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Case Report
Aortoesophageal fistula secondary to esophageal self-expandable partially covered metal stent: The first Latin American serie
Fístula aortoesofágica secundaria a stent esofágico metálico autoexpandible parcialmente cubierto: la primera serie latinoamericana
Luis Felipe Cabrera Vargasa,b, Daniel Gomezc, Isabella Garavis Montagutd,
Corresponding author
igaravis@unbosque.edu.co

Corresponding author.
, María Paula Olivera Bolívard
a Vascular Surgeon, Universidad Militar de Nueva Granada, Calle 94 A # 13-54, Bogotá, Colombia
b Santa Fe de Bogotá Foundation, Bogotá, Colombia
c Minimally Invasive Surgeon, Clinica Nogales, Calle 95 #23-61, Bogotá, Colombia
d El Bosque University, Faculty of Medicine, Research Group in General Surgery and Subspecialties, Ak. 9 #131a-2, Colombia
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          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">AngioCT&#58; CT shows direct contact of the esophageal self-expandable partially covered metal stent with the aortic wall generating the aortoesophageal fistula&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Aortoesophageal fistula &#40;AEF&#41; is a rare but life-threatening complication of esophageal stent placement&#46; AEF is characterized by the formation of a communication between the aorta and the esophagus&#44; which can result in catastrophic hemorrhage and sepsis&#46; Self-expandable partially covered esophageal stents &#40;PCSEMS&#41; are commonly used to manage malignant and benign esophageal structures&#46; Although PCSEMS effectively improves dysphagia and quality of life in patients with esophageal cancer&#44; the risk of AEF associated with PCSEMS placement remains a concern&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1&#8211;3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The exact incidence of AEF secondary to PCSEMS placement is unknown&#44; but several case reports and small case series have documented this complication&#46; In addition&#44; the risk factors and pathophysiology of AEF secondary to PCSEMS placement are poorly understood&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1&#8211;3</span></a> This study aims to show the first Latin American experience in the treatment of AEF secondary to PCSEMS&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Methods</span><p id="par0015" class="elsevierStylePara elsevierViewall">This retrospective case series study evaluates the surgical approach and postoperative outcomes of patients with AEF secondary to PCSEMS placement in 2 centers in Bogota&#44; Colombia&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Patient selection</span><p id="par0020" class="elsevierStylePara elsevierViewall">All patients diagnosed with AEF secondary to PCSEMS placement between January 2018 and April 2023 who underwent surgical intervention at two major academic medical centers in Bogota&#46; Patient data was obtained from electronic medical records&#44; intraoperative photos&#44; and radiological imaging studies&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Data collection</span><p id="par0025" class="elsevierStylePara elsevierViewall">Patient demographic data&#44; comorbidities&#44; details of the PCSEMS placement procedure&#44; time to development of AEF&#44; symptoms at presentation&#44; imaging findings&#44; surgical approach&#44; operative elements&#44; intraoperative complications&#44; length of hospital stay&#44; and postoperative outcomes were collected for each patient&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Surgical approach</span><p id="par0030" class="elsevierStylePara elsevierViewall">All patients underwent surgical intervention for the management of AEF secondary to PCSEMS placement&#46; The surgical approach was individualized based on the patient&#39;s clinical presentation&#44; hemodynamic stability&#44; and imaging findings&#46; Possible surgical approaches included thoracotomy and thoracoabdominal approach&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Statistical analysis</span><p id="par0035" class="elsevierStylePara elsevierViewall">Descriptive statistics were used to summarize the data&#46; Continuous variables were reported as mean and standard deviation or median and interquartile range&#44; depending on their distribution&#46; Categorical variables were reported as frequencies and percentages&#46;</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Results</span><p id="par0040" class="elsevierStylePara elsevierViewall">During this study that covered a period of five years in two major academic medical centers&#44; we found only 2 cases of AEF secondary to PCSEMS&#46; Demographic and clinical data are summarized in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46; The two patients were treated using an open surgical approach with laparotomy and left anterolateral thoracotomy due to the unavailability of endovascular management&#46; The incidence of this study was 1&#46;6&#37;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">The first patient was a 69-year-old man with a diagnosis of stage 4 cancer of the gastroesophageal junction with hepatic metastases in neoadjuvant treatment with chemotherapy and an esophageal stent in order to make the feeding process easier&#46; Three weeks after placing the stent&#44; the patient returns to the emergency room due to a massive upper digestive tract bleeding and hypovolemic shock stage three&#46; This patient went under an endoscopic procedure before the surgical approach that showed a distal aortoesophageal fistula associated with the distal part of the stent &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41; that required a left anterolateral thoracotomy with a vertical esophagostomy&#46; This procedure was converted into a clamshell due to the massive bleeding&#44; finally&#44; requiring aorta primary repair with polytetrafluoroethylene &#40;PTFE&#41; patch and primary closure of the distal esophagus over the PCSEMS&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">The second patient was a 73-year-old man diagnosed with stage 3 carcinoma of the gastroesophageal union that received neoadjuvant therapy with chemotherapy and radiotherapy&#46; The stent was placed&#44; but 20 days later he returned with hemodynamic instability stage 4 due to upper digestive tract bleeding&#44; with non-response to fluid resuscitation&#46; CT scan