3o com al\u00e7a diat\u00e9rmica. Para casos de recidiva junto ao \u00f3stio, pode-se aplicar plasma de arg\u00f4nio e, quando biliar intraductal, pode-se recorrer \u00e0 abla\u00e7\u00e3o endosc\u00f3pica com radiofrequ\u00eanciaxxv<\/sup>.<\/p>\n\n\n\n

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

A papilectomia endosc\u00f3pica \u00e9 uma t\u00e9cnica endosc\u00f3pica minimamente invasiva que permite a remo\u00e7\u00e3o tumoral completa de les\u00f5es ampulares precoces, na maioria dos casos, com taxas de eventos adversos aceit\u00e1veis.<\/p>\n\n\n\n

<\/p>\n\n\n\n

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

Como citar este artigo<\/strong><\/h3>\n\n\n\n

Bonin E.A. Papilectomia Endosc\u00f3pica \u2013 Revis\u00e3o da literatura. Endoscopia Terap\u00eautica; 2021. Dispon\u00edvel em: https:\/\/endoscopiaterapeutica.net\/pt\/assuntosgerais\/papilectomia-endoscopica–revisao-da-literatura<\/p>\n\n\n\n

Refer\u00eancias<\/strong><\/h3>\n\n\n\n

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ii Chini P, Draganov PV. Diagnosis and management of ampullary adenoma: The expanding role of endoscopy World J Gastrointest Endosc. 2011 Dec 16; 3(12): 241\u2013247.<\/p>\n\n\n\n

iii Cathcart Jr NS, Souza RCA, Noda RW, Taglieri E, Ardengh JC, Bonin EA.endoscopic papillectomy for early ampullary neoplastic lesions – a case series analysis. Arq gastroenterol. 2020 jul-sep;57(3):300-305.<\/p>\n\n\n\n

iv Ardengh JC, Kemp R, Lima-Filho ER, dos Santos JS. Endoscopic papillectomy: The limits of the indication, technique and results World J Gastrointest Endosc. 2015 Aug 10; 7(10): 987\u2013994.<\/p>\n\n\n\n

v Burke CA, Beck GJ, Church JM, van Stolk RU. The natural history of untreated duodenal and ampullary adenomas in patients with familial adenomatous polyposis followed in an endoscopic surveillance program. Gastrointest Endosc 1999; 49: 358-364<\/p>\n\n\n\n

vi Cheng CL, Sherman S, Fogel EL, McHenry L, Watkins JL, Fukushima T,Howard TJ, Lazzell-Pannell L, Lehman GA. Endoscopic snare papillectomy for tumors of the duodenal papillae. Gastrointest Endosc. 2004;60:757\u201364<\/p>\n\n\n\n

vii ASGE Standards of Practice Committee, Chathadi KV, Khashab MA, Acosta RD, Chandrasekhara V, Eloubeidi MA, Faulx AL, Fonkalsrud L, Lightdale JR, Salztman JR, Shaukat A, Wang A, Cash BD, DeWitt JM. The role of endoscopy in ampullary and duodenal adenomas. Gastrointest Endosc. 2015 Nov;82(5):773-81.<\/p>\n\n\n\n

viii Binmoeller K.F., Boaventura S., Ramsperger K., Soehendra N. Endoscopic snare excision of benign adenomas of the papilla of Vater. Gastrointest. Endosc. 1993;39:127\u2013131.<\/p>\n\n\n\n

ix Casta\u00f1o Llano R, Ruiz V\u00e9lez MH, San\u00edn Fonnegra E, Erebrie Granados F, Garc\u00eda Rend\u00f3n LH, N\u00fa\u00f1ez Cabarcas E. Experiencia local en la resecci\u00f3n endosc\u00f3pica de la papila. Rev Col Gastroenterol. 2007. Sep; 22( 3 ): 173-189.<\/p>\n\n\n\n

x Mendon\u00e7a EQ, Bernardo WM, Moura EG, Chaves DM, Kondo A, Pu LZ, Baracat FI. Endoscopic versus surgical treatment of ampullary adenomas: a systematic review and meta-analysis. Clinics (Sao Paulo). 2016 Jan;71(1):28-35.<\/p>\n\n\n\n

xi Heise C, Ali EA , Hasenclever D, Auriemma F , Gulla A, Regner S, Gaujoux S, Hollenbach M Systematic Review with Meta-Analysis: Endoscopic and Surgical Resection for Ampullary Lesions. J Clin Med. 2020 Nov 10;9(11):3622. doi: 10.3390\/jcm9113622.<\/p>\n\n\n\n

xii Onkendi EO, Naik ND, Rosedahl JK, Harmsen SW, Gostout CJ, Baron TH Sr, Sarr MG, Que FG. Adenomas of the ampulla of Vater: a comparison of outcomes of operative and endoscopic resections. J Gastrointest Surg. 2014 Sep;18(9):1588-96.<\/p>\n\n\n\n

xiii Elek G, Gy\u00f4ri S, T\u00f3th B, Pap A. Histological evaluation of preoperative biopsies from ampulla vateri.Pathol Oncol Res. 2003;9(1):32-41.<\/p>\n\n\n\n

