Infectious complications in head and neck surgery: Porto Oncology Centre retrospective analysis

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true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "6" "paginaFinal" => "15" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Miguel Sá Breda, Joaquim Castro Silva, Eurico Monteiro" "autores" => array:3 [ 0 => array:4 [ "nombre" => "Miguel" "apellidos" => "Sá Breda" "email" => array:1 [ 0 => "miguelbreda@gmail.com" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Joaquim" "apellidos" => "Castro Silva" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "Eurico" "apellidos" => "Monteiro" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Otorhinolaryngology Department, Instituto Português de Oncologia do Porto Francisco Gentil, E.P.E, Portugal" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Otorhinolaryngology & Head and Neck Department, Hospital de Braga, Portugal" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Complicaciones infecciosas en cirugía de cabeza y cuello: análisis retrospectivo del Instituto de Oncología de Porto" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 754 "Ancho" => 2083 "Tamanyo" => 75753 ] ] "descripcion" => array:1 [ "en" => "Binary logistic regression – independent factors for more than 30 days of inpatient stay." ] ] ] "textoCompleto" => "IntroductionSurgical site infection arousal has been reported after head and neck oncologic surgeries involving clean operations (like in thyroidectomy), clean-contaminated operations (like pharyngectomy or laryngectomy), and, as we could expect in contaminated injuries (active inflammation and/or violation of sterile technique) or dirty injuries (purulent active inflammation).<a class="elsevierStyleCrossRef" href="#bib0120">1</a> Despite the best preoperative care, meticulous surgical technique and careful postoperative management, complications frequently occur in head and neck cancer patients,<a class="elsevierStyleCrossRef" href="#bib0125">2</a> who often present multiple comorbidities predisposing to the development of infectious complications, namely malnutrition, advanced age, anemia and diabetes mellitus.<a class="elsevierStyleCrossRef" href="#bib0130">3</a> In addition, previous treatment with radiotherapy, associated or not with chemotherapy, increases the risk of surgical site infection and fistula formation.<a class="elsevierStyleCrossRef" href="#bib0135">4</a> These complications will increase hospitalization length, and associated health costs, delaying or canceling adjuvant treatment options, and, in this way, worsening clinical outcomes as well as patients’ quality of life.<a class="elsevierStyleCrossRefs" href="#bib0130">3,5</a> It is well known the positive impact of prevention, early recognition and timely introduction of properly treatment in the oncological results.The aim of this work was to perform a retrospective analysis of the impact of infectious status and microbiology in postoperative period of major neck surgeries, in a tertiary oncology center.Materials and methodsStudy design and patient selectionWe performed a single-center retrospective cohort study, including all consecutive patients who developed infectious complications after inaugural major neck cancer surgery, from October 2012 to May 2016 (44 months).Patients who underwent transoral laser microsurgery, diagnostic laryngoscopy or other minor surgical procedures of the oral cavity and oropharynx were excluded from the study. There were no hospital transfers during the studied period.Data collectionThe following data was collected from medical records: gender and age, tumor location, TNM stage,<a class="elsevierStyleCrossRef" href="#bib0145">6</a> type of complication, other medical comorbidities, American Society of Anesthesiologists (ASA) score, body mass index (BMI), alcohol and tobacco consumption, pre and postoperative hemoglobin levels (Hb), albumin serum levels (Alb), prior radio and/or chemotherapy, hospitalization length, isolated microbiological agents and mortality associated with complications.Normal course of preoperative and postoperative carePrior to admission, all patients were screened for Meticilin-Resistant Staphylococcus aureus (MRSA) infection, through nasal swab examination. Patients whose operations involve mucosal opening (clean contaminated wounds) received prophylactic antibiotic therapy (second generation cephalosporin – cefazolin 1g – associated with clindamycin – 600mg), started 1h before surgery and repeated in three doses postoperatively. In all cases the prophylaxis was extended because of the infectious complication, and the antibiotic was adapted to microbiology sensitivity.All surgeries were performed by surgeons with more than ten years of experience. Before initiating surgical procedure, surgical field was disinfected twice with povidone-iodine solution. Before wound closing, all surgical sites were irrigated with a sufficient amount of warm saline. The diagnosis of pharyngocutaneous fistula (PCF), surgical site infection and necrosis of the flap or skin was based on clinical features. In the presence of exudates, a sample was collected for microbiological examination and sensitivity test to the antibiotic. In cases of nosocomial respiratory infection, a microbiological examination of sputum was required.Statistical analysisStatistical analysis was performed using the Statistical Package for Social Sciences® software version 22. Categorical variables are presented as frequencies and percentages, and continuous variables as means and standard deviations. Normal distribution was checked using Shapiro–Wilk test or skewness and kurtosis. Categorical variables were compared with the use of Fisher's exact test or the chi-square test, as appropriate. All reported p values were two-tailed, with p value below 0.05 indicating statistical significance. After the inpatient stay analysis, we used multiple linear regression to verify the correlation between complication and hospitalization length. With the binary logistic regression, we aimed to know the relative risk of each main complication occurred so as to predict more than 30 days of hospitalization. Two groups of patients were established, having 30 days of inpatient stay as a cut-off. We defined as exposition factor the most frequent infectious complications occurred (flap/cutaneous necrosis, pharyngocutaneous fistula, surgical wound infection and nosocomial pneumonia), and the outcome (adverse event) as 30 or more days of inpatient stay. Then we resorted to a binary logistic regression model to determine the relative risk of possible predictors (the infectious complications occurred) that can lead to more than 30 days of inpatient stay (relative risk and their 95% confidence intervals were reported).ResultsSample characterizationIn the selected period, 761 major neck surgeries were performed. Among these, 96 patients had complications (12.6%). The sample was composed of 95% males and 5% females, with a mean age of 57 years. All patients had squamous cell carcinoma. Topographical distribution, local (T), node (N), metastases (M) staging, and ASA score are summarized in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>. Notice that almost 90% of our sample had locally advanced tumors (T3 and T4), and about 73% of these tumors were distributed between hypopharynx (46%) and larynx (27%).<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>In 81% of the cases, patients were submitted to surgery as primary treatment and in 30% of the surgeries there was a reconstructive component (overall, a regional pedicled myocutaneous flap was performed). 85% of the performed surgeries were associated to pharyngeal mucosa disruption.Observed complications are summarized in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>. PCF was the most frequent complication (56%; n=54). The most common systemic complication was nosocomial pneumonia (23%; n=22).<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>Twenty-six species of microorganisms were isolated, being Pseudomonas aeruginosa the leading one (15%; n=18). The rate of multidrug-resistant bacteria (MRSA and Acinectobacter) was of about 12% (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>).<elsevierMultimedia ident="tbl0015"></elsevierMultimedia>All patients extended prophylaxis because of infectious complication. As we stated in <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>, most frequent used antibiotics after microbiology sensitivity test were amoxicillin/acid clavulanic (18%), followed by piperacillin/tazobactam (13%) and ciprofloxacin (11%). Among the used antibiotics, 42% had anti-Pseudomonas activity (piperacillin/tazobactam, ciprofloxacin, gentamicin, amikacin, colistin, ceftazidime and imipenem).<elsevierMultimedia ident="fig0005"></elsevierMultimedia>In our series, 12 deaths (12.5%) were registered. Seven patients died of progression of oncologic disease itself, 3 died of nosocomial pneumonia and, finally, 2 died of sepsis.Analyzing comorbidities/habitsIn our sample, the mean BMI was 21.6kg/m2, and the mean Alb serum level was 3.0g/dL. The mean preoperative Hg level was 13.2g/dL and the postoperative was 9.5g/dL. This difference was statistically significant (t-test paired samples; p value<0.0001).The most commons comorbidities were arterial hypertension (40%) and dyslipidemia (32%), followed by chronic obstructive lung disease (28%), diabetes mellitus (10%), and a minority (9%) had a status pos-stroke. 51% of the patients had 3 or more comorbidities, being in line with the obtained values in the ASA score, 40% had 2 comorbidities, 8% had 1 comorbidity, and only 1% had no comorbidities. In what concerns patients’ habits, 93.8% were active smokers, and 66.7% were alcoholic.Analyzing complicationsAt the first analysis phase (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>), we observed the complications occurred crossed by the tumor T stage and type of surgical procedure (χ2 test). Here, all the principal complications were not statistically significant, except for nosocomial pneumonia occurrence, which showed a positive linkage to higher T stages, in our sample T3 stage (p<0.0001). When we attended to the main surgical procedures performed (χ2 test), we realized that there was a positive association between PCF and total pharyngo and laryngectomy (p<0.0001), as well as a linkage between COMMANDO procedure and flap or cutaneous necrosis (p=0.01). There was also a statistically significant positive association between total laryngectomy and nosocomial pneumonia occurrence (p=0.009).At a second phase (<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>), we analyzed the main complications observed, crossed by the main variables studied (χ2 test and Fisher's exact test as appropriated), and there, we verified a positive association, with statistical relevance, between reconstructive surgery and flap/cutaneous necrosis, and between lower BMI and PCF. Note that in the 5 cases where flap/cutaneous necrosis occurred, when reconstructive surgery was performed, 3 cases concerned reconstructive flap necrosis, and 2 cases concerned skin/cutaneous necrosis (not from the reconstructive flap). All the other studied variables did not obtain statistical relevance. Nevertheless, complications happened no matter the treatment modality, and patients with lower BMI and hypoAlb, as well as with pre-operative anemia, had more complications, as expected.<elsevierMultimedia ident="tbl0020"></elsevierMultimedia>When we analyzed the isolated microorganisms through the 4 main complications, we verified that except for PCF, in which Klebsiella pneumoniae was the leading specie, in all others complications the principal isolated specie was P. aeruginosa, foremost being the more frequent isolated specie in our sample, as we have already stated (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).<elsevierMultimedia ident="fig0010"></elsevierMultimedia>Inpatient stayIn our series, the mean time of hospitalization was 34.6 days (minimum 7 days, and maximum 99 days). Almost all of the patients (n=92) were admitted in the immediate post-op period in the Intermediate Care Unit, with a mean time of 2.7 days (minimum 1 day, and maximum 12 days). Some of the patients needed to stay in an Intensive Care Unit (n=9), there spending a mean period of 6 days (minimum 1 day, and maximum 20 days). The majority of patients entered the Intensive Care Unit directly from the infirmary, or after complication in the Intermediate Care Unit. A minority went directly from the Operating Room to Intensive Unit, and after stabilization made a downstage until reaching the infirmary.Complication impact in hospitalization lengthTo address this issue, we recurred to a multiple linear regression and we concluded that flap/cutaneous necrosis and PCF were complications with statistical significance that extended inpatient stay (<a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>).<elsevierMultimedia ident="tbl0025"></elsevierMultimedia>Relative risks for more than 30 days of inpatient stayThe binary logistic regression analysis showed that PCF and flap/cutaneous necrosis were linked to more than 30 days of hospitalization (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).