{"id":4852,"date":"2021-02-26T09:00:00","date_gmt":"2021-02-26T09:00:00","guid":{"rendered":"https:\/\/endoscopiaterapeutica.net\/pt\/uncategorized\/cpre-em-pacientes-com-y-de-roux\/"},"modified":"2021-11-25T21:04:34","modified_gmt":"2021-11-25T21:04:34","slug":"cpre-em-pacientes-com-y-de-roux","status":"publish","type":"post","link":"https:\/\/endoscopiaterapeutica.net\/pt\/assuntosgerais\/cpre-em-pacientes-com-y-de-roux\/","title":{"rendered":"CPRE em pacientes com Y-de-Roux"},"content":{"rendered":"<p>&nbsp;<\/p>\n<p style=\"text-align: center;\"><a href=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2021\/02\/Figura-1-Bypass-Gastrojejunal-em-Y-de-Roux-com-banda-de-silicone-Adaptado.jpg\" data-rel=\"penci-gallery-image-content\" ><img fetchpriority=\"high\" decoding=\"async\" class=\"alignnone size-medium wp-image-13475\" src=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2021\/08\/Figura-1-Bypass-Gastrojejunal-em-Y-de-Roux-com-banda-de-silicone-Adaptado.jpg\" alt=\"\" width=\"223\" height=\"300\" \/><\/a><\/p>\n<p><span style=\"font-weight: 400;\">A realiza\u00e7\u00e3o de <\/span><a href=\"https:\/\/endoscopiaterapeutica.net\/pt\/diretrizes\/dt-colangiopancreatogragia-endoscopica-retrograda\/\"><span style=\"font-weight: 400;\">colangiopancreatografia retr\u00f3grada<\/span><\/a><span style=\"font-weight: 400;\"> endosc\u00f3pica (CPRE) em pacientes com anatomia em Y de Roux representa um grande desafio para os endoscopistas.<\/span><\/p>\n<p><span style=\"font-weight: 400;\">Na era da epidemia de obesidade, essa situa\u00e7\u00e3o \u00e9 encontrada com frequ\u00eancia crescente devido \u00e0 popularidade da cirurgia de bypass g\u00e1strico em Y-de-Roux e \u00e0 alta preval\u00eancia de c\u00e1lculos biliares nesses pacientes.<\/span><\/p>\n<p><span style=\"font-weight: 400;\">Frequentemente, \u00e9 imposs\u00edvel acessar a papila usando um duodenosc\u00f3pio padr\u00e3o devido ao comprimento da al\u00e7a intestinal que deve ser percorrida. Para superar esses problemas, abordagens n\u00e3o padronizadas, t\u00e9cnicas inovadoras e acess\u00f3rios especializados foram desenvolvidos para realizar CPRE nesses casos.<\/span><\/p>\n<h2>Considera\u00e7\u00f5es gerais<\/h2>\n<p><span style=\"font-weight: 400;\">Antes de realizar a CPRE em pacientes submetidos \u00e0 reconstru\u00e7\u00e3o em Y de Roux, o endoscopista deve obter detalhes sobre a ressec\u00e7\u00e3o anat\u00f4mica, o tipo de reconstru\u00e7\u00e3o, o comprimento das al\u00e7as, os tipos de anastomoses e a presen\u00e7a ou aus\u00eancia de uma papilotomia pr\u00e9via.<\/span><\/p>\n<p><span style=\"font-weight: 400;\">\u00c9 importante ainda estar ciente do intervalo de tempo ap\u00f3s a cirurgia. No per\u00edodo p\u00f3s-operat\u00f3rio imediato, devem-se pesar os riscos em rela\u00e7\u00e3o \u00e0 ruptura da anastomose contra os benef\u00edcios potenciais da CPRE.<\/span><\/p>\n<h2>Escolhendo a melhor abordagem<\/h2>\n<p><span style=\"font-weight: 400;\">Existem v\u00e1rias t\u00e9cnicas dispon\u00edveis para realizar CPRE em pacientes com anatomia em Y-de-Roux, cada uma com vantagens e desvantagens Nenhuma abordagem foi identificada como a melhor para todos os pacientes, portanto, o endoscopista deve selecionar a abordagem caso a caso, levando em considera\u00e7\u00e3o os seguintes fatores:<\/span><\/p>\n<ul>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">Comprimento