{"id":8255,"date":"2024-04-25T06:30:00","date_gmt":"2024-04-25T09:30:00","guid":{"rendered":"https:\/\/gastropedia.pub\/pt\/?p=8255"},"modified":"2025-03-03T18:16:07","modified_gmt":"2025-03-03T21:16:07","slug":"impedancio-phmetria-esofagica-principios-tecnicos","status":"publish","type":"post","link":"https:\/\/gastropedia.pub\/pt\/gastroenterologia\/esofago\/impedancio-phmetria-esofagica-principios-tecnicos\/","title":{"rendered":"Imped\u00e2ncio-pHmetria esof\u00e1gica: Princ\u00edpios t\u00e9cnicos"},"content":{"rendered":"<div class=\"pdfprnt-buttons pdfprnt-buttons-post pdfprnt-top-right\"><a href=\"https:\/\/gastropedia.pub\/pt\/wp-json\/wp\/v2\/posts\/8255?print=pdf\" class=\"pdfprnt-button pdfprnt-button-pdf\" target=\"_blank\" ><img decoding=\"async\" src=\"https:\/\/gastropedia.pub\/pt\/wp-content\/plugins\/pdf-print\/images\/pdf.png\" alt=\"image_pdf\" title=\"Ver PDF\" \/><\/a><a href=\"https:\/\/gastropedia.pub\/pt\/wp-json\/wp\/v2\/posts\/8255?print=print\" class=\"pdfprnt-button pdfprnt-button-print\" target=\"_blank\" ><img decoding=\"async\" src=\"https:\/\/gastropedia.pub\/pt\/wp-content\/plugins\/pdf-print\/images\/print.png\" alt=\"image_print\" title=\"Conte\u00fado de impress\u00e3o\" \/><\/a><\/div>\n<p><\/p>\n\n\n\n<p>Em 1991, Silny descreveu t\u00e9cnica para medida da imped\u00e2ncia intraluminal esof\u00e1gica, que permitiu posteriormente o desenvolvimento do cateter de imped\u00e2ncio-pHmetria.<sup>1<\/sup> Para a compreens\u00e3o deste exame, \u00e9 necess\u00e1rio relembrar que imped\u00e2ncia \u00e9 a medida de resist\u00eancia ao fluxo de uma corrente entre dois eletrodos. Logo, quanto maior \u00e9 a condutividade do material pelo qual a corrente passa, menor ser\u00e1 a resist\u00eancia e, consequentemente, menor ser\u00e1 a imped\u00e2ncia.<sup>2<\/sup><\/p>\n\n\n\n<p>O cateter de imped\u00e2ncio-pHmetria (ZpH) tem o mesmo di\u00e2metro que o cateter convencional de pHmetria (2 mm) e apresenta, al\u00e9m do sensor de pH, an\u00e9is met\u00e1licos (eletrodos) que s\u00e3o capazes de registrar a resist\u00eancia ao fluxo (imped\u00e2ncia) \u00e0 corrente entre eles. Desta forma, em cateter padr\u00e3o, observam-se 6 canais (Z1 a Z6, de proximal a distal), sendo que cada um representa um segmento de imped\u00e2ncia el\u00e9trica ao redor do cateter no trecho compreendido entre um par de eletrodos, conforme representado na Figura 1.<sup>2,3<\/sup><\/p>\n\n\n\n<figure class=\"wp-block-image size-large\"><a href=\"https:\/\/gastropedia.pub\/pt\/?attachment_id=8256\"><img fetchpriority=\"high\" decoding=\"async\" width=\"1024\" height=\"743\" src=\"https:\/\/gastropedia.pub\/pt\/wp-content\/uploads\/2024\/04\/arte-1-BR-1024x743.jpeg\" alt=\"\" class=\"wp-image-8256\" srcset=\"https:\/\/gastropedia.pub\/pt\/wp-content\/uploads\/2024\/04\/arte-1-BR-1024x743.jpeg?v=1713261079 1024w, https:\/\/gastropedia.pub\/pt\/wp-content\/uploads\/2024\/04\/arte-1-BR-300x218.jpeg?v=1713261079 300w, https:\/\/gastropedia.pub\/pt\/wp-content\/uploads\/2024\/04\/arte-1-BR-768x557.jpeg?v=1713261079 