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Original articles
Impact of risk factors on the efficacy and complications of ultrasound-guided percutaneous liver biopsy of space-occupying lesions
Impacto de los factores de riesgo en la eficacia y complicaciones de la biopsia hepática percutánea ecoguiada de lesiones ocupantes de espacio
R. Varela-Pontea,
Corresponding author
Rafael.Varela.Ponte@sergas.es

Corresponding author.
, N. Martínez-Lagob, M. Vieito-Villarc, J. Martin Carreira-Villamora
a Servicio de Radiodiagnóstico, Complexo Hospitalario Universitario de Santiago, Santiago de Compostela, A Coruña, Spain
b Servicio de Oncología Médica, Complexo Hospitalario Universitario de A Coruña, A Coruña, Spain
c Unidad de Sacorma y Neuroncología, Hospital Universitario Vall d'Hebron, 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">Percutaneous liver biopsy with real-time ultrasound guidance is considered the technique of choice for obtaining diagnostic histological material from space-occupying lesions &#40;SOL&#41;&#44; given its good safety profile&#44; efficacy and low cost&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Due to the advances made in the last decade in genomic and molecular analysis&#44; as well as the appearance of drugs directed against molecular targets&#44; it is necessary to obtain a greater amount of histological material&#44; essential for the diagnosis&#44; therapeutic orientation and detection of biomarkers&#44; and prognostic and predictive factors&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;3</span></a> Moreover&#44; the amount of viable tissue and cellularity have been associated with the number of tissue cylinders obtained&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">On the other hand&#44; the use of ultrasound guidance in real time allows for visualising the tip of the needle at all times&#44; which reduces the risk of complications such as pneumothorax&#44; perforation of other viscera or early detection of bleeding&#46; However&#44; as it is an invasive technique&#44; it is not free of complications such as haemorrhage&#44; infection and perforation of the hollow viscus&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;6</span></a> Previous studies have reported a mortality of around 0&#46;001&#37;&#8722;0&#46;031&#37; and 0&#46;7&#37;&#8211;1&#46;4&#37; major complications&#44; among which the most frequent is haemorrhage&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#8211;9</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Multiple studies have attempted to identify risk factors related to the efficacy and&#47;or complications of the biopsy&#46; Boyum et al&#46;&#44; in an analysis of 6614 ultrasound-guided percutaneous liver biopsies with 0&#46;8&#37; major complications &#40;including 0&#46;1&#37; infections&#41; and 0&#46;0&#46;1&#37; mortality&#44; reported that the presence of less than 50&#44;000 platelets&#44; being of female sex&#44; and the need for more than two biopsy attempts&#44; were associated with a significant risk of complications&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> However&#44; in the study by Malcom et al&#46;&#44; which included 1060 diffuse liver and kidney or SOL biopsies&#44; the impact on the percentage of complications of factors such as age&#44; sex&#44; blood pressure&#44; coagulation or final histology was not evidenced&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> Finally&#44; in a study that analysed the impact of various risk factors on the percentage of haemorrhagic complications in 1876 percutaneous liver biopsies&#44; no significant differences were found based on their location &#40;subcapsular vs&#46; non-subcapsular&#41;&#44; the type of biopsy &#40;fine needle aspiration puncture &#91;FNAP&#93; vs&#46; core needle biopsy&#41;&#44; the size of the needle or the number of passes&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9&#44;11&#8211;13</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">On the other hand&#44; regarding the predictive factors of efficacy&#44; the bibliography is scarce&#46; Only one study is available&#44; in which&#44; based on 3085 percutaneous liver biopsies&#44; data from 78 repeated biopsies &#40;2&#46;5&#37;&#41; were analysed&#44; of which 83&#46;3&#37; were successful biopsies&#44; 10&#46;6&#37; had minor complications&#44; and there were no major complications or associated deaths&#46; Nor were any significant differences in efficacy observed depending on the size&#44; depth&#44; segment or number of passes&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;14</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Therefore&#44; the objective of our study is to evaluate the impact of various risk factors on the efficacy and complications of ultrasound-guided percutaneous liver biopsy in the diagnosis of SOLs&#44; in the