Clinical case
Minimally invasive treatment for traumatic chylopericardium. Paediatric case report
Tratamiento por mínima invasión del quilopericardio traumático. Reporte de un caso pediátrico
Carlos García-Hernández
, Lourdes Carvajal-Figueroa, Adriana Calderón-Urrieta, Araceli Lechuga-Tosqui, Sergio Landa-Juárez
Corresponding author
carloscirped@hotmail.com
Corresponding author at: Circuito Valle Dorado 12, Col.: Loma de Valle Escondido, C.P. 52930, Atizapán de Zaragoza, Estado de México, Mexico. Tel.: +52 (55) 5687 4976; fax: +52 (55) 5536 2256.
Corresponding author at: Circuito Valle Dorado 12, Col.: Loma de Valle Escondido, C.P. 52930, Atizapán de Zaragoza, Estado de México, Mexico. Tel.: +52 (55) 5687 4976; fax: +52 (55) 5536 2256.
Hospital Infantil Privado, México, D.F., Mexico
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Paediatric case report" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "45" "paginaFinal" => "49" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Carlos García-Hernández, Lourdes Carvajal-Figueroa, Adriana Calderón-Urrieta, Araceli Lechuga-Tosqui, Sergio Landa-Juárez" "autores" => array:5 [ 0 => array:4 [ "nombre" => "Carlos" "apellidos" => "García-Hernández" "email" => array:1 [ 0 => "carloscirped@hotmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Lourdes" "apellidos" => "Carvajal-Figueroa" ] 2 => array:2 [ "nombre" => "Adriana" "apellidos" => "Calderón-Urrieta" ] 3 => array:2 [ "nombre" => "Araceli" "apellidos" => "Lechuga-Tosqui" ] 4 => array:2 [ "nombre" => "Sergio" "apellidos" => "Landa-Juárez" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Hospital Infantil Privado, México, D.F., Mexico" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author at: Circuito Valle Dorado 12, Col.: Loma de Valle Escondido, C.P. 52930, Atizapán de Zaragoza, Estado de México, Mexico. Tel.: +52 (55) 5687 4976; fax: +52 (55) 5536 2256." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Tratamiento por mínima invasión del quilopericardio traumático. Reporte de un caso pediátrico" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 742 "Ancho" => 990 "Tamanyo" => 118651 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Ultrasound with radiolucent image, compatible with a pericardial effusion of approximately 500<span class="elsevierStyleHsp" style=""></span>ml.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Background</span><p id="par0005" class="elsevierStylePara elsevierViewall">Chylopericardium is the accumulation of chyle in the pericardial space. It is a rare disorder in children.<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">1,2</span></a> The most frequent causes are associated with cardiac surgery or malformations of the lymphatic system, lymphangiomas or even mediastinal tumours.<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">3–5</span></a> It is not always possible to establish its aetiology and these cases are referred to as idiopathic.<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">6–9</span></a> Most reports refer to adult patients.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">1</span></a> The few publications regarding children refer to patients who have undergone some form of cardiovascular surgery, there are very few reports on spontaneous chylopericardium in children.<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">6–11</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Initial treatment should be medical, using parenteral nutrition, diets with medium chain triglycerides, and in some cases the use of octreotide has been recommended. When medical treatment has failed, if the initial symptoms are serious or there is a high volume of drainage, surgical treatment should be considered, which consists of ligating the thoracic duct.<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">10–14</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The <span class="elsevierStyleItalic">objective</span> of this study is to present the case of a child who developed a chylopericardium seemingly as a consequence of a fall, its diagnostic methodology and its successful resolution by means of minimally invasive surgery.