<elsevierMultimedia ident="fig0015"></elsevierMultimedia>DiscussionHead and neck cancer represents the 5th cause of death related to cancer, primarily affecting males, a trend that was verified in our series.<a class="elsevierStyleCrossRef" href="#bib0150">7</a>Tobacco and alcohol consumption are the main risk factors for head and neck cancer development.<a class="elsevierStyleCrossRefs" href="#bib0150">7,8</a> In the present study, it was observed that the majority of patients held these two kinds of addictive behaviors.PCF was the principal complication observed in this review (56%). The PCF rate varies widely in the literature (3–65%),<a class="elsevierStyleCrossRef" href="#bib0160">9</a> so our data is in this range. There are several studies trying to identify the risk factors for the PCF occurrence. However, so far, no consensus has been achieved by the authors.<a class="elsevierStyleCrossRefs" href="#bib0130">3–5</a> Total pharyngo/laryngectomy, previous radiotherapy treatment, with or without chemotherapy, tumor location, perioperative anemia, hypoAlb, positive surgical margins, concurrent neck dissection, prior tracheotomy, and the presence of medical comorbidities, such as diabetes mellitus, are some of identified risk factors for PCF occurrence.<a class="elsevierStyleCrossRefs" href="#bib0130">3–5</a> In our series, we obtained a positive statistical association between this complication and total pharyngo/laryngectomy procedure, as we could already expect, as well as lower BMI, which reinforces the importance of patient systemic optimization as well as the overall nutritional status before surgery.Serum Alb has traditionally been used as a nutritional marker status.<a class="elsevierStyleCrossRef" href="#bib0165">10</a> Due to its relatively long half-life of approximately 21 days, Alb is a reliable marker for chronic nutrition status in critically ill patients,<a class="elsevierStyleCrossRef" href="#bib0165">10</a> and low serum Alb (<3.0g/dL) is associated with protein malnutrition, and is also predictive of poor surgical outcome and infectious postoperative complications, such as wound abscess and sepsis.<a class="elsevierStyleCrossRef" href="#bib0165">10</a> Also, it has been reported that patients with a weight loss of more than 10% during the 6 months before surgery are at greater risk for major surgical complications.<a class="elsevierStyleCrossRef" href="#bib0170">11</a> More recently, Gourin et al. concluded that weight loss was associated with increased medical and surgical complications and, therefore, with longer hospital stay and higher overall costs.<a class="elsevierStyleCrossRef" href="#bib0175">12</a> Malnutrition has been shown to be associated with immunoincompetence, which may be one obvious reason for infection susceptibility.<a class="elsevierStyleCrossRef" href="#bib0180">13</a> In this study, there was a mean BMI of 21.6kg/m2 and a mean serum Alb level of 3.0g/dL, both of these values being significantly lower than the normal (t-test – p value<0.0001). These results reflect the level of malnutrition of our patients, which may have contributed to the occurrence of such complications. Several factors contribute to malnutrition, in particular: the presence of poor dietary habits, detrimental lifestyle factors such as smoking and alcohol consumption, reduced oral ingestion due to odynophagia and dysphagia secondary to neoplasia and secretion of cachexia inducing cytokines such as interleukin I, α-tumor necrosis factor and γ-interferon.<a class="elsevierStyleCrossRefs" href="#bib0185">14,15</a> Also, it is well known malnutrition associated morbidities, such as<a class="elsevierStyleCrossRef" href="#bib0195">16</a>: delayed wound healing, impaired cardiac and respiratory function, depression, cachexia, increased risk of overall postoperative complications, and increased mortality rate. In our institution, all patients are evaluated by a nutritionist with implementation of dietary supportive measures to correct any nutritional deficit. Nevertheless, we should reflect on our results, and try to improve this issue with more pre and postoperative nutritional consultations and implementation of anticipatory support measures, such as percutaneous endoscopic gastrostomy and nasogastric feeding, as soon as there is a predictable worsening of overall nutritional status. So, a nutritional screening program becomes essential to prevent and conduct patients in risk to an early nutritional intervention program,<a class="elsevierStyleCrossRef" href="#bib0190">15</a> because it is well proved that perioperative nutritional support may reduce morbidity and mortality.<a class="elsevierStyleCrossRefs" href="#bib0180">13,15,17</a> In order to be effective with nutritional support and to influence clinical outcomes, patients should receive nutrition concealing for 7–15 days before surgery.<a class="elsevierStyleCrossRef" href="#bib0205">18</a>We found a statistically significant reduction in the Hb levels between pre and postoperative periods. The occurrence of postoperative anemia reflects longer and more extensive surgery and it is associated with less healing capacity.<a class="elsevierStyleCrossRef" href="#bib0210">19</a> Postoperative anemia also correlates with intraoperative blood transfusion, but this variable was not considered in this study. In our institution, all patients are subjected to serial analytical controls with monitoring of Hb values. The decision to perform blood transfusion depends on the Hb value, on the patient's general condition and on the presence of cardiovascular comorbidities.Also, our statistical analysis showed a positive association between nosocomial pneumonia occurrence and higher T stages, as well as with total laryngectomy procedure. We think that this result is due to a pro-inflammatory and unbalanced immune status that characterizes a higher tumor stage, as we have already mentioned. On the other hand, it does not come as a surprise that a major airway surgical procedure can be linked to this complication. In the postoperative period these patients have to adapt to a new condition, and in this transition period, respiratory aspirations episodes can occur, and hence the development of a pneumonia.<a class="elsevierStyleCrossRef" href="#bib0215">20</a> Other fact to add is that the COMMANDO's postoperative period was linked to a higher incidence of flap/cutaneous necrosis. We think that one possible reason is that the level of surgical field exposure to a contaminated ambient, like oral flora, is higher. Furthermore, the surgical wound is more complex, increasing the possibility of complication outcome. Nevertheless, we should be very cautious in what concerns the interpretation of this result because the number of cases is too small and, in addition, we did not have a control group.In our series, patients with flap or cutaneous necrosis as well as with PCF had a statistical impact in what concerns the extension of inpatient stay compared to patients with other type of complications. These patients often require revision surgery with further reconstruction with local, regional or microvascularized flaps, which could explain this result. We support this conclusion based on the binary logistic regression, which clearly corroborate that PCF and flap or cutaneous necrosis occurrence had higher and statistically significant relative risk for more than 30 days of hospitalization.The isolated microorganisms in this study were similar to other previously published,<a class="elsevierStyleCrossRef" href="#bib0160">9</a>P. aeruginosa being the leading specie. Considering the multidrug-resistant bacteria, our result (more than 10%) was higher than the published by Kamizono et al.<a class="elsevierStyleCrossRef" href="#bib0220">21</a> and Hirakawa et al.<a class="elsevierStyleCrossRef" href="#bib0225">22</a> – 3% and 7%, respectively. Regarding antibiotic therapy, we can conclude that was a reflex of the leading specie isolated, having almost half of the antibiotics used (42%) anti-Pseudomonas activity. The frequency of isolation of this agent (18 patients – 15%) is practically half of the frequency in which antibiotics with activity against Pseudomonas were used. The possible reason for this is due to the fact that in 6 of the 18 patients with Pseudomonas it was necessary to use more than one directed antibiotic, which explains the observed discrepancy. Another fact to add is that Pseudomonas infection susceptibility is well recognized among diabetic patients, and there is one report<a class="elsevierStyleCrossRef" href="#bib0230">23</a> that proves a statistically significant association between neck surgical wound infection and diabetes. Nevertheless, we reinforce that in our sample (all with infectious complications) only 10% were diabetic, and among these patients the principal isolated species were Enterobacteriaceae and MRSA. In spite of this fact, other studies failed to prove that diabetes itself could be a risk factor to surgical site infection occurrence,<a class="elsevierStyleCrossRefs" href="#bib0160">9,21,22</a> which demonstrates that a multiplicity of factors contribute to infectious complications, and, like in this tertiary oncologic center, there is a multidisciplinary team-work, with Internal Medicine optimization, which minimizes these patients’ potential risks.The main limitations of this study are those inherent to a retrospective analysis and selection bias of the patients, because we only selected one group with infectious complications. Even so, it is reinforced that our sample is similar to others already studied, concerning tumor staging and performed surgeries.<a class="elsevierStyleCrossRefs" href="#bib0220">21,22</a> We did not use a wound infection scale, like Tabet et al.,<a class="elsevierStyleCrossRef" href="#bib0120">1</a> because in a retrospective analysis like ours, it is difficult to be sure and systematic of certain aspects, such as the dimension of infection, and this scale<a class="elsevierStyleCrossRef" href="#bib0120">1</a> does not include a grade for necrosis, which we think should be included. Nevertheless, when planning a prospective analysis of this subject, we must definitively consider to include an updated wound evaluation scale, based on Tabet,<a class="elsevierStyleCrossRef" href="#bib0120">1</a> in order to achieve more objectivity and reproducibility.ConclusionsP. aeruginosa was the principal specie isolated in the infectious complications of neck major surgery. PCF and flap or cutaneous necrosis worsened outcomes, clearly being linked to lengthening of inpatient stay. Prevention and early recognition of these complications seem to be essential to optimize clinical oncologic results.Ethical standardsAll ethical issues were properly fulfilled and are in line with European law.Financial disclosureAuthors have no financial relationships relevant to this article to disclose.Conflict of interestThe authors declare no conflict of interests." "textoCompletoSecciones" => array:1 [ "secciones" => array:14 [ 0 => array:3 [ "identificador" => "xres1138403" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1069912" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xpalclavsec1069910" "titulo" => "Abbreviations" ] 3 => array:3 [ "identificador" => "xres1138404" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] 4 => array:2 [ "identificador" => "xpalclavsec1069911" "titulo" => "Palabras clave" ] 5 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 6 => array:3 [ "identificador" => "sec0010" "titulo" => "Materials and methods" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Study design and patient selection" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Data collection" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Normal course of preoperative and postoperative care" ] 3 => array:2 [ "identificador" => "sec0030" "titulo" => "Statistical analysis" ] ] ] 7 => array:3 [ "identificador" => "sec0035" "titulo" => "Results" "secciones" => array:6 [ 0 => array:2 [ "identificador" => "sec0040" "titulo" => "Sample characterization" ] 1 => array:2 [ "identificador" => "sec0045" "titulo" => "Analyzing comorbidities/habits" ] 2 => array:2 [ "identificador" => "sec0050" "titulo" => "Analyzing complications" ] 3 => array:2 [ "identificador" => "sec0055" "titulo" => "Inpatient stay" ] 4 => array:2 [ "identificador" => "sec0060" "titulo" => "Complication impact in hospitalization length" ] 5 => array:2 [ "identificador" => "sec0065" "titulo" => "Relative risks for more than 30 days of inpatient stay" ] ] ] 8 => array:2 [ "identificador" => "sec0070" "titulo" => "Discussion" ] 9 => array:2 [ "identificador" => "sec0075" "titulo" => "Conclusions" ] 10 => array:2 [ "identificador" => "sec0080" "titulo" => "Ethical standards" ] 11 => array:2 [ "identificador" => "sec0085" "titulo" => "Financial disclosure" ] 12 => array:2 [ "identificador" => "sec0090" "titulo" => "Conflict of interest" ] 13 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2017-08-30" "fechaAceptado" => "2017-11-26" "PalabrasClave" => array:2 [ "en" => array:2 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1069912" "palabras" => array:5 [ 0 => "Surgical site infection" 1 => "Head and neck cancer" 2 => "Post-operative period" 3 => "Microbiology" 4 => "Pharyngocutaneous fistula" ] ] 1 => array:4 [ "clase" => "abr" "titulo" => "Abbreviations" "identificador" => "xpalclavsec1069910" "palabras" => array:6 [ 0 => "Alb" 1 => "ASA" 2 => "BMI" 3 => "Hb" 4 => "MRSA" 5 => "PCF" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1069911" "palabras" => array:5 [ 0 => "Infección De La Herida Quirúrgica" 1 => "Cáncer De Cabeza Y Cuello" 2 => "Período Postoperatorio" 3 => "Microbiología" 4 => "Fístula Faringocutánea" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "ObjectiveTo analyze the impact of infectious complications and microbiology in the postoperative period after major oncologic neck surgeries. MethodsA retrospective study conducted in an oncology center, including all the consecutive patients who developed infectious complications after major neck cancer surgery, from October 2012 to May 2016 (44 months). Among other data, we collected TNM stage, ASA score, body mass index, comorbidities and habits, pre and postoperative hemoglobin levels, albumin serum levels, pre-surgical treatments, length of inpatient stay, isolated microbiological agents and the recorded complications and mortality rate. ResultsIn the studied period, 761 major neck surgeries were performed. Of these, 96 patients had complications (12.6%). Pharyngocutaneous fistula (PCF) was the most frequent complication (56%) and nosocomial pneumonia was the most common systemic complication (23%). Pseudomonas aeruginosa was the principal microorganism of the 26 species isolated (15%). 