context of routine clinical practice&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Study design</span><p id="par0035" class="elsevierStylePara elsevierViewall">We carried out an observational&#44; retrospective&#44; single-centre study&#44; which included patients who had undergone an ultrasound-guided percutaneous liver biopsy&#44; performed with real-time ultrasound guidance and a free-hand technique for the diagnosis of SOLs within the scope of routine clinical practice&#46; The biopsies were carried out in the Radiodiagnosis Service of the University Clinical Hospital of Santiago de Compostela&#44; in the period between December 2012 and February 2018&#44; and the patients had given their consent&#46; Patients unable to understand the study procedures and sign the informed consent&#44; those who lacked all the clinical-pathological data and those who underwent techniques other than real-time ultrasound-guided percutaneous liver biopsy and free-hand technique for the diagnosis of SOLs&#44; such as liver FNAP&#44; non-ultrasound-guided diffuse liver biopsy or transjugular biopsy&#44; were excluded&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Biopsy procedure</span><p id="par0040" class="elsevierStylePara elsevierViewall">Ultrasound-guided percutaneous liver biopsy with free-hand technique and real-time ultrasound guidance is the technique of choice at our centre for the histological diagnosis of SOLs in routine clinical practice&#46; For this reason&#44; in all percutaneous liver biopsies of SOLs included in our study&#44; the free-hand technique and real-time ultrasound guidance were always used&#44; and they were performed within the scope of routine clinical practice &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; Furthermore&#44; they were performed by a single radiologist expert in interventional ultrasound&#44; in accordance with the competence in vascular and interventional radiology guidelines of the Sociedad Espa&#241;ola de Radiolog&#237;a Vascular e Intervencionista &#40;SERVEI&#41; &#91;Spanish Society of Vascular and Interventional Radiology&#93;&#44; the Sociedad Espa&#241;ola de Radiolog&#237;a M&#233;dica &#40;SERAM&#41; &#91;Spanish Society of Medical Radiology&#93;&#44; the Sociedad Espa&#241;ola de Gesti&#243;n y Calidad en Radiolog&#237;a &#40;SEGECA&#41; &#91;Spanish Society of Management and Quality in Radiology&#93; and their quality standards&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">In accordance with the main clinical practice guidelines&#44; treatment with non-steroidal anti-inflammatory drugs &#40;NSAIDs&#41;&#44; antiaggregants or anticoagulants was suspended 7 days before the biopsy and their replacement with low molecular weight heparin up to 24<span class="elsevierStyleHsp" style=""></span>h before the procedure was left to the discretion of the treating clinician&#46; Meanwhile&#44; all patients with non-correctable coagulopathy&#44; defined by the presence of less than 50&#44;000 platelets or an international normalised index greater than 1&#46;5&#44; and which could not be corrected before performing the biopsy&#44; were excluded&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">The biopsies were performed under ultrasound guidance &#40;Philips HDI 5000 SonoCT with 4&#46;5<span class="elsevierStyleHsp" style=""></span>MHz multi-frequency convex probe&#41;&#46; In the biopsies performed by direct puncture technique&#44; we used a tru-cut or lateral cut&#44; semi-automatic&#44; 18 gauge&#44; 150<span class="elsevierStyleHsp" style=""></span>mm long needle &#40;SpeedyBell&#44; Biopsybell&#44; Mirandola&#44; Italy&#41;&#46; In the coaxial biopsies&#44; a coaxial puncture set consisting of a biopsy needle&#44; as described above&#44; and a coaxial needle &#40;SpeedyBell &#38; introduttore&#44; Biopsybell&#44; Mirandola&#44; Italy&#41; was used&#46; Regarding the choice of puncture technique&#44; it should be noted that&#44; due to the absence of conclusive studies on the technique of choice&#44; the radiologist used both techniques interchangeably&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Regarding the context of the biopsies performed&#44; they were performed either with patients hospitalised or on an outpatient basis&#46; The minimum observation period was 6<span class="elsevierStyleHsp" style=""></span>h&#46; In the biopsies performed in hospitalised patients&#44; due to the logistics at our centre&#44; vital signs were periodically monitored for the first 10<span class="elsevierStyleHsp" style=""></span>h after the procedure&#44; maintaining absolute rest for 8<span class="elsevierStyleHsp" style=""></span>h&#44; the first 2 in the right lateral decubitus position&#46; In outpatient biopsies&#44; the patient remained under hospital surveillance for the first 6<span class="elsevierStyleHsp" style=""></span>h&#44; after which home