Innovation in surgical technique
Robotic Approach for Collis Gastroplasty
Gastroplastia de Collis robótica
Laura Vidal Piñeiro
, Beniamino Pascotto, Juan Santiago Azagra Soria
Corresponding author
Departamento de Cirugía General y Visceral, Centro Hospitalario de Luxemburgo, Luxembourg, Luxembourg
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Visceral, Centro Hospitalario de Luxemburgo, Luxembourg, Luxembourg" "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" => "Gastroplastia de Collis robótica" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 755 "Ancho" => 755 "Tamanyo" => 68666 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Thoracoabdominal CT that evidences hiatal hernia.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The true short esophagus is an intraoperative diagnosis defined as an intraabdominal esophageal portion, without tension, less than 2–3<span class="elsevierStyleHsp" style=""></span>cm between the gastroesophageal junction and the diaphragmatic hiatus after an extensive mediastinal dissection of 7–10<span class="elsevierStyleHsp" style=""></span>cm.<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">1–3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The incidence between 3% and 20% of true short esophagus have been described in patients undergoing antireflux surgery.<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">1,4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Failure to perform a correct mediastinal dissection that allows evaluation of the real intraabdominal esophageal portion may entail an overdiagnosis of the true short esophagus. An insufficient dissection can also lead to an increase in the recurrence of hiatal hernia after surgical treatment, caused by migration of fundoplication to the mediastinum.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">1</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The treatment of hiatal hernia associated to a true short esophagus is still a matter of controversy among surgeons.<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">5–7</span></a> Although Bellevue et al.<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">8</span></a> did not find, in a case-control study, efficacy differences between patients treated with Hill's esophagopexy combined with Nissen fundoplication and patients treated with Collis gastroplasty associated with an antireflux technique; most of the current publications support Collis gastroplasty associated with an antireflux technique (Nissen, Toupet...) as the treatment for symptomatic hiatal hernia.<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">1–3,5,9</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Currently, there are multiple publications on laparoscopic treatment of true short esophagus, but there are no publications on the robotic approach. Our team in Center Hospitaliere of Luxembourg, which has an extensive experience in the field of minimally invasive surgery, wants to provide a case of management and treatment of true short esophagus with a robotic approach of a classic technique. Robotic surgery allows accuracy and safety in this specific technique.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case Report</span><p id="par0030" class="elsevierStylePara elsevierViewall">We present a 65 year old patient diagnosed with a symptomatic hiatal hernia of 2 years of evolution. Despite conservative treatment, postural and dietary recommendations, and the use of proton pump inhibitors (PPI), the patient presents worsening of gastroesophageal reflux symptoms. The radiological control shows a 4<span class="elsevierStyleHsp" style=""></span>cm increase in the size of the hiatal hernia (from 2 to 6<span class="elsevierStyleHsp" style=""></span>cm) (<a class="elsevierStyleCrossRefs" href="#fig0005">Figs. 1–3</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">Endoscopy is performed, as a preoperative test, reporting an important gastritis and esophagitis but absence of Barrett's esophagus and neoplasia. With the diagnostic of symptomatic hiatal hernia as well as a suspected diagnostic of short esophagus surgical treatment is indicated.</p><p id="par0040" class="elsevierStylePara elsevierViewall">With a robotic approach the reduction of the hiatal hernia and mediastinal dissection is performed and the diagnostic of true short esophagus is obtained. A Collis gastroplasty and a Toupet fundoplication are performed</p><p id="par0045" class="elsevierStylePara elsevierViewall">In the absence of perioperative complications the patient is discharged 48<span class="elsevierStyleHsp" style=""></span>h after the intervention, with complete oral tolerance and completely asymptomatic.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Surgical Technique</span><p id="par0050" class="elsevierStylePara elsevierViewall">After a year of experience in robotic surgery, with numerous interventions in bariatric surgery, colorectal surgery, pancreatic surgery, esophageal surgery and gastric surgery our team wants to add as a part of the learning curve a case of diaphragmatic hernia.</p><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Placement</span><p id="par0055" class="elsevierStylePara elsevierViewall">After the induction, the patient is placed in reverse Trendelenburg (30°), legs in abduction, and flexion (15°), as well as arms in complete adduction.