da al\u00e7a do Y (longa versus curta);<\/span><\/li>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">Se o paciente tem uma papila virgem ou uma anastomose biliodigestiva, por exemplo;<\/span><\/li>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">A indica\u00e7\u00e3o de CPRE, incluindo a probabilidade de repetir procedimentos e a necessidade de manobras terap\u00eauticas;<\/span><\/li>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">A experi\u00eancia do servi\u00e7o (enteroscopia profunda, radiologia intervencionista, cirurgia);<\/span><\/li>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">O risco cir\u00fargico do paciente.<\/span><\/li>\n<\/ul>\n<h2>T\u00e9cnicas<\/h2>\n<p><span style=\"font-weight: 400;\">As abordagens transorais envolvem o uso de duodenosc\u00f3pios, colonosc\u00f3pios pedi\u00e1tricos ou enterosc\u00f3pios.<\/span><\/p>\n<p><span style=\"font-weight: 400;\"><strong>CPRE usando duodenosc\u00f3pio padr\u00e3o:<\/strong> o duodenosc\u00f3pio de vis\u00e3o lateral \u00e9 o endosc\u00f3pio ideal para realizar CPRE, particularmente para a canula\u00e7\u00e3o de uma papila virgem. Infelizmente, a abordagem apenas com duodenosc\u00f3pio \u00e9 frequentemente malsucedida. Portanto, reservamos a abordagem transoral usando um duodenosc\u00f3pio padr\u00e3o para pacientes com um al\u00e7a curta do Y-de-Roux.<\/span><\/p>\n<p style=\"text-align: center;\"><a href=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2021\/02\/duo.jpg\" data-rel=\"penci-gallery-image-content\" ><img decoding=\"async\" class=\"alignnone wp-image-13465 size-medium\" title=\"duodenosc\u00f3pio padr\u00e3o\" src=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2021\/08\/duo.jpg\" alt=\"duodenosc\u00f3pio padr\u00e3o\" width=\"300\" height=\"228\" \/><\/a><\/p>\n<p>&nbsp;<\/p>\n<p><span style=\"font-weight: 400;\"><strong>CPRE usando um enterosc\u00f3pio ou colonosc\u00f3pio pedi\u00e1trico:<\/strong> um enterosc\u00f3pio ou colonosc\u00f3pio pedi\u00e1trico pode ser uma op\u00e7\u00e3o para realizar uma CPRE quando o uso de um duodenosc\u00f3pio n\u00e3o for vi\u00e1vel.<\/span><\/p>\n<p style=\"text-align: center;\"><a href=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2021\/02\/ped-colon.jpg\" data-rel=\"penci-gallery-image-content\" ><img decoding=\"async\" class=\"alignnone wp-image-13466 size-medium\" title=\"enterosc\u00f3pio ou colonosc\u00f3pio pedi\u00e1trico\" src=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2021\/08\/ped-colon.jpg\" alt=\"enterosc\u00f3pio ou colonosc\u00f3pio pedi\u00e1trico\" width=\"300\" height=\"148\" \/><\/a><\/p>\n<p><span style=\"font-weight: 400;\">Uma desvantagem dessa abordagem \u00e9 que a perspectiva de vis\u00e3o frontal e a falta do \u201celevador\u201d no aparelho tornam a canula\u00e7\u00e3o seletiva mais dif\u00edcil. Al\u00e9m disso, a capacidade de manobra do enterosc\u00f3pio longo ou colonosc\u00f3pio pode ser muito limitada devido \u00e0 forma\u00e7\u00e3o de al\u00e7a. A falta de eixo devido \u00e0 vis\u00e3o frontal desses aparelhos tamb\u00e9m pode dificultar ou impossibilitar a canula\u00e7\u00e3o.<\/span><\/p>\n<p><span style=\"font-weight: 400;\"><strong>CPRE usando t\u00e9cnicas de enteroscopia profunda:<\/strong> h\u00e1 uma experi\u00eancia crescente com o desempenho de CPREs usando t\u00e9cnicas de enteroscopia profunda, incluindo enteroscopia de bal\u00e3o duplo (DBE), enteroscopia de bal\u00e3o \u00fanico (SBE) e espiral enteroscopia.