Monosegmental ALPPS after Bilateral Hepatectomy
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"documento" => "article" "crossmark" => 0 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "fla" "cita" => "Ann Hepatol. 2017;16:812-3" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 558 "formatos" => array:3 [ "EPUB" => 20 "HTML" => 470 "PDF" => 68 ] ] "en" => array:11 [ "idiomaDefecto" => true "titulo" => "Multiple Biliary Hamartomas, The ‘‘Von Meyenburg Complexes’’" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "812" "paginaFinal" => "813" ] ] "contieneResumen" => array:1 [ "en" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "f0010" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 702 "Ancho" => 999 "Tamanyo" => 97170 ] ] "descripcion" => array:1 [ "en" => "<p id="sp0010" class="elsevierStyleSimplePara elsevierViewall">T1-weighted MR image reveals multiple hypointense lesions of the liver and of variable size.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Joel O. Jáquez-Quintana, Erick A. Reyes-Cabello, Francisco J. Bosques-Padilla" "autores" => array:3 [ 0 => array:2 [ "nombre" => "Joel O." "apellidos" => "Jáquez-Quintana" ] 1 => array:2 [ "nombre" => "Erick A." "apellidos" => "Reyes-Cabello" ] 2 => array:2 [ "nombre" => "Francisco J." "apellidos" => "Bosques-Padilla" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1665268119304429?idApp=UINPBA00004N" "url" => "/16652681/0000001600000005/v1_201905301208/S1665268119304429/v1_201905301208/en/main.assets" ] "en" => array:17 [ "idiomaDefecto" => true "titulo" => "Monosegmental ALPPS after Bilateral Hepatectomy" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "814" "paginaFinal" => "817" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Klaus Steinbrück, Marcelo D’Oliveira, Renato Cano, Marcelo Enne" "autores" => array:4 [ 0 => array:4 [ "nombre" => "Klaus" "apellidos" => "Steinbrück" "email" => array:1 [ 0 => "steinbruck@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "aff1" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor1" ] ] ] 1 => array:3 [ "nombre" => "Marcelo" "apellidos" => "D’Oliveira" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">**</span>" "identificador" => "aff2" ] ] ] 2 => array:3 [ "nombre" => "Renato" "apellidos" => "Cano" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">**</span>" "identificador" => "aff2" ] ] ] 3 => array:3 [ "nombre" => "Marcelo" "apellidos" => "Enne" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">**</span>" "identificador" => "aff2" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Hepatobiliary Surgery, Bonsucesso Federal Hospital, Health Ministry, Rio de Janeiro, Brazil" "etiqueta" => "*" "identificador" => "aff1" ] 1 => array:3 [ "entidad" => "Hepatobiliary Surgery, Ipanema Federal Hospital, Health Ministry, Rio de Janeiro, Brazil" "etiqueta" => "**" "identificador" => "aff2" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor1" "etiqueta" => "*" "correspondencia" => "Correspondence and reprint request:" ] ] ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "f0035" "etiqueta" => "Figure 6" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr6.jpeg" "Alto" => 811 "Ancho" => 1001 "Tamanyo" => 147562 ] ] "descripcion" => array:1 [ "en" => "<p id="sp0035" class="elsevierStyleSimplePara elsevierViewall">Stage 2 surgery. Final aspect of liver remnant after stage 2 surgery.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="s0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0020">Introduction</span><p id="p0010" class="elsevierStylePara elsevierViewall">Associated liver partition and portal vein ligation for staged hepatectomy (ALPPS) approach has recently emerged as an alternative treatment for patients with bilo-bar colorectal liver metastasis (CRLM) and a small future liver remnant (FLR). ALPPS promotes accelerated growth of the FLR in a short period of time (around seven days), and prevents post-hepatectomy liver failure.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">1,2</span></a> Initially described for patients using the left lateral segments as FLR,<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">1</span></a> ALPPS has been adapted to the right posterior segments, two separate segments, or even one segment as FLR.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">3-6</span></a> Herein, we describe a case of segment 4-1 ALPPS on a large bilobar CRLM case associated with liver-first approach.