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Case report
Preserving the organ donor pool and suprahepatic vena cava: Case series of transverse hepatectomy for polycystic liver disease
Thomas W. Smith Jr.a,
Corresponding author
thomas.w.smith@lumc.edu

Corresponding author:
, Ari Goldbergb, Amy D. Lua
a Department of Surgery, Loyola University Medical Center, Maywood, IL, United States
b Department of Radiology, Loyola University Medical Center, Maywood, IL, United States
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">1</span><span class="elsevierStyleSectionTitle" id="sect0015">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Polycystic liver disease &#40;PLD&#41; consists of the cystic replacement of healthy liver parenchyma&#44; caused by one of two autosomal dominant forms&#58; isolated hepatic cysts with autosomal dominant polycystic liver disease &#40;ADPLD&#41; or autosomal dominant polycystic kidney disease &#40;ADPKD&#41; with both renal and hepatic cysts <a class="elsevierStyleCrossRefs" href="#bib0110">&#91;1&#44;2&#93;</a>&#46; The majority of patients with PLD remain asymptomatic&#44; however cystic enlargement can lead to massive hepatomegaly and mass effect within the abdomen causing severe abdominal pain&#44; dyspnea&#44; gastric reflux&#44; early satiety&#44; malnutrition&#44; and chronic fatigue <a class="elsevierStyleCrossRefs" href="#bib0110">&#91;1&#44;3&#93;</a>&#46; PLD rarely causes derangements in liver function tests&#44; however severe hepatomegaly can lead to portal vein and bile duct compression leading to portal hypertension and hepatic decompensation <a class="elsevierStyleCrossRefs" href="#bib0110">&#91;1&#44;4&#93;</a>&#46; Moreover&#44; hepatic cysts can rupture or become infected&#44; potentially leading to hypovolemic or septic shock <a class="elsevierStyleCrossRefs" href="#bib0130">&#91;5&#44;6&#93;</a>&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Because liver function is infrequently impaired in PLD&#44; treatment is reserved for patients with symptomatic disease causing reductions and limitations in quality of life and activities of daily living &#40;ADLs&#41; <a class="elsevierStyleCrossRef" href="#bib0140">&#91;7&#93;</a>&#46; Medical therapies are infrequently successful in altering patients&#8217; symptoms but are current topics of research&#44; including somatostatin analogs&#46; Somatostatin analogs have been shown to reduce cystic fluid growth by inhibiting cAMP production in cystic cholangiocytes <a class="elsevierStyleCrossRef" href="#bib0145">&#91;8&#93;</a>&#46; Multiple randomized control trials have shown reduction in liver volume and minimal reduction in symptoms&#44; however treatment requires continuous use and long-term results are not known <a class="elsevierStyleCrossRefs" href="#bib0110">&#91;1&#44;9&#93;</a>&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Invasive techniques for treatment of PLD revolve around the mechanical reduction of hepatic cyst volume&#46; Less invasive treatment options center around radiologic guided cyst aspiration with and without sclerotherapy agents <a class="elsevierStyleCrossRefs" href="#bib0155">&#91;10&#44;11&#93;</a>&#46; This treatment is especially useful for large single dominant cysts&#44; however recurrence rates are significantly high approaching 20&#37; <a class="elsevierStyleCrossRefs" href="#bib0110">&#91;1&#44;10&#93;</a>&#46; Surgical cyst fenestration involves not only aspiration of cystic fluid but unroofing of cysts&#44; and can be done in an open or laparoscopic technique <a class="elsevierStyleCrossRef" href="#bib0145">&#91;8&#93;</a>&#46; Cyst fenestration has been extensively described in the literature back into the early 20<span class="elsevierStyleSup">th</span> century&#44; with multiple techniques to reduce re-accumulation of cystic fluid with marsupialization&#44; anastomosis to gastrointestinal tract&#44; and external drainage <a class="elsevierStyleCrossRefs" href="#bib0165">&#91;12&#44;13&#93;</a>&#46; However&#44; as with aspiration&#44; recurrence rates are above 20&#37; <a class="elsevierStyleCrossRefs" href="#bib0145">&#91;8&#44;10&#93;</a>&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">More definitive surgical options hinge on large resection with or without accompanied cyst fenestration&#44; including anatomic and non-anatomic hepatic resections &#40;including transverse hepatectomy&#41; <a class="elsevierStyleCrossRef" href="#bib0120">&#91;3&#93;</a>&#46; A large retrospective single center study&#44; from 1985 to 2014&#44; followed 186 patients who had undergone partial hepatectomy and accompanied cyst fenestration <a class="elsevierStyleCrossRef" href="#bib0175">&#91;14&#93;</a>&#46; Median liver volume pre-operatively was 6781 cc and post-operatively was 2502<span class="elsevierStyleHsp" style=""></span>cc&#44; with 61&#37; liver volume reduction <a class="elsevierStyleCrossRef" href="#bib0175">&#91;14&#93;</a>&#46; At mean follow-up of 8 years median liver volume was 2519<span class="elsevierStyleHsp" style=""></span>cc&#44; showing continued reduction in liver volume with minimal reoccurrence at prolonged follow-up periods <a class="elsevierStyleCrossRef" href="#bib0175">&#91;14&#93;</a>&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">However&#44; the