surveillance was continued under the supervision of a responsible adult&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">The results of the biopsies were classified&#44; based on the pathological results obtained&#44; as &#8220;satisfactory&#8221; if the material obtained allowed a definitive diagnosis to be established&#59; &#8220;insufficient material&#8221; if a sample had been taken from the lesion&#44; but this was insufficient for an accurate diagnosis&#59; or &#8220;failed&#8221; if the tissue obtained did not come from the lesion&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Biopsies were categorised according to their final clinical utility as&#58; initial diagnosis of malignancy&#44; confirmation of metastatic disease&#44; identification of a second neoplasm&#44; determination of the origin of metastatic disease in a patient with a history of 2 or more previous neoplasms&#44; exclusion of malignancy&#44; molecular studies&#44; and inconclusive if they lacked clinical utility for the patient&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">All complications recorded in the patient&#39;s medical history were registered within 72<span class="elsevierStyleHsp" style=""></span>h after the procedure&#46; Major complications were classified as those that required interventional measures&#44; such as transfusion of blood products&#44; embolisation or surgery&#44; and minor complications as those that resolved spontaneously with conservative measures&#44; such as fluid therapy and analgesia&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Patient- and&#47;or lesion-related clinical-radiological parameters that had previously been tested as predictive factors of efficacy and&#47;or complications were included&#58; location of the SOL in the upper liver segments &#40;II&#44; IVa&#44; VII and VIII&#41;&#44; proximity to the liver capsule&#44; distance between the skin and the SOL greater than 100<span class="elsevierStyleHsp" style=""></span>mm&#44; interposition of bone or vascular structures&#44; inability to traverse healthy parenchyma or lack of patient collaboration during the biopsy&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Statistical aspects</span><p id="par0080" class="elsevierStylePara elsevierViewall">The study was carried out using the statistical software SPSS version 25&#46; Qualitative variables were analysed descriptively using frequency or percentages&#44; and for quantitative variables the mean and standard deviation&#44; median and range were determined&#46; For the comparison of variables&#44; the &#967;<span class="elsevierStyleSup">2</span> test or Fisher&#39;s exact test was used&#44; depending on the sample size of the different subgroups&#44; considering an association between variables as significant if it was less than 0&#46;05&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Ethical and legal aspects</span><p id="par0085" class="elsevierStylePara elsevierViewall">This study has been carried out in accordance with the rules of good clinical practice and current regulations&#44; including Law 14&#47;2007&#44; the latest version of the Declaration of Helsinki and the Oviedo Convention&#46; Regarding data protection&#44; Organic Law 15&#47;1999 and its implementing regulation Royal Decree 1720&#47;2007&#44; have been complied with&#46; Prior to conducting the study&#44; authorisation was obtained from the corresponding research ethics committee&#46; All patients gave their informed consent&#46;</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Results</span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Characteristics of the sample population</span><p id="par0090" class="elsevierStylePara elsevierViewall">A total of 295 biopsies taken between December 2012 and February 2018 from 278 different patients were included&#46; The characteristics are detailed in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">The median age was 69 years &#40;range 33&#8722;88 years&#41; and 64&#46;1&#37; were male&#46; Regarding personal history&#44; 7&#46;9&#37; received antiplatelet treatment&#44; 7&#46;6&#37; were on anticoagulant treatment&#44; 4&#46;3&#37; had liver disease &#40;defined as the presence of liver cirrhosis and&#47;or infection by virus B or C&#41;&#44; and 3&#46;4&#37; had pathologies that made collaboration difficult during the procedure&#44; such as moderate-severe COPD or certain neurological pathologies&#46; Of the total number of biopsies&#44; 44&#46;7&#37; had a history of a previous neoplasm&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Over half &#40;61&#46;7&#37;&#41; were indicated for the initial diagnosis&#44; and 82&#46;4&#37; were performed in hospitalised patients&#46; Overall&#44; 51&#46;9&#37; were carried out using the coaxial puncture technique&#46; The SOLs were located mainly in the right liver lobe &#40;65&#46;1&#37;&#41;&#44; especially