Scientific letter
Chylous Fistula Following Axillary Lymphadenectomy
Fístula quilosa poslinfadenectomía axilar
Erene V. Flores
, Gonzalo de Castro, Enrique Casal, Constantino Sobrino
Corresponding author
Unidad de Senología y Patología Mamaria, Servicio de Cirugía General y del Aparato Digestivo, Hospital Xeral–Cíes, Complejo Hospitalario Universitario de Vigo, Vigo, Spain
Read
4643
Timeswas read the article
967
Total PDF
3676
Total HTML
Share statistics
array:24 [ "pii" => "S2173507714000349" "issn" => "21735077" "doi" => "10.1016/j.cireng.2012.09.003" "estado" => "S300" "fechaPublicacion" => "2014-01-01" "aid" => "988" "copyright" => "AEC" "copyrightAnyo" => "2012" "documento" => "simple-article" "crossmark" => 0 "subdocumento" => "cor" "cita" => "Cir Esp. 2014;92:55-6" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 2374 "formatos" => array:3 [ "EPUB" => 11 "HTML" => 1821 "PDF" => 542 ] ] "Traduccion" => array:1 [ "es" => array:19 [ "pii" => "S0009739X12003508" "issn" => "0009739X" "doi" => "10.1016/j.ciresp.2012.09.004" "estado" => "S300" "fechaPublicacion" => "2014-01-01" "aid" => "988" "copyright" => "AEC" "documento" => "simple-article" "crossmark" => 0 "subdocumento" => "cor" "cita" => "Cir Esp. 2014;92:55-6" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 4497 "formatos" => array:3 [ "EPUB" => 10 "HTML" => 3202 "PDF" => 1285 ] ] "es" => array:11 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Carta científica</span>" "titulo" => "Fístula quilosa poslinfadenectomía axilar" "tienePdf" => "es" "tieneTextoCompleto" => "es" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "55" "paginaFinal" => "56" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Chylous fistula following axillary lymphadenectomy" ] ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figura 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1165 "Ancho" => 900 "Tamanyo" => 104937 ] ] "descripcion" => array:1 [ "es" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Aspecto lactescente del líquido acumulado en el dispositivo del drenaje axilar.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Erene V. Flores, Gonzalo de Castro, Enrique Casal, Constantino Sobrino" "autores" => array:4 [ 0 => array:2 [ "nombre" => "Erene V." "apellidos" => "Flores" ] 1 => array:2 [ "nombre" => "Gonzalo" "apellidos" => "de Castro" ] 2 => array:2 [ "nombre" => "Enrique" "apellidos" => "Casal" ] 3 => array:2 [ "nombre" => "Constantino" "apellidos" => "Sobrino" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2173507714000349" "doi" => "10.1016/j.cireng.2012.09.003" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173507714000349?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0009739X12003508?idApp=UINPBA00004N" "url" => "/0009739X/0000009200000001/v1_201401150203/S0009739X12003508/v1_201401150203/es/main.assets" ] ] "itemSiguiente" => array:19 [ "pii" => "S2173507714000337" "issn" => "21735077" "doi" => "10.1016/j.cireng.2012.05.008" "estado" => "S300" "fechaPublicacion" => "2014-01-01" "aid" => "948" "copyright" => "AEC" "documento" => "simple-article" "crossmark" => 0 "subdocumento" => "cor" "cita" => "Cir Esp. 2014;92:57-8" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 3758 "formatos" => array:3 [ "EPUB" => 12 "HTML" => 2625 "PDF" => 1121 ] ] "en" => array:11 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Scientific letter</span>" "titulo" => "The Use of Glue in Hernia Surgery. Combined Fixation Technique in Laparoscopic Hernia Repair" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "57" "paginaFinal" => "58" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Sobre el uso de pegamento en la cirugía de las hernias. Técnica de fijación combinada en la eventroplastia laparoscópica" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 583 "Ancho" => 801 "Tamanyo" => 104401 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Initial mechanical fixation (Secure strap<span class="elsevierStyleSup">®</span>) to ensure contact of the mesh with the posterior abdominal wall.