only curative surgical approach to PLD is orthotopic liver transplantation &#40;OLT&#41; with or without concurrent kidney transplantation <a class="elsevierStyleCrossRefs" href="#bib0180">&#91;15&#8211;17&#93;</a>&#46; Of the near 120&#44;000 people listed for liver transplantation from 2002 to 2015 on the Organ Procurement and Transplantation Network &#40;OPTN&#41;&#44; 620 cases were for associated PLD <a class="elsevierStyleCrossRef" href="#bib0185">&#91;16&#93;</a>&#46; Although only a minority subset of patients undergo OLT&#44; patients with PLD had a statistically significant longer survival after transplant compared to patients with hepatocellular carcinoma &#40;HCC&#41; and chronic liver failure &#40;CLF&#41; <a class="elsevierStyleCrossRef" href="#bib0195">&#91;18&#93;</a>&#46; Increased survival post-transplant and the curative nature of the surgery for patients with PLD leads many centers to push for early transplantation in select cohort of patients <a class="elsevierStyleCrossRef" href="#bib0185">&#91;16&#93;</a>&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">2</span><span class="elsevierStyleSectionTitle" id="sect0020">Case series</span><p id="par0030" class="elsevierStylePara elsevierViewall">This is a retrospective case series review performed at one large academic tertiary care center from 2012 to 2018 focusing on transverse hepatectomy for PLD&#46; Two female patients with PLD have been treated with transverse hepatectomy with symptomatic relief since 2014&#46; Both patients had a longstanding diagnosis &#40;greater than ten years&#41; of ADPKD&#44; with strong family history disease penetrance&#46; Patient 1 &#40;43 years old&#41; had an initial incidental diagnosis of PLD due to interval CT scan for monitoring of ADPKD&#46; Patient 2 &#40;39 years old&#41; was diagnosed with PLD after an emergent hospitalization for the discovery of a bleeding liver cyst&#44; which was managed conservatively&#46; Both patients were referred to our medical center for surgical consultation for management of PLD&#46; They complained of severe abdominal distention with limitations to ADLs&#44; shortness of breath with activity&#44; decreased appetite&#44; and early satiety&#46; Patient 2 begun to have evidence of muscle wasting&#46; On physical exam both had massive hepatomegaly with visible and palpable liver cysts protruding below the right costal margin&#44; with palpable liver edges extending into and across to the left lower quadrant and pelvic brim&#46; At presentation both had normal renal and liver function with no laboratory abnormalities&#46; Preoperative CT scans for both patient showed complete replacement of liver parenchyma with cystic lesions&#44; varying from millimeters to greater than multiple centimeters in size &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">Patients 1 and 2 both underwent nonanatomic transverse hepatectomy&#44; significant unroofing and decortication of remaining liver parenchyma&#44; and cholecystectomy&#44; additionally patient 1 had multiple right renal cysts decorticated&#46; A bilateral subcostal incision was completed&#44; significant adhesions to anterior abdominal wall due to superficial cysts were dissected free to expose segments III&#44; IVB&#44; V&#44; and VI&#44; which were transected using a combination of electrocautery &#40;Argon beam coagulator and Aquamantys bipolar system&#41; and vascular stapling devices&#46; Specific attention was taken to avoid central hepatic veins&#44; deep hepatic parenchymal transection was performed with vascular stapling devices to minimize hepatic vein injury or stenosis with thermal injury from electrocautery&#46; Patient 1 had a pre-operatively liver volume of 7025&#46;61 cc&#44; post-operatively liver volume was 5549&#46;01 cc&#44; with 21&#37; liver volume reduction&#46; Patient 2 had liver volume reduction of 54&#37;&#46; Although patient 1 had a smaller total liver volume reduction&#44; the ratio of parenchymal volume to total volume significantly changed post-operatively&#44; increasing approximately 15&#37; &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">Blood loss during each operation was less than 1<span class="elsevierStyleHsp" style=""></span>L&#44; both patients were transferred post-operatively to the surgical intensive care unit for close monitoring&#46; Both were discharged home on post-operative day seven and six respectively&#46; Post-discharge course for patient 1 was complicated by right hemi-diaphragm excursion impairment&#44; furthermore a hydropneumothorax was visualized and underwent a thoracentesis with 60cc of transudative fluid removed on post-operative day 75&#46; Symptoms stabilized and improved&#59; however&#44; the patient returned to clinic 5 years post-operatively with recurrence of symptoms of fatigue and increased abdominal girth from hepatomegaly&#46; The patient is being considered for possible OLT and liver function remains within normal limits&#46; Patient 2 had development of ascites post-discharge due to portal hypertension secondary to surgery&#44; requiring large volume paracentesis on post-op day 34 and 76&#44; ascites subsequently controlled medically with diuretics&#46; Diuretics were able to be discontinued&#44; and patient