Multimodal Rehabilitation Programme in Elective Colorectal Surgery: Impact on Hospital Costs

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José Gil-Egea, Miguel Pera, Leyre Lorente, Francesc Cots, Marta Pascual, Sandra Alonso, Ricard Courtier, Luis Grande" "autores" => array:9 [ 0 => array:3 [ "nombre" => "Sílvia" "apellidos" => "Salvans" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 1 => array:4 [ "nombre" => "M. 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These programmes, which require the coordination of different specialists, are a combination of different perioperative care strategies to reduce surgical stress and facilitate postoperative patient recovery.<a class="elsevierStyleCrossRefs" href="#bib0010">2–5</a> The implementation of these measures has reduced hospital stays to 2–4 days without increasing morbidity<a class="elsevierStyleCrossRefs" href="#bib0030">6,7</a>; additionally, the experience of some authors indicates that such programmes may reduce postoperative complication rates.<a class="elsevierStyleCrossRefs" href="#bib0040">8,9</a>In 2005, the Enhanced Recovery After Surgery Project (ERAS)<a class="elsevierStyleCrossRef" href="#bib0050">10</a> was published, which combines different strategies for perioperative care based on the best scientific evidence. Since the emergence of the ERAS protocols, several randomised clinical trials and meta-analyses of new proposals for multidisciplinary performance have been published, with the aim of improving the functional recovery of patients following elective colorectal surgery.<a class="elsevierStyleCrossRefs" href="#bib0035">7,11–13</a> Although each specific strategy is beneficial in itself for achieving the best results, they should all be used together.<a class="elsevierStyleCrossRef" href="#bib0070">14</a> Furthermore, decreasing hospital stays and, in some cases, reducing postoperative complications must lower hospital costs. However, very few studies have assessed the impact of MMRH programmes on hospital costs after colorectal surgery.<a class="elsevierStyleCrossRef" href="#bib0075">15</a>In March 2006, the Colorectal Surgery unit of the Hospital del Mar in Barcelona launched an MMRH protocol for patients undergoing elective colorectal surgery. In the analysis of the initial results with a group of 90 patients,<a class="elsevierStyleCrossRef" href="#bib0080">16</a> we showed that MMRH is a safe protocol (as it does not increase complications) that reduces hospital stays to three days.The aim of this study is to confirm our preliminary results by increasing the number of patients in the MMRH programme and to analyse the impact on hospital costs.Materials and MethodsStudy DesignA prospective comparative study of two consecutive cohorts of patients undergoing elective colorectal surgery.Study PopulationThe MMRH group consisted of 231 patients undergoing elective colorectal surgery between March 2006 and December 2007. The control group included 134 patients who underwent surgery in 2005, before the implementation of the MMRH protocol. Inclusion criteria were all patients undergoing scheduled colon and rectal surgery. No exclusion criteria were established.The protocol of the MMRH group consisted of preoperative, intraoperative and postoperative strategies.<a class="elsevierStyleCrossRef" href="#bib0080">16</a> The preoperative strategies were providing oral and written information about the surgical procedure and the MMRH programme by the surgeon and a nurse from the hospital Colorectal Surgery Unit; performing colon preparation with polyethylene glycol (Bohm Laboratories, S.A.) while administering a hydrocarbon solution (135g carbohydrate in 1000cm3) as enteral nutrition (Edanec®, Abbott Laboratories, S.A.); prescribing a preoperative 6-h liquids and solids fast; providing antibiotic prophylaxis with metronidazole 1g gentamicin 240mg and antithrombotic bemiparin 2500 UI preoperatively and daily postoperatively for 4 weeks. During the intraoperative phase, analgesia was administered through an epidural catheter, and short-acting anaesthetics were used; hydration was performed at an adjusted rate of 6–8ml/kg/h; hypothermia was prevented with temperature-controlled fluid therapy and a heating blanket; and intra-abdominal drains and nasogastric tube placement were avoided. During the postoperative phase, multimodal analgesia was administered, the diet resumed gradually 6h after surgery, and early mobilisation was encouraged.The most important differential strategies for the control group protocol were as follows. During the preoperative phase, oral communication was only provided by the surgeon; the colon was prepared using Fosfosoda® (Fleet Company Inc., VA, USA) while administering intravenous hydration of 1000ml of 5% dextrose with 60mEq KCl; and preoperative fasting began the night before surgery. During the intraoperative phase, fluid therapy was administered at the discretion of the attending anaesthesiologist at a rate of approximately 10–14ml/kg/h, almost twice the established rate for the MMRH protocol. During the postoperative phase, the diet was resumed according to the surgeon's criterion, usually with the onset of peristalsis.In both groups, discharge occurred when the patient was able to tolerate a solid diet, had good pain control with oral analgesia and was ambulatory.VariablesThe demographic and clinical characteristics of the patients included in each group were compared. Medical and surgical complications occurring within 30 days after surgery in both groups were recorded. The average length of stay and readmission rate per group was also included. The nursing staff or attending physician's compliance with the MMRH programme's protocol for the start of the diet and the withdrawal of fluid therapy was analysed. Tolerance of diet and ambulation were measured as parameters of functional recovery. We analysed the progression of hospital discharge in both groups. The hospital discharge rate per day was studied for each group. Finally, total and specific costs were calculated (per hospitalisation unit, laboratory, radiology, pharmacy, surgical suite and disease) per patient in each group.Cost AnalysisOur hospital cost accounting provides patient-level details. It is characterised by a “full-costing” system and for basing the allocation of costs to activities on a cost-benefit analysis (CBA).<a class="elsevierStyleCrossRef" href="#bib0085">17</a> This cost analysis system ensures that all of the expenses are shared between all of the episodes. The cost of each episode is the sum of the costs of all variable costs (direct costs) plus the set of general costs charged per activity (indirect costs). The cost information available allows the disaggregation of costs, such as inpatient unit, laboratory, radiology, pharmacy, operating room and disease.Statistical AnalysisA descriptive and statistical comparison of variables was performed, considering a P-value of less than .05 to be statistically significant. Qualitative variables are expressed in absolute numbers or proportions, and quantitative variables are expressed as the median and range or as the mean and standard deviation. The test of the hypothesis was the Chi-squared test for qualitative ordinal variables (comparison of proportions), Student's t-test for continuous variables when their applicability criteria were met and the Mann–Whitney U test when applicability criteria were not met. All of the data were analysed using SPSS Version 12.0.ResultsThere were no differences in the patient characteristics or surgical procedures performed between the two study groups (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).<elsevierMultimedia ident="tbl0005"></elsevierMultimedia><a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> shows the overall morbidity of both groups; there were no significant differences between them. This morbidity rate also included patients who were readmitted. We did not observe significant differences when comparing medical and surgical complications. Surgical site infections were analysed separately, and they also showed no differences. Finally, mortality in both groups was less than 5%, and the differences were not statistically significant.<elsevierMultimedia ident="tbl0010"></elsevierMultimedia><a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a> shows a statistically significant decrease of three days in the average hospital stay of patients in the MMRH group compared with control patients; however, no differences were found in the percentage of readmissions. The three-day decrease was maintained when analysing the total stay as the sum of the initial stay and the readmission stay.<elsevierMultimedia ident="tbl0015"></elsevierMultimedia><a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a> shows an analysis of different aspects included in the programme to reflect the MMRH protocol compliance and functional recovery of patients, such as the beginning of ambulation and diet, diet tolerance and intravenous fluid therapy withdrawal. The percentage of patients discharged on a given postoperative day is also shown. We note that only 55 and 68% of patients started the diet and ambulated, respectively, on the first postoperative day. On the fifth postoperative day, only 37% of patients were discharged, although 80% of the patients met the discharge criteria.<elsevierMultimedia ident="fig0005"></elsevierMultimedia><a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a> shows the progression to hospital discharge in the both groups. Statistically significant differences were observed on the fifth postoperative day (37% vs 20%), the sixth postoperative day (66% vs 43%) and the eighth postoperative day (69% vs 47%).