in segments V &#40;20&#46;7&#37;&#41; and VI &#40;17&#46;6&#37;&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Efficacy and complications of biopsies</span><p id="par0105" class="elsevierStylePara elsevierViewall">The median number of cylinders extracted was 3 &#40;range 1&#8211;6&#41;&#46; In 6 patients &#40;2&#37;&#41; 1 cylinder was obtained&#59; 2 cylinders in 44 biopsies &#40;14&#46;9&#37;&#41;&#59; 3 cylinders in 200 biopsies &#40;67&#46;8&#37;&#41;&#59; 4 cylinders in 40 biopsies &#40;13&#46;6&#37;&#41;&#59; 5 cylinders in 4 procedures &#40;1&#46;4&#37;&#41;&#44; and in 1 procedure &#40;0&#46;3&#37;&#41; 6 cylinders were obtained&#46; Thus&#44; in 83&#46;1&#37; of the biopsies 3 or more cylinders were obtained&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Regarding the overall efficacy of the biopsies&#44; 269 &#40;91&#46;2&#37;&#41; were labelled as &#8220;successful&#8221;&#44; 19 &#40;6&#46;4&#37;&#41; as &#8220;failed&#44;&#8221; and 7 &#40;2&#46;4&#37;&#41; as &#8220;insufficient material&#8221;&#46; If we break down the overall efficacy per patient&#44; of the 278 patients&#44; 255 &#40;91&#46;7&#37;&#41; obtained a satisfactory biopsy&#44; 16 &#40;5&#46;8&#37;&#41; a failed biopsy and 7 &#40;2&#46;5&#37;&#41; a biopsy with insufficient material&#44; after performing a first biopsy&#46; After performing a second biopsy in 9 patients &#40;1 of the 7 patients with insufficient material and 8 of the 16 with a failed biopsy&#41;&#44; 6 patients obtained a satisfactory biopsy&#44; which means that&#44; in total&#44; 261 &#40;93&#46;8&#37;&#41; patients obtained a successful biopsy after a second attempt&#46; From a clinical point of view&#44; 92&#46;2&#37; of the biopsies were classified as useful&#46; The final utility of the biopsies is broken down in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0115" class="elsevierStylePara elsevierViewall">No patient died as a result of the biopsy&#46; Ten patients &#40;3&#46;4&#37;&#41; presented complications in the 72<span class="elsevierStyleHsp" style=""></span>h after the biopsy&#46; Of these&#44; 3 patients &#40;0&#46;9&#37;&#41; presented major complications&#58; 2 &#40;0&#46;6&#37;&#41; had haemorrhagic complications that required transfusion of blood products&#44; and 1 &#40;0&#46;3&#37;&#41; had infectious complications that required drainage and intravenous antibiotic therapy&#46; The remaining 7 patients &#40;2&#46;4&#37;&#41; had minor complications in the form of pain&#44; which was treated with first-stage analgesics and resolved completely 24<span class="elsevierStyleHsp" style=""></span>h after the procedure &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Impact of risk factors</span><p id="par0120" class="elsevierStylePara elsevierViewall">We identified 54&#46;5&#37; of SOLs located in the upper liver segments&#44; 69&#46;5&#37; of lesions close to the liver capsule&#44; 8&#46;5&#37; of SOLs with interposition of vascular or bone structures in the puncture tract&#44; 14&#46;2&#37; of lesions more than 100<span class="elsevierStyleHsp" style=""></span>mm from the percutaneous access&#44; 3&#46;4&#37; of patients that were non-cooperative during the procedure&#44; and 24&#46;1&#37; of procedures with an inability to traverse healthy liver parenchyma&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">No significant differences were observed in the percentage of successful biopsies based on the presence of risk factors such as location in upper liver segments &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;838&#41;&#44; proximity to the liver capsule &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;116&#41;&#44; interposition of vascular structures or bone &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;995&#41;&#44; path between the skin and the lesion greater than or equal to 100<span class="elsevierStyleHsp" style=""></span>mm &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;774&#41; or absence of patient collaboration &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;217&#41;&#46; We observed a non-significant trend regarding the inability to traverse healthy parenchyma &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;052&#41;&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">However&#44; we observed a significant increase in the appearance of complications during the procedure in non-cooperative patients &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;04&#41;&#44; without observing differences in other risk factors&#44; such as lesions located in the upper liver segments &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;995&#41;&#44; proximity to the liver capsule &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;995&#41;&#44; with interposition of vascular or bone structures in the puncture route &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;989&#41;&#44; distance