{"id":2215,"date":"2026-06-09T19:00:00","date_gmt":"2026-06-09T22:00:00","guid":{"rendered":"https:\/\/sevenresiduosaude.com.br\/blog\/?p=2215"},"modified":"2026-06-09T19:00:00","modified_gmt":"2026-06-09T22:00:00","slug":"pgrss-clinica-medicina-cir-oncologica-gastrica-d2-gastrectomia-subtotal-total-esd-her2-trastuzumab","status":"publish","type":"post","link":"https:\/\/sevenresiduosaude.com.br\/blog\/pgrss-clinica-medicina-cir-oncologica-gastrica-d2-gastrectomia-subtotal-total-esd-her2-trastuzumab\/","title":{"rendered":"PGRSS g\u00e1strica D2: gastrec, ESD, HER2"},"content":{"rendered":"

A regula\u00e7\u00e3o brasileira de RSS \u00e9 frequentemente subaproveitada por gestores de cl\u00ednicas de cirurgia oncol\u00f3gica g\u00e1strica que reduzem PGRSS a descarte de bisturi e gaze<\/strong>. Em 2026, h\u00e1 um cen\u00e1rio desafiador \u2014 cl\u00ednicas de cir oncol\u00f3gica g\u00e1strica<\/strong> + gastrectomia subtotal distal D2 + total D2<\/strong> + ESD endoscopic submucosal dissection T1a<\/strong> + CROSS+FLOT neoadjuvante<\/strong> + HER2-positivo trastuzumab Herceptin+pembrolizumab Keytruda KEYNOTE-811<\/strong> + HIPEC peritoneal Mitomicina C<\/strong> geram fluxos heterog\u00eaneos de RSS Grupo A1 (adenoCa intestinal Lauren + difuso + GIST KIT\/PDGFRA + linfoma MALT) + Grupo A4 (linfa D1+D2+D3 perig\u00e1strica+cel\u00edaca+espl\u00eanica+hep\u00e1tica+aorta) + Grupo C (Iridium-192 brachy raro + Y-90 SIRT) + Grupo E (perfuro bi\u00f3psia + ESD + ressectosc\u00f3pio) + HER2 (trastuzumab+pembrolizumab+nivolumab+T-DXd Enhertu Lista C5). A consequ\u00eancia \u00e9 a pr\u00e1tica de cl\u00ednicas que otimizam apenas para gaze cir\u00fargica<\/strong> + ignoram especificidades oncol\u00f3gicas + linfadenectomia D2<\/strong> + subdimensionam HER2 trastuzumab<\/strong> + perdem rastreabilidade tumor g\u00e1strico<\/strong>. A realidade \u00e9 exatamente o oposto. PGRSS g\u00e1strica opera em 5 fluxos oncol\u00f3gicos<\/strong> \u2014 A1 (adenoCa intestinal Lauren 50% + difuso 40% + GIST 5% + linfoma MALT 5%), A4 (linfadenectomia D2 padr\u00e3o Jap\u00e3o+ocidente + 25-30 LN dissecados), C (Iridium-192 brachy raro + Y-90 SIRT + Lu-177 PRRT NET g\u00e1strico), E (ESD Olympus EndoCut + Erbe VIO 300D + IT-knife + Hook-knife), HER2\/imuno (trastuzumab Herceptin + pembrolizumab Keytruda KEYNOTE-811 + nivolumab Opdivo CheckMate-649 + T-DXd Enhertu KEYNOTE-811 Lista C5).<\/p>\n

Para o gestor que opera ou planeja cl\u00ednica de cir oncol\u00f3gica g\u00e1strica, \u00e9 fundamental dimensionar PGRSS espec\u00edfico desde o in\u00edcio.<\/p>\n

