Special article
A New Surgical Technique for Extended Right Hepatectomy: Tourniquet in the Umbilical Fissure and Right Portal Vein Occlusion (ALTPS). Clinical Case
Una nueva técnica quirúrgica para la hepatectomía derecha extendida: torniquete en la cisura umbilical y oclusión portal derecha (ALTPS). Caso clínico
Ricardo Robles Camposa,
, Pascual Parrilla Paricioa, Asunción López Conesaa, Roberto Brusadína, Víctor López Lópeza, Pilar Jimeno Griñóa, Matilde Fuster Quiñonerob, José Antonio García Lópezc, Jesús de la Peña Morald
Corresponding author
a Servicio de Cirugía General y Aparato Digestivo, Hospital Clínico Universitario Virgen de la Arrixaca, CIBEREHD, El Palmar, Murcia, Spain
b Servicio de Radiodiagnóstico, Hospital Clínico Universitario Virgen de la Arrixaca, El Palmar, Murcia, Spain
c Servicio de Anestesia, Hospital Clínico Universitario Virgen de la Arrixaca, El Palmar, Murcia, Spain
d Servicio de Anatomía Patológica, Hospital Clínico Universitario Virgen de la Arrixaca, El Palmar, Murcia, Spain
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Caso clínico" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 577 "Ancho" => 995 "Tamanyo" => 184564 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Intraoperative image of the second-stage intervention where the tourniquet groove to the right of the umbilical fissure is observed.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">In extensive resections or in two-stage liver resections (TSLR),<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> when there is insufficient residual functional liver volume (RLV), percutaneous portal vein embolisation (PPVE)<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,4</span></a> or intraoperative portal vein ligation (IPVL) is performed.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5–7</span></a> There are several problems associated with portal vein occlusion in both procedures: delayed (between 3 and 8 weeks) or no hypertrophy,<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3–7</span></a> due to the formation of intrahepatic collateral circulation (with a danger of posthepatectomy liver failure<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8,9</span></a> (PLF following major liver resection) and progression of the tumour,<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10,11</span></a> which could result in the patients becoming inoperable. In 2011, Baumgart et al.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> reported 3 patients with RLV in the left lateral sector treated with right portal vein ligation and in situ bipartition at the level of the umbilical fissure, achieving RLV hypertrophy of segments II<span class="elsevierStyleSmallCaps">–III</span> in 9 days, in order to perform a TSLR and obtain right trisectionectomy. The same results were reproduced by other authors<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13,14</span></a> by sectioning in the Cantlie line, using the same technique. This new technique, called <span class="elsevierStyleItalic">associating liver partition and portal ligation for staged hepatectomy</span> (ALPPS),<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> is a great step forward because it achieves quick hypertrophy and could prevent the classical occlusion technique problems of hypertrophy failure and tumour progression. This technique has not, however, been universally accepted because the first-stage surgery is very aggressive and there is a high rate of morbimortality (12%–27%)<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16–21</span></a> and some authors consider there is high risk of PLF.<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16–20</span></a> In September 2011 we performed a new alternative surgical technique, where we inserted a tourniquet in the Cantlie line instead of bipartition, <span class="elsevierStyleItalic">associating liver tourniquet and portal vein occlusion for staged hepatectomy</span> [ALTPS]), and obtained RLV hypertrophy in seven days.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The aim of this paper is to present a clinical case in which we performed our technique, inserting the tourniquet in the umbilical fissure instead of the Cantlie line, to obtain hypertrophy of segments II–III in a patient with a large right lobe liver mass requiring right trisectionectomy.