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Cholangiohydatidosis: an Infrequent Cause of Obstructive Jaundice and Acute Cholangitis
Carlos Manterola
,**,
Corresponding author
carlos.manterola@ufrontera.cl

Corresponce and reprint request:
, Tamara Otzen**,***
* Department of Surgery and CEMyQ (Center of Morphological and Surgical Studies), Universidad de La Frontera, Chile
** Center for Biomedical Research, Universidad Autónoma de Chile, Temuco, Chile
*** Universidad de Tarapacá, Chile
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          "en" => "<p id="sp0010" class="elsevierStyleSimplePara elsevierViewall">Female 66-year-old patient presented with four days&#8217; evolution of right upper abdominal pain&#44; fever and jaundice&#46; Abdominal CT scan verified a heterogeneous cystic mass that represented germinative membrane residues and some daughter vesicles&#46; The intimate relation between the cyst and the right biliary tree can also be seen&#44; specifically with its anterior branches&#46; The biliary communication at this level &#40;segment VI&#41; gave rise to cholangiohydatidosis and secondary acute cholangitis&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="s0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0040">Introduction</span><p id="p0010" class="elsevierStylePara elsevierViewall">Intrabiliary rupture of hepatic echinococcosis &#40;HE&#41; is one of the most frequent evolutionary complications of this pathological entity&#46; Once this rupture occurs and there is communication between a cyst and the biliary tree&#44; the conditions are created that allow the further migration of the parasitic structures &#40;pieces of germinal layer or daughter vesicles&#41; into the biliary tract&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">1&#44;2</span></a> This situation &#40;cholangiohydatidosis&#41; may produce a secondary cholan-gitis<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">3</span></a> and even infection of the cyst with liver abscess&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">4</span></a> Obviously&#44; any of these situations might increase the risk of post-operative morbidity &#40;POM&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">3-5</span></a></p><p id="p0015" class="elsevierStylePara elsevierViewall">The reported prevalence of intrabiliary rupture of HE is between 9&#46;0&#37; and 42&#46;0&#37;&#44;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">2&#44;6-9</span></a> but the frequency of cholangiohydatidosis and secondary cholangitis is unclear&#46; There are few related reports&#59; most are about intrabiliary rupture&#44; but not about cholangiohydatidosis and secondary cholangitis&#44; about which we found only 15 articles&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">3&#44;10-23</span></a> The information available is scarce and with a low level of evidence&#44; so collecting specific data regarding the prevalence or incidence of cholangitis due to cholangiohydati-dosis is virtually impossible&#46;</p><p id="p0020" class="elsevierStylePara elsevierViewall">However&#44; a preoperative diagnosis of cholangiohy-datidosis and secondary cholangitis is difficult unless it can be observed in images such as those in <a class="elsevierStyleCrossRef" href="#f0010">Figure 1</a>&#46; Diagnosis is usually intraoperative once a dilatation of the bile duct has been confirmed&#44; where tension bile or bilious pus and parasite remnants may be flowing in the interior &#40;<a class="elsevierStyleCrossRef" href="#f0015">Figure 2</a>&#41;&#46;</p><elsevierMultimedia ident="f0010"></elsevierMultimedia><elsevierMultimedia ident="f0015"></elsevierMultimedia><p id="p0025" class="elsevierStylePara elsevierViewall">The aim of this study was to describe the results of surgical treatment on a group of patients with cholangiohy-datidosis and secondary cholangitis in terms of POM&#46;</p><p id="p0030" class="elsevierStylePara elsevierViewall">This report was written on the basis of the MINCIR Statement &#40;Methodology and Investigation in Surgery&#41; for reporting observational descriptive studies&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">24</span></a></p></span><span id="s0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0045">Material and Methods</span><span id="s0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0050">Study design</span><p id="p0035" class="elsevierStylePara elsevierViewall">A case series of patients operated on for cholangiohy-datidosis and secondary cholangitis&#44; who are part of a concurrent cohort of subjects operated on for HE&#46;</p></span><span id="s0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0055">Setting</span><p id="p0040" class="elsevierStylePara elsevierViewall">The study was conducted at the Department of Surgery of the Universidad de La Frontera and the Cl&#237;nica Mayor in Temuco&#44; Chile&#46; The recruitment period was between January 2004 and December 2014&#46; The minimum follow-up time