</p></span><span id="s0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0025">Case report</span><p id="p0015" class="elsevierStylePara elsevierViewall">A 37-year-old female was admitted with a two-month history of progressive epigastric pain, weight loss, fatigue, and dysmenorrhea. Physical examination revealed pale mucosa, tachycardia, and a visible and painful 20 cm mass at the abdominal upper-right-quadrant. There were no stigmas of chronic liver disease. BMI was 27 kg/m<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">2</span></a>. Patient denied fever, comorbidities, smoking, alcohol, or other substance abuse, and had no previous surgery. Laboratory exams confirmed elevation of serum liver enzymes and INR (AST 54 U/L, ALT 312 U/L, INR 1.39). Serology for hepatitis was negative. CEA value was over 9,000 ng/ mL. An abdominal CT scan showed two bulking liver tumors occupying the right liver and left lateral segments (<a class="elsevierStyleCrossRef" href="#f0010">Figure 1</a>). A colonoscopy revealed a left colon tumor at the spleen flexure, later confirmed as an adenocarcinoma by lesion biopsy. After multidisciplinary team discussion, the patient was referred to chemotherapy and was restaged after six and 13 cycles of Oxaliplatin plus Bevacizumab based therapy. CEA value then dropped to 200 ng/mL. A new CT scan showed that the tumors had reduced in volume, leaving segments 1 and 4 free of disease, but with margins close to the middle hepatic vein (MHV) (<a class="elsevierStyleCrossRef" href="#f0015">Figure 2</a>). Liver-first approach was proposed, but FLR was estimated at 389 g, corresponding to 22% of standard liver volume (SLV) and 0.51 FLR/BW ratio (<a class="elsevierStyleCrossRef" href="#f0020">Figure 3</a>). Based on recent literature, we decided to perform ALPPS seeking to achieve a rapid growth of the FLR.</p><elsevierMultimedia ident="f0010"></elsevierMultimedia><elsevierMultimedia ident="f0015"></elsevierMultimedia><elsevierMultimedia ident="f0020"></elsevierMultimedia><p id="p0020" class="elsevierStylePara elsevierViewall">Stage 1 surgery was carried out under open technique with a bilateral subcostal incision with midline extension. Due to the large volume of tumor load preventing liver mobilization, we opted first to do the left lateral segment resection associated with the clean up of hepatic lesions in segment 4, then proceeded with parenchyma transection using the anterior approach and hanging maneuver. Transection of the liver was done using an ultrasonic dissector/aspirator and bipolar diathermy. MHV was dissected with special care not to compromise the outflow of segment 4. The right portal vein was divided and vessel loops were placed around the right hilar plate and the right hepatic vein (<a class="elsevierStyleCrossRef" href="#f0025">Figure 4</a>). The procedure lasted 390 min and the patient received two blood units. Laboratory exams on the 2nd and 5th post-operative days (POD) are described in <a class="elsevierStyleCrossRef" href="#t0010">table 1</a>. Eight days after the stage 1 surgery, a CT scan revealed growth of the FRL to 633 g (an increase of 62%), corresponding to 36% of SLV and 0.83 FLR/BW ratio (<a class="elsevierStyleCrossRef" href="#f0030">Figure 5</a>)<span class="elsevierStyleItalic">.</span> Stage 2 surgery was carried out on the 10th POD without complications (<a class="elsevierStyleCrossRef" href="#f0035">Figure 6</a>). The patient developed ascites and mild encephalopathy after stage 2, probably due to venous congestion on liver remnant, but recovered promptly with no infections or surgical complications. A control CT scan was done on the 19th POD and the patient was discharged on the 20th POD. She was subjected to a left colectomy after six months and is disease-free twenty one months after surgery.</p><elsevierMultimedia ident="f0025"></elsevierMultimedia><elsevierMultimedia ident="t0010"></elsevierMultimedia><elsevierMultimedia ident="f0030"></elsevierMultimedia><elsevierMultimedia ident="f0035"></elsevierMultimedia></span><span id="s0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0030">Discussion</span><p id="p0025" class="elsevierStylePara elsevierViewall">Since the initial series published by Schnitzbauer, <span class="elsevierStyleItalic">et al.