<\/span><\/p>\n<p><span style=\"font-weight: 400;\">Embora as t\u00e9cnicas de enteroscopia profunda representem um avan\u00e7o significativo para a realiza\u00e7\u00e3o de CPRE em pacientes com anatomia alterada cirurgicamente, elas ainda n\u00e3o s\u00e3o amplamente realizadas fora de centros especializados. Al\u00e9m disso, elas t\u00eam as mesmas limita\u00e7\u00f5es supracitadas inerentes ao uso de enterosc\u00f3pios para CPRE, incluindo capacidade de manobra restrita, orienta\u00e7\u00e3o desfavor\u00e1vel da papila, falta de um elevador de instrumento e relativa escassez de acess\u00f3rios compat\u00edveis com enterosc\u00f3pio.<\/span><\/p>\n<p><span style=\"font-weight: 400;\"><strong>CPRE assistida por enterosc\u00f3pio de duplo bal\u00e3o:<\/strong> relatos de casos e algumas s\u00e9ries mostram que a papila pode ser alcan\u00e7ada em mais de 90% das vezes e a canula\u00e7\u00e3o seletiva em mais de 80% dos casos usando a t\u00e9cnica de CPRE assistida por enterosc\u00f3pio de duplo bal\u00e3o.<\/span><\/p>\n<p><span style=\"font-weight: 400;\">Tal como acontece nos casos que usam endosc\u00f3pios de visualiza\u00e7\u00e3o frontal, a canula\u00e7\u00e3o da papila pode ser dif\u00edcil por essa t\u00e9cnica. Um problema adicional \u00e9 que h\u00e1 um n\u00famero limitado de acess\u00f3rios que s\u00e3o compat\u00edveis com um enterosc\u00f3pio.<\/span><\/p>\n<p style=\"text-align: center;\"><a href=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2021\/08\/d-baloon.jpg\" data-rel=\"penci-gallery-image-content\" ><img loading=\"lazy\" decoding=\"async\" class=\"alignnone wp-image-13462 size-full\" title=\"enterosc\u00f3pio de duplo bal\u00e3o\" src=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2021\/08\/d-baloon.jpg\" alt=\"enterosc\u00f3pio de duplo bal\u00e3o\" width=\"225\" height=\"225\" \/><\/a><\/p>\n<p><span style=\"font-weight: 400;\"><strong>CPRE assistida por enterosc\u00f3pio de bal\u00e3o \u00fanico:<\/strong> desempenho de CPREs assistidas por enterosc\u00f3pio de bal\u00e3o \u00fanico em pacientes com Y de Roux foi associada a taxas de sucesso de diagn\u00f3stico que variam de 60 a 80%.<\/span><\/p>\n<p style=\"text-align: center;\"><a href=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2021\/08\/single-baloon.jpg\" data-rel=\"penci-gallery-image-content\" ><img loading=\"lazy\" decoding=\"async\" class=\"alignnone wp-image-13463 size-full\" title=\"enterosc\u00f3pio de bal\u00e3o \u00fanico\" src=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2021\/08\/single-baloon.jpg\" alt=\"enterosc\u00f3pio de bal\u00e3o \u00fanico\" width=\"225\" height=\"225\" \/><\/a><\/p>\n<p><strong>\u00a0<\/strong><\/p>\n<p><span style=\"font-weight: 400;\"><strong>CPRE assistida por enteroscopia em espiral:<\/strong> a enteroscopia em espiral utiliza um overtube rotativo que permite o avan\u00e7o profundo do aparelho. As vantagens potenciais da CPRE assistida por uma enteroscopia espiral sobre a duplo bal\u00e3o ou bal\u00e3o \u00fanico incluem relativa facilidade de uso, melhor controle do endosc\u00f3pio e, talvez, uma curva de aprendizado mais curta.