showed the image of the stent having direct contact with the aortic wall &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41; and went under open surgical procedure since vascular surgery was not available&#46; The patient required a laparotomy with distal esophagectomy and total gastrectomy &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a> &#40;A&#44; B&#41;&#41; plus thoracic descending aorta primary repair with polytetrafluoroethylene &#40;PTFE&#41; patch and extraction of the PCSEMS &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46; These previous two patients were hemodynamically unstable with no response to volume&#44; additionally&#44; the institutions did not have the availability of thoracic aortic endograft at the moment of the AEF massive bleeding&#46; Both patients died&#44; the first one in the first 24<span class="elsevierStyleHsp" style=""></span>h after the open surgical procedure and the second one in the 7 postoperative days in the intensive care unit due to a ventilator-associated pneumonia&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Discussion</span><p id="par0055" class="elsevierStylePara elsevierViewall">The initial report on AEF dates to 1818 when a fragment of beef bone was discovered&#46; In 1914&#44; Chiari described for the first time AEF as a triad of midthoracic pain or dysphagia&#44; followed by sentinel hemorrhage and fatal exsanguination after a symptom-free interval of hours to days&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1&#44;2</span></a> Aortoesophageal fistula &#40;AEF&#41; is a rare but devastating complication of esophageal self-expandable partially covered metal stent &#40;PCSEMS&#41; placement&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3&#8211;5</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">In this retrospective case series study&#44; we report two cases of AEF secondary to PCSEMS in Latin America&#44; data that is consistent with the unusual presentation of this complication&#46; Both patients were men with a mean age of 71 years with gastroesophageal adenocarcinoma cancer&#46; Indications for stent placement are palliative&#44; and include the reduction of dysphagia and the improvement of oral intake in patients with partial or total obstruction of the esophageal light secondary to cancer&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">In 1983&#44; Frimberger<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> treated a patient with an esophageal stricture by placing a stent&#46; Nowadays&#44; esophageal stents &#40;ESs&#41; have gained popularity for managing dysphagia in patients&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> A previous study by Li Y&#46; et al&#46; reported that out of 153 patients who experienced SEMS-related adverse events&#44; 43 died&#44; accounting for 28&#46;1&#37; of all adverse events&#46; Among these deaths&#44; 14 were due to massive bleeding&#44; representing 32&#46;6&#37; of deaths and 9&#46;15&#37; of all adverse events&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> According to our findings&#44; patients with gastroesophageal adenocarcinoma cancer who require SEMS placement should be closely monitored for the development of AEF&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1&#44;4&#44;5</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">The causes of SEMS-related AEF include repeated mechanical actions during interventional operations leading to injury&#44; tearing&#44; or rupture&#59; high pressure from the ES on the esophageal wall affecting the blood supply to the nourishing vessels&#59; increased swelling at both ends of the SEMS causing localized ischemia&#44; necrosis&#44; or ulceration resulting in AEF&#59; tumor growth and invasion&#59; and placement of the SEMS at an angle with the esophageal wall causing friction between the SEMS and the esophageal wall that combined with vessel pulsation and respiratory movement&#44; leads to AEF&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1&#44;8</span></a> The main risk factors for SEMS-related AEF development includes previously repeated dilations&#44; previous radiotherapy&#44; proximal stricture location&#44; and inappropriate stent choice&#46;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">5&#44;7</span></a> The incidence of AEF can be reduced by shortening the duration of retrievable SEMS placement or using a biodegradable fully covered stent&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Aryaie et al&#46; retrospectively reported the use of SEMS in treating 20 patients with anastomotic leaks following foregut surgery&#46; Among them&#44; AEF formation complicated the treatment in 2 patients &#40;10&#37;&#41;&#46; It is crucial to be attentive to SEMS-related AEF&#44; as the development of AEF after ES implantation can occur between 18 days and 11 months&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> The surgical approach for AEF secondary to SEMS has been controversial&#44; with no clear consensus on the optimal treatment&#46; In our study&#44; the two patients were treated using an open surgical approach with laparotomy and left anterolateral thoracotomy&#46; These two open surgical cases had a high intraoperative bleeding volume&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">However&#44; other approaches such as the endovascular approach have been associated with a higher risk of recurrence and mortality&#44; especially in cases of severe infection&#46; Notwithstanding&#44; the choice of surgical approach should be individualized based on the patient&#39;s clinical presentation and the availability of endovascular or open surgical expertise and resources&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3&#44;4&#44;7</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">Computed tomography angiography is a valuable diagnostic tool for ES-related AEF&#44; with a sensitivity ranging from 40&#37; to 90&#37; and specificity from 33&#37; to 100&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> In this report&#44; AEF was further confirmed through angiography of the aorta&#44; considered the &#8220;diagnostic criterion standard&#46;&#8221; Patients who underwent TEVAR &#40;endovascular repair of the thoracic aorta&#41; had significantly longer survival compared to those who did not receive treatment for aortic rupture and succumbed to hemorrhage shortly after