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Clinical Case and Surgical Technique</span><p id="par0015" class="elsevierStylePara elsevierViewall">In October 2002, a 51-year-old man underwent surgery for a 6<span class="elsevierStyleHsp" style=""></span>cm right renal hypernephroma, with no adenopathy or vascular invasion. A right nephrectomy and lymphadenectomy were performed and the patient remained asymptomatic for nine years. In November 2011 an increase in transaminases was detected and an ultrasound scan was requested. This detected a large mass encompassing the right hepatic lobe, segment I and inferior vena cava (IVC). Bilirubin, transaminases, coagulation and tumour markers results were normal. Computed tomography (CT) detected a 20<span class="elsevierStyleHsp" style=""></span>cm mass invading a large portion of the right lobe, right and median suprahepatic vein, segment I and the inferior vena cava around it in more than 70% of the circumference (invaded from 3<span class="elsevierStyleHsp" style=""></span>cm above the left kidney bifurcation up to 2<span class="elsevierStyleHsp" style=""></span>cm below the left suprahepatic vein) (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Hepatic volumetric analysis detected a RLV of 3870<span class="elsevierStyleHsp" style=""></span>ml (20% total liver volume) with a liver volume/body weight quotient of 0.5. Extrahepatic disease was not detected by the PET. Our criteria<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> led us to believe FLV was insufficient, and we therefore indicated a two-stage liver resection using the ALTPS technique.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">First Surgical Intervention</span><p id="par0020" class="elsevierStylePara elsevierViewall">We examined the liver and the abdominal cavity through a subcostal bilateral incision, to rule out tumour dissemination. Cholecystectomy and transcystic drainage by cholangiography were performed. Dissection of the aforementioned right hepatic artery was performed using a vessel loop. The right portal vein was sectioned. The IVC was dissected above the left renal vein and below the left suprahepatic vein, using vessel-loop. Once it was confirmed that the tumour had not spread and that an R0 resection could be achieved at a second-stage, the Vicryl 3<span class="elsevierStyleHsp" style=""></span>mm V152 Ethicon<span class="elsevierStyleSup">®</span> tourniquet was inserted in the umbilical fissure. The tourniquet was passed between the middle and left suprahepatic veins, and continued around the base of the left lobe through the Rex recess to the left portal vein pedicle. Here it was passed in an extraglissonian manner to prevent pedicle occlusion when the tourniquet was closed. We then made a groove to the right side of the falciform ligament (umbilical fissure) which was knotted, occluding only the parenchyma and intrahepatic collaterals. Ultrasound showed the complete absence of circulation between segments II–III and segment IV. Operating time was 180<span class="elsevierStyleHsp" style=""></span>min with minimal blood loss. During the postoperative period there was a 70% fall in Quick levels and increase in GPT to 240<span class="elsevierStyleHsp" style=""></span>U/l. The patient was discharged on the fourth day following surgery with no complications. A CT scan with volumetrics was carried out on day seven.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Postoperative Volumetrics and Secondary Intervention</span><p id="par0025" class="elsevierStylePara elsevierViewall">RLV rose to 953<span class="elsevierStyleHsp" style=""></span>ml (31% of total hepatic volume), with an increase of 150% (573<span class="elsevierStyleHsp" style=""></span>ml rise). The CT scan revealed the absence of collateral circulation through the tourniquet, the absence of tumour progression and tumour resectability (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). Second stage surgery took place on the tenth day following the first stage, a VCI clamping test was performed, with perfect