between skin and lesion equal to or greater than 100<span class="elsevierStyleHsp" style=""></span>mm &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;630&#41; or inability to traverse healthy parenchyma &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;064&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Discussion</span><p id="par0135" class="elsevierStylePara elsevierViewall">Thanks to advances in recent decades&#44; ultrasound-guided percutaneous liver biopsy represents the technique of choice for the histological diagnosis of SOLs&#44; given its cost-effectiveness and safety&#46; However&#44; the identification of risk factors predictive of efficacy or complications in the context of routine clinical practice continues to be a controversial issue&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">In our study&#44; we retrospectively analysed 295 real-time ultrasound-guided percutaneous liver biopsies with free-hand technique in 278 patients&#46; The biopsies were performed by a single radiologist expert in interventional ultrasound in the context of the usual clinical practice at a tertiary hospital&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">First&#44; we analysed the clinical-pathological characteristics of our series&#46; The median age of our patients was 69 years&#44; with 45&#46;1&#37; of patients older than 70 years&#44; in line with the data on cancer incidence in our country that place the median age at diagnosis in the seventh decade of life&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">Regarding the context of the biopsies performed&#44; only 17&#46;6&#37; were performed on an outpatient basis&#46; This is due to the fact that&#44; in order to perform the biopsies on an outpatient basis it is essential that the patient resides less than 30<span class="elsevierStyleHsp" style=""></span>min from the hospital&#44; is able to travel there&#44; and is accompanied by a responsible adult for the first 24<span class="elsevierStyleHsp" style=""></span>h after the procedure&#46; These requirements are difficult to achieve in a health area with a large&#44; very dispersed&#44; ageing population with limited socio-economic resources in many cases&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">When analysing the puncture technique used&#44; in 51&#46;9&#37; of patients the coaxial puncture was used&#44; compared to 48&#46;1&#37; carried out by direct puncture Due to the lack of conclusive studies indicating the best technique&#44; the radiologist did not follow any specific criteria and used both techniques interchangeably&#44; as shown by the fact that the characteristics of both groups are similar&#44; which does not condition any type of bias&#46; The fact that all the biopsies were performed by a single radiologist&#44; using a standardised procedure and in accordance with SERVEI&#44; SERAM and SEGECA standards minimises the biases related to interpersonal variability&#44; present in multicentre studies&#44; which in many cases can introduce almost imperceptible variations in the procedure&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">After characterising our study population&#44; we analysed the efficacy and safety of the biopsies&#46; In the first place&#44; regarding the number of cylinders obtained&#44; we observed that the median was 3&#44; and that 3 or more cylinders were obtained in 83&#46;1&#37; of patients&#46; These data&#44; not previously described&#44; give us an idea of the quality of the biopsies&#44; which make it possible obtain a large amount of histological material&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">Regarding the percentage of satisfactory biopsies&#44; 91&#46;2&#37; obtained a satisfactory result overall&#44; data that substantially improve the historical series with sensitivities of around 61&#37;&#8211;84&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a></p><p id="par0170" class="elsevierStylePara elsevierViewall">An innovative aspect of our work has been the definition of a classification called &#8220;final utility of the biopsy&#8221;&#46; This is absent in previously published studies on the efficacy and&#47;or complications of ultrasound-guided percutaneous liver biopsy&#44; which have merely focused on technical aspects and that do not analyse the clinical impact of such biopsies&#46; Our study has demonstrated real clinical utility in 92&#46;2&#37; of patients&#44; whether in obtaining an initial diagnosis&#44; confirming metastatic disease&#44; determining the origin of metastatic disease in a patient with a history of several neoplasms&#44; ruling out malignancy or in allowing molecular studies to be completed&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">Liver biopsy is a safe technique with a mortality rate of approximately 0&#46;01&#37; in published