<\/span><\/p>\n<p style=\"text-align: center;\"><a href=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2021\/02\/spiral.jpg\" data-rel=\"penci-gallery-image-content\" ><img loading=\"lazy\" decoding=\"async\" class=\"alignnone wp-image-13464 size-medium\" title=\"enteroscopia em espiral\" src=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2021\/08\/spiral.jpg\" alt=\"enteroscopia em espiral\" width=\"300\" height=\"154\" \/><\/a><\/p>\n<p>&nbsp;<\/p>\n<p><span style=\"font-weight: 400;\"><strong>Abordagens transorais menos comuns:<\/strong> foi desenvolvida uma t\u00e9cnica que usa a coloca\u00e7\u00e3o guiada por ecoendoscopia de um stent met\u00e1lico (LAMS) entre o \u201cpouch\u201d e o est\u00f4mago excluso para facilitar uma CPRE anter\u00f3grada transoral usando um duodenosc\u00f3pio. A experi\u00eancia preliminar com essa abordagem em pacientes com anatomia de bypass g\u00e1strico em Y de Roux tem sido promissora, com sucesso t\u00e9cnico semelhante e taxas de eventos adversos em compara\u00e7\u00e3o com CPRE assistida por laparoscopia e CPRE assistida por enteroscopia.<\/span><\/p>\n<p style=\"text-align: center;\"><a href=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2021\/08\/Axios.png\" data-rel=\"penci-gallery-image-content\" ><img loading=\"lazy\" decoding=\"async\" class=\"alignnone wp-image-13477 size-full\" title=\"Abordagens transorais menos comuns\" src=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2021\/08\/Axios.png\" alt=\"Abordagens transorais menos comuns\" width=\"279\" height=\"275\" \/><\/a><\/p>\n<h3 style=\"text-align: left;\">Como citar este artigo<\/h3>\n<p><span style=\"font-weight: 400;\">Ruiz R. CPRE em pacientes com Y-de-Roux. Endoscopia Terap\u00eautica; 2021. Dispon\u00edvel em: https:\/\/endoscopiaterapeutica.net\/pt\/assuntosgerais\/cpre-em-pacientes-com-y-de-roux<\/span><\/p>\n<h3 style=\"text-align: left;\">Refer\u00eancias bibliogr\u00e1ficas<\/h3>\n<ol id=\"reference\">\n<li><a class=\"nounderline abstract_t\" href=\"https:\/\/www.uptodate.com\/contents\/ercp-in-patients-with-roux-en-y-anatomy\/abstract\/1\">Nguyen NT, Root J, Zainabadi K, et al. Accelerated growth of bariatric surgery with the introduction of minimally invasive surgery. Arch Surg 2005; 140:1198.<\/a><\/li>\n<li><a class=\"nounderline abstract_t\" href=\"https:\/\/www.uptodate.com\/contents\/ercp-in-patients-with-roux-en-y-anatomy\/abstract\/2\">Pories WJ. Bariatric surgery: risks and rewards. J Clin Endocrinol Metab 2008; 93:S89.<\/a><\/li>\n<li><a class=\"nounderline abstract_t\" href=\"https:\/\/www.uptodate.com\/contents\/ercp-in-patients-with-roux-en-y-anatomy\/abstract\/3\">Shiffman ML, Sugerman HJ, Kellum JH, et al. Gallstones in patients with morbid obesity. Relationship to body weight, weight loss and gallbladder bile cholesterol solubility. Int J Obes Relat Metab Disord 1993; 17:153.<\/a><\/li>\n<li><a class=\"nounderline abstract_t\" href=\"https:\/\/www.uptodate.com\/contents\/ercp-in-patients-with-roux-en-y-anatomy\/abstract\/4\">Lopes TL, Wilcox CM. Endoscopic retrograde cholangiopancreatography in patients with Roux-en-Y anatomy. Gastroenterol Clin North Am 2010; 39:99.<\/a><\/li>\n<li><a class=\"nounderline abstract_t\" href=\"https:\/\/www.uptodate.com\/contents\/ercp-in-patients-with-roux-en-y-anatomy\/abstract\/5\">Hintze RE, Adler A, Veltzke W, Abou-Rebyeh H. Endoscopic access to the papilla of Vater for endoscopic retrograde cholangiopancreatography in patients with billroth II or Roux-en-Y gastrojejunostomy. Endoscopy 1997; 29:69.