hematemesis&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">9&#44;10</span></a> The mortality rate of AEF is reported to be approximately 77&#37; with intervention and 100&#37; with no treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> Conservative management approaches include the administration of broad-spectrum antibiotics and proton pump inhibitors&#44; along with potential enteral feeding via a percutaneous endoscopic gastrostomy or esophageal fistula bypass&#46; However&#44; these measures often result in fatal outcomes due to recurrent hemorrhage&#44; chronic infection&#44; and mediastinitis&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> Since 1994&#44; when endovascular treatment for aortic lesions associated with AEF was first reported&#44; TEVAR has emerged as a rapid&#44; minimally invasive&#44; and a very effective alternative to surgical intervention for urgent and emergent management of AEF patients&#46; It provides rapid stabilization of hemodynamics by controlling bleeding from the fistula site&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> However&#44; the prognosis varies depending on the underlying cause&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Our study had several limitations&#44; including its retrospective design and small sample size&#46; Additionally&#44; we did not have the availability of an endovascular approach&#46; Despite these limitations&#44; our study adds to the limited literature on AEF secondary to PCSEMS and highlights the challenges in the management of this devastating complication&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Conclusion</span><p id="par0095" class="elsevierStylePara elsevierViewall">AEF secondary to PCSEMS is a rare but potentially fatal complication that requires prompt diagnosis and management&#46; Our study suggests that patients with gastroesophageal adenocarcinoma cancer who require SEMS placement should be closely monitored for the development of AEF&#46; The choice of surgical approach should be individualized based on the patient&#39;s clinical presentation and the availability of endovascular or open surgical expertise and resources&#46; Our findings emphasize the need for further research to improve the management and outcomes of AEF secondary to PCSEMS&#46; Future studies should aim to identify risk factors for AEF development&#44; evaluate the optimal surgical approach&#44; and assess long-term outcomes&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Ethical considerations</span><p id="par0115" class="elsevierStylePara elsevierViewall">Informed consent was obtained from the relatives of both patients for the publication of this article&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conflict of interests</span><p id="par0120" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflict of interest&#46;</p></span></span>"
    "textoCompletoSecciones" => array:1 [
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          "titulo" => "Introduction"
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          "titulo" => "Methods"
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            0 => array:2 [
              "identificador" => "sec0015"
              "titulo" => "Patient selection"
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            1 => array:2 [
              "identificador" => "sec0020"
              "titulo" => "Data collection"
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              "identificador" => "sec0025"
              "titulo" => "Surgical approach"
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              "identificador" => "sec0030"
              "titulo" => "Statistical analysis"
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        6 => array:2 [
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          "titulo" => "Results"
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          "titulo" => "References"
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    "fechaRecibido" => "2023-06-23"
    "fechaAceptado" => "2023-09-13"
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        0 => array:4 [
          "clase" => "keyword"
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          "palabras" => array:5 [
            0 => "Esophageal fistula"
            1 => "Self expandable metallic stents"
            2 => "Endovascular procedures"
            3 => "Laparotomy"
            4 => "Aorta"
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        0 => array:4 [
          "clase" => "keyword"
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          "identificador" => "xpalclavsec1715315"
          "palabras" => array:5 [
            0 => "F&#237;stula esof&#225;gica"
            1 => "Stents met&#225;licos autoexpandibles"
            2 => "Procedimientos endovasculares"
            3 => "Laparotom&#237;a"
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    "resumen" => array:2 [
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Aortoesophageal fistula &#40;AEF&#41; is a rare but life-threatening complication of esophageal stent placement characterized by the formation of a communication between the aorta and the esophagus&#44; which can result in catastrophic hemorrhage and sepsis&#44; making it a potentially fatal complication that requires prompt diagnosis and management&#46; The surgical treatment strategy for each case should be designed based on the patient&#39;s clinical presentation and the availability of endovascular or open-surgical expertise and resources&#46;</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">The aim of this study is to show the first latinoamerican experience in the treatment of AEF secondary to self-expandable partially covered metal stents &#40;PCSEMS&#41; with a retrospective case series study between January 2018 and April 2023 aimed at evaluating the surgical approach and postoperative outcomes of patients with AEF secondary to PCSEMS placement in 2 centers in Bogota&#44; Colombia&#46; A study with a sample of 2 patients was performed&#46; The two patients were treated using an open surgical approach with laparotomy and left anterolateral thoracotomy&#46;</p></span>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">La f&#237;stula aortoesof&#225;gica es una complicaci&#243;n rara pero potencialmente mortal de la inserci&#243;n de un stent esof&#225;gico&#46; Est&#225; caracterizada por la formaci&#243;n de una