had resolution of ascites&#46; Patient 2 was subsequently found to have thrombocytopenia and evidence of an enlarged spleen&#44; hypothesized to be caused by portal hypertension&#46; At follow up 2 years after surgery&#44; patient 2 still notes complete resolution of symptoms related to abdominal girth and no limitations in ADLs &#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleLabel">3</span><span class="elsevierStyleSectionTitle" id="sect0025">Discussion</span><p id="par0045" class="elsevierStylePara elsevierViewall">There is little consensus to treatment protocols for patients with symptomatic PLD&#46; Medical treatments&#44; including somatostatin analogs&#44; have limited potential to reverse massive hepatomegaly once patients present with symptoms limiting quality of life &#40;however the use at earlier stages of diseases is still being researched&#41;&#46; Surgical interventions&#44; including cyst aspiration&#44; cyst fenestration&#44; and hepatic resection&#44; directly reduce the hepatomegaly that leads to compressive symptoms and discomfort&#59; however&#44; rates of recurrence are high&#46; In this setting patients are presenting for OLT at earlier stages of disease due to complete elimination of disease process and solution of hepatomegaly symptoms <a class="elsevierStyleCrossRef" href="#bib0200">&#91;19&#93;</a>&#46; Very few patients qualify for OLT in expedited fashion due to preservation of liver function tests&#44; leading to low biologic Model for End-Stage Liver Disease &#40;MELD&#41; scores&#46; Approximately 40&#37; of patients undergoing OLT for PLD undergo simultaneous liver kidney &#40;SLK&#41; transplantation due to concurrent renal dysfunction&#44; and MELD score is driven by creatinine for these patients <a class="elsevierStyleCrossRefs" href="#bib0195">&#91;18&#44;20&#93;</a>&#46; However&#44; for patients without concurrent renal dysfunction MELD exception points are needed to drive expedited transplantation&#46; In 2015&#44; the OPTN released the <span class="elsevierStyleItalic">Guidance on MELD PELD Exception Review</span> stating exception points are awarded for limited performance status following resection or fenestration&#44; hepatic decompensation&#44; or concurrent hemodialysis&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Even with MELD exception points only approximately 50&#37; of PLD cases listed for transplant undergo OLT&#44; with over 10&#37; of waitlisted PLD patients dying on the transplant list <a class="elsevierStyleCrossRefs" href="#bib0185">&#91;16&#8211;18&#93;</a>&#46; In this setting more aggressive treatment options need to be undertaken&#44; beyond transverse hepatectomy&#44; discussions need to include split liver transplant &#40;SLT&#41; and living donor liver transplantation &#40;LDLT&#41; to accommodate for patients with PLD and low MELD scores unable to obtain a liver on waitlist <a class="elsevierStyleCrossRef" href="#bib0210">&#91;21&#93;</a>&#46; SLT and LDLT are technically difficult in their own right&#59; furthermore&#44; when performed in the setting of PLD with massive hepatomegaly&#44; size mismatch with the graft is a technical issue hard to overcome <a class="elsevierStyleCrossRef" href="#bib0210">&#91;21&#93;</a>&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Limitations of this study include it being a case series with small sample size&#44; of only two patients&#44; with retrospective data collection thus limiting the external validity when applied to further patient populations&#46; However&#44; the limited prevalence of PLD&#44; moreover the limited prevalence of PLD with preserved liver and renal function&#44; allows insight to be gained from small case series discussing treatment options&#46; Transverse hepatectomy&#44; in select group of patients&#44; provides long term relief of symptoms and potential avoidance of OLT&#44; preventing a patient from requiring lifelong immunosuppressive medication and the multitude of other complications included with organ transplantation&#46; Furthermore&#44; transverse hepatectomy preserves the suprahepatic vena cava and deep hepatic veins preventing significant scarring&#44; a common complaint when aspiration and fenestration procedures fail and OLT is needed&#46; We propose that symptomatic PLD patients with preserved renal and hepatic function explore less invasive mechanical cyst removal&#44; including transverse hepatectomy&#44; to preserve limited donor organ pool and future surgical access for OLT&#46; Moreover&#44; this technique subsequently allows patients who proceed to need OLT MELD exception points under the current OPTN guidelines&#44; since such patients would have failed resection or fenestration&#46;<span class="elsevierStyleDefList"><span class="elsevierStyleSectionTitle" id="sect0030">Abbreviations</span><span class="elsevierStyleDefTerm">PLD</span><span class="elsevierStyleDefDescription"><p id="par0060" class="elsevierStylePara elsevierViewall">polycystic liver disease</p></span><span class="elsevierStyleDefTerm">ADPLD</span><span class="elsevierStyleDefDescription"><p id="par0065" class="elsevierStylePara elsevierViewall">autosomal dominant polycystic liver disease</p></span><span class="elsevierStyleDefTerm">ADPKD</span><span class="elsevierStyleDefDescription"><p