<\/a><\/li>\n<li><a class=\"nounderline abstract_t\" href=\"https:\/\/www.uptodate.com\/contents\/ercp-in-patients-with-roux-en-y-anatomy\/abstract\/6\">Elton E, Hanson BL, Qaseem T, Howell DA. Diagnostic and therapeutic ERCP using an enteroscope and a pediatric colonoscope in long-limb surgical bypass patients. Gastrointest Endosc 1998; 47:62.<\/a><\/li>\n<li><a class=\"nounderline abstract_t\" href=\"https:\/\/www.uptodate.com\/contents\/ercp-in-patients-with-roux-en-y-anatomy\/abstract\/7\">Wright BE, Cass OW, Freeman ML. ERCP in patients with long-limb Roux-en-Y gastrojejunostomy and intact papilla. Gastrointest Endosc 2002; 56:225.<\/a><\/li>\n<li><a class=\"nounderline abstract_t\" href=\"https:\/\/www.uptodate.com\/contents\/ercp-in-patients-with-roux-en-y-anatomy\/abstract\/8\">Aabakken L, Bretthauer M, Line PD. Double-balloon enteroscopy for endoscopic retrograde cholangiography in patients with a Roux-en-Y anastomosis. Endoscopy 2007; 39:1068.<\/a><\/li>\n<li><a class=\"nounderline abstract_t\" href=\"https:\/\/www.uptodate.com\/contents\/ercp-in-patients-with-roux-en-y-anatomy\/abstract\/9\">Emmett DS, Mallat DB. Double-balloon ERCP in patients who have undergone Roux-en-Y surgery: a case series. Gastrointest Endosc 2007; 66:1038.<\/a><\/li>\n<li><a class=\"nounderline abstract_t\" href=\"https:\/\/www.uptodate.com\/contents\/ercp-in-patients-with-roux-en-y-anatomy\/abstract\/10\">Itoi T, Ishii K, Sofuni A, et al. Long- and short-type double-balloon enteroscopy-assisted therapeutic ERCP for intact papilla in patients with a Roux-en-Y anastomosis. Surg Endosc 2011; 25:713.<\/a><\/li>\n<li><a href=\"https:\/\/www.semanticscholar.org\/author\/Thomas-J.-Wang\/152240671\">Thomas J. Wang<\/a><a href=\"https:\/\/www.semanticscholar.org\/author\/Thomas-J.-Wang\/152240671\">,\u00a0<\/a><a href=\"https:\/\/www.semanticscholar.org\/author\/Christopher-C.-Thompson\/152612215\">Christopher C. Thompson<\/a><a href=\"https:\/\/www.semanticscholar.org\/author\/Thomas-J.-Wang\/152240671\">,\u00a0<\/a><a href=\"https:\/\/www.semanticscholar.org\/author\/Marvin-Ryou\/1986335\">Marvin Ryou<\/a><a href=\"https:\/\/www.semanticscholar.org\/author\/Thomas-J.-Wang\/152240671\">Gastric access temporary for endoscopy (GATE): a proposed algorithm for EUS-directed transgastric ERCP in gastric bypass patients<\/a>\u00a0Surg Endosc 2019<\/li>\n<\/ol>\n<p><b>Confira tamb\u00e9m: <a href=\"https:\/\/endoscopiaterapeutica.net\/pt\/artigoscomentados\/cpre-em-pacientes-com-gastrectomia-a-billroth-ii-previa-30-anos-de-experiencia\/\" target=\"_blank\" rel=\"noopener\">CPRE em pacientes com gastrectomia a Billroth II<\/a><\/b><\/p>\n","protected":false},"excerpt":{"rendered":"<p>&nbsp; A realiza\u00e7\u00e3o de colangiopancreatografia retr\u00f3grada endosc\u00f3pica (CPRE) em pacientes com anatomia em Y&hellip;<\/p>\n","protected":false},"author":4256,"featured_media":4845,"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-4852","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-assuntosgerais","ano-262","tipo-cpre","volume-volume-i"],"yoast_head":"<!-- This site is optimized with the Yoast SEO Premium plugin v27.2 (Yoast SEO v27.2) - https:\/\/yoast.com\/product\/yoast-seo-premium-wordpress\/ -->\n<title>CPRE em pacientes com Y-de-Roux &#8226; 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\/cpre-em-pacientes-com-y-de-roux\/\" \/>\n<meta property=\"og:locale\" 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