</span>,<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">1</span></a> later named by Santibañes and Clavien,<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">2</span></a> ALPPS has been regularly performed in many centers around the globe. Initially reported for patients with primary or metastatic liver tumors,<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">1</span></a> ALLPS is now commonly recommended for patients with CRLM, especially in the presence of bilobar disease.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">7</span></a> In cases of HCC, intrahepatic cholangiocarcino-ma, and perihilar cholangiocarcinoma, ALPPS should be restricted due to higher associated morbidity and mortali-ty.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">7</span></a> Originally performed for a FLR consisting of the left lateral segment with or without segment 4,<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">1</span></a> ALPPS has been adapted, and reports using the right posterior segments, two separate segments, or even one segment as FLR have been released.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">3-6</span></a></p><p id="p0030" class="elsevierStylePara elsevierViewall">We present here a case of a young woman with large bilobar CRLM, initially considered unresectable. However, after preliminary response to chemotherapy, the patient was submitted to ALPPS leaving segments 1 and 4 as liver remnant. According to a “consensus” proposed by specialists, this kind of surgery should be called segment 4-1 ALPPS.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">8</span></a> This technique was first described by Santi-bañes, who performed it on two patients with CRLM.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">4</span></a> In a recent retrospective analysis of the ALPPS registry (<span class="elsevierStyleUnderline">www.alpps.net</span>), Schadde, et al. considered this kind of surgery as monosegment ALPPS (segment 1 was considered an accessory segment). Twelve patients were evaluated in this analysis, all of them with CRLM.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">9</span></a> The median time between stage 1 and 2 was 13 days (range 6-21) and the median degree of hypertrophy was 160% (range 93-250). Four out of the 12 patients experienced liver failure after stage 2. Eight out of 10 patients reaching 1-year follow-up were alive at 1 year (80%) and five out of 10 patients reaching 1-year follow-up were disease free at 1 year (50%). Our patient had similar results, with the exception of lower liver hypertrophy, probably due to congestion of the FLR. She is now in good condition and disease-free 21 months after surgery. Her last CEA value was 1.8 ng/mL. Naturally, ongoing followups will be necessary to determine the real disease-free and overall survivals.</p><p id="p0035" class="elsevierStylePara elsevierViewall">We understand that ALPPS is the decisive treatment for a select group of patients with advanced CRLM. Advanced liver resections for small liver remnants composed by one or two segments are feasible and safe, but should be performed by a multidisciplinary hepatobiliary team composed by surgeons, anesthesiologists, intensive care specialists, and hepatologists with great expertise.</p></span><span id="s0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0035">Supportive foundations</span><p id="p0040" class="elsevierStylePara elsevierViewall">There was no funding source.</p></span><span id="s0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0040">Conflicts of Interest</span><p id="p0045" class="elsevierStylePara elsevierViewall">There are no conflicts.</p></span><span id="s0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0045">Abbreviations</span><p id="p0145" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="l0010"><li class="elsevierStyleListItem" id="u0010"><span class="elsevierStyleLabel">•</span><p id="p0050" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">ALPPS:</span> associated liver partition and portal vein liga-tion for staged hepatectomy.</p></li><li class="elsevierStyleListItem" id="u0015"><span class="elsevierStyleLabel">•</span><p id="p0055" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">BW:</span> body weight.</p></li><li class="elsevierStyleListItem" id="u0020"><span class="elsevierStyleLabel">•</span><p id="p0060" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">CRLM:</span> colorectal liver metastasis.