768w, https:\/\/gastropedia.pub\/pt\/wp-content\/uploads\/2024\/04\/arte-1-BR-1536x1114.jpeg?v=1713261079 1536w, https:\/\/gastropedia.pub\/pt\/wp-content\/uploads\/2024\/04\/arte-1-BR-2048x1486.jpeg?v=1713261079 2048w, https:\/\/gastropedia.pub\/pt\/wp-content\/uploads\/2024\/04\/arte-1-BR-1920x1393.jpeg?v=1713261079 1920w, https:\/\/gastropedia.pub\/pt\/wp-content\/uploads\/2024\/04\/arte-1-BR-1170x849.jpeg?v=1713261079 1170w, https:\/\/gastropedia.pub\/pt\/wp-content\/uploads\/2024\/04\/arte-1-BR-585x424.jpeg?v=1713261079 585w\" sizes=\"(max-width: 1024px) 100vw, 1024px\" \/><\/a><figcaption class=\"wp-element-caption\"><br>Figura 1: Representa\u00e7\u00e3o da estrutura do cateter de imped\u00e2ncio-pHmetria composto por 8 eletrodos que determinam 6 canais de imped\u00e2ncia<\/figcaption><\/figure>\n\n\n\n<p>A imped\u00e2ncia intraluminal esof\u00e1gica \u00e9 baseada na medida das varia\u00e7\u00f5es de resist\u00eancia el\u00e9trica (em Ohms) nestes canais durante a passagem do bolo alimentar. Os l\u00edquidos apresentam alta condutividade e, portanto, baixa resist\u00eancia, sendo detectados pelo decr\u00e9scimo de 50% da imped\u00e2ncia basal. O oposto ocorre com conte\u00fados gasosos, que s\u00e3o identificados pela eleva\u00e7\u00e3o da imped\u00e2ncia basal em 50% <sup>4,5<\/sup><\/p>\n\n\n\n<p>A monitoriza\u00e7\u00e3o dessa imped\u00e2ncia intraluminal esof\u00e1gica possibilita a avalia\u00e7\u00e3o do transporte do bolo alimentar e de todos os tipos de refluxo, seja \u00e1cido ou n\u00e3o.<sup>4,6<\/sup> Na degluti\u00e7\u00e3o, observa-se a varia\u00e7\u00e3o de imped\u00e2ncia primeiro em sensores proximais e posteriormente nos distais, ao passo que no caso do refluxo \u00e9 verificado o oposto devido ao movimento retr\u00f3grado do bolo alimentar. Quando a imped\u00e2ncia \u00e9 associada \u00e0 pHmetria, \u00e9 poss\u00edvel avaliar se o material reflu\u00eddo \u00e9 \u00e1cido (pH &lt; 4), fracamente \u00e1cido (pH entre 4 e 7) ou n\u00e3o-\u00e1cido (pH &gt; 7), conforme est\u00e1 representado nas Figuras 2 e 3.<sup>3-5<\/sup><\/p>\n\n\n\n<figure class=\"wp-block-image size-full\"><a href=\"https:\/\/gastropedia.pub\/pt\/?attachment_id=8258\"><img decoding=\"async\" width=\"951\" height=\"418\" src=\"https:\/\/gastropedia.pub\/pt\/wp-content\/uploads\/2024\/04\/FIGURA-2.png\" alt=\"\" class=\"wp-image-8258\" srcset=\"https:\/\/gastropedia.pub\/pt\/wp-content\/uploads\/2024\/04\/FIGURA-2.png 951w, https:\/\/gastropedia.pub\/pt\/wp-content\/uploads\/2024\/04\/FIGURA-2-300x132.png 300w, https:\/\/gastropedia.pub\/pt\/wp-content\/uploads\/2024\/04\/FIGURA-2-768x338.png 768w, https:\/\/gastropedia.pub\/pt\/wp-content\/uploads\/2024\/04\/FIGURA-2-585x257.png 585w\" sizes=\"(max-width: 951px) 100vw, 951px\" \/><\/a><figcaption class=\"wp-element-caption\">Figura 2:  Identifica\u00e7\u00e3o de refluxo \u00e1cido em exame de imped\u00e2ncio-pHmetria<\/figcaption><\/figure>\n\n\n\n<p><\/p>\n\n\n\n<figure class=\"wp-block-image size-full\"><a href=\"https:\/\/gastropedia.pub\/pt\/?attachment_id=8260\"><img