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Clinical case</span><p id="par0020" class="elsevierStylePara elsevierViewall">A 6-year-old male patient, with no history of significance, onset of the disorder was 3 weeks before his admission when he fell from his own height, presenting pain in the cervical and lumbar region. Chest pain started after 2 weeks, and a chest X-ray was requested which showed cardiomegaly (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). It was evaluated by paediatric cardiology, who found reduced cardiac tone, with no signs of tamponade or heart failure. An electrocardiogram was performed which showed a drop in voltage in all branches, and an echocardiogram was undertaken which showed the presence of pericardial effusion, which was quantified at 500<span class="elsevierStyleHsp" style=""></span>ml (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Given these findings, a pericardial puncture was undertaken, and 300<span class="elsevierStyleHsp" style=""></span>ml of a milky fluid was obtained (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>), and an anterior pericardial tube was placed. Cytochemistry of the aspirated fluid reported: triglycerides 1910<span class="elsevierStyleHsp" style=""></span>mg/dl and 80<span class="elsevierStyleHsp" style=""></span>mg/dl cholesterol. Electrophoresis of the pericardial fluid showed: beta lipoproteins 13.6<span class="elsevierStyleHsp" style=""></span>mg/dl, pre beta lipoproteins 64.1<span class="elsevierStyleHsp" style=""></span>mg/dl, alpha lipoproteins 1<span class="elsevierStyleHsp" style=""></span>mg/dl, chylomicrons 21.3<span class="elsevierStyleHsp" style=""></span>mg/dl. Magnetic resonance was performed in order to rule out any lymphatic malformation or mediastinal tumour, and was normal.</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">Treatment was started with fasting, total parenteral nutrition and octreotide at a dose of 100<span class="elsevierStyleHsp" style=""></span>mcg/m<span class="elsevierStyleSup">2</span>, administered subcutaneously. Chyle loss through the drain on the first day was 0.3<span class="elsevierStyleHsp" style=""></span>ml/kg/h, which increased to 1<span class="elsevierStyleHsp" style=""></span>ml/kg/h, and therefore as medical treatment had failed, the option of surgical treatment was considered since, rather than reducing the loss, with medical treatment it had significantly increased.</p><p id="par0035" class="elsevierStylePara elsevierViewall">The patient underwent surgery using a right-sided thoracoscopic approach; with patient in the left lateral position, 3.5<span class="elsevierStyleHsp" style=""></span>mm ports were inserted, the first 1<span class="elsevierStyleHsp" style=""></span>cm below the scapula for the 30° optic and 5<span class="elsevierStyleHsp" style=""></span>mm, insufflated at 5<span class="elsevierStyleHsp" style=""></span>mm Hg, and flow at 1<span class="elsevierStyleHsp" style=""></span>l/min. Then 2.5<span class="elsevierStyleHsp" style=""></span>mm ports were inserted in the anterior axillary line in the 4th and 7th intercostal space. The initial exploration revealed a haematoma in the mediastinum (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>). The thoracic duct was dissected at its inlet to the chest, and 3 silk ligatures 2-0 were placed (<a class="elsevierStyleCrossRef" href="#fig0025">fig. 5</a>). Then 2.5<span class="elsevierStyleHsp" style=""></span>mm ports were inserted in the posterior axillary line in the 4th and 7th intercostal space, the phrenic nerve was identified and above it the pericardium was incised, to create a window from the diaphragm to the union of the superior vena cava and the auricle and an enlarged pericardium was found (<a class="elsevierStyleCrossRef" href="#fig0030">Fig. 6</a>). A water seal chest drain was inserted, and the approaches were closed with 3 and 4-0 absorbable suture. Surgical time was 50<span class="elsevierStyleHsp" style=""></span>min, without incident or complications.</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><elsevierMultimedia ident="fig0025"></elsevierMultimedia><elsevierMultimedia ident="fig0030"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">A normal oral diet was started 24<span class="elsevierStyleHsp" style=""></span>h post surgery, loss through the chest drain on the first post-operative day was 0.1<span class="elsevierStyleHsp" style=""></span>ml/kg/h until practically nil after 72<span class="elsevierStyleHsp" style=""></span>h, and therefore the drain was removed. The patient was discharged on the fourth postoperative day with no complications. Current follow-up is 12 months with no recurrence, with normal ultrasound and radiological monitoring.