id="par0070" class="elsevierStylePara elsevierViewall">autosomal dominant polycystic kidney disease</p></span><span class="elsevierStyleDefTerm">ADLs</span><span class="elsevierStyleDefDescription"><p id="par0075" class="elsevierStylePara elsevierViewall">activities of daily living</p></span><span class="elsevierStyleDefTerm">OLT</span><span class="elsevierStyleDefDescription"><p id="par0080" class="elsevierStylePara elsevierViewall">orthotopic liver transplantation</p></span><span class="elsevierStyleDefTerm">OPTN</span><span class="elsevierStyleDefDescription"><p id="par0085" class="elsevierStylePara elsevierViewall">Organ Procurement and Transplantation Network</p></span><span class="elsevierStyleDefTerm">HCC</span><span class="elsevierStyleDefDescription"><p id="par0090" class="elsevierStylePara elsevierViewall">hepatocellular carcinoma</p></span><span class="elsevierStyleDefTerm">CLF</span><span class="elsevierStyleDefDescription"><p id="par0095" class="elsevierStylePara elsevierViewall">chronic liver failure</p></span><span class="elsevierStyleDefTerm">MELD</span><span class="elsevierStyleDefDescription"><p id="par0100" class="elsevierStylePara elsevierViewall">Model for End-Stage Liver Disease</p></span><span class="elsevierStyleDefTerm">SLK</span><span class="elsevierStyleDefDescription"><p id="par0105" class="elsevierStylePara elsevierViewall">simultaneous liver kidney</p></span><span class="elsevierStyleDefTerm">SLT</span><span class="elsevierStyleDefDescription"><p id="par0110" class="elsevierStylePara elsevierViewall">split liver transplant</p></span><span class="elsevierStyleDefTerm">LDLT</span><span class="elsevierStyleDefDescription"><p id="par0115" class="elsevierStylePara elsevierViewall">living donor liver transplantation</p></span></span></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Author&#39;s contributions</span><p id="par0120" class="elsevierStylePara elsevierViewall">Thomas W&#46; Smith Jr&#46; &#8211; Study concept and design&#44; acquisition of data&#44; drafting of manuscript&#44; critical revision of manuscript&#46; Ari Goldberg &#8211; Analysis and interpretation of data&#44; technical imaging interpretation&#46; Amy D&#46; Lu &#8211; Study concept and design&#44; critical revision of manuscript&#44; administrative&#44; study supervision&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conflict of interest</span><p id="par0125" class="elsevierStylePara elsevierViewall">None&#46;</p></span></span>"
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      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Management of symptomatic polycystic liver disease &#40;PLD&#41; has remained primarily unchanged since the early 20th century when multiple case reports described management of non-parasitic liver cysts&#46; In 1968&#44; Lin et al&#46; described the fenestration procedure&#44; &#8220;aspiration of the cysts&#44; incision&#44; partial excision with or without external drainage&#44; or marsupilization and anastomosis to the gastrointestinal tract&#8221;&#46; Further surgical options have included cyst sclerotherapy&#44; laparoscopic cyst aspiration&#44; partial hepatectomy&#44; and orthotopic liver transplant &#40;OLT&#41;&#46; Recently there has been discussion of medical management with somatostatin analogs to reduce hepatomegaly in PLD with varying success&#46; There is no current consensus on treatment or standard of care for symptomatic PLD&#44; it is largely up to surgeon preference and ability&#59; however&#44; there has been a movement toward early OLT with Model for End-Stage Liver Disease &#40;MELD&#41; score exception points&#46; This case series reviews two female patients with normal renal and hepatic function with symptomatic PLD treated with transverse hepatectomy&#46; We propose that patients suffering from symptomatic PLD&#44; with retained renal and hepatic function&#44; can be treated with transverse hepatectomy conserving limited donor livers for decompensated patients&#59; moreover&#44; transverse hepatectomy does not disrupt the major suprahepatic vena cava preserving potential surgical access for future OLT&#46;</p></span>"
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">This research did not receive any specific grant from funding agencies in the public&#44; commercial&#44; or not-for-profit sectors&#46;</p>"
      ]
    ]
    "multimedia" => array:2 [
      0 => array:7 [
        "identificador" => "fig0005"
        "etiqueta" => "Fig&#46; 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
            "Alto" => 2683
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        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Coronal CT images representing pre-operative and post-operative scans for Pt&#46; 1 and Pt&#46; 2 respectively&#46; Pre-operative images&#44; the arrow represents the right lobe cystic tissue&#46;</p>"
        ]
      ]
      1 => array:8 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
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          0 => array:3 [
            "identificador" => "at1"
            "detalle" => "Table "