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Five trocars are necessary, which are placed after the creation of a pneumoperitoneum with Veress needle, inserted in the upper left quadrant of the abdomen.</p><p id="par0065" class="elsevierStylePara elsevierViewall">Following the scheme in <a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>, an 8<span class="elsevierStyleHsp" style=""></span>mm trocar is placed for the 30° camera in the supraumblical midline (20<span class="elsevierStyleHsp" style=""></span>cm from the xiphoid). From right to left of the patient and under direct vision; a 5<span class="elsevierStyleHsp" style=""></span>mm trocar is placed at the level of the right subcostal anterior axillary line for the liver retractor that will remain fixed throughout the surgery, a 8<span class="elsevierStyleHsp" style=""></span>mm trocar in the right middle clavicular line for the bipolar forceps, a 12<span class="elsevierStyleHsp" style=""></span>mm trocar in the left clavicular middle line for the stapler and the scissors, and finally an 8<span class="elsevierStyleHsp" style=""></span>mm trocar at the left anterior axillary line for the forceps.</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">The robot will be placed at the left of the patient.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Dissection</span><p id="par0075" class="elsevierStylePara elsevierViewall">The fixed hepatic retractor allows us to see the diaphragmatic hiatus, without having to use one of the arms of the robot and without requiring laparoscopic assistance.</p><p id="par0080" class="elsevierStylePara elsevierViewall">Dissection begins, using bipolar and scissors, at the right pillar of the esophageal hiatus, it is necessary to locate the vena cava and the branches of the vagus nerve. One of the arms of the robot, the 3rd or 4th, performs caudal traction of the stomach exposing the hernial sac. The dissection will follow an anterolateral direction until a complete exposure of His angle and gastric fundus is obtained. Carefully lysis of possible spleen adhesions is important in order to avoid bleeding that may interfere with the dissection. The 360° dissection is finished with the posterior part, being the most difficult one due to the difficulty of exposure, and the proximity of the aorta.</p><p id="par0085" class="elsevierStylePara elsevierViewall">Once the entire esophageal circumference is dissected a loop is placed allowing uniform caudal traction. The dissection continues cranial 3–4<span class="elsevierStyleHsp" style=""></span>cm, Type I dissection,<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">1</span></a> toward the mediastinum. If a 2<span class="elsevierStyleHsp" style=""></span>cm portion of tension-free intra-abdominal esophagus is not obtained, as in the case described, we continue dissecting the mediastinum up to 7–10<span class="elsevierStyleHsp" style=""></span>cm, type II dissection. If, as in the case presented, despite this dissection, the tension-free intra-abdominal esophageal portion is still less than 2<span class="elsevierStyleHsp" style=""></span>cm, a diagnostic of true short esophagus is achieved.</p><p id="par0090" class="elsevierStylePara elsevierViewall">In some centers, intraoperative endoscopy is performed to determine the exact location of the gastroesophageal junction (Video 1: dissection).<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">3,4,8,10</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Plasty Manufacture</span><p id="par0095" class="elsevierStylePara elsevierViewall">It is not possible to perform fundoplication without tension with short esophagus diagnostic, for this reason a Wedge-Collis gastroplasty<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">1</span></a> is performed with Toupet fundoplication as an antireflux technique.<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">11–14</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">A Wedge–Collis Gastroplasty as described for Terry et al.<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">15</span></a> is performed. The liberation of the gastric fundus and the most cranial part of the greater curvature is performed with coagulation of the gastric short vessels. The diameter of the gastric plasty is determined with a 42 Fr orogastric tube. With a linear endo-stapler, introduced by the 12<span class="elsevierStyleHsp" style=""></span>mm trocar, the stomach is sectioned. The section is performed from the greater curvature in a transverse direction an afterwards in a longitudinal direction taking into account the diameter of the orogastric tube, allowing an elongation of the esophagus of 3–4<span class="elsevierStyleHsp" style=""></span>cm.</p><p id="par0105" class="elsevierStylePara elsevierViewall">Once the gastroplasty is completed, the diaphragmatic pillars are approached from the posterior side creating a discrete angulation of the plasty, we use a nonabsorbable barbed suture (Video 2: plasty manufacture).</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Fundoplication</span><p id="par0110" class="elsevierStylePara elsevierViewall">Maintaining the orogastric tube, a Toupet fundoplication is elaborated and fixed with non absorbable barbed suture. Finally, the closure of the defect is completed with the anterior approach of the pillars.</p><p id="par0115" class="elsevierStylePara elsevierViewall">After reviewing the abdominal cavity, the surgical piece is removed, and the incisions are closed (Video 3: fundoplication).