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Discussion</span><p id="par0045" class="elsevierStylePara elsevierViewall">Chylopericardium is a very rare disorder in children, which almost always presents after cardiovascular surgery or associated with lymphatic malformations or thoracic tumours.<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">1–3,14–17</span></a> It is most likely that this case was associated with the traumatic event as this marked the onset of symptoms, for which a chest X-ray was necessary which revealed cardiomegaly, and because a haematoma was found in the upper part of the posterior mediastinum on thorascopic exploration. Regardless of the volume of accumulated fluid, and for some reason that we do not know, patients with this disorder can either have serious symptoms of tamponade or very few symptoms, as in the case we report here.<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">1–3</span></a> This disorder's physiopathology of an accumulation of fluid in the pericardium<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">1–6</span></a> and not in the pleural space is not well understood; it is believed that it might be a leak at the site where the thoracic duct enters the superior vena cava, and hence the build-up of chyle in the pericardial space. Once a diagnosis of chylopericardium has been made, and depending on the severity of symptoms, if the initial presentation is not severe medical treatment should be attempted, with fasting, parenteral nutrition, the use of diets with medium chain triglycerides and even the administration of drugs such as octreotide,<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">15</span></a> which in some cases reduces the production of chyle. But if it remains raised or if rather than decreasing it increases, or if the initial symptoms are severe, as with tamponade, surgical treatment is necessary. There are various surgical options, which might be to establish a communication of the pericardium towards the peritoneum, inserting a Denver valve, or establishing a communication towards the pleura with a wide pericardial window, or thoracic duct ligation.<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">1,5,10</span></a> We opted for the latter option, along with construction of a wide pericardial window, which was performed with minimal invasion. This alternative enabled the leakage of chyle to be controlled, and the patient recovered rapidly due to the advantages of minimally invasive surgery.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Conclusion</span><p id="par0050" class="elsevierStylePara elsevierViewall">Due to all of the above, we consider that thoracic duct ligation along with the creation of a pericardial window by thoracoscopy is a useful and safe alternative for the treatment of these patients.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conflict of interests</span><p id="par0055" class="elsevierStylePara elsevierViewall">The authors have no conflict of interests to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres611302" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Objective" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Clinical case" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec625330" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres611303" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Antecedentes" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Objetivo" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Caso clínico" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec625331" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Background" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Clinical case" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Conclusion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflict of interests" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2014-06-25" "fechaAceptado" => "2014-11-10" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec625330" "palabras" => array:3 [ 0 => "Chylopericardium" 1 => "Minimally invasive" 2 => "Thoracoscopic" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec625331" "palabras" => array:3 [ 0 => "Quilopericardio" 1 => "Mínima invasión" 2 => "Toracoscopia" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Background</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Chylopericardium is a rare occurrence in children. The most common causes are associated with cardiac surgery, malformations of the lymphatic system, idiopathic reasons, among others.