series&#46; The percentage of serious complications is between 0&#46;5&#37; and 1&#46;7&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;11&#44;18</span></a> Of these&#44; 60&#37; of complications appear in the first 2<span class="elsevierStyleHsp" style=""></span>h after the procedure and between 83&#37; and 96&#37; within the first 24<span class="elsevierStyleHsp" style=""></span>h&#46; Approximately 2&#37;&#8211;3&#37; of patients require hospital admission due to complications&#44; of which the most frequent are uncontrolled pain and hypotension&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18&#8211;20</span></a></p><p id="par0180" class="elsevierStylePara elsevierViewall">Regarding the safety of our biopsies&#44; we identified a percentage of complications of 3&#46;4&#37; in the following 72<span class="elsevierStyleHsp" style=""></span>h from the inpatient and&#47;or emergency care records&#46; These include minor complications &#40;such as pain&#41; present in 2&#46;4&#37;&#44; major complications &#40;such as bleeding&#41; in 0&#46;6&#37;&#44; and infectious complications in 0&#46;3&#37;&#46; No deaths related to the procedure were identified&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">If we compare our data with previous series&#44; we find that they are practically identical to those published by Malcom et al&#46;&#44; who&#44; in a series of 1066 percutaneous liver and kidney biopsies &#40;both diffuse and of SOLs&#41;&#44; of which 495 were liver biopsies&#44; identified 0&#46;8&#37; of major complications such as bleeding or infection and 2&#46;4&#37; of minor complications such as pain&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><p id="par0190" class="elsevierStylePara elsevierViewall">Regarding the importance of the radiologist&#39;s experience&#44; in the series by Malcom et al&#46; a significant increase in major complications was evidenced in radiologists classified as &#8220;inexperienced&#8221; &#40;2&#37; vs&#46; 0&#46;9&#37;&#41;&#46; If we analyse the data from our series&#44; the percentage of major complications is the same as that reported in Malcom&#39;s series for expert radiologists&#46; It is important to note that although it is true that SOL biopsies do not require specific training in interventional radiology&#44; it is recommended that they be performed by an expert radiologist in order to minimise the complications associated with them&#46; In our study&#44; in which we selected patient- and&#47;or lesion-related risk factors&#44; we did not observe significant differences in the efficacy of the biopsies&#44; in terms of satisfactory biopsies&#44; based on any of the risk factors analysed&#46; These data are in line with those previously reported&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">In relation to the impact of risk factors on the development of complications&#44; we have identified a significant increase in non-cooperative patients during the procedure &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;004&#41;&#46; The increase in complications in non-cooperating patients had already been reported previously&#44; justifying that this increased risk was due to the risk of liver rupture or laceration due to uncontrolled movements of the patient and&#44; consequently&#44; a higher risk of bleeding&#46; For this reason&#44; clinical guidelines have defined it as a contraindication&#44; either absolute or relative&#44; depending on the guideline&#46; In addition&#44; if the indication for a biopsy is essential&#44; it is recommended to administer moderate to deep sedation&#44; or even general anaesthesia&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> Based on these results&#44; we implemented a sedation protocol for non-cooperative patients at our centre&#44; and since then no significant complications have appeared&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">Moreover&#44; we have identified a non-significant trend in the impossibility of traversing healthy parenchyma both in terms of efficacy &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;052&#41; and the appearance of complications &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;064&#41;&#46; It is possible that this could be due to the limited size of our series&#44; which did not allow us to observe differences&#44; if they really existed&#44; which is why it should be studied in larger series&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">Finally&#44; our study is not without its limitations&#46; The fact that this is a retrospective&#44; observational&#44; single-centre study in which all biopsies were performed in the context of routine clinical practice&#44; by the same radiologist&#44; and that the choice of the puncture technique was not made randomly&#44; means that we cannot rule out operator-induced bias&#46; In addition&#44; the fact