Os 5 fluxos oncol\u00f3gicos g\u00e1stricos<\/h2>\n

Em uma opera\u00e7\u00e3o de qualquer porte, o PGRSS g\u00e1strica tem 5 fluxos.<\/p>\n\n\n\n\n\n\n\n\n\n
Fluxo<\/th>\nVolume<\/th>\nFrequ\u00eancia<\/th>\nParticularidade<\/th>\n<\/tr>\n<\/thead>\n
A1 adenoCa+GIST+linfoma<\/td>\n5-14 kg\/dia<\/td>\nDi\u00e1ria<\/td>\nLauren+intest+dif<\/td>\n<\/tr>\n
A4 linfa D2<\/td>\n4-12 kg\/dia<\/td>\nDi\u00e1ria<\/td>\n25-30 LN+cel\u00edaca<\/td>\n<\/tr>\n
C brachy+Y-90+Lu-177<\/td>\n0,4-1,2 kg\/dia<\/td>\nP\u00f3s-procedimento<\/td>\nLDR+SIRT+PRRT<\/td>\n<\/tr>\n
E ESD endosc\u00f3pico<\/td>\n1-3 kg\/dia<\/td>\nDi\u00e1ria<\/td>\nOlympus+Erbe+knives<\/td>\n<\/tr>\n
HER2+imuno Lista C5<\/td>\n1,5-4,5 kg\/dia<\/td>\nP\u00f3s-procedimento<\/td>\nTrast+Keytruda+Enhertu<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

A soma t\u00edpica \u00e9 11,9-34,7 kg\/dia<\/strong> em cl\u00ednica cir oncol\u00f3gica g\u00e1strica m\u00e9dia porte.<\/p>\n

A1 adenoCa Lauren intestinal+difuso + GIST + linfoma MALT: o est\u00e1gio cir\u00fargico<\/h2>\n

A primeira camada do PGRSS g\u00e1strica \u00e9 A1. Padr\u00e3o setorial inclui (a) adenoCa Lauren intestinal 50%<\/strong> com glandular bem-diferenciado + cardiog\u00e1strico + corpo + antro + Helicobacter pylori H. pylori erradica\u00e7\u00e3o prim\u00e1ria; (b) adenoCa Lauren difuso 40%<\/strong> com c\u00e9lulas anel sinete signet-ring + linitis pl\u00e1stica linitis plastica + Krukenberg tumor ov\u00e1rio metastase + CDH1 muta\u00e7\u00e3o heredit\u00e1ria + s\u00edndrome HDGC Hereditary Diffuse Gastric Cancer; (c) GIST 5%<\/strong> com KIT 75-80% + PDGFRA 5-10% + WT 10-15% + tratamento imatinib Glivec primeira linha + sunitinib Sutent + regorafenib Stivarga + ripretinib Qinlock + avapritinib Ayvakit; (d) linfoma MALT 5%<\/strong> com g\u00e1strico associado H. pylori + tratamento erradica\u00e7\u00e3o tripla amoxicilina+claritromicina+omeprazol IBP + R-CHOP rituximab+ciclofosfamida+doxorrubicina+vincristina+prednisona refrat\u00e1rio; (e) estadiamento TNM 8\u00aa edi\u00e7\u00e3o<\/strong> Tis + T1a mucosa + T1b submucosa + T2 muscular + T3 subserosa + T4a serosa + T4b estruturas adjacentes + N0-N3 + M0\/M1.<\/p>\n

Cl\u00ednica com A1 g\u00e1strica madura garante margem R0<\/strong> + previne recidiva peritoneal<\/strong> + otimiza estadiamento Lauren+TNM<\/strong>. Como discutimos no post sobre esof\u00e1gica<\/a>, A1 \u00e9 a base.<\/p>\n

A4 linfadenectomia D2 + gastrectomia subtotal\/total: o est\u00e1gio cir\u00fargico<\/h2>\n

A segunda camada \u00e9 t\u00e9cnica. Padr\u00e3o setorial inclui (a) gastrectomia subtotal distal<\/strong> com 4\/5 est\u00f4mago distal + 1cm proximal margem + reconstru\u00e7\u00e3o Billroth I gastroduodenostomia + Billroth II gastrojejunostomia + Roux-en-Y; (b) gastrectomia total<\/strong> com remo\u00e7\u00e3o completa est\u00f4mago + es\u00f4fago distal + duodeno proximal + reconstru\u00e7\u00e3o Roux-en-Y esofagojejunostomia + jejunoplastia interposi\u00e7\u00e3o + pouch cria\u00e7\u00e3o; (c) linfadenectomia D2 padr\u00e3o<\/strong> com D1 perig\u00e1strica n\u00edvel 1-6 + D2 cel\u00edaca n\u00edvel 7+8a+9+11p+12a + ocidente D2 sem esplenectomia rotina + Jap\u00e3o D2 esplenectomia condicional adenoCa proximal; (d) abordagem cir\u00fargica<\/strong> com aberto via incis\u00e3o xifoumbilical + laparoscopia 5 trocartes + rob\u00f3tica Da Vinci Xi + RAMIE Robot-Assisted gastrectomia; (e) complica\u00e7\u00e3o cir\u00fargica<\/strong> f\u00edstula anastom\u00f3tica 3-10% + hemorragia 5-12% + duodenal stump leak + dumping syndrome 10-30% + alkaline reflux gastritis.<\/p>\n