12 deaths were registered. Using multiple linear regression we concluded that flap/cutaneous necrosis and PCF were complications with statistical significance that prolonged inpatient stay. The same complications had significant relative risk for more than 30 days of hospitalization. ConclusionThe postoperative period is critical for the successful treatment of head and neck oncology patients. PCF and flap/cutaneous necrosis were the principal complications which worsened the outcomes during this critical period. The early recognition and treatment of these complications is crucial." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "ObjetivoAnalizar el impacto de las complicaciones infecciosas en el período posoperatorio de las cirugías oncológicas mayores de cabeza y cuello, y estudio de los agentes microbianos implicados. MétodosEstudio retrospectivo realizado en un instituto oncológico, en pacientes que desarrollaron complicaciones infecciosas después de la cirugía oncológica mayor de cuello, entre octubre de 2012 y mayo de 2016 (44 meses). Entre otros se recogieron el estadio TNM, la puntuación ASA, el índice de masa corporal, las comorbilidades, los hábitos tóxicos, los niveles de hemoglobina pre y postoperatoria, los niveles séricos de albúmina, los tratamientos previos a la cirugía, la duración de la hospitalización y los microorganismos aislados, así como las complicaciones sufridas y la tasa de mortalidad. ResultadosEn este período se realizaron 761 cirugías cervicales mayores. De estas, 96 pacientes presentaron complicaciones (12,6%). Las que con mayor frecuencia se registraron fueron la fístula faringocutánea (FFC) (56%) y la neumonía nosocomial (23%). Fueron aislados 26 tipos de microorganismos, siendo la Pseudomonas aeruginosa la más frecuente (15%). Se registraron 12 fallecimientos. Tras el estudio estadístico con regresión lineal múltiple, se detecta que la necrosis cutánea o del colgajo y la FFC fueron las complicaciones con un mayor impacto estadístico en la estancia hospitalaria. Asimismo, fueron los factores que más influyeron en las hospitalizaciones de 30 días o más. ConclusiónUna buena evolución durante el período postoperatorio es fundamental para obtener éxito en el tratamiento de los pacientes oncológicos de cabeza y cuello. La FFC y la necrosis de colgajo o cutánea constituyeron las principales complicaciones con un mayor impacto en los resultados obtenidos. La detección precoz de estas complicaciones, así como su tratamiento, son cruciales." 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"tablatextoimagen" => array:2 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Sample size (n)=96 \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Male \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">95% – (91) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Female \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5% – (5) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Age (mean±s.d.) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">57±9.4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Min \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">37 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Max \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">81 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Tumor location % – (n)</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hypopharynx \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">45.8% – (44) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Larynx \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">27.1% – (26) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Oropharynx \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">11.5% – (11) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Tongue \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10.4% – (10) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Oral cavity \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5.2% – (5) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Mortality % – (n) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12.5% – (12) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">TNM stage</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">T – % – (n) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1% – (1) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10.4% – (10) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">38.5% – (37) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">50% – (48) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">N – % – (n) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">29.2% – (28) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">18.8% – (18) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">49% – (47) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3.1% – (3) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">M – % – (n) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">97.9% – (94) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2.1% – (2) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">ASA stage</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">% – (n) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">I \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">13.5% – (13) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">II \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">43.8% – (42) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">III \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">41.7% – (40) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">IV \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1% – (1) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Treatment modality \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Primary surgery \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">81% – (78) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pre-RT \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">18.8% – (18) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pre-chemo \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">16.7% – (16) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Performed surgeries</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Total pharyngolaryngectomy+ND \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">37% – (36) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Total laryngectomy+ND \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">34% – (33) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Bucopharyngectomy+ND \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8% – (8) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">COMMANDO+ND \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6% – (6) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">ND \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">15% – (14) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pharyngeal mucosa disruption \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">85% – (82) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Surgery with reconstructive flap (all regional pedicled myocutaneous flap) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">30% – (29) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1942551.png" ] ] 1 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top">Other data</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">BMI – kg/m2(mean) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">21.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">p<0.0001<a class="elsevierStyleCrossRef" href="#tblfn0005">*</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Alb – g/dL (mean) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">p<0.0001<a class="elsevierStyleCrossRef" href="#tblfn0010">**</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Preoperative Hg – g/dL (mean) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">13.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " rowspan="2" align="left" valign="middle">p<0.0001<a class="elsevierStyleCrossRef" href="#tblfn0015">***</a></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Postoperative Hg – g/dL (mean) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9.5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Inpatient stay – days (mean) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " colspan="2" align="left" valign="top">34.6</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1942557.png" ] ] ] "notaPie" => array:3 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "*" "nota" => "Simple T-test (ref. value 25kg/m2)." ] 1 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "**" "nota" => "Simple T-test (ref. value 3.8g/dL)." ] 2 => array:3 [ "identificador" => "tblfn0015" "etiqueta" => "***" "nota" => "T-Test paired samples." ] ] ] "descripcion" => array:1 [ "en" => "Sample characterization." ] ] 4 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "ND, neck dissection; ns, non-significant; PCF, pharyngocutaneous fistula." "tablatextoimagen" => array:2 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Complications frequency – % – (n)</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " rowspan="5" align="left" valign="top">Local</td><td class="td" title="table-entry " align="left" valign="top">PCF \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">56% – (54) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Surgical wound infection \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">37% – (35) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Flap or cutaneous necrosis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5% – (5) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Cervical abscess \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2% – (2) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Thoracic duct fistula \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1% – (1) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="3" align="left" valign="top">Systemic</td><td class="td" title="table-entry " align="left" valign="top">Nosocomial pneumonia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">23% – (22) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Sepsis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2% – (2) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Urinary tract infection \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1% – (1) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1942554.png" ] ] 1 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="6" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Complications vs. T stage/complications vs. surgical procedure</th></tr><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">T stage (n)</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">χ2 test \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Surgical procedure (n)</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">χ2 test \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " rowspan="4" align="left" valign="middle">PCF (n=54)</td><td class="td" title="table-entry " align="left" valign="top">T1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " rowspan="4" align="left" valign="middle">ns</td><td class="td" title="table-entry " align="left" valign="top">Total pharyngolaryngectomy+ND \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">28 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " rowspan="4" align="left" valign="middle">p value<0.0001</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">T2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Total laryngectomy+ND \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">21 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">T3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">18 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Bucopharyngectomy+ND \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">T4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">31 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">COMMANDO+ND \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="7" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="4" align="left" valign="middle">Surgical wound infection (n=35)</td><td class="td" title="table-entry " align="left" valign="top">T1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " rowspan="4" align="left" valign="middle">ns</td><td class="td" title="table-entry " align="left" valign="top">Total pharyngolaryngectomy+ND \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " rowspan="4" align="left" valign="middle">ns</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">T2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Total laryngectomy+ND \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">T3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Bucopharyngectomy+ND \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">T4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">18 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">COMMANDO+ND \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="7" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="4" align="left" valign="middle">Flap or cutaneous necrosis (n=5)</td><td class="td" title="table-entry " align="left" valign="top">T1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " rowspan="4" align="left" valign="middle">ns</td><td class="td" title="table-entry " align="left" valign="top">Total pharyngolaryngectomy+ND \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " rowspan="4" align="left" valign="middle">p value=0.01</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">T2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Total laryngectomy+ND \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">T3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Bucopharyngectomy+ND \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">T4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">COMMANDO+ND \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="7" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="4" align="left" valign="middle">Nosocomial pneumonia (n=22)</td><td class="td" title="table-entry " align="left" valign="top">T1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " rowspan="4" align="left" valign="middle">p value<0.0001</td><td class="td" title="table-entry " align="left" valign="top">Total pharyngolaryngectomy+ND \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " rowspan="4" align="left" valign="middle">p value=0.009</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">T2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Total laryngectomy+ND \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">T3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">17 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Bucopharyngectomy+ND \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">T4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">COMMANDO+ND \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1942552.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Complications frequency and analysis by T stage and surgical procedure." ] ] 5 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at3" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Microorganism \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">n \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">% \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pseudomonas aeruginosa \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">18 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Escherichia coli \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Klebsiella pneumoniae \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Enterobacter cloacae \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">MRSA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Acinetobacter baumannii \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Aeromonas hydrophila \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Aspergillus fumigatus \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Candida albicans \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Candida krusei \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Candida tropicalis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Citrobacter freundii \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Corynebacterium striatum \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Enterobacter aerogenes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Enterobacter complex \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Enterococcus faecalis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Haemophilus influenza \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Halfia alvei \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Klebsiella oxytoca \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Morganella morganii \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Proteus mirabilis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Providencia stuartii \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Raoultella planticola \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Staphylococcus aureus \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Serratia marcescens \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Streptococcus agalactiae \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1% \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1942553.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Isolated microorganisms." ] ] 6 => array:8 [ "identificador" => "tbl0020" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at4" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:3 [ "leyenda" => "BMI, pre-op albuminemia and pre-op hemoglobin. BMI, body mass index; CRT, chemoradiotherapy; Hg, hemoglobin; ns, non-significant; PCF, pharyngocutaneous fistula." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="3" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">1st treatment modality</th><th class="td" title="table-head " colspan="3" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Reconstructive surgery</th><th class="td" title="table-head " colspan="3" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Body mass index</th><th class="td" title="table-head " colspan="3" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Pre-op albuminemia</th><th class="td" title="table-head " colspan="3" align="center" valign="top" scope="col">Pre-op Hg</th></tr><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col">Primary surgery \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col">Primary CRT \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col">p value \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col">Yes \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col">No \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col">p value \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col">BMI <25 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col">BMI ≥25 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col">p value \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col">Albumin <3.8g/dL \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col">Normal albumin \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col">p value \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="3" align="center" valign="top" scope="col">Ref. values</th></tr><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="3" align="center" valign="top" scope="col">♂<13.5 g/dL</th></tr><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="3" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">♀<12.0 g/dL</th></tr><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Anemia pre op \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Normal Hg pre op \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">p value \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">PCF (n) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">41 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ns<a class="elsevierStyleCrossRef" href="#tblfn0020">*</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">39 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ns<a class="elsevierStyleCrossRef" href="#tblfn0020">*</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">48 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.05<a class="elsevierStyleCrossRef" href="#tblfn0020">*</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">45 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ns<a class="elsevierStyleCrossRef" href="#tblfn0020">*</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">33 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">21 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ns<a class="elsevierStyleCrossRef" href="#tblfn0020">*</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Surgical wound infection (n) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">31 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ns<a class="elsevierStyleCrossRef" href="#tblfn0020">*</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">20 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ns<a class="elsevierStyleCrossRef" href="#tblfn0020">*</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">26 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ns<a class="elsevierStyleCrossRef" href="#tblfn0020">*</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">28 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ns<a class="elsevierStyleCrossRef" href="#tblfn0025">**</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">18 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">17 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ns<a class="elsevierStyleCrossRef" href="#tblfn0020">*</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Flap or cutaneous necrosis (n) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ns<a class="elsevierStyleCrossRef" href="#tblfn0025">**</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.002<a class="elsevierStyleCrossRef" href="#tblfn0025">**</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ns<a class="elsevierStyleCrossRef" href="#tblfn0025">**</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ns<a class="elsevierStyleCrossRef" href="#tblfn0025">**</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ns<a class="elsevierStyleCrossRef" href="#tblfn0025">**</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Nosocomial pneumonia (n) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">21 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ns<a class="elsevierStyleCrossRef" href="#tblfn0025">**</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">16 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ns<a class="elsevierStyleCrossRef" href="#tblfn0020">*</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">16 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ns<a class="elsevierStyleCrossRef" href="#tblfn0025">**</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">17 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ns<a class="elsevierStyleCrossRef" href="#tblfn0025">**</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ns<a class="elsevierStyleCrossRef" href="#tblfn0020">*</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1942556.png" ] ] ] "notaPie" => array:2 [ 0 => array:3 [ "identificador" => "tblfn0020" "etiqueta" => "*" "nota" => "χ2 test." ] 1 => array:3 [ "identificador" => "tblfn0025" "etiqueta" => "**" "nota" => "Fisher's exact test." ] ] ] "descripcion" => array:1 [ "en" => "Occurrence of complications through treatment modality, reconstructive surgery." ] ] 7 => array:8 [ "identificador" => "tbl0025" "etiqueta" => "Table 5" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at5" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Complications \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">β (CI 95%) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">p value \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Flap or cutaneous necrosis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">18.2 (4.3–32.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><0.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pharyngocutaneous fistula \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">13.6 (6.3–20.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.011 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Surgical wound infection \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.8 (−4.9 to 8.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.590 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Nosocomial pneumonia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.2 (−5.8 to 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Original article