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Objective</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">The case is presented of a patient with traumatic chylopericardium, the diagnostic methodology, and in particular, its successful resolution by surgical means.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Clinical case</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Male patient of 6 years old, previous accident of fall from patient's height. Chest X-ray showed evidence of cardiomegaly. An echocardiogram with pericardial effusion was performed. Pericardial puncture was performed with drainage of milky material, confirming chylous liquid. Treatment included pericardial catheterisation, total parenteral nutrition, octreotide, and diet with medium chain triglycerides, with persistent increased pericardial fluid. Lymphatic abnormalities were ruled out by MRI. He underwent surgical treatment due to failure of prior treatment. A thoracoscopic approach was adopted with a favourable outcome.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Chylopericardium occurs in children in most cases after cardiovascular surgery. The case presented here was classified as idiopathic. Patients with this condition may present with severe symptoms, such as tamponade, or can be asymptomatic as in the case presented. If medical treatment fails, it should be resolved by surgery; the best choice is minimally invasive treatment with its well-known advantages.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Objective" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Clinical case" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Antecedentes</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">El quilopericardio es una entidad rara en pediatría. Las causas más frecuentes están asociadas a cirugía cardiaca, malformaciones del sistema linfático o idiopáticas.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Objetivo</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Presentar el caso de un paciente con quilopericardio traumático, su metodología diagnóstica así como su resolución quirúrgica.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Caso clínico</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Paciente varón de 6 años de edad, con antecedente de caída desde su propia altura. Radiografía de tórax con evidencia de cardiomegalia. Ecocardiograma con presencia de derrame pericárdico. Se realizó punción pericárdica, con drenaje de líquido de aspecto lechoso, similar al quilo. El tratamiento fue mediante colocación de sonda pericárdica y NPT, octeótrido y dieta con triglicéridos de cadena media persistiendo el drenaje. Se descartaron anomalías linfáticas por resonancia magnética. Se sometió a tratamiento quirúrgico mediante un abordaje toracoscópico, por falla en la respuesta al manejo conservador, con resultado favorable.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">El quilopericardio en niños se presenta en la mayoría de los casos después de una cirugía cardiovascular. El caso aquí presentado ha sido catalogado como traumático. Los pacientes con este padecimiento pueden cursar con síntomas graves de tamponade o asintomáticos como el caso aquí reportado. Cuando hay falla al tratamiento médico se debe resolver con cirugía de mínima invasión, con las ventajas ya conocidas de estos abordajes.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Antecedentes" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Objetivo" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Caso clínico" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: García-Hernández C, Carvajal-Figueroa L, Calderón-Urrieta A, Lechuga-Tosqui A, Landa-Juárez S. Tratamiento por mínima invasión del quilopericardio traumático. Reporte de un caso pediátrico. Cir Cir. 2016;84:45–49.</p>" ] ] "multimedia" => array:6 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1272 "Ancho" => 950 "Tamanyo" => 155862 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Chest X-ray showing enlarged cardiac silhouette.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 742 "Ancho" => 990 "Tamanyo" => 118651 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Ultrasound with radiolucent image, compatible with a pericardial effusion of approximately 500<span class="elsevierStyleHsp" style=""></span>ml.