decoding=\"async\" width=\"961\" height=\"443\" src=\"https:\/\/gastropedia.pub\/pt\/wp-content\/uploads\/2024\/04\/FIGURA-3.png\" alt=\"\" class=\"wp-image-8260\" srcset=\"https:\/\/gastropedia.pub\/pt\/wp-content\/uploads\/2024\/04\/FIGURA-3.png 961w, https:\/\/gastropedia.pub\/pt\/wp-content\/uploads\/2024\/04\/FIGURA-3-300x138.png 300w, https:\/\/gastropedia.pub\/pt\/wp-content\/uploads\/2024\/04\/FIGURA-3-768x354.png 768w, https:\/\/gastropedia.pub\/pt\/wp-content\/uploads\/2024\/04\/FIGURA-3-585x270.png 585w\" sizes=\"(max-width: 961px) 100vw, 961px\" \/><\/a><figcaption class=\"wp-element-caption\">Figura 3: Identifica\u00e7\u00e3o de refluxo n\u00e3o-\u00e1cido em exame de imped\u00e2ncio-pHmetria<\/figcaption><\/figure>\n\n\n\n<p>A avalia\u00e7\u00e3o da correla\u00e7\u00e3o de sintomas com refluxo \u00e9 semelhante \u00e0 utilizada na pHmetria convencional. Um sintoma est\u00e1 associado ao refluxo quando for descrito at\u00e9 2 minutos ap\u00f3s este refluxo.<sup>7<\/sup> Os principais \u00edndices utilizados s\u00e3o:<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li><strong>\u00cdndice de sintomas (IS):<\/strong> calcula o percentual de epis\u00f3dios de sintomas relacionados a refluxos durante o estudo (= [N\u00famero de sintomas relacionados ao refluxo x 100] \/ N\u00famero total de sintomas). Um IS acima de 50% \u00e9 considerado uma associa\u00e7\u00e3o positiva entre sintomas e refluxo;<sup>3<\/sup><\/li>\n\n\n\n<li><strong>Probabilidade de Associa\u00e7\u00e3o de Sintomas (PAS):<\/strong> \u00c9 calculado dividindo os dados da monitoriza\u00e7\u00e3o de pH de 24 horas em segmentos consecutivos de 2 minutos. Para cada um desses 2 minutos, \u00e9 determinado se ocorreu refluxo, fornecendo o n\u00famero total de segmentos de 2 minutos com (R+) ou sem (R-) refluxo. Ent\u00e3o, para cada epis\u00f3dio de sintoma, \u00e9 determinado se ocorreu (S+R+) ou n\u00e3o (S+R-) refluxo no per\u00edodo de dois minutos precedente (Figura 4). A subtra\u00e7\u00e3o de S+R+ do total R+ resulta em S-R+ e a subtra\u00e7\u00e3o de S+R- do total de R- resulta em S-R-. Uma tabela 2&#215;2 \u00e9 ent\u00e3o montada, tabulando-se nas colunas o n\u00famero de segmentos com e sem sintomas e nas linhas o n\u00famero de segmentos com e sem refluxo (Tabela 1). O teste exato de Fisher \u00e9 usado para calcular a probabilidade (p) da distribui\u00e7\u00e3o ser ao acaso. A PAS \u00e9 calculada por (1 \u2013 p) x 100%. Por conven\u00e7\u00e3o estat\u00edstica, PAS maior ou igual a 95% significa que h\u00e1 uma associa\u00e7\u00e3o positiva entre sintomas e refluxo. <sup>7,8<\/sup><\/li>\n<\/ul>\n\n\n\n<p>Segundo o Roma IV, estes \u00edndices t\u00eam utilidade na determina\u00e7\u00e3o de pacientes com hipersensibilidade esof\u00e1gica, que seriam aqueles com exposi\u00e7\u00e3o \u00e1cida normal mas associa\u00e7\u00e3o de sintomas positiva.\u0007\u0003<sup>9<\/sup>\b O uso destes escores \u00e9, contudo, limitado, pela baixa quantidade de sintomas reportados durante a monitoriza\u00e7\u00e3o ambulatorial e pela varia\u00e7\u00e3o di\u00e1ria.<sup>10<\/sup><\/p>\n\n\n\n<figure class=\"wp-block-image size-full\"><a href=\"https:\/\/gastropedia.pub\/pt\/?attachment_id=8261\"><img loading=\"lazy\" decoding=\"async\" width=\"961\" height=\"443\" src=\"https:\/\/gastropedia.pub\/pt\/wp-content\/uploads\/2024\/04\/FIGURA-4.png\" alt=\"\" class=\"wp-image-8261\" srcset=\"https:\/\/gastropedia.pub\/pt\/wp-content\/uploads\/2024\/04\/FIGURA-4.png 961w, https:\/\/gastropedia.pub\/pt\/wp-content\/uploads\/2024\/04\/FIGURA-4-300x138.png 300w, https:\/\/gastropedia.pub\/pt\/wp-content\/uploads\/2024\/04\/FIGURA-4-768x354.png 768w, https:\/\/gastropedia.pub\/pt\/wp-content\/uploads\/2024\/04\/FIGURA-4-585x270.png 585w\" sizes=\"(max-width: 961px) 100vw, 961px\" \/><\/a><figcaption class=\"wp-element-caption\">Fonte: Adaptado de Bredenoord et al., 2005.<sup>7<\/sup><br>Figura 4: Representa\u00e7\u00e3o esquem\u00e1tica de tra\u00e7ado de pHmetria para c\u00e1lculo de Probabilidade de Associa\u00e7\u00e3o de Sintomas (PAS).<\/figcaption><\/figure>\n\n\n\n<p>Neste exemplo (Figura 4), existem dois momentos em que o paciente pressionou o bot\u00e3o de sintomas. O primeiro deles \u00e9 precedido de refluxo \u00e1cido (S+R+), ao passo que o segundo n\u00e3o tem associa\u00e7\u00e3o com refluxo (S+R-).<\/p>\n\n\n\n<figure class=\"wp-block-table is-style-regular\"><div class=\"pcrstb-wrap\"><table class=\"has-very-light-gray-to-cyan-bluish-gray-gradient-background has-background\"><tbody><tr><td><\/td><td><\/td><td><br><strong>Sintomas (S)<\/strong><\/td><td><\/td><\/tr><tr><td><\/td><td><\/td><td><br>+<\/td><td><br>&#8211;<\/td><\/tr><tr><td><br><strong>Refluxo (R)<\/strong><\/td><td><br>+<\/td><td><br>S+R+<\/td><td><br>S-R+<\/td><\/tr><tr><td><\/td><td><br>&#8211;<\/td><td><br>S+R-<\/td><td><br>S-R-<\/td><\/tr><\/tbody><\/table><\/div><figcaption class=\"wp-element-caption\"><br>Fonte: Adaptado de Bredenoord et al, 2005 <sup>7<\/sup><br>Legenda: S+R+: Sintoma precedido por refluxo; S+R-: Sintoma n\u00e3o precedido por refluxo; S-R+: Refluxo sem presen\u00e7a de sintomas; S-R-: Aus\u00eancia de refluxo ou de sintoma. <br>Tabela 1 \u2013 Tabela 2&#215;2 para c\u00e1lculo da Probabilidade de Associa\u00e7\u00e3o de Sintomas<\/figcaption><\/figure>\n\n\n\n<p>Outras duas m\u00e9tricas que vem ganhando relev\u00e2ncia na imped\u00e2ncio-phmetria s\u00e3o a <strong>m\u00e9dia noturna basal da imped\u00e2ncia (MNBI)<\/strong> e o <strong>\u00edndice de onda perist\u00e1ltica induzida por degluti\u00e7\u00e3o p\u00f3s-refluxo<\/strong> (\u00edndice <strong>PSPW<\/strong>, sigla j\u00e1 consagrada de <em>post-reflux swallow-induced peristaltic wave<\/em>). Contudo, iremos discutir estes t\u00f3picos em outra postagem futura do Gastropedia!<\/p>\n\n\n\n<p>Por fornecer mais informa\u00e7\u00f5es sobre o refluxo, a <strong>imped\u00e2ncio-pHmetria \u00e9 considerada o m\u00e9todo mais eficiente de monitoriza\u00e7\u00e3o prolongada em DRGE<\/strong>.<sup>13,14<\/sup> No entanto, assim como na pHmetria tradicional, a necessidade de cateter nasal por 24 horas \u00e9 desagrad\u00e1vel para o paciente, acarretando por vezes mudan\u00e7as nos seus h\u00e1bitos di\u00e1rios. Existe ainda a possibilidade de varia\u00e7\u00e3o di\u00e1ria de refluxos e sintomas, reduzindo a sensibilidade do m\u00e9todo.<sup>2,3<\/sup><\/p>\n\n\n\n<blockquote class=\"wp-block-quote has-pale-ocean-gradient-background has-background is-layout-flow wp-block-quote-is-layout-flow\">\n<p>Conhe\u00e7a nosso curso <strong><a href=\"https:\/\/gastropedia.pub\/pt\/cursos\/gastroenterologia-do-consultorio\/\" target=\"_blank\" rel=\"noreferrer noopener\">Gastroenterologia do Consult\u00f3rio<\/a><\/strong> e saiba como lidar com as queixas mais comuns que encontramos no dia a dia<\/p>\n<\/blockquote>\n\n\n\n<h2 class=\"wp-block-heading\" id=\"h-saiba-mais\"><strong>Saiba mais:<\/strong><\/h2>\n\n\n\n<ul class=\"wp-block-list\">\n<li><a href=\"https:\/\/gastropedia.pub\/pt\/gastroenterologia\/esofago\/highlights-sobre-diagnostico-de-doenca-do-refluxo-gastroesofagico-drge-novo-guideline-do-american-college-of-gastroenterology-acg-2022\/\"><\/a><a href=\"https:\/\/gastropedia.pub\/pt\/gastroenterologia\/esofago\/highlights-sobre-diagnostico-de-doenca-do-refluxo-gastroesofagico-drge-novo-guideline-do-american-college-of-gastroenterology-acg-2022\/\" target=\"_blank\" rel=\"noreferrer noopener\">Guideline do American College of Gastroenterology (ACG) 2022<\/a><\/li>\n\n\n\n<li><a href=\"https:\/\/gastropedia.pub\/pt\/gastroenterologia\/esofago\/endoluminal-functional-lumen-imaging-probe-endofliptm-conhecendo-tecnologia-e-seus-potenciais-usos\/\">Endoflip<\/a><\/li>\n\n\n\n<li><a href=\"https:\/\/gastropedia.pub\/pt\/gastroenterologia\/minha-tosse-e-por-causa-do-refluxo\/\">Minha tosse \u00e9 por refluxo?<\/a><\/li>\n<\/ul>\n\n\n\n<h2 class=\"wp-block-heading\" id=\"h-referencias\"><strong>Refer\u00eancias<\/strong><\/h2>\n\n\n\n<ol class=\"wp-block-list\">\n<li>Silny J. Intraluminal Multiple Electric Impedance Procedure for Measurement of Gastrointestinal Motility. J Gastrointest Motil. 1991;3(3):151\u201362.<\/li>\n\n\n\n<li>Patel DA, Vaezi MF. Utility of esophageal mucosal impedance as a diagnostic test for esophageal disease. Curr Opin Gastroenterol. 2017;33(4):277\u201384.<\/li>\n\n\n\n<li>Fontes LHS, Navarro-Rodriguez T, Lages RB, Freitas DGV de, Assiratti FS, Teixeira AC de S. Manual pr\u00e1tico de imped\u00e2ncio-pHmetria esof\u00e1gica. 1st ed. S\u00e3o Paulo: Editora dos Editores; 2020. 88 p.<\/li>\n\n\n\n<li>Herbella FAM, Del Grande JC. Novas t\u00e9cnicas ambulatoriais para avalia\u00e7\u00e3o da motilidade esof\u00e1gica e sua aplica\u00e7\u00e3o no estudo do megaes\u00f4fago. Rev Col Bras Cir. 2008;35(3):199\u2013202.<\/li>\n\n\n\n<li>Sifrim D, Fornari F. Esophageal impedance\u2013pH monitoring. Dig Liver Dis. 2008;40(3):161\u20136.<\/li>\n\n\n\n<li>Sifrim D, Castell D, Dent J, Kahrilas PJ. Gastro-oesophageal reflux monitoring: review and consensus report on detection and definitions of acid, non-acid, and gas reflux. Gut. 2004;53(7):1024\u201331.<\/li>\n\n\n\n<li>Bredenoord AJ, Weusten BLAM, Smout AJPM. Symptom association analysis in ambulatory gastro-oesophageal reflux monitoring. Gut. 2005;54(12):1810\u20137.<\/li>\n\n\n\n<li>Weusten BL, Roelofs JM, Akkermans LM, Van Berge-Henegouwen GP, Smout AJ. The symptom-association probability: an improved method for symptom analysis of 24-hour esophageal pH data. Gastroenterology. 1994;107(6):1741\u20135.<\/li>\n\n\n\n<li>Aziz Q, Fass R, Gyawali CP, Miwa H, Pandolfino JE, Zerbib F. Esophageal Disorders. Gastroenterology. 2016;150(6):1368\u201379.<\/li>\n\n\n\n<li>Vaezi MF, Sifrim D. Assessing Old and New Diagnostic Tests for Gastroesophageal Reflux Disease. Gastroenterology. 2018;154(2):289\u2013301.<\/li>\n\n\n\n<li>Frazzoni M, Savarino E, de Bortoli N, Martinucci I, Furnari M, Frazzoni L, et al. Analyses of the Post-reflux Swallow-induced Peristaltic Wave Index and Nocturnal Baseline Impedance Parameters Increase the Diagnostic Yield of Impedance-pH Monitoring of Patients With Reflux Disease. Clin Gastroenterol Hepatol. 2016;14(1):40\u20136.<\/li>\n\n\n\n<li>Frazzoni L, Frazzoni M, de Bortoli N, Tolone S, Furnari M, Martinucci I, et al. Postreflux swallow-induced peristaltic wave index and nocturnal baseline impedance can link PPI-responsive heartburn to reflux better than acid exposure time. Neurogastroenterol Motil. 2017;29(11):e13116.<\/li>\n\n\n\n<li>Nasi A, Queiroz NSF, Michelsohn NH. Prolonged gastroesophageal reflux monitoring by impedance-pHmetry: a review of the subject pondered with our experience with 1,200 cases. Arq Gastroenterol. 2018;55(Suppl 1):76\u201384.<\/li>\n\n\n\n<li>Marabotto E, Savarino V, Ghisa M, Frazzoni M, Ribolsi M, Barberio B, et al. Advancements in the use of 24-hour impedance-pH monitoring for GERD diagnosis. Curr Opin Pharmacol. 2022 Aug;65:102264.<\/li>\n<\/ol>\n\n\n\n<h2 class=\"wp-block-heading\" id=\"h-como-citar-este-artigo\"><strong>Como citar este artigo<\/strong><\/h2>\n\n\n\n<p class=\"has-very-light-gray-to-cyan-bluish-gray-gradient-background has-background\">Lages RB. Imped\u00e2ncio-pHmetria esof\u00e1gica: Princ\u00edpios t\u00e9cnicos Gastropedia 2024, vol. 1. Dispon\u00edvel em: <a href=\"https:\/\/gastropedia.pub\/pt\/?p=8255\" target=\"_blank\" rel=\"noreferrer noopener\">https:\/\/gastropedia.pub\/pt\/gastroenterologia\/impedancio-phmetria-esofagica-principios-tecnicos<\/a><\/p>\n\n\n\n<p><\/p>\n","protected":false},"excerpt":{"rendered":"<p>Em 1991, Silny descreveu t\u00e9cnica para medida da imped\u00e2ncia intraluminal esof\u00e1gica, que permitiu posteriormente o desenvolvimento do cateter de imped\u00e2ncio-pHmetria.1 Para a compreens\u00e3o deste exame, \u00e9 necess\u00e1rio relembrar que imped\u00e2ncia&hellip;<\/p>\n","protected":false},"author":4165,"featured_media":8256,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_lmt_disableupdate":"","_lmt_disable":"","footnotes":""},"categories":[19,18],"tags":[],"ano":[396],"tipo":[121],"volume":[57],"class_list":["post-8255","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-esofago","category-gastroenterologia","ano-396","tipo-assuntos-gerais","volume-volume-i"],"yoast_head":"<!-- This site is optimized with the Yoast SEO Premium plugin v27.2 (Yoast SEO v27.3) - 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