was six months&#46;</p></span><span id="s0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0060">Participants</span><p id="p0045" class="elsevierStylePara elsevierViewall">Patients operated on for HE &#40;only <span class="elsevierStyleItalic">E&#46; granulosus</span> variety&#41; by the first author &#40;CM&#41; during the study period were included&#46; Patients with a history of prior surgery for HE or other concomitant hepatic pathologies were excluded&#46; A non-probabilistic sampling of consecutive cases was used&#46;</p></span><span id="s0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0065">Diagnostic criteria</span><p id="p0050" class="elsevierStylePara elsevierViewall">Diagnosis of cholangiohydatidosis and secondary cholangitis was suspected by images &#40;abdominal CT-Scan or IMR&#41; in all patients and confirmed intraoperatively by the observation of a solution of continuity in the bile duct and the existence of pus and parasitic structures in the biliary ducts&#46; Typification of echinococcosis was made post-operatively at a parasitology laboratory&#44; using direct microscope observation of protoscolices&#44; and histological study of surgical specimens confirmed the preoperative diagnosis in all the patients&#46;</p></span><span id="s0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0070">Surgical procedure</span><p id="p0055" class="elsevierStylePara elsevierViewall">All patients underwent emergency surgery with prior antibiotic prophylaxis&#46; The criterion for open surgery in acute cholangitis in our center is&#58; patient with Charcot triad associated with dilatation of the biliary tract verified by abdomi-<span class="elsevierStyleInf">atio</span>n<span class="elsevierStyleInf">n&#46;</span>al ultrasonography when endoscopic surgery is not available&#46; Surgery consisted of the exploration of the bile duct&#44; removal of hydatid structures&#44; choledochal drainage &#40;Kehr drain&#41; and concomitant treatment of the cyst with pericystectomy or liver resection&#46; Then&#44; all patients continued with antibiotics postoperatively for seven days&#46;</p></span><span id="s0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0075">Study protocol</span><p id="p0060" class="elsevierStylePara elsevierViewall">After hospital discharge&#44; all patients were followed with strict check-ups at least at months 1 and 6 and then once per year &#40;where possible&#41;&#46; At these check-ups&#44; clinical evaluation was performed as well as general laboratory and liver function tests&#44; immunodiagnostics and abdominal ultrasound&#46;</p></span><span id="s0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0080">Variables</span><p id="p0065" class="elsevierStylePara elsevierViewall">The principal outcome variable was &#8220;development of POM&#8221;&#44; measured at least six months after surgery&#46; This was considered dichotomously &#40;present or absent&#41;&#44; and from the point of view of the severity of POM&#44; applying the Clavien-Dindo surgical complications classification&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">25</span></a> Other variables of interest were age&#44; sex&#44; cyst diameter&#44; hematocrit&#44; leukocytes&#44; total bilirubin&#44; alkaline phos-phatase and transaminases&#44; type of surgery &#40;categorized in pericystectomy and liver resection&#41;&#44; existence of concomitant evolutionary complications in the cyst &#40;dichotomized as yes or no&#41;&#44; length of hospital stay&#44; need for surgical re-intervention and operative mortality&#46;</p></span><span id="s0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0085">Biases</span><p id="p0070" class="elsevierStylePara elsevierViewall">In the recruitment and follow-up stage&#44; biases were reduced with a complete follow-up and blinded data collection&#46; Then&#44; data were encoded and not revealed until the analysis period was complete&#46;</p></span><span id="s0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0090">Study size</span><p id="p0075" class="elsevierStylePara elsevierViewall">Since it is an observational and descriptive study&#44; no sample size was estimated&#46;</p></span><span id="s0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0095">Statistical methods</span><p id="p0080" class="elsevierStylePara elsevierViewall">The data were analyzed with the Stata 11&#46;0&#47;SE<span class="elsevierStyleSup">&#174;</span> program&#46; Descriptive statistics were used to calculate percentages&#44; averages and standard deviations&#44; medians and extreme values&#46;</p></span><span id="s0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0100">Ethics</span><p id="p0085" class="elsevierStylePara elsevierViewall">Written informed consent was obtained from each patient&#46; All the ethical guidelines for research on human beings as defined by the Helsinki Declaration<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">26</span></a> were observed&#46;</p></span><span