Infectious complications in head and neck surgery: Porto Oncology Centre retrospective analysis

Complicaciones infecciosas en cirugía de cabeza y cuello: análisis retrospectivo del Instituto de Oncología de Porto

Miguel Sá Bredaa,b,

Corresponding author

miguelbreda@gmail.com

Corresponding author.

, Joaquim Castro Silvaa, Eurico Monteiroa

a Otorhinolaryngology Department, Instituto Português de Oncologia do Porto Francisco Gentil, E.P.E, Portugal

b Otorhinolaryngology & Head and Neck Department, Hospital de Braga, Portugal

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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Surgical site infection arousal has been reported after head and neck oncologic surgeries involving clean operations &#40;like in thyroidectomy&#41;&#44; clean-contaminated operations &#40;like pharyngectomy or laryngectomy&#41;&#44; and&#44; as we could expect in contaminated injuries &#40;active inflammation and&#47;or violation of sterile technique&#41; or dirty injuries &#40;purulent active inflammation&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">1</span></a> Despite the best preoperative care&#44; meticulous surgical technique and careful postoperative management&#44; complications frequently occur in head and neck cancer patients&#44;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">2</span></a> who often present multiple comorbidities predisposing to the development of infectious complications&#44; namely malnutrition&#44; advanced age&#44; anemia and diabetes mellitus&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">3</span></a> In addition&#44; previous treatment with radiotherapy&#44; associated or not with chemotherapy&#44; increases the risk of surgical site infection and fistula formation&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">4</span></a> These complications will increase hospitalization length&#44; and associated health costs&#44; delaying or canceling adjuvant treatment options&#44; and&#44; in this way&#44; worsening clinical outcomes as well as patients&#8217; quality of life&#46;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">3&#44;5</span></a> It is well known the positive impact of prevention&#44; early recognition and timely introduction of properly treatment in the oncological results&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">The aim of this work was to perform a retrospective analysis of the impact of infectious status and microbiology in postoperative period of major neck surgeries&#44; in a tertiary oncology center&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Materials and methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Study design and patient selection</span><p id="par0015" class="elsevierStylePara elsevierViewall">We performed a single-center retrospective cohort study&#44; including all consecutive patients who developed infectious complications after inaugural major neck cancer surgery&#44; from October 2012 to May 2016 &#40;44 months&#41;&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Patients who underwent transoral laser microsurgery&#44; diagnostic laryngoscopy or other minor surgical procedures of the oral cavity and oropharynx were excluded from the study&#46; There were no hospital transfers during the studied period&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Data collection</span><p id="par0025" class="elsevierStylePara elsevierViewall">The following data was collected from medical records&#58; gender and age&#44; tumor location&#44; TNM stage&#44;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">6</span></a> type of complication&#44; other medical comorbidities&#44; American Society of Anesthesiologists &#40;ASA&#41; score&#44; body mass index &#40;BMI&#41;&#44; alcohol and tobacco consumption&#44; pre and postoperative hemoglobin levels &#40;Hb&#41;&#44; albumin serum levels &#40;Alb&#41;&#44; prior radio and&#47;or chemotherapy&#44; hospitalization length&#44; isolated microbiological agents and mortality associated with complications&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Normal course of preoperative and postoperative care</span><p id="par0030" class="elsevierStylePara elsevierViewall">Prior to admission&#44; all patients were screened for Meticilin-Resistant <span class="elsevierStyleItalic">Staphylococcus aureus</span> &#40;MRSA&#41; infection&#44; through nasal swab examination&#46; Patients whose operations involve mucosal opening &#40;clean contaminated wounds&#41; received prophylactic antibiotic therapy &#40;second generation cephalosporin &#8211; cefazolin 1<span class="elsevierStyleHsp" style=""></span>g &#8211; associated with clindamycin &#8211; 600<span class="elsevierStyleHsp" style=""></span>mg&#41;&#44; started 1<span class="elsevierStyleHsp" style=""></span>h before surgery and repeated in three doses postoperatively&#46; In all cases the prophylaxis was extended because of the infectious complication&#44; and the antibiotic was adapted to microbiology sensitivity&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">All surgeries were performed by surgeons with more than ten years of experience&#46; Before initiating surgical procedure&#44; surgical field was disinfected twice with povidone-iodine solution&#46; Before wound closing&#44; all surgical sites were irrigated with a sufficient amount of warm saline&#46; The diagnosis of pharyngocutaneous fistula &#40;PCF&#41;&#44; surgical site infection and necrosis of the flap or skin was based on clinical features&#46; In the presence of exudates&#44; a sample was collected for microbiological examination and sensitivity test to the antibiotic&#46; In cases of nosocomial respiratory infection&#44; a microbiological examination of sputum was required&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Statistical analysis</span><p id="par0040" class="elsevierStylePara elsevierViewall">Statistical analysis was performed using the Statistical Package for Social Sciences<span class="elsevierStyleSup">&#174;</span> software version 22&#46; Categorical variables are presented as frequencies and percentages&#44; and continuous variables as means and standard deviations&#46; Normal distribution was checked using Shapiro&#8211;Wilk test or skewness and kurtosis&#46; Categorical variables were compared with the use of Fisher&#39;s exact test or the chi-square test&#44; as appropriate&#46; All reported <span class="elsevierStyleItalic">p</span> values were two-tailed&#44; with <span class="elsevierStyleItalic">p</span> value below 0&#46;05 indicating statistical significance&#46; After the inpatient stay analysis&#44; we used multiple linear regression to verify the correlation between complication and hospitalization length&#46; With the binary logistic regression&#44; we aimed to know the relative risk of each main complication occurred so as to predict more than 30 days of hospitalization&#46; Two groups of patients were established&#44; having 30 days of inpatient stay as a cut-off&#46; We defined as exposition factor the most frequent infectious complications occurred &#40;flap&#47;cutaneous necrosis&#44; pharyngocutaneous fistula&#44; surgical wound infection and nosocomial pneumonia&#41;&#44; and the outcome &#40;adverse event&#41; as 30 or more days of inpatient stay&#46; Then we resorted to a binary logistic regression model to determine the relative risk of possible predictors &#40;the infectious complications occurred&#41; that can lead to more than 30 days of inpatient stay &#40;relative risk and their 95&#37; confidence intervals were reported&#41;&#46;</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Results</span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Sample characterization</span><p id="par0045" class="elsevierStylePara elsevierViewall">In the selected period&#44; 761 major neck surgeries were performed&#46; Among these&#44; 96 patients had complications &#40;12&#46;6&#37;&#41;&#46; The sample was composed of 95&#37; males and 5&#37; females&#44; with a mean age of 57 years&#46; All patients had squamous cell carcinoma&#46; Topographical distribution&#44; local &#40;T&#41;&#44; node &#40;N&#41;&#44; metastases &#40;M&#41; staging&#44; and ASA score are summarized in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46; Notice that almost 90&#37; of our sample had locally advanced tumors &#40;T3 and T4&#41;&#44; and about 73&#37; of these tumors were distributed between hypopharynx &#40;46&#37;&#41; and larynx &#40;27&#37;&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">In 81&#37; of the cases&#44; patients were submitted to surgery as primary treatment and in 30&#37; of the surgeries there was a reconstructive component &#40;overall&#44; a regional pedicled myocutaneous flap was performed&#41;&#46; 85&#37; of the performed surgeries were associated to pharyngeal mucosa disruption&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Observed complications are summarized in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#46; PCF was the most frequent complication &#40;56&#37;&#59; <span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>54&#41;&#46; The most common systemic complication was nosocomial pneumonia &#40;23&#37;&#59; <span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>22&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">Twenty-six species of microorganisms were isolated&#44; being <span class="elsevierStyleItalic">Pseudomonas aeruginosa</span> the leading one &#40;15&#37;&#59; <span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>18&#41;&#46; The rate of multidrug-resistant bacteria &#40;MRSA and <span class="elsevierStyleItalic">Acinectobacter</span>&#41; was of about 12&#37; &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">All patients extended prophylaxis because of infectious complication&#46; As we stated in <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#44; most frequent used antibiotics after microbiology sensitivity test were amoxicillin&#47;acid clavulanic &#40;18&#37;&#41;&#44; followed by piperacillin&#47;tazobactam &#40;13&#37;&#41; and ciprofloxacin &#40;11&#37;&#41;&#46; Among the used antibiotics&#44; 42&#37; had anti-<span class="elsevierStyleItalic">Pseudomonas</span> activity &#40;piperacillin&#47;tazobactam&#44; ciprofloxacin&#44; gentamicin&#44; amikacin&#44; colistin&#44; ceftazidime and imipenem&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">In our series&#44; 12 deaths &#40;12&#46;5&#37;&#41; were registered&#46; Seven patients died of progression of oncologic disease itself&#44; 3 died of nosocomial pneumonia and&#44; finally&#44; 2 died of sepsis&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Analyzing comorbidities&#47;habits</span><p id="par0075" class="elsevierStylePara elsevierViewall">In our sample&#44; the mean BMI was 21&#46;6<span class="elsevierStyleHsp" style=""></span>kg&#47;m<span class="elsevierStyleSup">2</span>&#44; and the mean Alb serum level was 3&#46;0<span class="elsevierStyleHsp" style=""></span>g&#47;dL&#46; The mean preoperative Hg level was 13&#46;2<span class="elsevierStyleHsp" style=""></span>g&#47;dL and the postoperative was 9&#46;5<span class="elsevierStyleHsp" style=""></span>g&#47;dL&#46; This difference was statistically significant &#40;<span class="elsevierStyleItalic">t</span>-test paired samples&#59; <span class="elsevierStyleItalic">p</span> value<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;0001&#41;&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">The most commons comorbidities were arterial hypertension &#40;40&#37;&#41; and dyslipidemia &#40;32&#37;&#41;&#44; followed by chronic obstructive lung disease &#40;28&#37;&#41;&#44; diabetes mellitus &#40;10&#37;&#41;&#44; and a minority &#40;9&#37;&#41; had a status pos-stroke&#46; 51&#37; of the patients had 3 or more comorbidities&#44; being in line with the obtained values in the ASA score&#44; 40&#37; had 2 comorbidities&#44; 8&#37; had 1 comorbidity&#44; and only 1&#37; had no comorbidities&#46; In what concerns patients&#8217; habits&#44; 93&#46;8&#37; were active smokers&#44; and 66&#46;7&#37; were alcoholic&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Analyzing complications</span><p id="par0085" class="elsevierStylePara elsevierViewall">At the first analysis phase &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#44; we observed the complications occurred crossed by the tumor T stage and type of surgical procedure &#40;<span class="elsevierStyleItalic">&#967;</span><span class="elsevierStyleSup">2</span> test&#41;&#46; Here&#44; all the principal complications were not statistically significant&#44; except for nosocomial pneumonia occurrence&#44; which showed a positive linkage to higher T stages&#44; in our sample T3 stage &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;0001&#41;&#46; When we attended to the main surgical procedures performed &#40;<span class="elsevierStyleItalic">&#967;</span><span class="elsevierStyleSup">2</span> test&#41;&#44; we realized that there was a positive association between PCF and total pharyngo and laryngectomy &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;0001&#41;&#44; as well as a linkage between COMMANDO procedure and flap or cutaneous necrosis &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;01&#41;&#46; There was also a statistically significant positive association between total laryngectomy and nosocomial pneumonia occurrence &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;009&#41;&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">At a second phase &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#41;&#44; we analyzed the main complications observed&#44; crossed by the main variables studied &#40;<span class="elsevierStyleItalic">&#967;</span><span class="elsevierStyleSup">2</span> test and Fisher&#39;s exact test as appropriated&#41;&#44; and there&#44; we verified a positive association&#44; with statistical relevance&#44; between reconstructive surgery and flap&#47;cutaneous necrosis&#44; and between lower BMI and PCF&#46; Note that in the 5 cases where flap&#47;cutaneous necrosis occurred&#44; when reconstructive surgery was performed&#44; 3 cases concerned reconstructive flap necrosis&#44; and 2 cases concerned skin&#47;cutaneous necrosis &#40;not from the reconstructive flap&#41;&#46; All the other studied variables did not obtain statistical relevance&#46; Nevertheless&#44; complications happened no matter the treatment modality&#44; and patients with lower BMI and hypoAlb&#44; as well as with pre-operative anemia&#44; had more complications&#44; as expected&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">When we analyzed the isolated microorganisms through the 4 main complications&#44; we verified that except for PCF&#44; in which <span class="elsevierStyleItalic">Klebsiella pneumoniae</span> was the leading specie&#44; in all others complications the principal isolated specie was <span class="elsevierStyleItalic">P&#46; aeruginosa</span>&#44; foremost being the more frequent isolated specie in our sample&#44; as we have already stated &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Inpatient stay</span><p id="par0100" class="elsevierStylePara elsevierViewall">In our series&#44; the mean time of hospitalization was 34&#46;6 days &#40;minimum 7 days&#44; and maximum 99 days&#41;&#46; Almost all of the patients &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>92&#41; were admitted in the immediate post-op period in the Intermediate Care Unit&#44; with a mean time of 2&#46;7 days &#40;minimum 1 day&#44; and maximum 12 days&#41;&#46; Some of the patients needed