<elsevierMultimedia ident="fig0010"></elsevierMultimedia><a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a> shows the hospital costs per patient in each group. We found a significant reduction in total cost of 912 € per patient in the MMRH group compared with the control group. This significant reduction of costs was found mainly for the hospitalisation unit, with a cost decrease of 831 € in the MMRH group. We also observed a significant reduction in laboratory costs. The costs per patient for radiology and pharmacy were also lower in the MMRH group, but this difference did not reach statistical significance.<elsevierMultimedia ident="tbl0020"></elsevierMultimedia>DiscussionFirst, the present study confirms the preliminary results published by our group<a class="elsevierStyleCrossRef" href="#bib0080">16</a> in a series with a larger number of patients included in the MMRH protocol. This protocol is safe, does not increase patient morbidity or mortality and reduces hospital stay by three days compared with conventional perioperative care. These results are also consistent with previous studies and systematic reviews.<a class="elsevierStyleCrossRefs" href="#bib0035">7–13</a> Second, this study shows how faster patient recovery is associated with a significant reduction in hospital costs. Although it is obvious, little published work has quantified this cost reduction.Although the overall morbidity and mortality in this study were similar to that described in other studies on the implementation of MMRH programmes,<a class="elsevierStyleCrossRefs" href="#bib0090">18,19</a> we found no differences in postoperative complications between groups. Therefore, we can say that the hospital stay reductions were not caused by reduced morbidity. The impact of MMRH programmes on postoperative morbidity is controversial. In the systematic review by Wind et al.,<a class="elsevierStyleCrossRef" href="#bib0035">7</a> morbidity rates between 8% and 75% were found; however, the differences between groups reached statistical significance only in one study.<a class="elsevierStyleCrossRef" href="#bib0045">9</a> A systematic review of the Cochrane Database<a class="elsevierStyleCrossRef" href="#bib0065">13</a> showed a reduction in overall complications, but the most serious complications did not decrease. The absence of differences in morbidity in our study and in others may be related to several reasons. First, each study used different definitions of complications and different classifications. Second, the need to optimise the implemented protocol in accordance with all the recommendations of ERAS protocols may have minimised differences in morbidity.<a class="elsevierStyleCrossRef" href="#bib0050">10</a> For example, we established a 6h preoperative fast, while the ERAS protocol consensus recommends fluid intake 2h before anaesthetic induction and solid intake 6h<a class="elsevierStyleCrossRef" href="#bib0100">20</a> before anaesthesia. We also need to improve the treatment of postoperative nausea and vomiting<a class="elsevierStyleCrossRef" href="#bib0105">21</a> by implementing strategies to prevent postoperative ileus, such as administering magnesium hydroxide<a class="elsevierStyleCrossRef" href="#bib0050">10</a> and other prokinetics.<a class="elsevierStyleCrossRef" href="#bib0095">19</a> Currently, we are considering implementing some of these strategies with the intention of improving our protocol. For example, beginning two years ago, patients undergoing colon resection did not receive preoperative bowel preparation, based on the scientific evidence.<a class="elsevierStyleCrossRef" href="#bib0110">22</a> The implementation of all the recommendations recently examined by the ERAS group could significantly reduce postoperative morbidity.<a class="elsevierStyleCrossRef" href="#bib0115">23</a>We have achieved a significant reduction in hospital stay despite a low level of compliance with the MMRH programme. Protocol compliance has been identified as one of the problems of MMRH programmes,<a class="elsevierStyleCrossRef" href="#bib0065">13</a> reflecting the difficulty of changing a traditional protocol and implementing new strategies for perioperative care. However, this problem has hardly been studied. In a previous study, we observed that compliance with a new protocol is initially low but gradually improves, along with the results of the MMRH programme and the experience of the professionals involved.<a class="elsevierStyleCrossRef" href="#bib0120">24</a> Delaney et al.<a class="elsevierStyleCrossRef" href="#bib0025">5</a> also observed that the hospital stay was shorter when these programmes were implemented by experienced surgeons. The difficulty of implementing an ERAS protocol outside clinical trials has been recently investigated by Ahmed et al.<a class="elsevierStyleCrossRef" href="#bib0125">25</a> The authors found that protocol compliance was lower in daily practice compared with compliance during a clinical trial. Interestingly, as in the present study, the clinical results improved despite low compliance. This suggests that greater compliance could further improve postoperative recovery and even reduce morbidity.Moreover, the reduction to a three-day hospital stay was achieved without increasing the rate of readmission. Reducing inappropriate hospital stay often comes at the expense of increasing the percentage of readmissions. In the study by Basse et al.,<a class="elsevierStyleCrossRef" href="#bib0130">26</a> the average hospital stay was only two days in the MMRH programme, but readmission was necessary in 20% of patients. Our readmission rate since starting the MMRH programme is acceptable, as it does not exceed the 10% recommended by some authors.<a class="elsevierStyleCrossRef" href="#bib0135">27</a>Another aspect that should be discussed is the inability to discharge patients even when they fulfilled the established clinical criteria. This is a very important limiting factor for improving the results. For example, in this study, only 37% of patients in the MMRH group were discharged on the fifth postoperative day, although 80% of them met the criteria to be discharged. We believe that in our country, the main cause is a lack of adequate social or family support. According to a report by the Ministry of Health and Social Services for the Elderly in Spain, 21% of people over the age of 65 years live alone.<a class="elsevierStyleCrossRef" href="#bib0140">28</a> Greater collaboration with discharge care programmes should improve these results. The patient's fear and insecurity about continuing recovery at home could be another cause for discharge delays. Maessen et al.,<a class="elsevierStyleCrossRef" href="#bib0060">12</a> also found delays in hospital discharge among patients who met the discharge criteria. The authors propose better home health care after early discharge. We believe that analysing patient satisfaction after their participation in an MMRH programme might lead to a better understanding of the problem.After confirming that our MMRH programme improved our patients’ functional recovery, we evaluated the programme's impact on hospital costs. This is a very important point because there is a growing need to improve economic efficiency in perioperative care without compromising results.<a class="elsevierStyleCrossRef" href="#bib0145">29</a> We found a reduction of nearly 1000 euros per patient in total costs in the MMRH group compared with the control group. The main factor contributing to this statistically significant difference was the reduction in the costs associated with the hospitalisation unit. This result is consistent with the decline we have observed in the three-day hospital stay in the MMRH group. This cost reduction was also described by the group at the Cleveland Clinic after they initiated a clinical pathway for postoperative care after ileoanal reservoir surgery.<a class="elsevierStyleCrossRef" href="#bib0075">15</a> In that study, the direct costs and complications were analysed for the first 30 postoperative days and longer term. The patients who were treated according to a MMRH protocol were matched with controls who received conventional care from a different group of surgeons. The major complication rates were comparable, and there were no differences in the rates of readmission or reoperation. The patients in the MMRH group had a shorter hospital stay, and the median direct cost per patient within 30 days was almost 1000 USD less than that of patients receiving traditional care, mainly because of a decrease in the costs of anaesthesia, nursing care, lab tests and other services such as respiratory therapy, stoma management education and nutrition services. In the present study, the decrease in costs was not only related to the Hospitalisation Unit; laboratory costs were also significantly lower in the MMRH group. The costs per patient in radiology and pharmacy were lower, but the difference was not statistically significant. Another economic benefit that should be expected by the institution is greater availability of beds. The reduction in hospital costs even with a low level of compliance with the protocol indicates that, at present, resource utilisation and the costs of perioperative care are far from optimal in most institutions. As highlighted in the meta-analysis by Adamina et al.,<a class="elsevierStyleCrossRef" href="#bib0150">30</a> MMRH programmes optimise resources while accelerating the recovery of patients, thus reducing hospital stay. Additionally, the results of the LAFA3 study<a class="elsevierStyleCrossRef" href="#bib0155">31</a> move in the same direction. LAFA3 is the first randomised, prospective four-cohort study conducted in nine centres in the Netherlands to show that the combination of laparoscopic surgery with perioperative MMRH care leads to faster recovery compared with other treatment combinations. This combination is able to reduce costs primarily by reducing hospital stay, although this cost reduction was not statistically significant. Therefore, these programmes should be used routinely for colorectal surgery. Such routine use is especially important in times of serious economic difficulties, as is currently the case. In this regard, further studies specifically designed to investigate how to minimise costs will provide additional information that may be useful for making treatment choices and investment strategies in hospitals, as was the case of the TAPAS study, a three-cohort prospective study conducted in five Dutch hospitals.<a class="elsevierStyleCrossRef" href="#bib0160">32</a>In conclusion, this study demonstrates that the use of a MMRH protocol for elective colorectal surgery reduces both hospital stay and costs without increasing postoperative morbidity or the percentage of readmissions.Conflict of InterestThe authors declare no conflict of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:2 [ "identificador" => "xres314978" "titulo" => array:5 [ 0 => "Abstract" 1 => "Introduction" 2 => "Method" 3 => "Results" 4 => "Conclusion" ] ] 1 => array:2 [ "identificador" => "xpalclavsec297719" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres314979" "titulo" => array:5 [ 0 => "Resumen" 1 => "Introducción" 2 => "Material y métodos" 3 => "Resultados" 4 => "Conclusiones" ] ] 3 => array:2 [ "identificador" => "xpalclavsec297718" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Materials and Methods" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Study Design" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Study Population" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Variables" ] 3 => array:2 [ "identificador" => "sec0030" "titulo" => "Cost Analysis" ] 4 => array:2 [ "identificador" => "sec0035" "titulo" => "Statistical Analysis" ] ] ] 6 => array:2 [ "identificador" => "sec0040" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0045" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0050" "titulo" => "Conflict of Interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2012-09-17" "fechaAceptado" => "2013-01-05" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec297719" "palabras" => array:5 [ 0 => "Colorectal surgery" 1 => "Multimodal rehabilitation" 2 => "Fast-track" 3 => "Clinical pathway" 4 => "Costs" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec297718" "palabras" => array:5 [ 0 => "Cirugía colorrectal" 1 => "Rehabilitación multimodal" 2 => "Fast-track" 3 => "Vía clínica" 4 => "Costes" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "IntroductionMultimodal rehabilitation (MMRH) programmes in surgery have proven to be beneficial in functional recovery of patients. The aim of this study is to evaluate the impact of a MMRH programme on hospital costs. MethodA comparative study of 2 consecutive cohorts of patients undergoing elective colorectal surgery has been designed. In the first cohort, we analysed 134 patients who received conventional perioperative care (control group). The second cohort included 231 patients treated with a multimodal rehabilitation protocol (fast-track group). Compliance with the protocol and functional recovery after fast-track surgery were analysed. We compared postoperative complications, length of stay and readmission rates in both groups. The cost analysis was performed according to the system “full-costing”. ResultsThere were no differences in clinical features, type of surgical excision and surgical approach. No differences in overall morbidity and mortality rates were found. The mean length of hospital stay was 3 days shorter in the fast-track group. There were no differences in the 30-day readmission rates. The total cost per patient was significantly lower in the fast-track group (fast-track: 8107±4117 euros vs control: 9019±4667 euros; P=.02). The main factor contributing to the cost reduction was a decrease in hospitalisation unit costs. ConclusionThe application of a multimodal rehabilitation protocol after elective colorectal surgery decreases not only the length of hospital stay but also the hospitalisation costs without increasing postoperative morbidity or the percentage of readmissions." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "IntroducciónLos programas de rehabilitación multimodal (RHMM) en cirugía han demostrado un beneficio en la recuperación funcional de los pacientes. Nuestro objetivo fue evaluar el impacto de un programa de RHMM en los costes hospitalarios. Material y métodosEstudio prospectivo comparativo de cohortes consecutivas de pacientes intervenidos de cirugía colorrectal electiva. En la primera cohorte analizamos 134 pacientes que recibieron un control postoperatorio convencional (grupo control). En la segunda cohorte se incluye a 231 pacientes tratados con un programa de RHMM (grupo RHMM). Se analiza el cumplimiento del protocolo y la recuperación funcional de los pacientes del grupo RHMM. Se comparan las complicaciones postoperatorias, la estancia hospitalaria y los reingresos en ambos grupos. El análisis de costes se ha basado en la contabilidad analítica del centro. ResultadosLas características demográficas y clínicas de los pacientes fueron similares entre grupos. No encontramos diferencias en la morbimortalidad global. La estancia media postoperatoria fue 3 días menor en el grupo RHMM. No se observaron diferencias significativas en la tasa de reingresos. Los costes totales por paciente fueron significativamente menores en el grupo RHMM (RHMM: 8.107±4.117 euros vs control: 9.019±4.667 euros; P=0,02). El principal factor que contribuyó a la reducción de los costes fue el descenso de los gastos de la Unidad de Hospitalización. ConclusionesLa aplicación de un protocolo de RHMM en cirugía electiva colorrectal reduce, no solo la estancia hospitalaria, sino también los costes hospitalarios, sin aumentar la morbilidad postoperatoria ni el porcentaje de reingresos." ] ] "NotaPie" => array:2 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Salvans S, Gil-Egea MJ, Pera M, Lorente L, Cots F, Pascual M, et al. Impacto de un programa de rehabilitación multimodal en cirugía electiva colorrectal sobre los costes hospitalarios. Cir Esp. 2013;91:638–644." ] 1 => array:2 [ "etiqueta" => "☆☆" "nota" => "Presented at the XIII National Meeting of the Spanish Association of Coloproctology (Barcelona, 27–29 May 2009) and the XXVII National Meeting of Surgery (Las Palmas de Gran Canaria, 21–24 October 2009)." ] ] "multimedia" => array:6 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 535 "Ancho" => 1652 "Tamanyo" => 93945 ] ] "descripcion" => array:1 [ "en" => "Analysis of protocol compliance (with the items onset of diet and withdrawal of fluid therapy) and functional recovery (with the items tolerance of diet and ambulation) in the MMRH group. The hospital discharge progression rate according to the postoperative day is also shown for the MMRH group." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 650 "Ancho" => 1646 "Tamanyo" => 70383 ] ] "descripcion" => array:1 [ "en" => "Analysis of progression of the number of hospital admissions by postoperative day in the MMRH and control groups *P<.05." ] ] 2 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td 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" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">MMRH group n=231 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Control group n=134 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">P \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Sex (No.) (female/male) \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">93/138 \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">56/78 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.859<a class="elsevierStyleCrossRef" href="#tblfn0010">b</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Age (years)<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> \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">68.8±12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">70.4±11 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.206<a class="elsevierStyleCrossRef" href="#tblfn0015">c</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">ASA 1/2/3/4 (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3/64/31/2 \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">1/53/44/2 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.992<a class="elsevierStyleCrossRef" href="#tblfn0010">b</a> \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="4" align="left" valign="\n \t\t\t\t\ttop\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="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Type of surgical intervention, n (%)</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Right hemicolectomy \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">57 (25) \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">46 (34) \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.063<a class="elsevierStyleCrossRef" href="#tblfn0010">b</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Left hemicolectomy \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">75 (32) \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">45 (34) \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.918<a class="elsevierStyleCrossRef" href="#tblfn0010">b</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Anterior resection of the rectum \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">59 (25) \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">26 (20) \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.226<a class="elsevierStyleCrossRef" href="#tblfn0010">b</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Abdominoperineal resection \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">13 (6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8 (6) \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.000<a class="elsevierStyleCrossRef" href="#tblfn0010">b</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Other<a class="elsevierStyleCrossRef" href="#tblfn0020">d</a> \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">27 (12) \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">9 (6) \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.146<a class="elsevierStyleCrossRef" href="#tblfn0010">b</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Laparoscopy \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">41 (18) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">31 (23) \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.267<a class="elsevierStyleCrossRef" href="#tblfn0010">b</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab463229.png" ] ] ] "notaPie" => array:4 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "Mean±standard deviation." ] 1 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "b" "nota" => "Chi-squared test." ] 2 => array:3 [ "identificador" => "tblfn0015" "etiqueta" => "c" "nota" => "Student's t-test." ] 3 => array:3 [ "identificador" => "tblfn0020" "etiqueta" => "d" "nota" => "MMRH group: Hartmann reconstruction (13), Hartmann procedure (7), resection for recurrence and carcinomatosis (7). Control group: Hartmann reconstruction (2), Hartmann procedure (2), resection for recurrence (5)." ] ] ] "descripcion" => array:1 [ "en" => "Demographic and Clinical Characteristics of the Patients in Each Group." ] ] 3 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td 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" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">RHMM group n=231 (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Control group n=134 (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">P \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">General morbidity \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">85 (37) \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">46 (34) \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.718<a class="elsevierStyleCrossRef" href="#tblfn0025">a</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Medical complications \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">43 (19) \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">23 (17) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.836<a class="elsevierStyleCrossRef" href="#tblfn0025">a</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Surgical complications \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">50 (22) \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">34 (25) \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.492<a class="elsevierStyleCrossRef" href="#tblfn0025">a</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Surgical site infection \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">40 (17) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">26 (19) \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.720<a class="elsevierStyleCrossRef" href="#tblfn0025">a</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Infection of the surgical incision \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">24 (10) \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">18 (13) \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.478<a class="elsevierStyleCrossRef" href="#tblfn0030">b</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Organ-space infection \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">16 (7) \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8 (6) \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.828<a class="elsevierStyleCrossRef" href="#tblfn0030">b</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> Intra-abdominal abscess \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9 (4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 (1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.340<a class="elsevierStyleCrossRef" href="#tblfn0030">b</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Anastomotic leak \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 (3)<a class="elsevierStyleCrossRef" href="#tblfn0035">c</a> \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 (5)<a class="elsevierStyleCrossRef" href="#tblfn0035">c</a> \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.560<a class="elsevierStyleCrossRef" href="#tblfn0030">b</a> \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="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Mortality \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 (1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 (4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.149<a class="elsevierStyleCrossRef" href="#tblfn0030">b</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab463231.png" ] ] ] "notaPie" => array:3 [ 0 => array:3 [ "identificador" => "tblfn0025" "etiqueta" => "a" "nota" => "Chi-squared test." ] 1 => array:3 [ "identificador" => "tblfn0030" "etiqueta" => "b" "nota" => "Student's t-test." ] 2 => array:3 [ "identificador" => "tblfn0035" "etiqueta" => "c" "nota" => "Anastomotic leak percentage was calculated in relation to the number of anastomosis: 206 and 130, respectively." ] ] ] "descripcion" => array:1 [ "en" => "Morbimortality Compared Between the MMRH and Control Groups." ] ] 4 => array:7 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td 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" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">MMRH group n=231 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Control group n=134 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">P \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Stay (days)<a class="elsevierStyleCrossRef" href="#tblfn0040">a</a> \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">9±7 \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">11.9±13 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.007<a class="elsevierStyleCrossRef" href="#tblfn0045">b</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Readmission, n (%) \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">22 (9) \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">11 (8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.815<a class="elsevierStyleCrossRef" href="#tblfn0050">c</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Total stay (days)<a class="elsevierStyleCrossRef" href="#tblfn0040">a</a> \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">9.9±8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">13.1±15 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.007<a class="elsevierStyleCrossRef" href="#tblfn0045">b</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab463228.png" ] ] ] "notaPie" => array:3 [ 0 => array:3 [ "identificador" => "tblfn0040" "etiqueta" => "a" "nota" => "Mean (standard deviation)." ] 1 => array:3 [ "identificador" => "tblfn0045" "etiqueta" => "b" "nota" => "Student's t-test." ] 2 => array:3 [ "identificador" => "tblfn0050" "etiqueta" => "c" "nota" => "Chi-squared test. Total stay is the sum of the initial stay and the stay at readmission." ] ] ] "descripcion" => array:1 [ "en" => "Length of Hospital Stay and Readmission Rates for the MMRH and Control Groups." ] ] 5 => array:7 [ "identificador" => "tbl0020" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "Units: euros." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td 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" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">MMRH group n=231 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Control group n=134 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">P \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Total \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8107±4117 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9019±4667 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.023 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Hospitalisation unit \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2461±1874 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3292±2755 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.002 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Laboratory \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">180±253 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">254±273 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.015 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Radiology \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">110±374 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">191±385 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.051 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Pharmacy \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">291±399 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">373±544 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.252 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Operating room \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4483±1770 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4185±1310 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.154 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Pathology \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">473±239 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">427±242 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.087 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab463230.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Costs Per Patient in the MMRH and Control Groups. 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Multimodal Rehabilitation Programme in Elective Colorectal Surgery: Impact on Hospital Costs

Impacto de un programa de rehabilitación multimodal en cirugía electiva colorrectal sobre los costes hospitalarios

Sílvia Salvansa, M. José Gil-Egeaa,

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35780@parcdesalutmar.cat

Corresponding author.

, Miguel Peraa, Leyre Lorentea, Francesc Cotsb, Marta Pascuala, Sandra Alonsoa, Ricard Courtiera, Luis Grandea

a Unidad de Cirugía Colorrectal, Servicio de Cirugía General y Digestiva, Hospital Universitario del Mar, Barcelona, Spain

b Servicio de Control de Gestión, Parc de Salut Mar, Barcelona, Spain

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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">In recent years&#44; there has been a slow but steady increase in the use of multimodal rehabilitation &#40;MMRH&#41; programmes &#40;also called &#8220;fast track&#8221;&#41; proposed by Kehlet<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> after elective colorectal surgery&#46; These programmes&#44; which require the coordination of different specialists&#44; are a combination of different perioperative care strategies to reduce surgical stress and facilitate postoperative patient recovery&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#8211;5</span></a> The implementation of these measures has reduced hospital stays to 2&#8211;4 days without increasing morbidity<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;7</span></a>&#59; 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they should all be used together&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> Furthermore&#44; decreasing hospital stays and&#44; in some cases&#44; reducing postoperative complications must lower hospital costs&#46; However&#44; very few studies have assessed the impact of MMRH programmes on hospital costs after colorectal surgery&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">In March 2006&#44; the Colorectal Surgery unit of the Hospital del Mar in Barcelona launched an MMRH protocol for patients undergoing elective colorectal surgery&#46; In the analysis of the initial results with a group of 90 patients&#44;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> we showed that MMRH is a safe protocol &#40;as it does not increase complications&#41; that reduces hospital stays to three days&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The aim of this study is to confirm our preliminary results by increasing the number of patients in the MMRH programme and to analyse the impact on hospital costs&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Materials and Methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Study Design</span><p id="par0025" class="elsevierStylePara elsevierViewall">A prospective comparative study of two consecutive cohorts of patients undergoing elective colorectal surgery&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Study Population</span><p id="par0030" class="elsevierStylePara elsevierViewall">The MMRH group consisted of 231 patients undergoing elective colorectal surgery between March 2006 and December 2007&#46; 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as enteral nutrition &#40;Edanec<span class="elsevierStyleSup">&#174;</span>&#44; Abbott Laboratories&#44; S&#46;A&#46;&#41;&#59; prescribing a preoperative 6-h liquids and solids fast&#59; providing antibiotic prophylaxis with metronidazole 1<span class="elsevierStyleHsp" style=""></span>g gentamicin 240<span class="elsevierStyleHsp" style=""></span>mg and antithrombotic bemiparin 2500 UI preoperatively and daily postoperatively for 4 weeks&#46; During the <span class="elsevierStyleItalic">intraoperative</span> phase&#44; analgesia was administered through an epidural catheter&#44; and short-acting anaesthetics were used&#59; hydration was performed at an adjusted rate of 6&#8211;8<span class="elsevierStyleHsp" style=""></span>ml&#47;kg&#47;h&#59; hypothermia was prevented with temperature-controlled fluid therapy and a heating blanket&#59; and intra-abdominal drains and nasogastric tube placement were avoided&#46; During the <span class="elsevierStyleItalic">postoperative</span> phase&#44; multimodal analgesia was administered&#44; the diet resumed gradually 6<span class="elsevierStyleHsp" style=""></span>h after surgery&#44; and early mobilisation was encouraged&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The most important differential strategies for the control group protocol were as follows&#46; During the <span class="elsevierStyleItalic">preoperative</span> phase&#44; oral communication was only provided by the surgeon&#59; the colon was prepared using Fosfosoda<span class="elsevierStyleSup">&#174;</span> &#40;Fleet Company Inc&#46;&#44; VA&#44; USA&#41; while administering intravenous hydration of 1000<span class="elsevierStyleHsp" style=""></span>ml of 5&#37; dextrose with 60<span class="elsevierStyleHsp" style=""></span>mEq KCl&#59; and preoperative fasting began the night before surgery&#46; During the <span class="elsevierStyleItalic">intraoperative</span> phase&#44; fluid therapy was administered at the discretion of the attending anaesthesiologist at a rate of approximately 10&#8211;14<span class="elsevierStyleHsp" style=""></span>ml&#47;kg&#47;h&#44; almost twice the established rate for the MMRH protocol&#46; During the <span class="elsevierStyleItalic">postoperative</span> phase&#44; the diet was resumed according to the surgeon&#39;s criterion&#44; usually with the onset of peristalsis&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">In both groups&#44; discharge occurred when the patient was able to tolerate a solid diet&#44; had good pain control with oral analgesia and was ambulatory&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Variables</span><p id="par0050" class="elsevierStylePara elsevierViewall">The demographic and clinical characteristics of the patients included in each group were compared&#46; Medical and surgical complications occurring within 30 days after surgery in both groups were recorded&#46; The average length of stay and readmission rate per group was also included&#46; The nursing staff or attending physician&#39;s compliance with the MMRH programme&#39;s protocol for the start of the diet and the withdrawal of fluid therapy was analysed&#46; Tolerance of diet and ambulation were measured as parameters of functional recovery&#46; We analysed the progression of hospital discharge in both groups&#46; The hospital discharge rate per day was studied for each group&#46; Finally&#44; total and specific costs were calculated &#40;per hospitalisation unit&#44; laboratory&#44; radiology&#44; pharmacy&#44; surgical suite and disease&#41; per patient in each group&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Cost Analysis</span><p id="par0055" class="elsevierStylePara elsevierViewall">Our hospital cost accounting provides patient-level details&#46; It is characterised by a &#8220;full-costing&#8221; system and for basing the allocation of costs to activities on a cost-benefit analysis &#40;CBA&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> This cost analysis system ensures that all of the expenses are shared between all of the episodes&#46; The cost of each episode is the sum of the costs of all variable costs &#40;direct costs&#41; plus the set of general costs charged per activity &#40;indirect costs&#41;&#46; The cost information available allows the disaggregation of costs&#44; such as inpatient unit&#44; laboratory&#44; radiology&#44; pharmacy&#44; operating room and disease&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Statistical Analysis</span><p id="par0060" class="elsevierStylePara elsevierViewall">A descriptive and statistical comparison of variables was performed&#44; considering a <span class="elsevierStyleItalic">P</span>-value of less than &#46;05 to be statistically significant&#46; Qualitative variables are expressed in absolute numbers or proportions&#44; and quantitative variables are expressed as the median and range or as the mean and standard deviation&#46; The test of the hypothesis was the Chi-squared test for qualitative ordinal variables &#40;comparison of proportions&#41;&#44; Student&#39;s <span class="elsevierStyleItalic">t</span>-test for continuous variables when their applicability criteria were met and the Mann&#8211;Whitney <span class="elsevierStyleItalic">U</span> test when applicability criteria were not met&#46; All of the data were analysed using SPSS Version 12&#46;0&#46;</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Results</span><p id="par0065" class="elsevierStylePara elsevierViewall">There were no differences in the patient characteristics or surgical procedures performed between the two study groups &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> shows the overall morbidity of both groups&#59; there were no significant differences between them&#46; This morbidity rate also included patients who were readmitted&#46; We did not observe significant differences when comparing medical and surgical complications&#46; Surgical site infections were analysed separately&#44; and they also showed no differences&#46; Finally&#44; mortality in both groups was less than 5&#37;&#44; and the differences were not statistically significant&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a> shows a statistically significant decrease of three days in the average hospital stay of patients in the MMRH group compared with control patients&#59; however&#44; no differences were found in the percentage of readmissions&#46; The three-day decrease was maintained when analysing the total stay as the sum of the initial stay and the readmission stay&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a> shows an analysis of different aspects included in the programme to reflect the MMRH protocol compliance and functional recovery of patients&#44; such as the beginning of ambulation and diet&#44; diet tolerance and intravenous fluid therapy withdrawal&#46; The percentage of patients discharged on a given postoperative day is also shown&#46; We note that only 55 and 68&#37; of patients started the diet and ambulated&#44; respectively&#44; on the first postoperative day&#46; On the fifth postoperative day&#44; only 37&#37; of patients were discharged&#44; although 80&#37; of the patients met the discharge criteria&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a> shows the progression to hospital discharge in the both groups&#46; Statistically significant differences were observed on the fifth postoperative day &#40;37&#37; vs 20&#37;&#41;&#44; the sixth postoperative day &#40;66&#37; vs 43&#37;&#41; and the eighth postoperative day &#40;69&#37; vs 47&#37;&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a> shows the hospital costs per patient in each group&#46; We found a significant reduction in total cost of 912 &#8364; per patient in the MMRH group compared with the control group&#46; This significant reduction of costs was found mainly for the hospitalisation unit&#44; with a cost decrease of 831 &#8364; in the MMRH group&#46; We also observed a significant reduction in laboratory costs&#46; The costs per patient for radiology and pharmacy were also lower in the MMRH group&#44; but this difference did not reach statistical significance&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Discussion</span><p id="par0095" class="elsevierStylePara elsevierViewall">First&#44; the present study confirms the preliminary results published by our group<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> in a series with a larger number of patients included in the MMRH protocol&#46; This protocol is safe&#44; does not increase patient morbidity or mortality and reduces hospital stay by three days compared with conventional perioperative care&#46; These results are also consistent with previous studies and systematic reviews&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#8211;13</span></a> Second&#44; this study shows how faster patient recovery is associated with a significant reduction in hospital costs&#46; Although it is obvious&#44; little published work has quantified this cost reduction&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Although the overall morbidity and mortality in this study were similar to that described in other studies on the implementation of MMRH programmes&#44;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18&#44;19</span></a> we found no differences in postoperative complications between groups&#46; Therefore&#44; we can say that the hospital stay reductions were not caused by reduced morbidity&#46; The impact of MMRH programmes on postoperative morbidity is controversial&#46; In the systematic review by Wind et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> morbidity rates between 8&#37; and 75&#37; were found&#59; however&#44; the differences between groups reached statistical significance only in one study&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> A systematic review of the Cochrane Database<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> showed a reduction in overall complications&#44; but the most serious complications did not decrease&#46; The absence of differences in morbidity in our study and in others may be related to several reasons&#46; First&#44; each study used different definitions of complications and different classifications&#46; Second&#44; the need to optimise the implemented protocol in accordance with all the recommendations of ERAS protocols may have minimised differences in morbidity&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> For example&#44; we established a 6<span class="elsevierStyleHsp" style=""></span>h preoperative fast&#44; while the ERAS protocol consensus recommends fluid intake 2<span class="elsevierStyleHsp" style=""></span>h before anaesthetic induction and solid intake 6<span class="elsevierStyleHsp" style=""></span>h<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> before anaesthesia&#46; We also need to improve the treatment of postoperative nausea and vomiting<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> by implementing strategies to prevent postoperative ileus&#44; such as administering magnesium hydroxide<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> and other prokinetics&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> Currently&#44; we are considering implementing some of these strategies with the intention of improving our protocol&#46; For example&#44; beginning two years ago&#44; patients undergoing colon resection did not receive preoperative bowel preparation&#44; based on the scientific evidence&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> The implementation of all the recommendations recently examined by the ERAS group could significantly reduce postoperative morbidity&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">We have achieved a significant reduction in hospital stay despite a low level of compliance with the MMRH programme&#46; Protocol compliance has been identified as one of the problems of MMRH programmes&#44;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> reflecting the difficulty of changing a traditional protocol and implementing new strategies for perioperative care&#46; However&#44; this problem has hardly been studied&#46; In a previous study&#44; we observed that compliance with a new protocol is initially low but gradually improves&#44; along with the results of the MMRH programme and the experience of the professionals involved&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> Delaney et al&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> also observed that the hospital stay was shorter when these programmes were implemented by experienced surgeons&#46; The difficulty of implementing an ERAS protocol outside clinical trials has been recently investigated by Ahmed et al&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> The authors found that protocol compliance was lower in daily practice compared with compliance during a clinical trial&#46; Interestingly&#44; as in the present study&#44; the clinical results improved despite low compliance&#46; This suggests that greater compliance could further improve postoperative recovery and even reduce morbidity&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Moreover&#44; the reduction to a three-day hospital stay was achieved without increasing the rate of readmission&#46; Reducing inappropriate hospital stay often comes at the expense of increasing the percentage of readmissions&#46; In the study by Basse et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> the average hospital stay was only two days in the MMRH programme&#44; but readmission was necessary in 20&#37; of patients&#46; Our readmission rate since starting the MMRH programme is acceptable&#44; as it does not exceed the 10&#37; recommended by some authors&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">Another aspect that should be discussed is the inability to discharge patients even when they fulfilled the established clinical criteria&#46; This is a very important limiting factor for improving the results&#46; For example&#44; in this study&#44; only 37&#37; of patients in the MMRH group were discharged on the fifth postoperative day&#44; although 80&#37; of them met the criteria to be discharged&#46; We believe that in our country&#44; the main cause is a lack of adequate social or family support&#46; According to a report by the Ministry of Health and Social Services for the Elderly in Spain&#44; 21&#37; of people over the age of 65 years live alone&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> Greater collaboration with discharge care programmes should improve these results&#46; The patient&#39;s fear and insecurity about continuing recovery at home could be another cause for discharge delays&#46; Maessen et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> also found delays in hospital discharge among patients who met the discharge criteria&#46; The authors propose better home health care after early discharge&#46; We believe that analysing patient satisfaction after their participation in an MMRH programme might lead to a better understanding of the problem&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">After confirming that our MMRH programme improved our patients&#8217; functional recovery&#44; we evaluated the programme&#39;s impact on hospital costs&#46; This is a very important point because there is a growing need to improve economic efficiency in perioperative care without compromising results&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a> We found a reduction of nearly 1000 euros per patient in total costs in the MMRH group compared with the control group&#46; The main factor contributing to this statistically significant difference was the reduction in the costs associated with the hospitalisation unit&#46; This result is consistent with the decline we have observed in the three-day hospital stay in the MMRH group&#46; This cost reduction was also described by the group at the Cleveland Clinic after they initiated a clinical pathway for postoperative care after ileoanal reservoir surgery&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> In that study&#44; the direct costs and complications were analysed for the first 30 postoperative days and longer term&#46; The patients who were treated according to a MMRH protocol were matched with controls who received conventional care from a different group of surgeons&#46; The major complication rates were comparable&#44; and there were no differences in the rates of readmission or reoperation&#46; The patients in the MMRH group had a shorter hospital stay&#44; and the median direct cost per patient within 30 days was almost 1000 USD less than that of patients receiving traditional care&#44; mainly because of a decrease in the costs of anaesthesia&#44; nursing care&#44; lab tests and other services such as respiratory therapy&#44; stoma management education and nutrition services&#46; In the present study&#44; the decrease in costs was not only related to the Hospitalisation Unit&#59; laboratory costs were also significantly lower in the MMRH group&#46; The costs per patient in radiology and pharmacy were lower&#44; but the difference was not statistically significant&#46; Another economic benefit that should be expected by the institution is greater availability of beds&#46; The reduction in hospital costs even with a low level of compliance with the protocol indicates that&#44; at present&#44; resource utilisation and the costs of perioperative care are far from optimal in most institutions&#46; As highlighted in the meta-analysis by Adamina et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> MMRH programmes optimise resources while accelerating the recovery of patients&#44; thus reducing hospital stay&#46; Additionally&#44; the results of the LAFA3 study<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a> move in the same direction&#46; LAFA3 is the first randomised&#44; prospective four-cohort study conducted in nine centres in the Netherlands to show that the combination of laparoscopic surgery with perioperative MMRH care leads to faster recovery compared with other treatment combinations&#46; This combination is able to reduce costs primarily by reducing hospital stay&#44; although this cost reduction was not statistically significant&#46; Therefore&#44; these programmes should be used routinely for colorectal surgery&#46; Such routine use is especially important in times of serious economic difficulties&#44; as is currently the case&#46; In this regard&#44; further studies specifically designed to investigate how to minimise costs will provide additional information that may be useful for making treatment choices and investment strategies in hospitals&#44; as was the case of the TAPAS study&#44; a three-cohort prospective study conducted in five Dutch hospitals&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">In conclusion&#44; this study demonstrates that the use of a MMRH protocol for elective colorectal surgery reduces both hospital stay and costs without increasing postoperative morbidity or the percentage of readmissions&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Conflict of Interest</span><p id="par0130" class="elsevierStylePara elsevierViewall">The authors declare no conflict of interest&#46;</p></span></span>"
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            0 => "Colorectal surgery"
            1 => "Multimodal rehabilitation"
            2 => "Fast-track"
            3 => "Clinical pathway"
            4 => "Costs"
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          "palabras" => array:5 [
            0 => "Cirug&#237;a colorrectal"
            1 => "Rehabilitaci&#243;n multimodal"
            2 => "Fast-track"
            3 => "V&#237;a cl&#237;nica"
            4 => "Costes"
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        "titulo" => "Abstract"
        "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Multimodal rehabilitation &#40;MMRH&#41; programmes in surgery have proven to be beneficial in functional recovery of patients&#46; The aim of this study is to evaluate the impact of a MMRH programme on hospital costs&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0015">Method</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A comparative study of 2 consecutive cohorts of patients undergoing elective colorectal surgery has been designed&#46; In the first cohort&#44; we analysed 134 patients who received conventional perioperative care &#40;control group&#41;&#46; The second cohort included 231 patients treated with a multimodal rehabilitation protocol &#40;fast-track group&#41;&#46; Compliance with the protocol and functional recovery after fast-track surgery were analysed&#46; We compared postoperative complications&#44; length of stay and readmission rates in both groups&#46; The cost analysis was performed according to the system &#8220;full-costing&#8221;&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">There were no differences in clinical features&#44; type of surgical excision and surgical approach&#46; No differences in overall morbidity and mortality rates were found&#46; The mean length of hospital stay was 3 days shorter in the fast-track group&#46; There were no differences in the 30-day readmission rates&#46; The total cost per patient was significantly lower in the fast-track group &#40;fast-track&#58; 8107<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4117 euros vs control&#58; 9019<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4667 euros&#59; <span class="elsevierStyleItalic">P</span>&#61;&#46;02&#41;&#46; The main factor contributing to the cost reduction was a decrease in hospitalisation unit costs&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The application of a multimodal rehabilitation protocol after elective colorectal surgery decreases not only the length of hospital stay but also the hospitalisation costs without increasing postoperative morbidity or the percentage of readmissions&#46;</p>"
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      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0035">Introducci&#243;n</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Los programas de rehabilitaci&#243;n multimodal &#40;RHMM&#41; en cirug&#237;a han demostrado un beneficio en la recuperaci&#243;n funcional de los pacientes&#46; Nuestro objetivo fue evaluar el impacto de un programa de RHMM en los costes hospitalarios&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0040">Material y m&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudio prospectivo comparativo de cohortes consecutivas de pacientes intervenidos de cirug&#237;a colorrectal electiva&#46; En la primera cohorte analizamos 134 pacientes que recibieron un control postoperatorio convencional &#40;grupo control&#41;&#46; En la segunda cohorte se incluye a 231 pacientes tratados con un programa de RHMM &#40;grupo RHMM&#41;&#46; Se analiza el cumplimiento del protocolo y la recuperaci&#243;n funcional de los pacientes del grupo RHMM&#46; Se comparan las complicaciones postoperatorias&#44; la estancia hospitalaria y los reingresos en ambos grupos&#46; El an&#225;lisis de costes se ha basado en la contabilidad anal&#237;tica del centro&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Las caracter&#237;sticas demogr&#225;ficas y cl&#237;nicas de los pacientes fueron similares entre grupos&#46; No encontramos diferencias en la morbimortalidad global&#46; La estancia media postoperatoria fue 3 d&#237;as menor en el grupo RHMM&#46; No se observaron diferencias significativas en la tasa de reingresos&#46; Los costes totales por paciente fueron significativamente menores en el grupo RHMM &#40;RHMM&#58; 8&#46;107<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4&#46;117 euros vs control&#58; 9&#46;019<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>4&#46;667 euros&#59; P<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;02&#41;&#46; El principal factor que contribuy&#243; a la reducci&#243;n de los costes fue el descenso de los gastos de la Unidad de Hospitalizaci&#243;n&#46;</p> <span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La aplicaci&#243;n de un protocolo de RHMM en cirug&#237;a electiva colorrectal reduce&#44; no solo la estancia hospitalaria&#44; sino tambi&#233;n los costes hospitalarios&#44; sin aumentar la morbilidad postoperatoria ni el porcentaje de reingresos&#46;</p>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0055">Please cite this article as&#58; Salvans S&#44; Gil-Egea MJ&#44; Pera M&#44; Lorente L&#44; Cots F&#44; Pascual M&#44; et al&#46; Impacto de un programa de rehabilitaci&#243;n multimodal en cirug&#237;a electiva colorrectal sobre los costes hospitalarios&#46; Cir Esp&#46; 2013&#59;91&#58;638&#8211;644&#46;</p>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0060">Presented at the XIII National Meeting of the Spanish Association of Coloproctology &#40;Barcelona&#44; 27&#8211;29 May 2009&#41; and the XXVII National Meeting of Surgery &#40;Las Palmas de Gran Canaria&#44; 21&#8211;24 October 2009&#41;&#46;</p>"
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Analysis of protocol compliance &#40;with the items onset of diet and withdrawal of fluid therapy&#41; and functional recovery &#40;with the items tolerance of diet and ambulation&#41; in the MMRH group&#46; The hospital discharge progression rate according to the postoperative day is also shown for the MMRH group&#46;</p>"
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Analysis of progression of the number of hospital admissions by postoperative day in the MMRH and control groups &#42;<span class="elsevierStyleItalic">P</span>&#60;&#46;05&#46;</p>"
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                  \t\t\t\t" style="border-bottom: 2px solid black">MMRH group n&#61;231&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">Control group n&#61;134&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">P</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Sex &#40;No&#46;&#41; &#40;female&#47;male&#41;</span>&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">93&#47;138&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">56&#47;78&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#46;859<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Age &#40;years&#41;</span><a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&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
                  \t\t\t\t\ttop\n
                  \t\t\t\t">68&#46;8&#177;12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">70&#46;4&#177;11&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#46;206<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">c</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">ASA 1&#47;2&#47;3&#47;4 &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#47;53&#47;44&#47;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#46;992<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>&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="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Type of surgical intervention&#44; n &#40;&#37;&#41;</span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Right hemicolectomy&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">57 &#40;25&#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">46 &#40;34&#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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#46;063<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Left hemicolectomy&nbsp;\t\t\t\t\t\t\n
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                  \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">75 &#40;32&#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">45 &#40;34&#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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#46;918<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Anterior resection of the rectum&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">59 &#40;25&#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">26 &#40;20&#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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#46;226<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Abdominoperineal resection&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13 &#40;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8 &#40;6&#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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;000<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Other<a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">d</span></a>&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">27 &#40;12&#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">9 &#40;6&#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="char" valign="\n
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                  \t\t\t\t">&#46;146<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \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"><span class="elsevierStyleHsp" style=""></span>Laparoscopy&nbsp;\t\t\t\t\t\t\n
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                  \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">41 &#40;18&#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">31 &#40;23&#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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#46;267<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">RHMM group n&#61;231 &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">Control group n&#61;134 &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">85 &#40;37&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">46 &#40;34&#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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#46;718<a class="elsevierStyleCrossRef" href="#tblfn0025"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Medical complications</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">43 &#40;19&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">23 &#40;17&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">&#46;836<a class="elsevierStyleCrossRef" href="#tblfn0025"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Surgical complications</span>&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">50 &#40;22&#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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">34 &#40;25&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">&#46;492<a class="elsevierStyleCrossRef" href="#tblfn0025"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Surgical site infection</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">40 &#40;17&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">26 &#40;19&#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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#46;720<a class="elsevierStyleCrossRef" href="#tblfn0025"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Infection of the surgical incision&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">24 &#40;10&#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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">18 &#40;13&#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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#46;478<a class="elsevierStyleCrossRef" href="#tblfn0030"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \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"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Organ-space 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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16 &#40;7&#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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8 &#40;6&#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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#46;828<a class="elsevierStyleCrossRef" href="#tblfn0030"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span> Intra-abdominal abscess&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9 &#40;4&#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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;1&#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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#46;340<a class="elsevierStyleCrossRef" href="#tblfn0030"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Anastomotic leak&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7 &#40;3&#41;<a class="elsevierStyleCrossRef" href="#tblfn0035"><span class="elsevierStyleSup">c</span></a>&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6 &#40;5&#41;<a class="elsevierStyleCrossRef" href="#tblfn0035"><span class="elsevierStyleSup">c</span></a>&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#46;560<a class="elsevierStyleCrossRef" href="#tblfn0030"><span class="elsevierStyleSup">b</span></a>&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="4" 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  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">Mortality</span>&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 &#40;1&#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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5 &#40;4&#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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#46;149<a class="elsevierStyleCrossRef" href="#tblfn0030"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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            1 => array:3 [
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              "identificador" => "tblfn0035"
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          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Morbimortality Compared Between the MMRH and Control Groups&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td 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" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">MMRH group n&#61;231&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">Control group n&#61;134&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">P</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Stay &#40;days&#41;<a class="elsevierStyleCrossRef" href="#tblfn0040"><span class="elsevierStyleSup">a</span></a>&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">9&#177;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">11&#46;9&#177;13&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#46;007<a class="elsevierStyleCrossRef" href="#tblfn0045"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Readmission&#44; n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">22 &#40;9&#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">11 &#40;8&#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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#46;815<a class="elsevierStyleCrossRef" href="#tblfn0050"><span class="elsevierStyleSup">c</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Total stay &#40;days&#41;<a class="elsevierStyleCrossRef" href="#tblfn0040"><span class="elsevierStyleSup">a</span></a>&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">9&#46;9&#177;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13&#46;1&#177;15&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#46;007<a class="elsevierStyleCrossRef" href="#tblfn0045"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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            2 => array:3 [
              "identificador" => "tblfn0050"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td 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" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" style="border-bottom: 2px solid black">MMRH group n&#61;231&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">Control group n&#61;134&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">P</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Total</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8107&#177;4117&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9019&#177;4667&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#46;023&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Hospitalisation unit&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2461&#177;1874&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3292&#177;2755&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
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#46;002&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Laboratory&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">180&#177;253&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">254&#177;273&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#46;015&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Radiology&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">110&#177;374&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="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">191&#177;385&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="char" valign="\n
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]

Article information

ISSN: 21735077
Original language: English

DOI:10.1016/j.cireng.2014.01.019

The statistics are updated each day

Year/Month	Html	Pdf	Total

2024 November	2	1	3
2024 October	15	3	18
2024 September	43	13	56
2024 August	30	3	33
2024 July	19	6	25
2024 June	25	3	28
2024 May	21	6	27
2024 April	69	4	73
2024 March	48	5	53
2024 February	44	3	47
2024 January	79	1	80
2023 December	74	4	78
2023 November	26	9	35
2023 October	19	4	23
2023 September	18	1	19
2023 August	17	5	22
2023 July	19	3	22
2023 June	25	3	28
2023 May	34	2	36
2023 April	35	1	36
2023 March	20	1	21
2023 February	30	4	34
2023 January	20	3	23
2022 December	42	6	48
2022 November	35	10	45
2022 October	24	13	37
2022 September	30	12	42
2022 August	21	13	34
2022 July	18	7	25
2022 June	19	5	24
2022 May	24	6	30
2022 April	18	11	29
2022 March	31	5	36
2022 February	18	5	23
2022 January	26	8	34
2021 December	20	9	29
2021 November	57	10	67
2021 October	53	9	62
2021 September	37	12	49
2021 August	58	3	61
2021 July	25	10	35
2021 June	19	6	25
2021 May	17	9	26
2021 April	63	15	78
2021 March	13	12	25
2021 February	13	5	18
2021 January	27	8	35
2020 December	9	8	17
2020 November	13	9	22
2020 October	13	5	18
2020 September	14	11	25
2020 August	21	6	27
2020 July	18	8	26
2020 June	16	3	19
2020 May	26	8	34
2020 April	10	2	12
2020 March	18	3	21
2020 February	14	6	20
2020 January	20	5	25
2019 December	25	4	29
2019 November	16	9	25
2019 October	7	3	10
2019 September	18	2	20
2019 August	13	5	18
2019 July	15	19	34
2019 June	31	25	56
2019 May	132	24	156
2019 April	53	21	74
2019 March	8	9	17
2019 February	16	12	28
2019 January	5	3	8
2018 December	8	8	16
2018 November	21	8	29
2018 October	18	7	25
2018 September	5	2	7
2018 August	7	4	11
2018 July	7	0	7
2018 June	3	3	6
2018 May	10	0	10
2018 April	6	2	8
2018 March	6	0	6
2018 February	5	0	5
2018 January	8	1	9
2017 December	3	0	3
2017 November	5	3	8
2017 October	10	0	10
2017 September	8	2	10
2017 August	17	1	18
2017 July	12	0	12
2017 June	22	1	23
2017 May	17	4	21
2017 April	11	9	20
2017 March	10	14	24
2017 February	7	1	8
2017 January	29	1	30
2016 December	18	9	27
2016 November	13	2	15
2016 October	40	6	46
2016 September	34	10	44
2016 August	20	5	25
2016 July	22	1	23
2016 June	30	8	38
2016 May	23	3	26
2016 April	21	8	29
2016 March	24	15	39
2016 February	10	5	15
2016 January	15	4	19
2015 December	12	2	14
2015 November	24	3	27
2015 October	22	5	27
2015 September	43	6	49
2015 August	14	2	16
2015 July	13	7	20
2015 June	12	1	13
2015 May	18	3	21
2015 April	23	9	32
2015 March	24	5	29
2015 February	16	4	20
2015 January	28	2	30
2014 December	39	10	49
2014 November	39	4	43
2014 October	29	6	35
2014 September	18	3	21
2014 August	23	3	26
2014 July	30	0	30
2014 June	17	6	23
2014 May	15	1	16
2014 April	16	6	22
2014 March	16	5	21

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