id="s0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0105">Funding</span><p id="p0090" class="elsevierStylePara elsevierViewall">There was no special funding for this study&#46;</p></span></span><span id="s0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0110">Results</span><p id="p0095" class="elsevierStylePara elsevierViewall">A total of 22 patients operated on for cholangiohydatido-sis were recruited in this period&#46; Two were not included in the final analysis due to a lack of follow-up &#40;<a class="elsevierStyleCrossRef" href="#f0020">Figure 3</a>&#41;&#46;</p><elsevierMultimedia ident="f0020"></elsevierMultimedia><p id="p0100" class="elsevierStylePara elsevierViewall">The patients comprising the series are characterized by a median age of 53 years&#44; 50&#46;0&#37; female and 20&#46;0&#37; of them having two or more cysts with a mean diameter of 13&#46;3 &#177; 6&#46;3 cm &#40;<a class="elsevierStyleCrossRef" href="#t0010">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="t0010"></elsevierMultimedia><p id="p0105" class="elsevierStylePara elsevierViewall">Two patients &#40;10&#46;0&#37;&#41; had a history of previous surgery for hepatic hydatid disease and another due to pulmonary hydatid disease&#46; Five patients &#40;25&#46;0&#37;&#41; had comorbidities&#58; heart disease &#40;2 cases&#41;&#44; diabetes mellitus &#40;2 cases&#41; and cholelithiasis &#40;1 case&#41;&#46;</p><p id="p0110" class="elsevierStylePara elsevierViewall">Nine subjects &#40;45&#46;0&#37;&#41; had concomitant parasitic diseases&#58; hepatic abscess of hydatid origin &#40;7 cases&#44; 35&#46;0&#37;&#41;&#44; and hepatothoracic transit &#40;2 cases&#44; 10&#46;0&#37;&#41;&#46;</p><p id="p0115" class="elsevierStylePara elsevierViewall">Laboratory tests revealed anemia &#40;5 cases&#44; 25&#46;0&#37;&#41;&#44; leu-kocytosis &#40;11 cases&#44; 55&#46;0&#37;&#41;&#44; signs of cholestasis &#40;17 cases&#44; 85&#46;0&#37;&#41; and hepatocyte cytolysis &#40;17 cases&#44; 85&#46;0&#37;&#41; &#40;<a class="elsevierStyleCrossRef" href="#t0010">Table 1</a>&#41;&#46;</p><p id="p0120" class="elsevierStylePara elsevierViewall">The existence of concomitant hydatid disease in the peritoneum &#40;2 cases&#41; and spleen &#40;one case&#41; was verified&#46; The most common location of cysts communicated to the bile duct was the right hepatic lobe &#40;12 cases&#44; 60&#46;0&#37;&#41; &#40;<a class="elsevierStyleCrossRef" href="#t0015">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="t0015"></elsevierMultimedia><p id="p0125" class="elsevierStylePara elsevierViewall">The mean diameter of the common bile duct was 18&#46;5 &#177; 2&#46;1 mm and biliary communications were found in all patients &#40;<a class="elsevierStyleCrossRefs" href="#t0010">Tables 1 and 3</a>&#41;&#46;</p><p id="p0130" class="elsevierStylePara elsevierViewall">A median hospital stay of six days was recorded with a median follow-up of 34 months &#40;<a class="elsevierStyleCrossRef" href="#t0010">Table 1</a>&#41;&#44; 30&#46;0&#37; morbidity and a re-intervention rate of 10&#46;0&#37; &#40;<a class="elsevierStyleCrossRef" href="#t0015">Table 2</a>&#41;&#46; The related morbidity was secondary to pulmonary&#44; cardiac and metabolic complications &#40;1 case of each&#41;&#44; infection at the surgical site&#44; incisional hernia&#44; biliary fistula &#40;1 case of each&#41; &#40;<a class="elsevierStyleCrossRef" href="#t0020">Table 3</a>&#41;&#46;</p><elsevierMultimedia ident="t0020"></elsevierMultimedia><p id="p0135" class="elsevierStylePara elsevierViewall">Mortality rate was 5&#46;0&#37;&#46; This was a 76-year-old patient with a coronary cardiopathy who presented episodes of projectile vomiting&#44; and then developed aspiration pneumonia&#44; secondary respiratory insufficiency and finally multiple organ failure&#46;</p><p id="p0140" class="elsevierStylePara elsevierViewall">All the diagnosed cases of acute cholangitis due to cholangiohydatidosis in the reported period were treated according to the protocol described in material and methods section&#46; There were no cases of medical or endoscop-ic treatment&#46;</p></span><span id="s0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0115">Discussion</span><p id="p0145" class="elsevierStylePara elsevierViewall">There are few reports regarding the study of cholan-giohydatidosis as an associated factor for POM in HE surgery&#44; and most are retrospective case series&#44; contributing evidence level 4&#46; Reports in the literature are scarce because it is a rare entity&#44; with a low incidence among patients who have undergone surgery for HE&#46; In general&#44; there have only been isolated case reports and small case series &#40;single case report&#44;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">13&#44;15&#44;16&#44;18-20&#44;22&#44;23</span></a> between 4 and 6 cases of endoscopic treatment<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">10-12&#44;21</span></a>&#41;&#44; 13 cases reported by our group in 20013&#44; 25 cases treated