comunicaci&#243;n entre la aorta y el es&#243;fago&#44; lo cual puede resultar en hemorragia masiva y sepsis&#44; convirti&#233;ndola en una complicaci&#243;n potencialmente mortal que requiere un diagn&#243;stico y manejo oportuno&#46; La estrategia de tratamiento quir&#250;rgico para cada caso debe dise&#241;arse en funci&#243;n de la presentaci&#243;n cl&#237;nica del paciente y la disponibilidad de recursos endovasculares o de cirug&#237;a abierta seg&#250;n la experticia&#46;</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">El objetivo de este estudio es mostrar la primera experiencia latinoamericana en el tratamiento de la f&#237;stula aortoesof&#225;gica secundaria a stents met&#225;licos autoexpandibles parcialmente cubiertos &#40;PCSEMS&#41; con un estudio de serie de casos retrospectivo entre enero de 2018 y abril de 2023 con el objetivo de evaluar el abordaje quir&#250;rgico y los resultados postoperatorios de pacientes con FAE secundaria a colocaci&#243;n de PCSEMS en 2 centros de Bogot&#225;&#44; Colombia&#46; Se realiz&#243; un estudio con una muestra de 2 pacientes&#46; Ambos pacientes fueron tratados mediante abordaje quir&#250;rgico abierto con laparotom&#237;a y toracotom&#237;a anterolateral izquierda&#46;</p></span>"
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          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Endoscopic view&#58; distal aortoesophageal fistula associated to the distal segment of the esophageal self-expandable partially covered metal stent&#46;</p>"
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          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">AngioCT&#58; CT shows direct contact of the esophageal self-expandable partially covered metal stent with the aortic wall generating the aortoesophageal fistula&#46;</p>"
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        "identificador" => "fig0015"
        "etiqueta" => "Fig&#46; 3"
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          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">&#40;A&#44; B&#41; Surgical specimen&#58; result of the total gastrectomy plus distal esophagectomy with resection of the distal aortoesophageal fistula and esophageal self-expandable partially covered metal stent extraction&#46;</p>"
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      3 => array:7 [
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          "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Extracted specimen&#58; extracted esophageal self-expandable partially covered metal stent extraction showing the distal segment that was inside the aortic lumen&#46;</p>"
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="3" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Aortoesophageal fistula demographic and clinical data</th></tr><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&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  " colspan="2" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Patient</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="" 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="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">2&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">Age&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">69&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">73&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">Gender&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">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">Male&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">Cancer type&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">Distal esophageal adenocarcinoma&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">Distal esophageal adenocarcinoma&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">Associated diseases&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">Arterial hypertension&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">Arterial hypertension&#44; type 2 diabetes mellitus&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">Surgical approach&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">Left anterolateral thoracotomy plus vertical esophagostomy plus primary repair with polytetrafluoroethylene and primary closure of distal esophagus&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">Laparotomy plus total gastrectomy plus distal esophagectomy plus thoracic descending aorta primary repair with polytetrafluoroethylene patch and extraction of the PCSEMS&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">Bleeding&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">1500<span class="elsevierStyleHsp" style=""></span>cc&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">2500<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">Intensive care unit &#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">7&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">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\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">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">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">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\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">Mortality during 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">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">No&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">Mortality after 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">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">Yes&nbsp;\t\t\t\t\t\t\n
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                  \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">Aortic endograft infection&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">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">No&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">Reintervention&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">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">No&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
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                  \t\t\t\t">Final surgical treatment&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">No&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">No&nbsp;\t\t\t\t\t\t\n
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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