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Alfredo Moreno-Egea" "autores" => array:1 [ 0 => array:2 [ "nombre" => "Alfredo" "apellidos" => "Moreno-Egea" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0009739X12002631" "doi" => "10.1016/j.ciresp.2012.05.024" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0009739X12002631?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173507714000337?idApp=UINPBA00004N" "url" => "/21735077/0000009200000001/v1_201403010158/S2173507714000337/v1_201403010158/en/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S2173507714000350" "issn" => "21735077" "doi" => "10.1016/j.cireng.2013.02.006" "estado" => "S300" "fechaPublicacion" => "2014-01-01" "aid" => "1064" "copyright" => "AEC" "documento" => "simple-article" "crossmark" => 0 "subdocumento" => "cor" "cita" => "Cir Esp. 2014;92:53-4" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 2223 "formatos" => array:3 [ "EPUB" => 14 "HTML" => 1808 "PDF" => 401 ] ] "en" => array:11 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Scientific letter</span>" "titulo" => "Urgent Liver Transplantation After Complete Resection of Hepatic Pedicle During Laparoscopic Cholecystectomy" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "53" "paginaFinal" => "54" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Trasplante hepático urgente tras resección completa del pedículo hepático durante una colecistectomía laparoscópica" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 623 "Ancho" => 901 "Tamanyo" => 105053 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">CT scan showing widespread hepatic hypoperfusion, several hemoclips and gas in the portal vein.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Anna Muñoz, Gerardo Rodriguez, Jaume Torras, Lluís Secanella, Joan Fabregat" "autores" => array:5 [ 0 => array:2 [ "nombre" => "Anna" "apellidos" => "Muñoz" ] 1 => array:2 [ "nombre" => "Gerardo" "apellidos" => "Rodriguez" ] 2 => array:2 [ "nombre" => "Jaume" "apellidos" => "Torras" ] 3 => array:2 [ "nombre" => "Lluís" "apellidos" => "Secanella" ] 4 => array:2 [ "nombre" => "Joan" "apellidos" => "Fabregat" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0009739X13001371" "doi" => "10.1016/j.ciresp.2013.02.006" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0009739X13001371?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173507714000350?idApp=UINPBA00004N" "url" => "/21735077/0000009200000001/v1_201403010158/S2173507714000350/v1_201403010158/en/main.assets" ] "en" => array:14 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Scientific letter</span>" "titulo" => "Chylous Fistula Following Axillary Lymphadenectomy" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "55" "paginaFinal" => "56" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Erene V. Flores, Gonzalo de Castro, Enrique Casal, Constantino Sobrino" "autores" => array:4 [ 0 => array:4 [ "nombre" => "Erene V." "apellidos" => "Flores" "email" => array:1 [ 0 => "rne227@yahoo.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Gonzalo" "apellidos" => "de Castro" ] 2 => array:2 [ "nombre" => "Enrique" "apellidos" => "Casal" ] 3 => array:2 [ "nombre" => "Constantino" "apellidos" => "Sobrino" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Unidad de Senología y Patología Mamaria, Servicio de Cirugía General y del Aparato Digestivo, Hospital Xeral–Cíes, Complejo Hospitalario Universitario de Vigo, Vigo, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Fístula quilosa poslinfadenectomía axilar" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1165 "Ancho" => 900 "Tamanyo" => 114316 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Lactescent appearance of the liquid accumulated in the axillary drain device.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Axillary lymph node dissection is one of the pillars of locoregional breast cancer treatment. Its possible complications include seroma, lymphorrhea, lymphocele, chronic lymphedema and sensory alterations on the underside of the arm.