endoscopically14 and the most numerous series &#40;80 cases&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">17</span></a> However&#44; secondary cholangitis is not clearly reported in any of them&#46;</p><p id="p0150" class="elsevierStylePara elsevierViewall">In addition to being a rare entity&#44; the biggest problems are the complications which cholangiohydatidosis can cause&#58; biliary obstructive syndrome&#44;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">3&#44;14</span></a> acute suppurated cholangitis&#44;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">3&#44;13&#44;14</span></a> and even acute secondary pancreatitis&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">13&#44;15</span></a></p><p id="p0155" class="elsevierStylePara elsevierViewall">The fact that 35&#46;0&#37; of cases concomitantly presented a liver abscess of hydatid origin&#44;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">4</span></a> and 10&#46;0&#37; also had a hepatotho-racic transit&#44;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">27</span></a> underscores these patients&#8217; severe condition&#46;</p><p id="p0160" class="elsevierStylePara elsevierViewall">The mean diameter of the cysts was 19&#46;0 &#177; 9&#46;0 cm&#44; with a mostly heterogeneous sonographic appearance&#44; and these were generally complicated cysts&#46; This fact at least partly undermines the thesis of exclusive endoscopic treatment for this problema&#44;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">12&#44;14</span></a> because if so&#44; we would be rendering treatment for the original lesion null&#44; which&#44; as discussed in this manuscript&#44; in more than 30&#37; of cases can be found abscessed as well&#46; For this reason&#44; we believe that surgery remains the treatment of choice for cholan-giohydatidosis and secondary cholangitis&#44; and endoscopic drainage may be useful only in select cases&#44;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">16&#44;28&#44;29</span></a> and more as a bridge procedure to drain the bile duct while awaiting definitive surgery&#46;</p><p id="p0165" class="elsevierStylePara elsevierViewall">Clinical presentation and laboratory findings are not specific&#44; and may simulate an obstructive jaundice and acute cholangitis &#40;predominantly lithiasic in Chile&#41;&#44; which is similar to that reported by other groups&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">16&#44;29</span></a></p><p id="p0170" class="elsevierStylePara elsevierViewall">The existence of biliary communications in all patients explains the genesis of cholangiohydatidosis&#44; because it is through these communications that parasitic structures migrate into the bile duct&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">3</span></a></p><p id="p0175" class="elsevierStylePara elsevierViewall">Treatment of cholangiohydatidosis and secondary cholangitis is to drain and clean the bile duct&#44; which can be performed by open &#40;conventional&#41; surgery or closed surgery &#40;endoscopic papillotomy&#41;&#59; however&#44; as discussed above&#44; while it is true that endoscopic papillotomy offers all the advantages of a minimally invasive surgery &#40;particularly useful in high-risk patients&#41;&#44; it does not allow a rational and definitive treatment of the whole problem&#46; Therefore&#44; in general&#44; surgery remains the option of choice through biliary drainage &#40;choledochostomy or choledocoduodenoanastomosis&#41; and simultaneous resection of the hydatid cyst&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">16&#44;28&#44;29</span></a></p><p id="p0180" class="elsevierStylePara elsevierViewall">It would be of great interest to ascertain the effectiveness of endoscopic and laparoscopic treatments in patients with cholangitis secondary to cholangiohydatidosis&#46; However&#44; the actual number of available cases is insufficient to conduct a comparative study with a methodologically adequate power and level of confidence&#46;</p><p id="p0185" class="elsevierStylePara elsevierViewall">We believe that the reported morbidity &#40;30&#46;0&#37;&#41; is relevant&#59; however&#44; the clinical severity in these patients and their concomitant comorbidities must also be consid-ered3&#44;17&#44; as should the mortality of the series &#40;5&#46;0&#37;&#41;&#44; which guides a clinical entity of poor prognosis for which no effort should be spared to make an early diagnosis and take prompt and appropriate action&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">3&#44;28</span></a></p><p id="p0190" class="elsevierStylePara elsevierViewall">However&#44; we are aware that the study presents some potential sources of bias that merit comment&#46; One of these has to do with the heterogeneity of the population&#46; Another is related to the sample size&#44; because there are no more cases to report&#46; The loss of follow-up at less than 10&#37; and an extensive follow-up time&#44; however&#44; are tools that