</p></li><li class="elsevierStyleListItem" id="u0025"><span class="elsevierStyleLabel">•</span><p id="p0065" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">FLR:</span> future liver remnant.</p></li><li class="elsevierStyleListItem" id="u0030"><span class="elsevierStyleLabel">•</span><p id="p0070" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">MHV:</span> middle hepatic vein.</p></li><li class="elsevierStyleListItem" id="u0035"><span class="elsevierStyleLabel">•</span><p id="p0075" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">POD:</span> post operative day</p></li><li class="elsevierStyleListItem" id="u0040"><span class="elsevierStyleLabel">•</span><p id="p0080" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">SLV:</span> standard liver volume.</p></li></ul></p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:9 [ 0 => array:3 [ "identificador" => "xres1197563" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abs0010" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1116249" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "s0010" "titulo" => "Introduction" ] 3 => array:2 [ "identificador" => "s0015" "titulo" => "Case report" ] 4 => array:2 [ "identificador" => "s0020" "titulo" => "Discussion" ] 5 => array:2 [ "identificador" => "s0025" "titulo" => "Supportive foundations" ] 6 => array:2 [ "identificador" => "s0030" "titulo" => "Conflicts of Interest" ] 7 => array:2 [ "identificador" => "s0035" "titulo" => "Abbreviations" ] 8 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2016-08-06" "fechaAceptado" => "2016-09-17" "PalabrasClave" => array:1 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1116249" "palabras" => array:3 [ 0 => "Liver" 1 => "Cancer" 2 => "Surgery" ] ] ] ] "tieneResumen" => true "resumen" => array:1 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abs0010" class="elsevierStyleSection elsevierViewall"><p id="sp0045" class="elsevierStyleSimplePara elsevierViewall">Associated liver partition and portal vein ligation for staged hepatectomy (ALPPS) has emerged as an alternative for patients with bilobar colorectal liver metastasis and a small future liver remnant (FLR). In cases of extensive disease, ALPPS can be performed, leaving only one segment of the liver as FLR. We describe a case of monosegmental ALPPS using segment 4 as FLR. In conclusion, ALPPS should be reserved for a selected group of patients. Monosegmental ALPPS is feasible, but should be performed by hepatobiliary surgeons in specialized centers.</p></span>" ] ] "multimedia" => array:7 [ 0 => array:7 [ "identificador" => "f0010" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1223 "Ancho" => 1394 "Tamanyo" => 187284 ] ] "descripcion" => array:1 [ "en" => "<p id="sp0010" class="elsevierStyleSimplePara elsevierViewall">Initial CT scan. CT scan evidencing 2 bulking liver tumors in right liver and left lateral section.</p>" ] ] 1 => array:7 [ "identificador" => "f0015" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 684 "Ancho" => 1000 "Tamanyo" => 108270 ] ] "descripcion" => array:1 [ "en" => "<p id="sp0015" class="elsevierStyleSimplePara elsevierViewall">Post-chemoterapy CT scan. CT scan after 13 cycles of chemoter-apy: segments 1 and 4 are free of disease. MHV (arrow) is close to margin.</p>" ] ] 2 => array:7 [ "identificador" => "f0020" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 684 "Ancho" => 1000 "Tamanyo" => 105743 ] ] "descripcion" => array:1 [ "en" => "<p id="sp0020" class="elsevierStyleSimplePara elsevierViewall">Initial future liver remnant. FLR (segments 1 and 4) estimated at 389 g, corresponding to 22% of SLV.</p>" ] ] 3 => array:7 [ "identificador" => "f0025" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 896 "Ancho" => 1000 "Tamanyo" => 185670 ] ] "descripcion" => array:1 [ "en" => "<p id="sp0025" class="elsevierStyleSimplePara elsevierViewall">Stage 1 surgery. Intraoperative view of liver transection. MHV (arrow) is preserved.</p>" ] ] 4 => array:7 [ "identificador" => "f0030" "etiqueta" => "Figure 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 806 "Ancho" => 1002 "Tamanyo" => 135017 ] ] "descripcion" => array:1 [ "en" => "<p id="sp0030" class="elsevierStyleSimplePara elsevierViewall">Future liver remnant after stage 1 surgery. CT scan on 8th POD: FLR increased to 633g (36% of SLV).