</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Discussion</span><p id="par0120" class="elsevierStylePara elsevierViewall">Taking into account that the diagnostic of the true short esophagus is intraoperative, the hiatal hernia should be treated by a team capable of modifying the surgical technique according to the findings seen during surgery.</p><p id="par0125" class="elsevierStylePara elsevierViewall">In the case presented, the surgical technique was chosen according to the recommendations of the current literature,<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">1–3,5,9</span></a> deciding to perform a Collis gastroplasty for esophageal lengthening because it is the technique that has less hiatus hernia recurrence and equal morbidity. Regarding to antireflux technique, there are no differences in efficacy between Nissen and Toupet fundoplication,<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">11,14</span></a> but Toupet has less incidence of postoperative dysphagia.<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">10–12</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">A primary approximation of the pillars without prosthetic material is chosen since there is currently no evidence that the prosthesis offers advantages involving risk of adhesions and dysphagia.<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">10,16</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">At the time, we know that the conventional laparoscopic approach, compared to the laparotomy approach, offers the same incidence of recurrence of hiatal hernia with less morbidity and less hospital stay.<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">17</span></a> Despite the rise of robotic surgery, there are no publications about robotic Collis gastroplasty. A meta-analysis done by Markar et al.<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">18</span></a> composed by 5 randomized studies that compare Nissen fundoplication with laparoscopic technique and with robotic approach do not find differences in hospital stay, dysphagia or need for reoperation.</p><p id="par0140" class="elsevierStylePara elsevierViewall">Our perception is that the robotic approach allows a more complete mediastinal dissection and a more precise suturing technique thanks to a better sense of depth offered by 3D vision, greater articulation of the robotic instruments and abolition of the tremor of the operator and the camera. Horgan et al.<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">19</span></a> suggest, after analyzing 34 surgeries performed with Da Vinci (among which there is a Nissen and a Toupet fundoplication), that there is an improvement in accuracy and safety of the surgeon with the robotic approach obtained by better eye-hand coordination, 3D vision and abolition of tremor. Further studies are necessary to rule out possible differences in efficacy between the conventional laparoscopic approach and the robotic approach.</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Funding</span><p id="par0145" class="elsevierStylePara elsevierViewall">We declare no funding for this article.</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Conflict of Interest</span><p id="par0150" class="elsevierStylePara elsevierViewall">We declare that we have no conflict of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:3 [ "identificador" => "xres1341832" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1234935" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1341831" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1234934" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Case Report" ] 6 => array:3 [ "identificador" => "sec0015" "titulo" => "Surgical Technique" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0020" "titulo" => "Placement" ] 1 => array:2 [ "identificador" => "sec0025" "titulo" => "Dissection" ] 2 => array:2 [ "identificador" => "sec0030" "titulo" => "Plasty Manufacture" ] 3 => array:2 [ "identificador" => "sec0035" "titulo" => "Fundoplication" ] ] ] 7 => array:2 [ "identificador" => "sec0040" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0045" "titulo" => "Funding" ] 9 => array:2 [ "identificador" => "sec0050" "titulo" => "Conflict of Interest" ] 10 => array:2 [ "identificador" => "xack464227" "titulo" => "Acknowledgments" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2019-06-17" "fechaAceptado" => "2019-11-28" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1234935" "palabras" => array:4 [ 0 => "Collis gastroplasty" 1 => "Robotic" 2 => "True short esophagus" 3 => "Toupet fundoplication" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1234934" "palabras" => array:4 [ 0 => "Gastroplastia de Collis" 1 => "Robótica" 2 => "Verdadero esófago corto" 3 => "Fundoplicatura de Toupet" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The true short esophagus is an entity of controversy among surgeons. Studies have been published about its diagnosis and laparoscopic treatment, without existing to date, publication of the treatment with robotic approach. We present, as a case report, our experience in robotic surgery for hiatal hernia with true short esophagus treated with Collis gastroplasty and Toupet fundoplication. Robotic surgery on the true short esophagus can facilitate mediastinal dissection and allow a more accurate suture technique. Studies are needed to compare the long-term results of this surgical technique between the conventional laparoscopic approach and the robotic approach.