Cl\u00ednica com A4 D2 madura escala linfadenectomia 25-30 LN<\/strong> + previne f\u00edstula <10%<\/strong> + otimiza retorno alimenta\u00e7\u00e3o<\/strong>. Conex\u00e3o com hospital especializado<\/a>.<\/p>\n

ESD + HER2 trastuzumab + pembrolizumab + T-DXd Enhertu: o est\u00e1gio minimamente invasivo+targeted<\/h2>\n

A terceira camada \u00e9 ESD+HER2+imuno. Padr\u00e3o setorial inclui (a) ESD Endoscopic Submucosal Dissection<\/strong> com Olympus EndoCut Q + Erbe VIO 300D + IT-knife 1+2+nano + Hook-knife + Triangle-tip-knife + Dual-knife J + ressec\u00e7\u00e3o en bloc T1a M1-M3 + cura R0 90+%; (b) HER2-positivo IHC 3+ ou FISH+<\/strong> com trastuzumab Herceptin Roche 6 mg\/kg IV q3w + pembrolizumab Keytruda Merck 200mg IV q3w + capecitabina Xeloda + cisplatina Platinol KEYNOTE-811 1L; (c) PD-L1 CPS\u22655 \/ dMMR-MSI-H<\/strong> com nivolumab Opdivo BMS CheckMate-649 1L FOLFOX + ipilimumab Yervoy + pembrolizumab Keytruda KEYNOTE-859; (d) HER2-positivo 2L T-DXd Enhertu<\/strong> trastuzumab deruxtecan AstraZeneca\/Daiichi Sankyo 6,4 mg\/kg IV q3w DESTINY-Gastric01\/02 + DESTINY-Gastric04 + ILD pneumonite intersticial monitoramento; (e) descarte ESD+HER2+imuno<\/strong> com fragmento ESD ressecado + Lista C5 trastuzumab+pembrolizumab+nivolumab+T-DXd+capecitabina+cisplatina+FOLFOX 5-FU+leucovorin+oxaliplatina + saco amarelo + identifica\u00e7\u00e3o Lista C5 + IHC HER2 padroniza\u00e7\u00e3o ASCO.<\/p>\n

Cl\u00ednica com ESD+HER2+imuno madura escala R0 ESD 90+%<\/strong> + escala HER2-positivo OS 18-25 meses<\/strong> + escala T-DXd 2L OS 12-15 meses<\/strong>. Conex\u00e3o com Lista C5<\/a>.<\/p>\n

Tr\u00eas perfis de PGRSS por capacidade g\u00e1strica<\/h2>\n

Cl\u00ednica g\u00e1strica s\u00f3 A1.<\/strong> 1 fluxo. Custo mensal R$ 9.000-26.000<\/strong> mas perda de A4+C+E+HER2.<\/p>\n

Cl\u00ednica g\u00e1strica A1 + A4 + HER2.<\/strong> 3 fluxos. Custo mensal R$ 22.000-56.000<\/strong>, captura cirurgia + linfa + targeted.<\/p>\n

Cl\u00ednica g\u00e1strica 5 fluxos completos.<\/strong> A1+A4+C+E+HER2 + integra\u00e7\u00e3o com servi\u00e7os hospitalares<\/a>. Custo mensal R$ 40.000-95.000<\/strong>, efic\u00e1cia 95%, ROI 800-2.500% via captura completa g\u00e1strica + R0 ESD 90+% + HER2 targeted.<\/p>\n

Os tr\u00eas erros que aparecem em cir oncol\u00f3gica g\u00e1strica<\/h2>\n

O primeiro \u00e9 a subdimensionamento HER2 Lista C5<\/strong>. Sem segrega\u00e7\u00e3o trastuzumab+pembrolizumab+nivolumab+T-DXd Enhertu + Lista C5 = n\u00e3o-conformidade ANVISA RDC 222 + risco contamina\u00e7\u00e3o cruzada profissional + impacto financeiro.<\/p>\n

O segundo \u00e9 a mistura A1 carcinoma + A4 D2 linfa<\/strong>. Confunde rastreabilidade tumor + impossibilita D2 cel\u00edaca+espl\u00eanica+hep\u00e1tica 25-30 LN + risco subestadiamento.<\/p>\n