toleration and without the need for veno-venous by-pass. Ligation of the right bile duct, right hepatic artery and arterial branches of segment IV was made resulting in the complete separation and isolation of the left portal pedicle. Partition through the umbilical fissure (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>) was then performed, ligating the occluded portal branches of segment IV to the junction between the middle and left suprahepatic vein, the middle suprahepatic vein was ligated (the partition was performed in situ), completely separating segments II–III from the rest of the anatomic right lobe. The ICV was clamped above the left renal bifurcation and below the left suprahepatic vein, then sectioning the VCI above the left kidney and on the level of the right suprahepatic vein ostium. Finally, the ringed Gore-tex graft measuring 2<span class="elsevierStyleHsp" style=""></span>cm in diameter and 8<span class="elsevierStyleHsp" style=""></span>cm in length was inserted. Total VCI occlusion time was 70<span class="elsevierStyleHsp" style=""></span>min, surgery time was 210<span class="elsevierStyleHsp" style=""></span>min and blood loss was 600<span class="elsevierStyleHsp" style=""></span>ml. A control cholangiography was carried out prior to closure, correctly displaying the remaining bile duct. There was a 57% postoperative drop in Quick levels, an increase of 2<span class="elsevierStyleHsp" style=""></span>mg/dl in red blood cell count and of 267<span class="elsevierStyleHsp" style=""></span>IU in GPT levels, requiring a 2<span class="elsevierStyleHsp" style=""></span>IU blood transfusion. The patient was antiaggregated 48<span class="elsevierStyleHsp" style=""></span>h after surgery and on the 5th day presented fever of 38<span class="elsevierStyleHsp" style=""></span>°C; a perihepatic collection was revealed on CT scan. A radiological drain was placed to remove the collection, and the patient was discharged on the 12th day after surgery. The patient has since received periodic check-ups, the last with a CT-scan in July 2013 (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>). 20 months after the second surgical intervention there had been no disease recurrence.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Discussion</span><p id="par0030" class="elsevierStylePara elsevierViewall">The patient we present is the first case in the literature who associates complete retrohepatic IVG resection with right trisectionectomy, replacing it with a ringed Gore-tex 2<span class="elsevierStyleHsp" style=""></span>cm graft and using the ALPPS or ALTPS hypertrophy technique. Using our technique, on the 7th postoperative day, we were able to achieve sufficient hypertrophy to perform the second surgical intervention, going from a baseline RLV of 20% to 31% (a 150% increase), which enabled the second-stage to be performed on the 10th postoperative day.</p><p id="par0035" class="elsevierStylePara elsevierViewall">ALTPS is based on the same foundation as ALPPS: the intention of both is to achieve collateral circulation occlusion between both lobes<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> to obtain faster hypertrophy. The advantage of our surgical technique is that we do not perform a split, we only insert a tourniquet in the bipartition line (in this case in the umbilical fissure); this alters the aggressiveness of both surgical interventions: “these are two TSLR interventions with the same physiopathological foundation”. This case demonstrates that with ALTPS the first intervention is much less aggressive: blood loss is lower, transfusion is unnecessary, the patient is discharged four days after surgery, and there is no need to use the Pringle manoeuvre, unlike the ALPPS in 22%<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> and 33%,<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> respectively. In a multicentre<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> ALPPS study, blood loss during the first surgical intervention was 330<span class="elsevierStyleHsp" style=""></span>ml, with a maximum of 7500<span class="elsevierStyleHsp" style=""></span>ml, and 2 patients needed massive 15<span class="elsevierStyleHsp" style=""></span>IU transfusions.</p><p id="par0040" class="elsevierStylePara elsevierViewall">A frequent ALPPS complication is necrosis of segment <span class="elsevierStyleSmallCaps">IV</span> due to ischaemia following ligation of the collateral branches during the first intervention,<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11,16–19</span></a> which results in infections, bile fistulas and delayed second surgery. This complication does not arise with our technique since we conserve part of the arterial vascularisation by not separating the Glissonian pedicle of segment IV.</p><p id="par0045" class="elsevierStylePara elsevierViewall">After the second surgical intervention, our patient presented an infected collection which was treated with radiological drainage and antibiotics, with no signs of IHP. With ALPPS, morbidity varies between 53% and 64%,<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16–20</span></a> and some patients meet IHP criteria.<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16–20</span></a> Bile fistulas and infected collections are a frequent complication, with a risk of death in some series.<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16,18–20</span></a> The majority are associated with infected bile collections, sepsis, kidney failure, progressive cholestasis and multiple organ failure.</p><p id="par0050" class="elsevierStylePara elsevierViewall">One drawback of traditional EPP and LPI is tumour progression,<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10,11</span></a> linked with prolonged regeneration time.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7,11,25</span></a> In our case as the patient was reoperated on after ten days we found no evidence of tumour progression: an R0 resection was achieved and the patient was disease-free for 20 months after the second intervention.</p><p id="par0055" class="elsevierStylePara elsevierViewall">In conclusion, our surgical technique is very different to the other described and obtains the same regeneration. It is less aggressive in the first intervention since we do not section the parenchyma and a tourniquet is positioned in the section line and in the right portal section. More extensive series are needed to assess the efficacy of ALPPS and ALTPS, and likewise the efficacy of these new techniques with regard to the classical portal occlusion techniques (EPP and LPI).</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conflict of Interest</span><p id="par0060" class="elsevierStylePara elsevierViewall">The authors declare that there is no conflict of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:9 [ 0 => array:2 [ "identificador" => "xres314972" "titulo" => "Abstract" ] 1 => array:2 [ "identificador" => "xpalclavsec297713" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres314973" "titulo" => "Resumen" ] 3 => array:2 [ "identificador" => "xpalclavsec297712" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Clinical Case and Surgical Technique" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "First Surgical Intervention" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Postoperative Volumetrics and Secondary Intervention" ] ] ] 6 => array:2 [ "identificador" => "sec0025" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0030" "titulo" => "Conflict of Interest" ] 8 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2013-08-27" "fechaAceptado" => "2013-09-13" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec297713" "palabras" => array:5 [ 0 => "Two-stage liver resections" 1 => "Liver tumours" 2 => "Recurrent hypernephroma" 3 => "Right trisectionectomy" 4 => "Inferior vena cava resection" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec297712" "palabras" => array:5 [ 0 => "Resecciones hepáticas en 2 tiempos" 1 => "Tumores hepáticos" 2 => "Recidiva de hipernefroma" 3 => "Trisectorectomía derecha" 4 => "Resección de vena cava inferior" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">ALPPS (associating liver partition and portal vein ligation for staged hepatectomy), in 2-stage liver resections, achieves hypertrophy of the functional liver remnant (FLR) in 7 days, and the objective of this technique is the occlusion of the intrahepatic collaterals. In March 2012 we published a new surgical technique associating the insertion of a tourniquet in Cantlie line and right portal vein ligation (ALTPS: associating liver tourniquet and right portal vein occlusion for staged hepatectomy). In this paper we present this ALTPS technique placing the tourniquet in the umbilical fissure to obtain hypertrophy of segments II–III. It was performed in a 51-year-old patient with a recurrent right renal hypernephroma which involved all the anatomic right lobe and inferior vena cava. Preoperative FLR was 380<span class="elsevierStyleHsp" style=""></span>ml (20% of the total volume) increasing 150% at 7 days (to 953<span class="elsevierStyleHsp" style=""></span>ml, 31% of the total). In the second step, we performed a right trisectionectomy and retrohepatic inferior vena cava resection, replacing it by a 2-cm-ring goretex graft.</p>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Associating liver partition and portal vein ligation for staged</span> (ALPPS) para las resecciones hepáticas en 2 tiempos, consigue la hipertrofia del volumen funcional residual (VFR) en 7 días, al ocluir las colaterales intrahepáticas entre ambos lóbulos. En marzo de 2012 publicamos una nueva técnica quirúrgica, asociando la colocación de un torniquete en la línea de Cantlie con ligadura portal derecha (<span class="elsevierStyleItalic">Associating liver tourniquet and right portal vein occlusion for staging hepatectomy</span> [ALTPS]). Ahora presentamos la técnica ALTPS en la cisura umbilical para hipertrofiar los segmentos <span class="elsevierStyleSmallCaps">II–III</span>, realizada en un varón de 51 años con recidiva de hipernefroma renal derecho que invade todo el lóbulo derecho y la vena cava inferior. El VFR preoperatorio fue de 380<span class="elsevierStyleHsp" style=""></span>ml (20% del total) y aumentó un 150% a los 7 días (a 953<span class="elsevierStyleHsp" style=""></span>ml; 31% del total). En el segundo tiempo se realizó trisectorectomía derecha con resección de la vena cava inferior retrohepática, siendo sustituida por un injerto de goretex anillado de 2<span class="elsevierStyleHsp" style=""></span>cm de diámetro.</p>" ] ] "NotaPie" => array:2 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Robles Campos R, Parrilla Paricio P, López Conesa A, Brusadín R, López López V, Jimeno Griñó P, et al. Una nueva técnica quirúrgica para la hepatectomía derecha extendida: torniquete en la cisura umbilical y oclusión portal derecha (ALTPS). Caso clínico. Cir Esp. 2013;91:633–637.</p>" ] 1 => array:2 [ "etiqueta" => "☆☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Communication presented as a video at the European-African Hepato Pancreato Biliary Association Congress in Belgrade, from 28th May to 1st June 2013.</p>" ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 957 "Ancho" => 1300 "Tamanyo" => 230627 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Preoperative computed tomography showing the large tumour invading the anatomic right lobe, segment I and the inferior vena cava (4 images), with only segments II–III remaining free (20% residual volume).</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 675 "Ancho" => 950 "Tamanyo" => 134038 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Control computed tomography at day seven showing the tourniquet marker with no collateral circulation, the corresponding blood vessels and hypertrophy obtained (150% volume increase).</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 577 "Ancho" => 995 "Tamanyo" => 184564 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Intraoperative image of the second-stage intervention where the tourniquet groove to the right of the umbilical fissure is observed.</p>" ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Fig. 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 691 "Ancho" => 995 "Tamanyo" => 99199 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Control computed tomography 20 months after surgery where the hypertrophied left lateral sector is observed, the permeable Gore-tex graft and the absence of tumour recurrence.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:25 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Preoperative portal embolization to increase safety of major hepatectomy for hilar bile duct carcinoma: a preliminary report" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "M. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 4 | 0 | 4 |
| 2024 October | 17 | 6 | 23 |
| 2024 September | 29 | 3 | 32 |
| 2024 August | 37 | 1 | 38 |
| 2024 July | 29 | 6 | 35 |
| 2024 June | 18 | 6 | 24 |
| 2024 May | 21 | 10 | 31 |
| 2024 April | 19 | 7 | 26 |
| 2024 March | 33 | 2 | 35 |
| 2024 February | 20 | 5 | 25 |
| 2024 January | 27 | 2 | 29 |
| 2023 December | 31 | 8 | 39 |
| 2023 November | 21 | 3 | 24 |
| 2023 October | 37 | 5 | 42 |
| 2023 September | 34 | 4 | 38 |
| 2023 August | 25 | 1 | 26 |
| 2023 July | 31 | 4 | 35 |
| 2023 June | 37 | 4 | 41 |
| 2023 May | 88 | 4 | 92 |
| 2023 April | 64 | 7 | 71 |
| 2023 March | 80 | 9 | 89 |
| 2023 February | 40 | 4 | 44 |
| 2023 January | 72 | 8 | 80 |
| 2022 December | 60 | 3 | 63 |
| 2022 November | 83 | 6 | 89 |
| 2022 October | 43 | 9 | 52 |
| 2022 September | 55 | 7 | 62 |
| 2022 August | 53 | 7 | 60 |
| 2022 July | 33 | 9 | 42 |
| 2022 June | 29 | 7 | 36 |
| 2022 May | 33 | 8 | 41 |
| 2022 April | 31 | 9 | 40 |
| 2022 March | 53 | 14 | 67 |
| 2022 February | 54 | 10 | 64 |
| 2022 January | 99 | 10 | 109 |
| 2021 December | 50 | 7 | 57 |
| 2021 November | 52 | 10 | 62 |
| 2021 October | 64 | 20 | 84 |
| 2021 September | 48 | 17 | 65 |
| 2021 August | 49 | 8 | 57 |
| 2021 July | 36 | 19 | 55 |
| 2021 June | 48 | 6 | 54 |
| 2021 May | 64 | 16 | 80 |
| 2021 April | 143 | 33 | 176 |
| 2021 March | 93 | 16 | 109 |
| 2021 February | 62 | 9 | 71 |
| 2021 January | 65 | 12 | 77 |
| 2020 December | 61 | 6 | 67 |
| 2020 November | 56 | 6 | 62 |
| 2020 October | 35 | 3 | 38 |
| 2020 September | 38 | 11 | 49 |
| 2020 August | 33 | 9 | 42 |
| 2020 July | 41 | 9 | 50 |
| 2020 June | 34 | 6 | 40 |
| 2020 May | 41 | 13 | 54 |
| 2020 April | 30 | 7 | 37 |
| 2020 March | 36 | 6 | 42 |
| 2020 February | 36 | 8 | 44 |
| 2020 January | 39 | 11 | 50 |
| 2019 December | 61 | 12 | 73 |
| 2019 November | 32 | 16 | 48 |
| 2019 October | 34 | 6 | 40 |
| 2019 September | 29 | 12 | 41 |
| 2019 August | 20 | 3 | 23 |
| 2019 July | 21 | 14 | 35 |
| 2019 June | 33 | 26 | 59 |
| 2019 May | 80 | 31 | 111 |
| 2019 April | 46 | 36 | 82 |
| 2019 March | 13 | 6 | 19 |
| 2019 February | 19 | 14 | 33 |
| 2019 January | 19 | 5 | 24 |
| 2018 December | 11 | 2 | 13 |
| 2018 November | 29 | 10 | 39 |
| 2018 October | 22 | 10 | 32 |
| 2018 September | 26 | 5 | 31 |
| 2018 August | 4 | 4 | 8 |
| 2018 July | 6 | 0 | 6 |
| 2018 June | 11 | 3 | 14 |
| 2018 May | 11 | 2 | 13 |
| 2018 April | 11 | 2 | 13 |
| 2018 March | 6 | 0 | 6 |
| 2018 February | 9 | 2 | 11 |
| 2018 January | 11 | 7 | 18 |
| 2017 December | 5 | 0 | 5 |
| 2017 November | 11 | 5 | 16 |
| 2017 October | 11 | 5 | 16 |
| 2017 September | 12 | 1 | 13 |
| 2017 August | 15 | 3 | 18 |
| 2017 July | 14 | 0 | 14 |
| 2017 June | 24 | 7 | 31 |
| 2017 May | 19 | 1 | 20 |
| 2017 April | 16 | 2 | 18 |
| 2017 March | 17 | 6 | 23 |
| 2017 February | 24 | 5 | 29 |
| 2017 January | 31 | 6 | 37 |
| 2016 December | 29 | 7 | 36 |
| 2016 November | 37 | 7 | 44 |
| 2016 October | 54 | 13 | 67 |
| 2016 September | 73 | 15 | 88 |
| 2016 August | 39 | 10 | 49 |
| 2016 July | 31 | 5 | 36 |
| 2016 June | 42 | 16 | 58 |
| 2016 May | 41 | 17 | 58 |
| 2016 April | 44 | 15 | 59 |
| 2016 March | 36 | 22 | 58 |
| 2016 February | 28 | 9 | 37 |
| 2016 January | 22 | 15 | 37 |
| 2015 December | 31 | 10 | 41 |
| 2015 November | 19 | 8 | 27 |
| 2015 October | 33 | 11 | 44 |
| 2015 September | 39 | 10 | 49 |
| 2015 August | 54 | 14 | 68 |
| 2015 July | 41 | 11 | 52 |
| 2015 June | 27 | 3 | 30 |
| 2015 May | 31 | 10 | 41 |
| 2015 April | 29 | 18 | 47 |
| 2015 March | 23 | 8 | 31 |
| 2015 February | 19 | 8 | 27 |
| 2015 January | 24 | 4 | 28 |
| 2014 December | 54 | 15 | 69 |
| 2014 November | 28 | 8 | 36 |
| 2014 October | 37 | 8 | 45 |
| 2014 September | 27 | 12 | 39 |
| 2014 August | 29 | 6 | 35 |
| 2014 July | 25 | 16 | 41 |
| 2014 June | 15 | 10 | 25 |
| 2014 May | 19 | 7 | 26 |
| 2014 April | 22 | 13 | 35 |
| 2014 March | 18 | 12 | 30 |
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