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">El verdadero esófago corto es una entidad que causa mucha controversia entre los cirujanos. Se han publicado estudios acerca de su diagnóstico y tratamiento laparoscópico, sin que a día de hoy existan publicaciones del tratamiento con abordaje robótico. Presentamos, en forma de caso clínico, nuestra experiencia en cirugía robótica de hernia de hiato con verdadero esófago corto tratada con gastroplastia de Collis y fundoplicatura de Toupet. La cirugía robótica en el verdadero esófago corto puede facilitar la disección mediastínica y permitir una técnica de sutura más precisa. Son necesarios estudios para comparar los resultados a largo plazo de esta técnica quirúrgica entre el abordaje laparoscópico convencional y el abordaje robótico.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Vidal Piñeiro L, Pascotto B, Azagra Soria JS. Gastroplastia de Collis robótica. Cir Esp. 2020;98:288–291.</p>" ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "<p id="par0165" class="elsevierStylePara elsevierViewall">The following are the supplementary data to this article:<elsevierMultimedia ident="upi0005"></elsevierMultimedia><elsevierMultimedia ident="upi0010"></elsevierMultimedia><elsevierMultimedia ident="upi0015"></elsevierMultimedia></p>" "etiqueta" => "Appendix A" "titulo" => "Supplementary Data" "identificador" => "sec0060" ] ] ] ] "multimedia" => array:7 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1064 "Ancho" => 755 "Tamanyo" => 130230 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Barium transit of hiatal hernia.</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" => 755 "Ancho" => 755 "Tamanyo" => 68666 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Thoracoabdominal CT that evidences hiatal hernia.</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" => 792 "Ancho" => 755 "Tamanyo" => 107769 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Thoracoabdominal CT that evidences hiatal hernia.</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" => 693 "Ancho" => 755 "Tamanyo" => 71825 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Trocars placement. LR: liver retractor. B: bipolar. 30°: 30° camera. SS: scissors/stapler. C: cadiere (forceps).</p>" ] ] 4 => array:5 [ "identificador" => "upi0005" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:3 [ "fichero" => "mmc1.mp4" "ficheroTamanyo" => 19865810 "Video" => array:2 [ "mp4" => array:5 [ "fichero" => "mmc1.m4v" "poster" => "mmc1.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] "flv" => array:5 [ "fichero" => "mmc1.flv" "poster" => "mmc1.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] ] ] ] 5 => array:5 [ "identificador" => "upi0010" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:3 [ "fichero" => "mmc2.mp4" "ficheroTamanyo" => 6647738 "Video" => array:2 [ "mp4" => array:5 [ "fichero" => "mmc2.m4v" "poster" => "mmc2.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] "flv" => array:5 [ "fichero" => "mmc2.flv" "poster" => "mmc2.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] ] ] ] 6 => array:5 [ "identificador" => "upi0015" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:3 [ "fichero" => "mmc3.mp4" "ficheroTamanyo" => 45555932 "Video" => array:2 [ "mp4" => array:5 [ "fichero" => "mmc3.m4v" "poster" => "mmc3.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] "flv" => array:5 [ "fichero" => "mmc3.flv" "poster" => "mmc3.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] ] ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:19 [ 0 => array:3 [ "identificador" => "bib0100" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The short esophagus: pathophysiology, incidence, presentation and treatment in the era of laparoscopic antireflux surgery" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "K. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 October | 11 | 14 | 25 |
| 2024 September | 42 | 12 | 54 |
| 2024 August | 44 | 24 | 68 |
| 2024 July | 22 | 7 | 29 |
| 2024 June | 26 | 5 | 31 |
| 2024 May | 22 | 11 | 33 |
| 2024 April | 35 | 6 | 41 |
| 2024 March | 56 | 2 | 58 |
| 2024 February | 47 | 2 | 49 |
| 2024 January | 46 | 1 | 47 |
| 2023 December | 50 | 4 | 54 |
| 2023 November | 40 | 7 | 47 |
| 2023 October | 52 | 2 | 54 |
| 2023 September | 24 | 0 | 24 |
| 2023 August | 13 | 1 | 14 |
| 2023 July | 27 | 0 | 27 |
| 2023 June | 18 | 1 | 19 |
| 2023 May | 21 | 4 | 25 |
| 2023 April | 13 | 1 | 14 |
| 2023 March | 7 | 2 | 9 |
| 2023 February | 13 | 7 | 20 |
| 2023 January | 24 | 2 | 26 |
| 2022 December | 28 | 8 | 36 |
| 2022 November | 22 | 10 | 32 |
| 2022 October | 20 | 6 | 26 |
| 2022 September | 22 | 9 | 31 |
| 2022 August | 17 | 15 | 32 |
| 2022 July | 19 | 10 | 29 |
| 2022 June | 20 | 8 | 28 |
| 2022 May | 22 | 11 | 33 |
| 2022 April | 16 | 5 | 21 |
| 2022 March | 14 | 9 | 23 |
| 2022 February | 21 | 5 | 26 |
| 2022 January | 30 | 10 | 40 |
| 2021 December | 18 | 19 | 37 |
| 2021 November | 15 | 13 | 28 |
| 2021 October | 24 | 17 | 41 |
| 2021 September | 24 | 15 | 39 |
| 2021 August | 17 | 10 | 27 |
| 2021 July | 35 | 11 | 46 |
| 2021 June | 20 | 13 | 33 |
| 2021 May | 25 | 15 | 40 |
| 2021 March | 0 | 7 | 7 |
| 2021 February | 1 | 5 | 6 |
| 2021 January | 0 | 4 | 4 |
| 2020 December | 0 | 4 | 4 |
| 2020 October | 4 | 2 | 6 |
| 2020 September | 11 | 6 | 17 |
| 2020 August | 4 | 5 | 9 |
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