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Pt&#46; 1</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">PRE</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">Parenchymal volume &#8211; 2970&#46;55<span class="elsevierStyleHsp" style=""></span>cc&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Total volume &#8211; 7025&#46;61<span class="elsevierStyleHsp" style=""></span>cc&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  " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">POST</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">Parenchymal volume &#8211; 3149&#46;50<span class="elsevierStyleHsp" style=""></span>cc&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Total volume &#8211; 5549&#46;01<span class="elsevierStyleHsp" style=""></span>cc&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  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Pt&#46; 2</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">PRE</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">Parenchymal volume &#8211; 2871&#46;68<span class="elsevierStyleHsp" style=""></span>cc&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Total volume &#8211; 11&#44;292&#46;97<span class="elsevierStyleHsp" style=""></span>cc&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  " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">POST</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">Parenchymal volume &#8211; 1463&#46;47<span class="elsevierStyleHsp" style=""></span>cc&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Total volume &#8211; 5198&#46;63<span class="elsevierStyleHsp" style=""></span>cc&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Volumetric Analysis &#8211; CT liver volumetry was measured pre-operatively and post-operatively&#44; by manually segmenting the liver on stack of axial images&#44; creating a segmented 3D liver volume&#46; Quantification was further analyzed comparing parenchymal volume to total volume&#44; indirectly showing cystic capacity of liver&#46;</p>"
        ]
      ]
    ]
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      "titulo" => "References"
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                            "web" => "Medline"
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                        0 => array:2 [
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                            1 => "L&#46; Missiaen"
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                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
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                            0 => "L&#46;B&#46; Johnson"
                            1 => "P&#46;C&#46; Kuo"
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                          ]
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            3 => array:3 [
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              "etiqueta" => "&#91;4&#93;"
              "referencia" => array:1 [
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                            0 => "M&#46; Gallegos"
                            1 => "D&#46;P&#46; Bradly"
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                    0 => array:1 [
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                      "titulo" => "Infection of hepatic cysts in polycystic disease"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
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                            0 => "J&#46; Abascal"
                            1 => "M&#46; Moya"
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                          ]
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                      ]
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                  ]
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              "identificador" => "bib0135"
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              "referencia" => array:1 [
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                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "Q&#46; Qian"
                            1 => "A&#46; Li"
                            2 => "B&#46;F&#46; King"
                            3 => "P&#46;S&#46; Kamath"
                            4 => "D&#46;J&#46; Lager"
                            5 => "J&#46; Huston 3rd"
                          ]
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                      ]
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                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1053/jhep.2003.50006"
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                        "tituloSerie" => "Hepatology"
                        "fecha" => "2003"
                        "volumen" => "37"
                        "paginaInicial" => "164"
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                          ]
                        ]
                        "itemHostRev" => array:3 [
                          "pii" => "S0959804916320664"
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                          "issn" => "09598049"
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              "identificador" => "bib0140"