increase the quality of the data&#46;</p><p id="p0195" class="elsevierStylePara elsevierViewall">With respect to the external validity of this study&#44; it is worth noting that the study results correspond to the reality of one center of reference for hepatobiliary surgery located in an endemic region of echinococcosis&#59; therefore&#44; the reader must assess the external validity and reproduci-bility of the results with caution&#46;</p><p id="p0200" class="elsevierStylePara elsevierViewall">The protocol treatment did not include surgery prophylaxis with chemotherapy for Echinococcus Granulosus&#46; This is a controversial point&#59; however&#44; we chose not to use it because of a previous study where we described al-bendazole as having no effect on the viability of proto-scoleces in patients treated with this drug preoperatively&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">30</span></a> With respect to medical treatment with albendazole&#44; there is strong evidence &#40;systematic reviews and clinical trials&#41; that indicate that anthelmintic treatment alone is not ideal for liver hydatid cysts&#46;<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">31-33</span></a> On the other hand&#44; the World Health Organization carried out multicenter trials in Europe to compare albendazole and mebendazole and verified that both drugs had similar efficacy&#44; but mebendazole required higher doses and a different treatment with longer periods of adverse reactions&#46;<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">34&#44;35</span></a></p><p id="p0205" class="elsevierStylePara elsevierViewall">Finally&#44; it is important to note that cholangiohydatidosis is a rare cause of obstructive jaundice and cholangitis associated with important rates of POM and mortality which occurs in the context of complex patients&#44; so it must be treated in centers with experience in such diseases&#46;</p></span><span id="s0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0120">Abbreviations</span><p id="p0210" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="l0010"><li class="elsevierStyleListItem" id="u0010"><span class="elsevierStyleLabel">&#8226;</span><p id="p0215" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">HE&#58;</span> hepatic echinococcosis&#46;</p></li><li class="elsevierStyleListItem" id="u0015"><span class="elsevierStyleLabel">&#8226;</span><p id="p0220" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">POM&#58;</span> post-operative morbidity&#46;</p></li></ul></p><p id="p0225" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Financial Support</span></p><p id="p0230" class="elsevierStylePara elsevierViewall">None&#46;</p></span></span>"
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          "titulo" => "Introduction"
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          "titulo" => "Material and Methods"
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              "titulo" => "Participants"
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    "pdfFichero" => "main.pdf"
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    "fechaRecibido" => "2016-05-06"
    "fechaAceptado" => "2016-08-08"
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        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
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          "palabras" => array:7 [
            0 => "Echinococcosis &#91;MeSH&#93;"
            1 => "Hydatidosis &#91;Multi&#93;"
            2 => "Echinococcosis"
            3 => "Hepatic &#91;Mesh&#93;"
            4 => "Hepatic Hydatid Cyst"
            5 => "Echinococco-sis"
            6 => "Hepatic&#47;complications &#91;MeSH&#93;"
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    "resumen" => array:1 [
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        "titulo" => "Abstract"
        "resumen" => "<span id="abs0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0015"><span class="elsevierStyleBold">Background</span></span><p id="sp0045" class="elsevierStyleSimplePara elsevierViewall">One of the evolutionary complications of hepatic echinococcosis &#40;HE&#41; is cholangiohydatidosis&#44; a rare cause of obstructive jaundice and cholangitis&#46; The aim of this study was to describe the results of surgical treatment on a group of patients with cholangiohydatidosis and secondary cholangitis in terms of post-operative morbidity &#40;POM&#41;&#46;</p></span> <span id="abs0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0020"><span class="elsevierStyleBold">Material and method</span></span><p id="sp0050" class="elsevierStyleSimplePara elsevierViewall">Case series of patients operated on for cholangiohydatidosis and cholangitis in the Department at Surgery of the Universidad de La Frontera and the Cl&#237;nica Mayor in Temuco&#44; Chile between 2004 and 2014&#46; The minimum follow-up time was six months&#46; The principal outcome variable was the development of POM&#46; Other variables of interest