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Chylous fistula is a complication that presents in thoracic, abdominal and neck surgery, but it is rare in axillary clearance. These complications can delay the start of adjuvant therapy. We present a case report of a chylous fistula after axillary lymphadenectomy due to breast cancer. We also performed a search of the literature related to the clinical presentation and treatment of this entity.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The patient is a 55-year-old woman with a history of iodine allergy, hypertension, type II diabetes mellitus and liver transplantation due to cirrhosis of the liver 10 years earlier. A tumor in the upper half of the left breast and hemorrhage through an orifice in the nipple had been detected.</p><p id="par0015" class="elsevierStylePara elsevierViewall">A mammogram showed small breast asymmetry with increased density of the left breast at the level of the upper outer quadrant, which had multiple fatty areas and was not accompanied by distortion of the tracts or clustered microcalcifications. Ultrasound detected no clear alterations. Magnetic resonance imaging revealed findings consistent with a malignant lesion affecting the upper quadrants of the left breast (probably lobular carcinoma) and axillary lymphadenopathies of a pathological size. Core needle biopsy (CNB) of the left breast was positive for grade II infiltrating ductal carcinoma and ductal carcinoma <span class="elsevierStyleItalic">in situ</span> without vascular invasion. Immunohistochemical study revealed estrogen receptor (−), progesterone receptor (−), Ki67: 65% and 45 Her2/neu (c-erbB2): 1+. The extension study was completed with thoracic computed tomography (CT) and bone scan, which showed no metastasis. The case was submitted to the Committee on Breast Cancer, at which time it was decided to perform surgery with adjuvant treatment. The left mastectomy technique described by Madden was used with left axillary lymph node dissection of levels I and II. The pathology study revealed: multicentric infiltrating ductal carcinoma, Nottingham grade 3 (T2, P3, M3), with an approximate size of 10<span class="elsevierStyleHsp" style=""></span>cm×10<span class="elsevierStyleHsp" style=""></span>cm; high-grade intraductal carcinoma with intratumoral comedo-necrosis; neoplastic infiltration in 6 of the 12 isolated lymph nodes; lymphovascular invasion; pathological stage pT3 pN2a. Surgical resection margins were free of neoplastic involvement. Immunohistochemical study showed estrogen receptor (−), progesterone receptor (−) Her 2neu 45 (−) and Ki67: 24%.</p><p id="par0020" class="elsevierStylePara elsevierViewall">On the second day of the postoperative period, the discharge through the axillary drain was 230<span class="elsevierStyleHsp" style=""></span>mL, and from the fifth day its characteristics were suggestive of chylous effusion (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The analysis of the extracted liquid showed that it contained 2751<span class="elsevierStyleHsp" style=""></span>mg/dL of triglycerides. After initiating a fat-free diet, it was possible to reduce the discharge to 90<span class="elsevierStyleHsp" style=""></span>mL/day and modify the characteristics of the liquid, which allowed us to withdraw the drain 20 days post-op and discharge the patient (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). At the 3-month follow-up office visit, no seroma or other complications were observed, and the patient was able to start adjuvant treatment with radiotherapy and chemotherapy.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Chylous fistula is a rare complication of axillary lymph node dissection, with some 10 cases having been described in the literature.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3</span></a> It can be caused by injury to the aberrant lymphatic vessels associated with the thoracic duct. Anatomical studies have demonstrated that in over 30% of cases the thoracic duct divides into branches and up to 4% empty into the venous system through these multiple branches<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a>; in these cases, 1% empty into the higher and medial portions of the axillary vein. These anatomical variations make the problem more prevalent in lymph node dissection on the left side. Usually, lymphadenectomy is performed outside the area where the thoracic duct and the venous system connect.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Diagnosis is made by the presence of suspiciously high discharge through the postoperative axillary drains (more than 500<span class="elsevierStyleHsp" style=""></span>mL/day) or with the presentation of a thick lactescent effusion. It is confirmed by triglyceride content (>110<span class="elsevierStyleHsp" style=""></span>mg/dL) and/or a high percentage of chylomicrons. It is estimated that triglyceride levels above 110<span class="elsevierStyleHsp" style=""></span>mg/dL are diagnostic of chylous fistula, while values between 50 and 110<span class="elsevierStyleHsp" style=""></span>mg/dL require determination of chylomicrons to confirm the diagnosis.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> As complementary diagnostic tests, lymphoscintigraphy and lymphography are recommended, which are used to assess the injury to the thoracic duct.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">During axillary lymph node dissection, especially on the left side, care should be taken not to injure the lymphatic ducts in the deepest part of the axillary space. However, if the chylous fistula is found during surgery, these should be ligated. If it occurs in the immediate postoperative period, treatment should be conservative.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,7,8</span></a> When the liquid through the drain tube acquires a chylous appearance after the start of food intake, it is recommended to establish a fat-free diet and, for the most persistent cases, peripheral or enteral nutrition is recommended with medium-chain media triglycerides.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> The use of digestive secretion inhibitors (somatostatin, octreotide) may also be considered as they are applied in the treatment of chylothorax.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> Surgery should only be considered in exceptional cases in order to ligate the vessels causing the effusion.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Flores EV, de Castro G, Casal E, Sobrino C. Fístula quilosa poslinfadenectomía axilar. Cir Esp. 2014;94:55–56.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1165 "Ancho" => 900 "Tamanyo" => 114316 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Lactescent appearance of the liquid accumulated in the axillary drain device.</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" => 851 "Ancho" => 1571 "Tamanyo" => 92956 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Chart showing the evolution of the discharge and characteristics of the axillary drain liquid.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Morbidity associated with axillary surgery for breast cancer" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "K. Taylor" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1445-1433.2004.02992.x" "Revista" => array:6 [ "tituloSerie" => "ANZ J Surg" "fecha" => "2004" "volumen" => "74" "paginaInicial" => "314" "paginaFinal" => "317" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15144248" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Variations in the terminal portion of the human thoracic duct" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "M.I. Gottlieb" 1 => "J. Greenfield" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "AMA Arch Surg" "fecha" => "1956" "volumen" => "73" "paginaInicial" => "955" "paginaFinal" => "959" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/13372020" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Fístula quilosa postlinfadenectomía axilar" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "A. Piñero" 1 => "P. Galindo" 2 => "J. Illana" 3 => "P. Parrilla" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Rev