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1432 "Ancho" => 600 "Tamanyo" => 101664 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Milky appearance of the fluid obtained from pericardial puncture which cytochemical study revealed as a chylothorax.</p>" ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 710 "Ancho" => 900 "Tamanyo" => 68130 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Initial thoracoscopic image showing a haematoma in the upper third of the posterior mediastinum.</p>" ] ] 4 => array:7 [ "identificador" => "fig0025" "etiqueta" => "Figure 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 700 "Ancho" => 900 "Tamanyo" => 72535 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Thoracoscopic image. The thoracic duct can be observed at the time of dissection.</p>" ] ] 5 => array:7 [ "identificador" => "fig0030" "etiqueta" => "Figure 6" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr6.jpeg" "Alto" => 742 "Ancho" => 900 "Tamanyo" => 75677 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Thoracoscopic image. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 5 | 0 | 5 |
| 2024 October | 29 | 2 | 31 |
| 2024 September | 21 | 4 | 25 |
| 2024 August | 18 | 3 | 21 |
| 2024 July | 25 | 2 | 27 |
| 2024 June | 19 | 10 | 29 |
| 2024 May | 11 | 4 | 15 |
| 2024 April | 28 | 4 | 32 |
| 2024 March | 44 | 3 | 47 |
| 2024 February | 17 | 8 | 25 |
| 2024 January | 21 | 3 | 24 |
| 2023 December | 15 | 6 | 21 |
| 2023 November | 26 | 10 | 36 |
| 2023 October | 36 | 9 | 45 |
| 2023 September | 7 | 3 | 10 |
| 2023 August | 13 | 5 | 18 |
| 2023 July | 7 | 6 | 13 |
| 2023 June | 13 | 1 | 14 |
| 2023 May | 26 | 8 | 34 |
| 2023 April | 28 | 6 | 34 |
| 2023 March | 38 | 0 | 38 |
| 2023 February | 22 | 8 | 30 |
| 2023 January | 22 | 1 | 23 |
| 2022 December | 19 | 5 | 24 |
| 2022 November | 33 | 7 | 40 |
| 2022 October | 18 | 8 | 26 |
| 2022 September | 18 | 11 | 29 |
| 2022 August | 19 | 11 | 30 |
| 2022 July | 13 | 8 | 21 |
| 2022 June | 11 | 5 | 16 |
| 2022 May | 20 | 5 | 25 |
| 2022 April | 34 | 11 | 45 |
| 2022 March | 27 | 3 | 30 |
| 2022 February | 27 | 6 | 33 |
| 2022 January | 55 | 5 | 60 |
| 2021 December | 31 | 11 | 42 |
| 2021 November | 12 | 10 | 22 |
| 2021 October | 12 | 8 | 20 |
| 2021 September | 17 | 10 | 27 |
| 2021 August | 18 | 6 | 24 |
| 2021 July | 21 | 7 | 28 |
| 2021 June | 19 | 15 | 34 |
| 2021 May | 21 | 8 | 29 |
| 2021 April | 25 | 12 | 37 |
| 2021 March | 12 | 10 | 22 |
| 2021 February | 12 | 10 | 22 |
| 2021 January | 17 | 15 | 32 |
| 2020 December | 15 | 5 | 20 |
| 2020 November | 15 | 7 | 22 |
| 2020 October | 20 | 9 | 29 |
| 2020 September | 22 | 15 | 37 |
| 2020 August | 35 | 9 | 44 |
| 2020 July | 26 | 13 | 39 |
| 2020 June | 11 | 11 | 22 |
| 2020 May | 19 | 5 | 24 |
| 2020 April | 12 | 1 | 13 |
| 2020 March | 20 | 6 | 26 |
| 2020 February | 16 | 9 | 25 |
| 2020 January | 26 | 10 | 36 |
| 2019 December | 14 | 4 | 18 |
| 2019 November | 8 | 4 | 12 |
| 2019 October | 15 | 5 | 20 |
| 2019 September | 14 | 10 | 24 |
| 2019 August | 7 | 2 | 9 |
| 2019 July | 13 | 4 | 17 |
| 2019 June | 28 | 8 | 36 |
| 2019 May | 61 | 27 | 88 |
| 2019 April | 45 | 1 | 46 |
| 2019 March | 12 | 8 | 20 |
| 2019 February | 14 | 2 | 16 |
| 2019 January | 12 | 3 | 15 |
| 2018 December | 9 | 2 | 11 |
| 2018 November | 10 | 2 | 12 |
| 2018 October | 12 | 3 | 15 |
| 2018 September | 21 | 7 | 28 |
| 2018 August | 5 | 7 | 12 |
| 2018 July | 3 | 2 | 5 |
| 2018 June | 4 | 0 | 4 |
| 2018 May | 9 | 3 | 12 |
| 2018 April | 5 | 0 | 5 |
| 2018 March | 4 | 0 | 4 |
| 2018 February | 7 | 0 | 7 |
| 2018 January | 9 | 2 | 11 |
| 2017 December | 8 | 0 | 8 |
| 2017 November | 13 | 2 | 15 |
| 2017 October | 10 | 1 | 11 |
| 2017 September | 16 | 1 | 17 |
| 2017 August | 10 | 4 | 14 |
| 2017 July | 6 | 2 | 8 |
| 2017 June | 8 | 1 | 9 |
| 2017 May | 12 | 4 | 16 |
| 2017 April | 8 | 4 | 12 |
| 2017 March | 8 | 41 | 49 |
| 2017 February | 14 | 1 | 15 |
| 2017 January | 10 | 0 | 10 |
| 2016 December | 16 | 6 | 22 |
| 2016 November | 10 | 2 | 12 |
| 2016 October | 26 | 4 | 30 |
| 2016 September | 17 | 6 | 23 |
| 2016 August | 15 | 1 | 16 |
| 2016 July | 13 | 1 | 14 |
| 2016 June | 27 | 8 | 35 |
| 2016 May | 25 | 18 | 43 |
| 2016 April | 29 | 14 | 43 |
| 2016 March | 54 | 24 | 78 |
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