were age&#44; sex&#44; cyst diameter&#44; hematocrit&#44; leukocytes&#44; total bi-lirubin&#44; alkaline phosphatase and transaminases&#44; type of surgery&#44; existence of concomitant evolutionary complications in the cyst&#44; length of hospital stay&#44; need for surgical re-intervention and mortality&#46; Descriptive statistics were calculated&#46;</p></span> <span id="abs0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0025"><span class="elsevierStyleBold">Results</span></span><p id="sp0055" class="elsevierStyleSimplePara elsevierViewall">A total of 20 patients were studied characterized by a median age of 53 years&#44; 50&#46;0&#37; female and 20&#46;0&#37; having two or more cysts with a mean diameter of 13&#46;3 &#177; 6&#46;3 cm&#46; A median hospital stay of six days and follow-up of 34 months was recorded&#46; POM was 30&#46;0&#37;&#44; re-intervention rate was 10&#46;0&#37; and mortality rate was 5&#46;0&#37;&#46;</p></span> <span id="abs0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0030"><span class="elsevierStyleBold">Conclusion</span></span><p id="sp0060" class="elsevierStyleSimplePara elsevierViewall">Cholangiohydatidosis is a rare cause of obstructive jaundice and cholangitis associated with significant rates of POM and mortality&#46;</p></span>"
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          "en" => "<p id="sp0010" class="elsevierStyleSimplePara elsevierViewall">Female 66-year-old patient presented with four days&#8217; evolution of right upper abdominal pain&#44; fever and jaundice&#46; Abdominal CT scan verified a heterogeneous cystic mass that represented germinative membrane residues and some daughter vesicles&#46; The intimate relation between the cyst and the right biliary tree can also be seen&#44; specifically with its anterior branches&#46; The biliary communication at this level &#40;segment VI&#41; gave rise to cholangiohydatidosis and secondary acute cholangitis&#46;</p>"
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                  \t\t\t\t">48&#46;0 &#177; 19&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">53&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">17&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">76&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Hematocrits &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">38&#46;4 &#177; 3&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">39&#46;0&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Leukocytes &#40;x mm<span class="elsevierStyleSup">3</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13&#44;507&#46;6 &#177; 7&#44;281&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&#44;850&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#44;500&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">31&#44;900&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Bilirubin &#40;mg&#47;dL&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&#46;6 &#177; 3&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">20&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Alkaline phosphatase &#40;U&#47;L&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">940&#46;3 &#177; 636&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">762&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">228&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#44;260&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">ASAT &#40;U&#47;L&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">178&#46;4&#177; 224&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">147&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">38&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;020&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">ALAT &#40;U&#47;L&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">205&#46;9 &#177; 179&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">162&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">48&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">738&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Cyst diameter &#40;cm&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">19&#46;0 &#177; 9&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Bile duct diameter &#40;mm&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">19&#46;0 &#177; 2&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">17&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">34&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Hospital stay &#40;days&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16&#46;0 &#177; 17&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">28&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Follow-up &#40;months&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">40&#46;0 &#177; 28&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">34&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">84&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab2045069.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="sp0025" class="elsevierStyleSimplePara elsevierViewall">Distribution of clinical data in the study patients &#40;N &#61; 20&#41;&#46;</p>"