Senología Patol Mam" "fecha" => "2007" "volumen" => "20" "paginaInicial" => "29" "paginaFinal" => "32" ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Lumphoscintigraphic demonstration of chylous leak after axillary lymph node dissection" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "A. Abdelrazeq" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Clin Nucl Med" "fecha" => "2005" "volumen" => "30" "paginaInicial" => "299" "paginaFinal" => "301" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15827395" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Four cases of chylous fistula after breast cancer resection" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "E. Nakajima" 1 => "H. Iwata" 2 => "T. Iwase" 3 => "H. Murai" 4 => "M. Mituhiro" 5 => "S. Miura" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1023/B:BREA.0000010675.87358.b6" "Revista" => array:6 [ "tituloSerie" => "Breast Cancer Res Treat" "fecha" => "2004" "volumen" => "83" "paginaInicial" => "11" "paginaFinal" => "14" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/14997050" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0030" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Fistula after neck dissection for an unusual breast cancer recurrence" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "A. Harlak" 1 => "S. Karahatay" 2 => "O. Onguru" 3 => "O. Mentes" 4 => "M. Gerek" 5 => "T. Chyle" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1159/000144491" "Revista" => array:6 [ "tituloSerie" => "Breast Care" "fecha" => "2008" "volumen" => "3" "paginaInicial" => "274" "paginaFinal" => "276" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21076608" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0035" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Six cases of chylous leakage after axillary lymph node dissection" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "M. Cong" 1 => "Q. Liu" 2 => "W. Zhou" 3 => "J. Zhu" 4 => "C. Song" 5 => "X. Tian" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1159/000131218" "Revista" => array:6 [ "tituloSerie" => "Onkologie" "fecha" => "2008" "volumen" => "31" "paginaInicial" => "321" "paginaFinal" => "324" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18547973" "web" => "Medline" ] ] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0040" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A rare complication in breast cancer surgery: chylous fistula and its treatment" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "G. Sakman" 1 => "C. Parsak" 2 => "O. Demircan" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Acta Chir Belg" "fecha" => "2007" "volumen" => "107" "paginaInicial" => "317" "paginaFinal" => "319" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17685261" "web" => "Medline" ] ] ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0045" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Chyle fistulae: treatment with total parenteral nutrition" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "M. Younus" 1 => "R. Chang" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "J Laryngol Otol" "fecha" => "1988" "volumen" => "102" "paginaInicial" => "384" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/3133438" "web" => "Medline" ] ] ] ] ] ] ] ] 9 => array:3 [ "identificador" => "bib0050" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Octreotide for conservative management of postoperative chylotorax" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "A. Gómez-Caro" 1 => "C. Marrón" 2 => "F. Moradiellos" 3 => "V. Díaz-Hellín" 4 => "J. Pérez" 5 => "J.L. Martín de Nicolás" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Arch Broconeumol" "fecha" => "2004" "volumen" => "40" "paginaInicial" => "473" "paginaFinal" => "475" ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/21735077/0000009200000001/v1_201403010158/S2173507714000349/v1_201403010158/en/main.assets" "Apartado" => array:4 [ "identificador" => "15076" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Scientific letters" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/21735077/0000009200000001/v1_201403010158/S2173507714000349/v1_201403010158/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173507714000349?idApp=UINPBA00004N" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 October | 17 | 2 | 19 |
| 2024 September | 48 | 17 | 65 |
| 2024 August | 34 | 8 | 42 |
| 2024 July | 24 | 3 | 27 |
| 2024 June | 20 | 1 | 21 |
| 2024 May | 26 | 4 | 30 |
| 2024 April | 27 | 4 | 31 |
| 2024 March | 31 | 4 | 35 |
| 2024 February | 44 | 7 | 51 |
| 2024 January | 24 | 1 | 25 |
| 2023 December | 39 | 2 | 41 |
| 2023 November | 22 | 3 | 25 |
| 2023 October | 20 | 2 | 22 |
| 2023 September | 16 | 1 | 17 |
| 2023 August | 31 | 0 | 31 |
| 2023 July | 23 | 5 | 28 |
| 2023 June | 48 | 6 | 54 |
| 2023 May | 62 | 1 | 63 |
| 2023 April | 64 | 4 | 68 |
| 2023 March | 45 | 5 | 50 |
| 2023 February | 48 | 8 | 56 |
| 2023 January | 51 | 14 | 65 |
| 2022 December | 43 | 5 | 48 |
| 2022 November | 42 | 20 | 62 |
| 2022 October | 39 | 14 | 53 |
| 2022 September | 36 | 5 | 41 |
| 2022 August | 39 | 18 | 57 |
| 2022 July | 24 | 14 | 38 |
| 2022 June | 21 | 18 | 39 |
| 2022 May | 25 | 11 | 36 |
| 2022 April | 27 | 7 | 34 |
| 2022 March | 50 | 13 | 63 |
| 2022 February | 32 | 8 | 40 |
| 2022 January | 75 | 6 | 81 |
| 2021 December | 25 | 20 | 45 |
| 2021 November | 30 | 5 | 35 |
| 2021 October | 29 | 7 | 36 |
| 2021 September | 34 | 11 | 45 |
| 2021 August | 42 | 6 | 48 |
| 2021 July | 29 | 8 | 37 |
| 2021 June | 13 | 12 | 25 |
| 2021 May | 27 | 10 | 37 |
| 2021 April | 55 | 8 | 63 |
| 2021 March | 29 | 6 | 35 |
| 2021 February | 35 | 3 | 38 |
| 2021 January | 30 | 11 | 41 |
| 2020 December | 28 | 9 | 37 |
| 2020 November | 33 | 6 | 39 |
| 2020 October | 30 | 8 | 38 |
| 2020 September | 30 | 9 | 39 |
| 2020 August | 22 | 11 | 33 |
| 2020 July | 16 | 7 | 23 |
| 2020 June | 26 | 13 | 39 |
| 2020 May | 25 | 8 | 33 |
| 2020 April | 24 | 2 | 26 |
| 2020 March | 22 | 2 | 24 |
| 2020 February | 17 | 3 | 20 |
| 2020 January | 20 | 4 | 24 |
| 2019 December | 39 | 5 | 44 |
| 2019 November | 14 | 6 | 20 |
| 2019 October | 20 | 6 | 26 |
| 2019 September | 20 | 4 | 24 |
| 2019 August | 16 | 3 | 19 |
| 2019 July | 19 | 19 | 38 |
| 2019 June | 49 | 28 | 77 |
| 2019 May | 146 | 55 | 201 |
| 2019 April | 66 | 29 | 95 |
| 2019 March | 9 | 11 | 20 |
| 2019 February | 14 | 5 | 19 |
| 2019 January | 12 | 3 | 15 |
| 2018 December | 15 | 6 | 21 |
| 2018 November | 14 | 4 | 18 |
| 2018 October | 12 | 4 | 16 |
| 2018 September | 15 | 6 | 21 |
| 2018 August | 13 | 6 | 19 |
| 2018 July | 19 | 9 | 28 |
| 2018 June | 15 | 1 | 16 |
| 2018 May | 12 | 2 | 14 |
| 2018 April | 19 | 1 | 20 |
| 2018 March | 10 | 0 | 10 |
| 2018 February | 11 | 0 | 11 |
| 2018 January | 13 | 1 | 14 |
| 2017 December | 8 | 0 | 8 |
| 2017 November | 18 | 3 | 21 |
| 2017 October | 13 | 5 | 18 |
| 2017 September | 10 | 3 | 13 |
| 2017 August | 26 | 4 | 30 |
| 2017 July | 13 | 2 | 15 |
| 2017 June | 18 | 3 | 21 |
| 2017 May | 53 | 4 | 57 |
| 2017 April | 20 | 3 | 23 |
| 2017 March | 27 | 13 | 40 |
| 2017 February | 53 | 5 | 58 |
| 2017 January | 30 | 0 | 30 |
| 2016 December | 29 | 6 | 35 |
| 2016 November | 38 | 4 | 42 |
| 2016 October | 84 | 1 | 85 |
| 2016 September | 75 | 5 | 80 |
| 2016 August | 48 | 4 | 52 |
| 2016 July | 17 | 3 | 20 |
| 2016 June | 38 | 9 | 47 |
| 2016 May | 36 | 17 | 53 |
| 2016 April | 33 | 17 | 50 |
| 2016 March | 32 | 31 | 63 |
| 2016 February | 19 | 22 | 41 |
| 2016 January | 13 | 26 | 39 |
| 2015 December | 14 | 15 | 29 |
| 2015 November | 16 | 20 | 36 |
| 2015 October | 29 | 11 | 40 |
| 2015 September | 25 | 8 | 33 |
| 2015 August | 33 | 9 | 42 |
| 2015 July | 35 | 5 | 40 |
| 2015 June | 17 | 1 | 18 |
| 2015 May | 14 | 1 | 15 |
| 2015 April | 14 | 3 | 17 |
| 2015 March | 18 | 5 | 23 |
| 2015 February | 16 | 1 | 17 |
| 2015 January | 28 | 6 | 34 |
| 2014 December | 37 | 12 | 49 |
| 2014 November | 23 | 5 | 28 |
| 2014 October | 22 | 2 | 24 |
| 2014 September | 27 | 5 | 32 |
| 2014 August | 20 | 4 | 24 |
| 2014 July | 18 | 5 | 23 |
| 2014 June | 14 | 3 | 17 |
| 2014 May | 11 | 4 | 15 |
| 2014 April | 14 | 8 | 22 |
Show all