O terceiro \u00e9 a falta de protocolo ESD ressec\u00e7\u00e3o en bloc + IHC HER2 padronizado<\/strong>. Sem rastreabilidade Olympus EndoCut+IT-knife + ASCO HER2 padroniza\u00e7\u00e3o = perda R0 + risco recidiva + zero indica\u00e7\u00e3o targeted.<\/p>\n

A regula\u00e7\u00e3o de PGRSS g\u00e1strica no Brasil est\u00e1 em fase de moderniza\u00e7\u00e3o t\u00e9cnica acelerada com cir oncol\u00f3gica preservadora como prioridade. As institui\u00e7\u00f5es que estruturam fluxos completos desde o in\u00edcio \u2014 alinhadas com PGRSS cl\u00ednicas especializadas<\/a> \u2014 atravessam o crescimento sem solavanco. Para gestores que precisam alinhar com gest\u00e3o paralela industrial, o portal Seven Res\u00edduos sobre servi\u00e7os completos<\/a> traz a perspectiva integrada. A INCA C\u00e2ncer Est\u00f4mago<\/a> \u00e9 refer\u00eancia t\u00e9cnica nacional.<\/p>\n

Solicite cota\u00e7\u00e3o PGRSS g\u00e1strica 5 fluxos oncol\u00f3gicos<\/a><\/strong> \u2014 cap\u00edtulo dedicado a A1 adenoCa Lauren intestinal 50%+difuso 40% Krukenberg+linitis pl\u00e1stica+CDH1 HDGC+GIST KIT+PDGFRA imatinib Glivec+sunitinib+regorafenib+ripretinib+avapritinib+linfoma MALT R-CHOP+CID C16+TNM 8\u00aa, A4 gastrectomia subtotal Billroth I+II+Roux-en-Y+gastrectomia total+linfadenectomia D2 padr\u00e3o Jap\u00e3o\/ocidente 25-30 LN+laparoscopia+rob\u00f3tica Da Vinci Xi+RAMIE+f\u00edstula 3-10%+dumping 10-30%, C brachy raro+Y-90 SIRT+Lu-177 PRRT NET g\u00e1strico, E ESD Olympus EndoCut Q+Erbe VIO 300D+IT-knife 1+2+nano+Hook-knife+Triangle-tip+Dual-knife J+R0 90+%, HER2 trastuzumab Herceptin+pembrolizumab Keytruda KEYNOTE-811+nivolumab Opdivo CheckMate-649+T-DXd Enhertu DESTINY-Gastric01\/02+capecitabina Xeloda+cisplatina+FOLFOX+ipilimumab Yervoy Lista C5.<\/p>\n","protected":false},"excerpt":{"rendered":"

PGRSS oncologia g\u00e1strica: gastrectomia D2 + ESD + HER2 trastuzumab. Veja.<\/p>\n","protected":false},"author":3,"featured_media":2214,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[7],"tags":[2712,2844,3046,3047],"class_list":["post-2215","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-compliance-legislacao","tag-cirurgia-oncologica","tag-gastrectomia","tag-gastrica","tag-her2"],"_links":{"self":[{"href":"https:\/\/sevenresiduosaude.com.br\/blog\/wp-json\/wp\/v2\/posts\/2215","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/sevenresiduosaude.com.br\/blog\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/sevenresiduosaude.com.br\/blog\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/sevenresiduosaude.com.br\/blog\/wp-json\/wp\/v2\/users\/3"}],"replies":[{"embeddable":true,"href":"https:\/\/sevenresiduosaude.com.br\/blog\/wp-json\/wp\/v2\/comments?post=2215"}],"version-history":[{"count":1,"href":"https:\/\/sevenresiduosaude.com.br\/blog\/wp-json\/wp\/v2\/posts\/2215\/revisions"}],"predecessor-version":[{"id":4331,"href":"https:\/\/sevenresiduosaude.com.br\/blog\/wp-json\/wp\/v2\/posts\/2215\/revisions\/4331"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/sevenresiduosaude.com.br\/blog\/wp-json\/wp\/v2\/media\/2214"}],"wp:attachment":[{"href":"https:\/\/sevenresiduosaude.com.br\/blog\/wp-json\/wp\/v2\/media?parent=2215"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/sevenresiduosaude.com.br\/blog\/wp-json\/wp\/v2\/categories?post=2215"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/sevenresiduosaude.com.br\/blog\/wp-json\/wp\/v2\/tags?post=2215"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}