        ]
      ]
      4 => array:7 [
        "identificador" => "t0015"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "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="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Variable&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Sex &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Female&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">50&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Male&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">50&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Other evolutionary complication in the cyst &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">65&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">35&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Number of cysts &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">One&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">80&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Two or more&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">20&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Surgery performed &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Lobectomy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">30&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Morbidity &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">70&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">30&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Need for re-operation &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">90&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Mortality &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">95&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab2045071.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="sp0035" class="elsevierStyleSimplePara elsevierViewall">Distribution of clinical data and surgical characteristics in the study patients &#40;N &#61; 20&#41;&#46;</p>"
        ]
      ]
      5 => array:7 [
        "identificador" => "t0020"
        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
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        "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="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Variable&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Location of the cyst &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Right lobe&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">60&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Left lobe&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">25&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Bilateral&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">15&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Biliary communications &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">One&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">65&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Two&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">25&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Three or more&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Treatment of the residual cavity &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">None&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">60&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Capitonnage&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">25&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Omentoplasty&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">15&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Other surgeries performed concomitantly &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Cholecystectomy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">15&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Cholecystectomy and choledocostomy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">20&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Cholecystectomy &#43; choledocostomy &#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">60&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">splenectomy and peritoneal hydatidosis surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Morbidity according to Dindo &#38; Clavien&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">70&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab2045070.png"
              ]
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        ]
        "descripcion" => array:1 [
          "en" => "<p id="sp0040" class="elsevierStyleSimplePara elsevierViewall">Distribution of surgical characteristics in the study patients &#40;N &#61; 20&#41;&#46;</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bs0010"
          "bibliografiaReferencia" => array:35 [
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es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos