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ARTIGOS ORIGINAIS _____________Qualidade da informação da internet disponível para pacientes em páginas em português ___________________________________________________________645 Acesso a informações de saúde na internet: uma questão de saúde pública? ______650 Maus-tratos contra a criança e o adolescente no Estado de São Paulo, 2009_______659 Obesidade e hipertensão arterial em escolares de Santa Cruz do Sul – RS, Brasil ___666 Bone mineral density in postmenopausal women with and without breast cancer ___673 Prevalence and factors associated with thoracic alterations in infants born prematurely __________________________________________________679 Análise espacial de óbitos por acidentes de trânsito, antes e após a Lei Seca, nas microrregiões do estado de São Paulo ___________________________________685 Sobrevida e complicações em idosos com doenças neurológicas em nutrição enteral ______________________________________________________691 Infliximab reduces cardiac output in rheumatoid arthritis patients without heart failure ______________________________________________________698 Análise dos resultados maternos e fetais dos procedimentos invasivos genéticos fetais: um estudo exploratório em Hospital Universitário _______________703 Frequência dos tipos de cefaleia no centro de atendimento terciário do Hospital das Clínicas da Universidade Federal de Minas Gerais __________________709
ARTIGO DE REVISÃO ______________Influência das variáveis nutricionais e da obesidade sobre a saúde e o metabolismo __714
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Conclusão: como exibir a cereja do bolo 633
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Os paradoxos da medicina contemporânea 634
IMAGEM EM MEDICINAObstrução duodenal maligna: tratamento endoscópico paliativo utilizando prótese metálica autoexpansível 636 Gossypiboma 638
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Hérnia de disco cervical no adulto: tratamento cirúrgico 639
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REV ASSOC MED BRAS. 2013;59(5):409-410
At the bedside
What is the role of endoscopic ultrasound in palliative
drainage of malignant biliary obstruction?
Qual o papel da ecoendoscopia na drenagem paliativa da via biliar
por obstrução maligna?
Jarbas Faraco Maldonado Loureiro
a, Everson Luiz de Almeida Artifon
b, Elias Jirjoss Ilias
c,*
a Service of Endoscopy, Hospital Sírio-Libanês, São Paulo, SP, Brazil b Medical School, Universidade de São Paulo, São Paulo, SP, Brazil
c Brazilian College of Surgeons, São Paulo, SP, Brazil
A RT I C L E I N F O
Article history: Received 29 July 2013 Accepted 31 July 2013
* Corresponding author.
E-mail: [email protected] (E.J. Ilias).
Most diagnoses of malignant tumors of the biliary tree are attained at the advanced stages of the disease, so about 85% of patients with such diseases are not candidates for curative surgical treatment. Due to late diagnosis, jaundice is a very common clinical sign in these patients, which results in the need for drainage of obstructed biliary ducts, as untreated bile stasis can cause intense itching, anorexia, liver dysfunction,
cholangitis and even early death.1
Endoscopic retrograde cholangiopancreatography (ERCP) with biliary stent implantation is the method of choice in the palliative treatment of obstructive jaundice, achieving a success rate of around 90%. However, even in experienced hands, this method fails in approximately 5-10% of cases. If
failure occurs, surgical treatment may be indicated; however, this intervention, when compared to the endoscopic procedure, has 30% and 10% of morbidity and mortality, respectively. The percutaneous transhepatic drainage (PTHD) is also a method of palliative drainage of obstructive jaundice in these patients; however, complications such as biliary fistula, hepatic
abscesses and hemorrhage can occur in up to 30% of cases.2
410
REV ASSOC MED BRAS. 2013;59(5):409-410the intrahepatic and the extrahepatic one; there are three access pathways: transmural, anterograde transpapillary and
retrograde transpapillary ductal access.3
In transmural drainage, a fistulous trajectory is performed between the biliary tree and the lumen of another organ, which may be the stomach or the duodenum. This trajectory is “molded” by a prosthesis, resulting in the flow of bile into the lumen of this organ, decompressing the biliary tree. Antegrade transpapillary drainage is when the prosthesis placement is performed from the echoendoscope channel (using a guide-wire), traversing the biliary duct and leaving through the papilla. Finally, retrograde transpapillary drainage is when the guidewire leaves through the papilla in an anterograde manner; however, the stent is positioned in the biliary tract from a duodenoscope positioned in the duodenum and in front
of the papilla (rendezvous technique).
Echo-guided drainage has shown a technical success of around 90% of cases in addition to a statistically significant improvement in laboratory parameters (total bilirubin and GGT). However, there is a complication rate of around 18%,
which included abdominal pain, bleeding, biliary fistula and stent migration into the abdominal cavity or into the organ lumen.
In summary, one can say that echo-guided biliary drainage is safe and effective, has acceptable complication rates that do not alter the favorable outcome of the procedure, taking into account the severity of the underlying disease.
R E F E R E N C E S
1. Bergasa NV. Medical palliation of the jaundiced patient with pruritus. Gastroenterol Clin North Am. 2006;35:113-23.
2. Kahaleh M, Hernandez AJ, Tokar J, Adams, RB, Shami VM, Yeaton P. Interventional EUS guided cholangiography: evaluation of a technique in evolution. Gastrointest Endosc. 2006;64:52-9. 3. Huibregtse K, Kimmey MB. Endoscopic retrograde