              "etiqueta" => "&#91;7&#93;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Impact of liver volume on polycystic liver disease-related symptoms and quality of life"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "M&#46;K&#46; Neijenhuis"
                            1 => "W&#46; Kievit"
                            2 => "S&#46;M&#46; Verheesen"
                            3 => "H&#46;M&#46; D&#8217;Agnolo"
                            4 => "T&#46;J&#46; Gevers"
                            5 => "J&#46;P&#46; Drenth"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
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                        "fecha" => "2018"
                        "volumen" => "6"
                        "paginaInicial" => "81"
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              "identificador" => "bib0145"
              "etiqueta" => "&#91;8&#93;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Clinical management of polycystic liver disease"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "R&#46;M&#46;M&#46; van Aerts"
                            1 => "L&#46;F&#46;M&#46; van de Laarschot"
                            2 => "J&#46;M&#46; Banales"
                            3 => "J&#46;P&#46;H&#46; Drenth"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jhep.2013.10.028"
                      "Revista" => array:3 [
                        "tituloSerie" => "J Hepatol"
                        "fecha" => "2017"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24211739"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
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              ]
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              "identificador" => "bib0150"
              "etiqueta" => "&#91;9&#93;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Somatostatin analogues improve health-related quality of life in polycystic liver disease&#58; a pooled analysis of two randomised&#44; placebo-controlled trials"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "M&#46;K&#46; Neijenhuis"
                            1 => "T&#46;J&#46; Gevers"
                            2 => "F&#46; Nevens"
                            3 => "M&#46;C&#46; Hogan"
                            4 => "V&#46;E&#46; Torres"
                            5 => "W&#46; Kievit"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Aliment Pharmacol Therap"
                        "fecha" => "2015"
                        "volumen" => "42"
                        "paginaInicial" => "591"
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                      ]
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              ]
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              "identificador" => "bib0155"
              "etiqueta" => "&#91;10&#93;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Medical and surgical treatment options for polycystic liver disease"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "J&#46;P&#46; Drenth"
                            1 => "M&#46; Chrispijn"
                            2 => "D&#46;M&#46; Nagorney"
                            3 => "P&#46;S&#46; Kamath"
                            4 => "V&#46;E&#46; Torres"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1002/hep.24036"
                      "Revista" => array:6 [
                        "tituloSerie" => "Hepatology"
                        "fecha" => "2010"
                        "volumen" => "52"
                        "paginaInicial" => "2223"
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                          ]
                        ]
                      ]
                    ]
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                ]
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              "etiqueta" => "&#91;11&#93;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Percutaneous aspiration and ethanolamine oleate sclerotherapy for sustained resolution of symptomatic polycystic liver disease&#58; an initial experience"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "R&#46; Nakaoka"
                            1 => "K&#46; Das"
                            2 => "M&#46; Kudo"
                            3 => "H&#46; Chung"
                            4 => "T&#46; Innoue"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
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                        "fecha" => "2009"
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                        ]
                      ]
                    ]
                  ]
                ]
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            ]
            11 => array:3 [
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              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Nonparasitic hepatocystic disease&#58; a report of nine cases"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "R&#46;J&#46; Coffey"
                            1 => "M&#46;T&#46; Fitzmaurice"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
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                            "web" => "Medline"
                          ]
                        ]
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ISSN: 16652681
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