xiv Bellizzi AM, Kahaleh M, Stelow EB. The assessment of specimens procured by endoscopic ampullectomy.Am J Clin Pathol. 2009 Oct;132(4):506-13. doi: 10.1309\/AJCPUZWJ8WA2IHBG.<\/p>\n\n\n\n

xv Laleman W, Verreth A, Topal B, Aerts R, Komuta M, Roskams T, Van der Merwe S, Cassiman D, Nevens F, Verslype C, Van Steenbergen W. Endoscopic resection of ampullary lesions: a single-center 8-year retrospective cohort study of 91 patients with long-term follow-up. Surg Endosc. 2013 Oct;27(10):3865-76. doi: 10.1007\/s00464-013-2996-2.<\/p>\n\n\n\n

xvi Will U, Bosseckert H, Meyer F. Correlation of endoscopic ultrasonography (EUS) for differential diagnostics between inflammatory and neoplastic lesions of the papilla of Vater and the peripapillary region with results of histologic investigation. Ultraschall Med. 2008 Jun;29(3):275-80. doi: 10.1055\/s-2008-1027327.<\/p>\n\n\n\n

xvii Han J, Kim MH. Endoscopic papillectomy for adenomas of the major duodenal papilla. Gastrointest Endosc 2006; 63:292-301<\/p>\n\n\n\n

xviii Chung KH, Lee SH, Choi JH, Kang J, Paik WH, Ahn DW, Ryu JK, Kim YT Effect of submucosal injection in endoscopic papillectomy of ampullary tumor: Propensity-score matching analysis United European Gastroenterol J. 2018 May; 6(4): 576\u2013585.<\/p>\n\n\n\n

xix Singh P, Das A, Isenberg G, Wong RC, Sivak MV, Agrawal D, Chak A. Does prophylactic pancreatic stent placement reduce the risk of post-ERCP acute pancreatitis? A meta-analysis of controlled trials. Gastrointest Endosc. 2004;60:544\u2013550<\/p>\n\n\n\n

xx Yining Wang Y, Qi M, Hao Y, Hong J. The efficacy of prophylactic pancreatic stents against complications of post-endoscopic papillectomy or endoscopic ampullectomy: a systematic review and meta-analysis Therap Adv Gastroenterol. 2019; 12: 1756284819855342. Published online 2019 Jun 26.<\/p>\n\n\n\n

xxi Chang WI, Min YW, Yun HS, Lee KH, Lee JK, Lee KT, Rhee PL Prophylactic pancreatic stent placement for endoscopic duodenal ampullectomy: a single-center retrospective study. Gut Liver. 2014 May;8(3):306-12.<\/p>\n\n\n\n

xxii Taglieri E, Micelli-Neto O, Bonin EA, Goldman SM, Kemp R, dos Santos JS, Ardengh JC, Analysis of risk factors associated with acute pancreatitis after endoscopic papillectomy. Sci Rep. 2020; 10: 4132.<\/p>\n\n\n\n

xxiii Moon JH, Cha SW, Cho YD, Ryu CB, Cheon YK, Kwon KW, Kim YS, Kim YS, Lee JS, Lee MS, Shim CS, Kim BS. Wire-guided endoscopic snare papillectomy for tumors of the major duodenal papilla. Gastrointest Endosc. 2005 Mar;61(3):461-6.<\/p>\n\n\n\n

xxiv Takahara N, Tsuji Y, Nakai Y, et al. A Novel Technique of Endoscopic Papillectomy with Hybrid Endoscopic Submucosal Dissection for Ampullary Tumors: A Proof-of-Concept Study (with Video). J Clin Med. 2020 Aug; 9(8): 2671.<\/p>\n\n\n\n

xxv Camus M, Napol\u00e9on B, Vienne A, Le Rhun M, Leblanc S, Barret M, Chaussade S, Robin F, Kaddour N, Prat F. Efficacy and safety of endobiliary radiofrequency ablation for the eradication of residual neoplasia after endoscopic papillectomy: a multicenter prospective study. Gastrointest Endosc. 2018 Sep;88(3):511-518.<\/p>\n\n\n\n

Autores<\/strong><\/h3>\n\n\n\n

Eduardo Aimore Bonin<\/p>\n\n\n\n

Nelson Silveira Cathcart Junior<\/p>\n\n\n\n

Acesse o Endoscopia Terap\u00eautica<\/a> para tomar contato com mais artigos comentados<\/a>, assuntos gerais<\/a>, casos cl\u00ednicos<\/a>, quizzes<\/a>, classifica\u00e7\u00f5es<\/a> e mais!<\/p>\n","protected":false},"excerpt":{"rendered":"

Os tumores localizados na papila duodenal maior (ou ampola de Vater) s\u00e3o um grupo…<\/p>\n","protected":false},"author":1513,"featured_media":5409,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_lmt_disableupdate":"","_lmt_disable":"","footnotes":""},"categories":[151],"tags":[],"ano":[262],"tipo":[155],"volume":[263],"class_list":["post-4832","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-assuntosgerais","ano-262","tipo-cpre","volume-volume-i"],"yoast_head":"\nPapilectomia endosc\u00f3pica \u2013 revis\u00e3o da literatura • 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\/papilectomia-endoscopica-revisao-da-literatura-2\/\" \/>\n<meta property=\"og:locale\" content=\"pt_BR\" \/>\n<meta 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