</p>" ] ] 5 => array:7 [ "identificador" => "f0035" "etiqueta" => "Figure 6" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr6.jpeg" "Alto" => 811 "Ancho" => 1001 "Tamanyo" => 147562 ] ] "descripcion" => array:1 [ "en" => "<p id="sp0035" class="elsevierStyleSimplePara elsevierViewall">Stage 2 surgery. Final aspect of liver remnant after stage 2 surgery.</p>" ] ] 6 => array:7 [ "identificador" => "t0010" "etiqueta" => "Table 1" "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">Blood test \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">2nd POD \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">5th POD \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">Bilirubin \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">3.1 \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">0.8 \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">INR \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">1.78 \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">1.1 \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">AST \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">870 \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 \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">ALT \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">682 \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 \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">Creatinine \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">0.4 \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">0.5 \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">Hemoglobin \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">6.8 \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">8.5 \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">MELD \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 \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">7 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2045130.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="sp0040" class="elsevierStyleSimplePara elsevierViewall">Laboratory exams on 2nd and 5th POD.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bs0010" "bibliografiaReferencia" => array:9 [ 0 => array:3 [ "identificador" => "bib0010" "etiqueta" => "1." 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 5 | 1 | 6 |
| 2024 October | 11 | 3 | 14 |
| 2024 September | 35 | 5 | 40 |
| 2024 August | 24 | 11 | 35 |
| 2024 July | 6 | 3 | 9 |
| 2024 June | 7 | 5 | 12 |
| 2024 May | 7 | 5 | 12 |
| 2024 April | 11 | 5 | 16 |
| 2024 March | 33 | 9 | 42 |
| 2024 February | 20 | 5 | 25 |
| 2024 January | 37 | 4 | 41 |
| 2023 December | 11 | 4 | 15 |
| 2023 November | 25 | 9 | 34 |
| 2023 October | 45 | 6 | 51 |
| 2023 September | 27 | 0 | 27 |
| 2023 August | 31 | 7 | 38 |
| 2023 July | 20 | 3 | 23 |
| 2023 June | 27 | 2 | 29 |
| 2023 May | 65 | 4 | 69 |
| 2023 April | 27 | 0 | 27 |
| 2023 March | 30 | 2 | 32 |
| 2023 February | 20 | 2 | 22 |
| 2023 January | 7 | 7 | 14 |
| 2022 December | 16 | 4 | 20 |
| 2022 November | 15 | 6 | 21 |
| 2022 October | 22 | 10 | 32 |
| 2022 September | 22 | 8 | 30 |
| 2022 August | 15 | 9 | 24 |
| 2022 July | 13 | 11 | 24 |
| 2022 June | 23 | 15 | 38 |
| 2022 May | 15 | 5 | 20 |
| 2022 April | 31 | 10 | 41 |
| 2022 March | 38 | 11 | 49 |
| 2022 February | 17 | 5 | 22 |
| 2022 January | 29 | 6 | 35 |
| 2021 December | 12 | 13 | 25 |
| 2021 November | 25 | 9 | 34 |
| 2021 October | 42 | 8 | 50 |
| 2021 September | 38 | 7 | 45 |
| 2021 August | 28 | 8 | 36 |
| 2021 July | 29 | 6 | 35 |
| 2021 June | 17 | 8 | 25 |
| 2021 May | 12 | 6 | 18 |
| 2021 April | 26 | 9 | 35 |
| 2021 March | 18 | 8 | 26 |
| 2021 February | 14 | 9 | 23 |
| 2021 January | 19 | 12 | 31 |
| 2020 December | 30 | 13 | 43 |
| 2020 November | 15 | 7 | 22 |
| 2020 October | 10 | 10 | 20 |
| 2020 September | 24 | 9 | 33 |
| 2020 August | 21 | 10 | 31 |
| 2020 July | 12 | 11 | 23 |
| 2020 June | 18 | 6 | 24 |
| 2020 May | 20 | 8 | 28 |
| 2020 April | 10 | 4 | 14 |
| 2020 March | 17 | 11 | 28 |
| 2020 February | 13 | 6 | 19 |
| 2020 January | 11 | 10 | 21 |
| 2019 December | 9 | 8 | 17 |
| 2019 November | 11 | 4 | 15 |
| 2019 October | 9 | 2 | 11 |
| 2019 September | 2 | 0 | 2 |
| 2019 August | 6 | 1 | 7 |
| 2019 July | 6 | 9 | 15 |
| 2019 June | 17 | 10 | 27 |
| 2019 May | 3 | 5 | 8 |
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