to stay in an Intensive Care Unit &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>9&#41;&#44; there spending a mean period of 6 days &#40;minimum 1 day&#44; and maximum 20 days&#41;&#46; The majority of patients entered the Intensive Care Unit directly from the infirmary&#44; or after complication in the Intermediate Care Unit&#46; A minority went directly from the Operating Room to Intensive Unit&#44; and after stabilization made a downstage until reaching the infirmary&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Complication impact in hospitalization length</span><p id="par0105" class="elsevierStylePara elsevierViewall">To address this issue&#44; we recurred to a multiple linear regression and we concluded that flap&#47;cutaneous necrosis and PCF were complications with statistical significance that extended inpatient stay &#40;<a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0025"></elsevierMultimedia></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Relative risks for more than 30 days of inpatient stay</span><p id="par0110" class="elsevierStylePara elsevierViewall">The binary logistic regression analysis showed that PCF and flap&#47;cutaneous necrosis were linked to more than 30 days of hospitalization &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Discussion</span><p id="par0115" class="elsevierStylePara elsevierViewall">Head and neck cancer represents the 5th cause of death related to cancer&#44; primarily affecting males&#44; a trend that was verified in our series&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">7</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">Tobacco and alcohol consumption are the main risk factors for head and neck cancer development&#46;<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">7&#44;8</span></a> In the present study&#44; it was observed that the majority of patients held these two kinds of addictive behaviors&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">PCF was the principal complication observed in this review &#40;56&#37;&#41;&#46; The PCF rate varies widely in the literature &#40;3&#8211;65&#37;&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">9</span></a> so our data is in this range&#46; There are several studies trying to identify the risk factors for the PCF occurrence&#46; However&#44; so far&#44; no consensus has been achieved by the authors&#46;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">3&#8211;5</span></a> Total pharyngo&#47;laryngectomy&#44; previous radiotherapy treatment&#44; with or without chemotherapy&#44; tumor location&#44; perioperative anemia&#44; hypoAlb&#44; positive surgical margins&#44; concurrent neck dissection&#44; prior tracheotomy&#44; and the presence of medical comorbidities&#44; such as diabetes mellitus&#44; are some of identified risk factors for PCF occurrence&#46;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">3&#8211;5</span></a> In our series&#44; we obtained a positive statistical association between this complication and total pharyngo&#47;laryngectomy procedure&#44; as we could already expect&#44; as well as lower BMI&#44; which reinforces the importance of patient systemic optimization as well as the overall nutritional status before surgery&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Serum Alb has traditionally been used as a nutritional marker status&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">10</span></a> Due to its relatively long half-life of approximately 21 days&#44; Alb is a reliable marker for chronic nutrition status in critically ill patients&#44;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">10</span></a> and low serum Alb &#40;&#60;3&#46;0<span class="elsevierStyleHsp" style=""></span>g&#47;dL&#41; is associated with protein malnutrition&#44; and is also predictive of poor surgical outcome and infectious postoperative complications&#44; such as wound abscess and sepsis&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">10</span></a> Also&#44; it has been reported that patients with a weight loss of more than 10&#37; during the 6 months before surgery are at greater risk for major surgical complications&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">11</span></a> More recently&#44; Gourin et al&#46; concluded that weight loss was associated with increased medical and surgical complications and&#44; therefore&#44; with longer hospital stay and higher overall costs&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">12</span></a> Malnutrition has been shown to be associated with immunoincompetence&#44; which may be one obvious reason for infection susceptibility&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">13</span></a> In this study&#44; there was a mean BMI of 21&#46;6<span class="elsevierStyleHsp" style=""></span>kg&#47;m<span class="elsevierStyleSup">2</span> and a mean serum Alb level of 3&#46;0<span class="elsevierStyleHsp" style=""></span>g&#47;dL&#44; both of these values being significantly lower than the normal &#40;<span class="elsevierStyleItalic">t</span>-test &#8211; <span class="elsevierStyleItalic">p</span> value<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;0001&#41;&#46; These results reflect the level of malnutrition of our patients&#44; which may have contributed to the occurrence of such complications&#46; Several factors contribute to malnutrition&#44; in particular&#58; the presence of poor dietary habits&#44; detrimental lifestyle factors such as smoking and alcohol consumption&#44; reduced oral ingestion due to odynophagia and dysphagia secondary to neoplasia and secretion of cachexia inducing cytokines such as interleukin I&#44; &#945;-tumor necrosis factor and &#947;-interferon&#46;<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">14&#44;15</span></a> Also&#44; it is well known malnutrition associated morbidities&#44; such as<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">16</span></a>&#58; delayed wound healing&#44; impaired cardiac and respiratory function&#44; depression&#44; cachexia&#44; increased risk of overall postoperative complications&#44; and increased mortality rate&#46; In our institution&#44; all patients are evaluated by a nutritionist with implementation of dietary supportive measures to correct any nutritional deficit&#46; Nevertheless&#44; we should reflect on our results&#44; and try to improve this issue with more pre and postoperative nutritional consultations and implementation of anticipatory support measures&#44; such as percutaneous endoscopic gastrostomy and nasogastric feeding&#44; as soon as there is a predictable worsening of overall nutritional status&#46; So&#44; a nutritional screening program becomes essential to prevent and conduct patients in risk to an early nutritional intervention program&#44;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">15</span></a> because it is well proved that perioperative nutritional support may reduce morbidity and mortality&#46;<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">13&#44;15&#44;17</span></a> In order to be effective with nutritional support and to influence clinical outcomes&#44; patients should receive nutrition concealing for 7&#8211;15 days before surgery&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">18</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">We found a statistically significant reduction in the Hb levels between pre and postoperative periods&#46; The occurrence of postoperative anemia reflects longer and more extensive surgery and it is associated with less healing capacity&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">19</span></a> Postoperative anemia also correlates with intraoperative blood transfusion&#44; but this variable was not considered in this study&#46; In our institution&#44; all patients are subjected to serial analytical controls with monitoring of Hb values&#46; The decision to perform blood transfusion depends on the Hb value&#44; on the patient&#39;s general condition and on the presence of cardiovascular comorbidities&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Also&#44; our statistical analysis showed a positive association between nosocomial pneumonia occurrence and higher T stages&#44; as well as with total laryngectomy procedure&#46; We think that this result is due to a pro-inflammatory and unbalanced immune status that characterizes a higher tumor stage&#44; as we have already mentioned&#46; On the other hand&#44; it does not come as a surprise that a major airway surgical procedure can be linked to this complication&#46; In the postoperative period these patients have to adapt to a new condition&#44; and in this transition period&#44; respiratory aspirations episodes can occur&#44; and hence the development of a pneumonia&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">20</span></a> Other fact to add is that the COMMANDO&#39;s postoperative period was linked to a higher incidence of flap&#47;cutaneous necrosis&#46; We think that one possible reason is that the level of surgical field exposure to a contaminated ambient&#44; like oral flora&#44; is higher&#46; Furthermore&#44; the surgical wound is more complex&#44; increasing the possibility of complication outcome&#46; Nevertheless&#44; we should be very cautious in what concerns the interpretation of this result because the number of cases is too small and&#44; in addition&#44; we did not have a control group&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">In our series&#44; patients with flap or cutaneous necrosis as well as with PCF had a statistical impact in what concerns the extension of inpatient stay compared to patients with other type of complications&#46; These patients often require revision surgery with further reconstruction with local&#44; regional or microvascularized flaps&#44; which could explain this result&#46; We support this conclusion based on the binary logistic regression&#44; which clearly corroborate that PCF and flap or cutaneous necrosis occurrence had higher and statistically significant relative risk for more than 30 days of hospitalization&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">The isolated microorganisms in this study were similar to other previously published&#44;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">9</span></a><span class="elsevierStyleItalic">P&#46; aeruginosa</span> being the leading specie&#46; Considering the multidrug-resistant bacteria&#44; our result &#40;more than 10&#37;&#41; was higher than the published by Kamizono et al&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">21</span></a> and Hirakawa et al&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">22</span></a> &#8211; 3&#37; and 7&#37;&#44; respectively&#46; Regarding antibiotic therapy&#44; we can conclude that was a reflex of the leading specie isolated&#44; having almost half of the antibiotics used &#40;42&#37;&#41; anti-<span class="elsevierStyleItalic">Pseudomonas</span> activity&#46; The frequency of isolation of this agent &#40;18 patients &#8211; 15&#37;&#41; is practically half of the frequency in which antibiotics with activity against <span class="elsevierStyleItalic">Pseudomonas</span> were used&#46; The possible reason for this is due to the fact that in 6 of the 18 patients with <span class="elsevierStyleItalic">Pseudomonas</span> it was necessary to use more than one directed antibiotic&#44; which explains the observed discrepancy&#46; Another fact to add is that <span class="elsevierStyleItalic">Pseudomonas</span> infection susceptibility is well recognized among diabetic patients&#44; and there is one report<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">23</span></a> that proves a statistically significant association between neck surgical wound infection and diabetes&#46; Nevertheless&#44; we reinforce that in our sample &#40;all with infectious complications&#41; only 10&#37; were diabetic&#44; and among these patients the principal isolated species were <span class="elsevierStyleItalic">Enterobacteriaceae</span> and MRSA&#46; In spite of this fact&#44; other studies failed to prove that diabetes itself could be a risk factor to surgical site infection occurrence&#44;<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">9&#44;21&#44;22</span></a> which demonstrates that a multiplicity of factors contribute to infectious complications&#44; and&#44; like in this tertiary oncologic center&#44; there is a multidisciplinary team-work&#44; with Internal Medicine optimization&#44; which minimizes these patients&#8217; potential risks&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">The main limitations of this study are those inherent to a retrospective analysis and selection bias of the patients&#44; because we only selected one group with infectious complications&#46; Even so&#44; it is reinforced that our sample is similar to others already studied&#44; concerning tumor staging and performed surgeries&#46;<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">21&#44;22</span></a> We did not use a wound infection scale&#44; like Tabet et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">1</span></a> because in a retrospective analysis like ours&#44; it is difficult to be sure and systematic of certain aspects&#44; such as the dimension of infection&#44; and this scale<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">1</span></a> does not include a grade for necrosis&#44; which we think should be included&#46; Nevertheless&#44; when planning a prospective analysis of this subject&#44; we must definitively consider to include an updated wound evaluation scale&#44; based on Tabet&#44;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">1</span></a> in order to achieve more objectivity and reproducibility&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Conclusions</span><p id="par0160" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">P&#46; aeruginosa</span> was the principal specie isolated in the infectious complications of neck <span class="elsevierStyleItalic">major</span> surgery&#46; PCF and flap or cutaneous necrosis worsened outcomes&#44; clearly being linked to lengthening of inpatient stay&#46; Prevention and early recognition of these complications seem to be essential to optimize clinical oncologic results&#46;</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Ethical standards</span><p id="par0165" class="elsevierStylePara elsevierViewall">All ethical issues were properly fulfilled and are in line with European law&#46;</p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Financial disclosure</span><p id="par0170" class="elsevierStylePara elsevierViewall">Authors have no financial relationships relevant to this article to disclose&#46;</p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Conflict of interest</span><p id="par0175" class="elsevierStylePara elsevierViewall">The authors declare no conflict of interests&#46;</p></span></span>"
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          "titulo" => "Introduction"
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          "titulo" => "Materials and methods"
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              "titulo" => "Normal course of preoperative and postoperative care"
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              "titulo" => "Sample characterization"
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              "titulo" => "Analyzing comorbidities&#47;habits"
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              "titulo" => "Analyzing complications"
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              "titulo" => "Inpatient stay"
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              "titulo" => "Complication impact in hospitalization length"
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              "titulo" => "Relative risks for more than 30 days of inpatient stay"
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    "fechaRecibido" => "2017-08-30"
    "fechaAceptado" => "2017-11-26"
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          "clase" => "keyword"
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          "palabras" => array:5 [
            0 => "Surgical site infection"
            1 => "Head and neck cancer"
            2 => "Post-operative period"
            3 => "Microbiology"
            4 => "Pharyngocutaneous fistula"
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        1 => array:4 [
          "clase" => "abr"
          "titulo" => "Abbreviations"
          "identificador" => "xpalclavsec1069910"
          "palabras" => array:6 [
            0 => "Alb"
            1 => "ASA"
            2 => "BMI"
            3 => "Hb"
            4 => "MRSA"
            5 => "PCF"
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          "palabras" => array:5 [
            0 => "Infecci&#243;n De La Herida Quir&#250;rgica"
            1 => "C&#225;ncer De Cabeza Y Cuello"
            2 => "Per&#237;odo Postoperatorio"
            3 => "Microbiolog&#237;a"
            4 => "F&#237;stula Faringocut&#225;nea"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To analyze the impact of infectious complications and microbiology in the postoperative period after major oncologic neck surgeries&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A retrospective study conducted in an oncology center&#44; including all the consecutive patients who developed infectious complications after major neck cancer surgery&#44; from October 2012 to May 2016 &#40;44 months&#41;&#46; Among other data&#44; we collected TNM stage&#44; ASA score&#44; body mass index&#44; comorbidities and habits&#44; pre and postoperative hemoglobin levels&#44; albumin serum levels&#44; pre-surgical treatments&#44; length of inpatient stay&#44; isolated microbiological agents and the recorded complications and mortality rate&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">In the studied period&#44; 761 major neck surgeries were performed&#46; Of these&#44; 96 patients had complications &#40;12&#46;6&#37;&#41;&#46; Pharyngocutaneous fistula &#40;PCF&#41; was the most frequent complication &#40;56&#37;&#41; and nosocomial pneumonia was the most common systemic complication &#40;23&#37;&#41;&#46; <span class="elsevierStyleItalic">Pseudomonas aeruginosa</span> was the principal microorganism of the 26 species isolated &#40;15&#37;&#41;&#46; 12 deaths were registered&#46; Using multiple linear regression we concluded that flap&#47;cutaneous necrosis and PCF were complications with statistical significance that prolonged inpatient stay&#46; The same complications had significant relative risk for more than 30 days of hospitalization&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The postoperative period is critical for the successful treatment of head and neck oncology patients&#46; PCF and flap&#47;cutaneous necrosis were the principal complications which worsened the outcomes during this critical period&#46; The early recognition and treatment of these complications is crucial&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Analizar el impacto de las complicaciones infecciosas en el per&#237;odo posoperatorio de las cirug&#237;as oncol&#243;gicas mayores de cabeza y cuello&#44; y estudio de los agentes microbianos implicados&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudio retrospectivo realizado en un instituto oncol&#243;gico&#44; en pacientes que desarrollaron complicaciones infecciosas despu&#233;s de la cirug&#237;a oncol&#243;gica mayor de cuello&#44; entre octubre de 2012 y mayo de 2016 &#40;44 meses&#41;&#46; Entre otros se recogieron el estadio TNM&#44; la puntuaci&#243;n ASA&#44; el &#237;ndice de masa corporal&#44; las comorbilidades&#44; los h&#225;bitos t&#243;xicos&#44; los niveles de hemoglobina pre y postoperatoria&#44; los niveles s&#233;ricos de alb&#250;mina&#44; los tratamientos previos a la cirug&#237;a&#44; la duraci&#243;n de la hospitalizaci&#243;n y los microorganismos aislados&#44; as&#237; como las complicaciones sufridas y la tasa de mortalidad&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">En este per&#237;odo se realizaron 761 cirug&#237;as cervicales mayores&#46; De estas&#44; 96 pacientes presentaron complicaciones &#40;12&#44;6&#37;&#41;&#46; Las que con mayor frecuencia se registraron fueron la f&#237;stula faringocut&#225;nea &#40;FFC&#41; &#40;56&#37;&#41; y la neumon&#237;a nosocomial &#40;23&#37;&#41;&#46; Fueron aislados 26 tipos de microorganismos&#44; siendo la <span class="elsevierStyleItalic">Pseudomonas aeruginosa</span> la m&#225;s frecuente &#40;15&#37;&#41;&#46; Se registraron 12 fallecimientos&#46; Tras el estudio estad&#237;stico con regresi&#243;n lineal m&#250;ltiple&#44; se detecta que la necrosis cut&#225;nea o del colgajo y la FFC fueron las complicaciones con un mayor impacto estad&#237;stico en la estancia hospitalaria&#46; Asimismo&#44; fueron los factores que m&#225;s influyeron en las hospitalizaciones de 30 d&#237;as o m&#225;s&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusi&#243;n</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Una buena evoluci&#243;n durante el per&#237;odo postoperatorio es fundamental para obtener &#233;xito en el tratamiento de los pacientes oncol&#243;gicos de cabeza y cuello&#46; La FFC y la necrosis de colgajo o cut&#225;nea constituyeron las principales complicaciones con un mayor impacto en los resultados obtenidos&#46; La detecci&#243;n precoz de estas complicaciones&#44; as&#237; como su tratamiento&#44; son cruciales&#46;</p></span>"
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Tongue</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10&#46;4&#37; &#8211; &#40;10&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Oral cavity</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&#46;2&#37; &#8211; &#40;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:1.0px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">Mortality &#37; &#8211; &#40;</span><span class="elsevierStyleItalic"><span class="elsevierStyleBold">n</span></span><span class="elsevierStyleBold">&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">12&#46;5&#37; &#8211; &#40;12&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleBold">TNM stage</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">T &#8211; &#37; &#8211; &#40;n&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#37; &#8211; &#40;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10&#46;4&#37; &#8211; &#40;10&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">38&#46;5&#37; &#8211; &#40;37&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">50&#37; &#8211; &#40;48&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">N &#8211; &#37; &#8211; &#40;n&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">29&#46;2&#37; &#8211; &#40;28&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">18&#46;8&#37; &#8211; &#40;18&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">49&#37; &#8211; &#40;47&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&#46;1&#37; &#8211; &#40;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">M &#8211; &#37; &#8211; &#40;n&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">97&#46;9&#37; &#8211; &#40;94&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#46;1&#37; &#8211; &#40;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:1.0px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleBold">ASA stage</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#37; &#8211; &#40;n&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>I&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">13&#46;5&#37; &#8211; &#40;13&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>II&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">43&#46;8&#37; &#8211; &#40;42&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>III&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">41&#46;7&#37; &#8211; &#40;40&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>IV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#37; &#8211; &#40;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:1.0px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">Treatment modality</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Primary surgery</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">81&#37; &#8211; &#40;78&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Pre-RT</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">18&#46;8&#37; &#8211; &#40;18&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Pre-chemo</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">16&#46;7&#37; &#8211; &#40;16&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:1.0px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleBold">Performed surgeries</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Total pharyngolaryngectomy</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#43;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">ND</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">37&#37; &#8211; &#40;36&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Total laryngectomy</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#43;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">ND</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">34&#37; &#8211; &#40;33&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Bucopharyngectomy</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#43;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">ND</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">8&#37; &#8211; &#40;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">COMMANDO</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#43;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">ND</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6&#37; &#8211; &#40;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">ND</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">15&#37; &#8211; &#40;14&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Pharyngeal mucosa disruption</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">85&#37; &#8211; &#40;82&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Surgery with reconstructive flap &#40;all regional pedicled myocutaneous flap&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">30&#37; &#8211; &#40;29&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleBold">Other data</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">BMI &#8211; kg&#47;m</span><span class="elsevierStyleSup"><span class="elsevierStyleItalic">2</span></span><span class="elsevierStyleItalic">&#40;mean&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">21&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;0001<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">&#42;</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Alb &#8211; g&#47;dL &#40;mean&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;0001<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">&#42;&#42;</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Preoperative Hg &#8211; g&#47;dL &#40;mean&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">13&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " rowspan="2" align="left" valign="middle"><span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;0001<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">&#42;&#42;&#42;</span></a></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Postoperative Hg &#8211; g&#47;dL &#40;mean&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Inpatient stay &#8211; days &#40;mean&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " colspan="2" align="left" valign="top">34&#46;6</td></tr></tbody></table>
                  """
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              "identificador" => "tblfn0005"
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              "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Simple <span class="elsevierStyleItalic">T</span>-test &#40;ref&#46; value 25<span class="elsevierStyleHsp" style=""></span>kg&#47;m<span class="elsevierStyleSup">2</span>&#41;&#46;</p>"
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            1 => array:3 [
              "identificador" => "tblfn0010"
              "etiqueta" => "&#42;&#42;"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Simple <span class="elsevierStyleItalic">T</span>-test &#40;ref&#46; value 3&#46;8<span class="elsevierStyleHsp" style=""></span>g&#47;dL&#41;&#46;</p>"
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              "nota" => "<p class="elsevierStyleNotepara" id="npar0015"><span class="elsevierStyleItalic">T</span>-Test paired samples&#46;</p>"
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          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Sample characterization&#46;</p>"
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        "tipo" => "MULTIMEDIATABLA"
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          "leyenda" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">ND&#44; neck dissection&#59; ns&#44; non-significant&#59; PCF&#44; pharyngocutaneous fistula&#46;</p>"
          "tablatextoimagen" => array:2 [
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Complications frequency &#8211; &#37; &#8211; &#40;<span class="elsevierStyleItalic">n</span>&#41;</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " rowspan="5" align="left" valign="top">Local</td><td class="td" title="table-entry  " align="left" valign="top">PCF&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">56&#37; &#8211; &#40;54&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Surgical wound infection&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">37&#37; &#8211; &#40;35&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Flap or cutaneous necrosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&#37; &#8211; &#40;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Cervical abscess&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#37; &#8211; &#40;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Thoracic duct fistula&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#37; &#8211; &#40;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="3" align="left" valign="top">Systemic</td><td class="td" title="table-entry  " align="left" valign="top">Nosocomial pneumonia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">23&#37; &#8211; &#40;22&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Sepsis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#37; &#8211; &#40;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Urinary tract infection&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#37; &#8211; &#40;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab1942554.png"
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            1 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " colspan="6" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Complications vs&#46; T stage&#47;complications vs&#46; surgical procedure</th></tr><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">T stage &#40;<span class="elsevierStyleItalic">n</span>&#41;</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">&#967;</span><span class="elsevierStyleSup">2</span> test&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Surgical procedure &#40;<span class="elsevierStyleItalic">n</span>&#41;</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">&#967;</span><span class="elsevierStyleSup">2</span> test&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " rowspan="4" align="left" valign="middle">PCF &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>54&#41;</td><td class="td" title="table-entry  " align="left" valign="top">T1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " rowspan="4" align="left" valign="middle">ns</td><td class="td" title="table-entry  " align="left" valign="top">Total pharyngolaryngectomy<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>ND&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">28&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " rowspan="4" align="left" valign="middle"><span class="elsevierStyleItalic">p</span> value<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;0001</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">T2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Total laryngectomy<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>ND&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">21&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">T3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">18&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Bucopharyngectomy<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>ND&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">T4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">31&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">COMMANDO<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>ND&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="7" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="4" align="left" valign="middle">Surgical wound infection &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>35&#41;</td><td class="td" title="table-entry  " align="left" valign="top">T1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " rowspan="4" align="left" valign="middle">ns</td><td class="td" title="table-entry  " align="left" valign="top">Total pharyngolaryngectomy<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>ND&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " rowspan="4" align="left" valign="middle">ns</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">T2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Total laryngectomy<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>ND&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">T3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Bucopharyngectomy<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>ND&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">T4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">18&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">COMMANDO<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>ND&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="7" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="4" align="left" valign="middle">Flap or cutaneous necrosis &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>5&#41;</td><td class="td" title="table-entry  " align="left" valign="top">T1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " rowspan="4" align="left" valign="middle">ns</td><td class="td" title="table-entry  " align="left" valign="top">Total pharyngolaryngectomy<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>ND&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " rowspan="4" align="left" valign="middle"><span class="elsevierStyleItalic">p</span> value<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;01</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">T2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Total laryngectomy<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>ND&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">T3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Bucopharyngectomy<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>ND&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">T4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">COMMANDO<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>ND&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="7" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="4" align="left" valign="middle">Nosocomial pneumonia &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>22&#41;</td><td class="td" title="table-entry  " align="left" valign="top">T1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " rowspan="4" align="left" valign="middle"><span class="elsevierStyleItalic">p</span> value<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;0001</td><td class="td" title="table-entry  " align="left" valign="top">Total pharyngolaryngectomy<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>ND&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " rowspan="4" align="left" valign="middle"><span class="elsevierStyleItalic">p</span> value<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;009</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">T2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Total laryngectomy<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>ND&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">T3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">17&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Bucopharyngectomy<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>ND&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">T4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">COMMANDO<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>ND&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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        "descripcion" => array:1 [
          "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Complications frequency and analysis by T stage and surgical procedure&#46;</p>"
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      5 => array:8 [
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        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
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        "detalles" => array:1 [
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              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Microorganism&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">n</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Pseudomonas aeruginosa</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">18&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Escherichia coli</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Klebsiella pneumoniae</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Enterobacter cloacae</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">MRSA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Acinetobacter baumannii</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Aeromonas hydrophila</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Aspergillus fumigatus</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Candida albicans</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Candida krusei</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Candida tropicalis</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Citrobacter freundii</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Corynebacterium striatum</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Enterobacter aerogenes</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Enterobacter complex</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Enterococcus faecalis</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Haemophilus influenza</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Halfia alvei</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Klebsiella oxytoca</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Morganella morganii</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Proteus mirabilis</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Providencia stuartii</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Raoultella planticola</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Staphylococcus aureus</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Serratia marcescens</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Streptococcus agalactiae</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "leyenda" => "<p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">BMI&#44; pre-op albuminemia and pre-op hemoglobin&#46; BMI&#44; body mass index&#59; CRT&#44; chemoradiotherapy&#59; Hg&#44; hemoglobin&#59; ns&#44; non-significant&#59; PCF&#44; pharyngocutaneous fistula&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " colspan="3" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">1st treatment modality</th><th class="td" title="table-head  " colspan="3" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Reconstructive surgery</th><th class="td" title="table-head  " colspan="3" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Body mass index</th><th class="td" title="table-head  " colspan="3" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Pre-op albuminemia</th><th class="td" title="table-head  " colspan="3" align="center" valign="top" scope="col">Pre-op Hg</th></tr><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col">Primary surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col">Primary CRT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col"><span class="elsevierStyleItalic">p</span> value&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col"><span class="elsevierStyleItalic">p</span> value&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col">BMI<br><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col">BMI<br><span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col"><span class="elsevierStyleItalic">p</span> value&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col">Albumin<br><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>3&#46;8<span class="elsevierStyleHsp" style=""></span>g&#47;dL&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col">Normal albumin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col"><span class="elsevierStyleItalic">p</span> value&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " colspan="3" align="center" valign="top" scope="col">Ref&#46; values</th></tr><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " colspan="3" align="center" valign="top" scope="col">&#9794;<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>13&#46;5 g&#47;dL</th></tr><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " colspan="3" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">&#9792;<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>12&#46;0 g&#47;dL</th></tr><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Anemia pre op&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ns<a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">&#42;</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">20&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ns<a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">&#42;</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ns<a class="elsevierStyleCrossRef" href="#tblfn0025"><span class="elsevierStyleSup">&#42;&#42;</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ns<a class="elsevierStyleCrossRef" href="#tblfn0025"><span class="elsevierStyleSup">&#42;&#42;</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Wound infection in head and neck surgery&#58; prophylaxis&#44; etiology and management"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "J&#46;C&#46; Tabet"
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                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "J Otolaryngol"
                        "fecha" => "1990"
                        "volumen" => "19"
                        "paginaInicial" => "197"
                        "paginaFinal" => "200"
                      ]
                    ]
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              "identificador" => "bib0125"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Chapter 27&#58; complications in head and neck cancer surgery"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "E&#46; Barker"
                            1 => "A&#46; Curran"
                            2 => "P&#46;J&#46; Gullane"
                            3 => "J&#46;C&#46; Irish"
                          ]
                        ]
                      ]
                    ]
                  ]
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                    0 => array:1 [
                      "LibroEditado" => array:5 [
                        "titulo" => "Principles and practice of head and neck surgery and oncology"
                        "paginaInicial" => "512"
                        "paginaFinal" => "526"
                        "edicion" => "2nd ed&#46;"
                        "serieFecha" => "2009"
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              "identificador" => "bib0130"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Pharyngocutaneous fistula after total laryngectomy&#58; a systematic review and meta-analysis of risk factors"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "J&#46;W&#46; Liang"
                            1 => "Z&#46;D&#46; Li"
                            2 => "S&#46;C&#46; Li"
                            3 => "F&#46;Q&#46; Fang"
                            4 => "Y&#46;J&#46; Zhao"
                            5 => "Y&#46;G&#46; Li"
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                        ]
                      ]
                    ]
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                    0 => array:2 [
                      "doi" => "10.1016/j.anl.2015.04.002"
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                        "tituloSerie" => "Auris Nasus Larynx"
                        "fecha" => "2015"
                        "volumen" => "42"
                        "paginaInicial" => "353"
                        "paginaFinal" => "359"
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                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25933584"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
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              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Salvage laryngectomy after primary radiotherapy&#58; what are prognostic factors for the development of pharyngocutaneous fistulae&#63;"
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                          "etal" => false
                          "autores" => array:5 [
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  "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0001651918300554?idApp=UINPBA00004N"
]

Article information

ISSN: 00016519
Original language: English

DOI:10.1016/j.otorri.2017.11.004

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Year/Month	Html	Pdf	Total

2023 November	1	0	1
2023 March	1	0	1
2021 March	0	2	2
2021 February	0	1	1
2020 December	0	5	5
2020 November	0	1	1
2020 September	0	5	5
2020 July	0	2	2
2020 June	0	1	1
2020 March	18	5	23
2020 February	31	7	38
2020 January	12	3	15
2019 August	1	0	1
2019 May	4	0	4
2019 April	1	0	1
2019 March	16	8	24
2019 February	4	2	6
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2018 August	0	2	2
2018 July	0	1	1

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