that the complications have been obtained from the patient&#39;s medical history means that we cannot rule out information bias&#44; especially in the case of minor complications such as mild pain&#44; in which analgesic treatment was not necessary and&#44; therefore&#44; was not included in the patient&#39;s history&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Conclusions</span><p id="par0210" class="elsevierStylePara elsevierViewall">Ultrasound-guided percutaneous liver biopsy is an effective and safe technique for the diagnosis of SOLs&#46; Our series confirms the impact on the development of complications in non-cooperative patients during the biopsy procedure&#44; with no differences in the risk factors related to the lesion itself&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Authorship</span><p id="par0275" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1</span><p id="par0215" class="elsevierStylePara elsevierViewall">Persons responsible for the integrity of the study&#58; RVP&#44; NML&#44; MVV&#44; JMCV&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2</span><p id="par0220" class="elsevierStylePara elsevierViewall">Study concept&#58; RVP&#44; NML&#44; MVV&#44; JMCV&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3</span><p id="par0225" class="elsevierStylePara elsevierViewall">Study design&#58; RVP&#44; NML&#44; MVV&#44; JMCV&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">4</span><p id="par0230" class="elsevierStylePara elsevierViewall">Data collection&#58; RVP&#44; NML&#44; MVV&#44; JMCV&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">5</span><p id="par0235" class="elsevierStylePara elsevierViewall">Data analysis and interpretation&#58; RVP&#44; NML&#44; MVV&#44; JMCV&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">6</span><p id="par0240" class="elsevierStylePara elsevierViewall">Statistical processing&#58; RVP&#44; NML&#44; MVV&#44; JMCV&#46;</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">7</span><p id="par0245" class="elsevierStylePara elsevierViewall">Literature search&#58; RVP&#44; NML&#44; MVV&#44; JMCV&#46;</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">8</span><p id="par0250" class="elsevierStylePara elsevierViewall">Drafting of the paper&#58; RVP&#44; NML&#44; MVV&#44; JMCV&#46;</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">9</span><p id="par0255" class="elsevierStylePara elsevierViewall">Critical review of the manuscript with intellectually relevant contributions&#58; RVP&#44; NML&#44; MVV&#44; JMCV&#46;</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">10</span><p id="par0260" class="elsevierStylePara elsevierViewall">Approval of the final version&#58; RVP&#44; NML&#44; MVV&#44; JMCV&#46;</p></li></ul></p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Conflicts of interest</span><p id="par0265" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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    "fechaRecibido" => "2020-07-07"
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    "resumen" => array:2 [
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Ultrasound-guided percutaneous liver biopsy is considered the technique of choice for the histological diagnosis of space-occupying lesions&#44; given its high level of safety and diagnostic performance&#46; However&#44; since it is an invasive diagnostic procedure&#44; complications can occur&#46; Various clinical and radiological parameters have been analysed as factors related with the efficacy of the technique or with its complications&#59; however&#44; the results have been contradictory&#46; Thus&#44; we aimed to evaluate the impact of various risk factors on the efficacy and complications of ultrasound-guided percutaneous liver biopsy in the diagnosis of space-occupying lesions in ordinary clinical practice&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material and methods</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">This retrospective observational study included all patients who underwent real-time ultrasound-guided percutaneous biopsies of space-occupying liver lesions with the free-hand technique between December 2012 and February 2018 in the diagnostic imaging department at the Hospital Cl&#237;nico Universitario de Santiago de Compostela&#46;</p><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">We analysed the following risk factors&#58; location of the lesion in upper liver segments &#40;II&#44; IVa&#44; VII&#44; or VIII&#41;&#59; proximity to the liver capsule&#44; distance from the skin &#62;100<span class="elsevierStyleHsp" style=""></span>mm&#44; interposition of osseus or vascular structures&#44; inability to go through healthy parenchyma&#44; and lack of patient cooperation during the procedure&#46;</p><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Efficacy was analysed in terms of the number of cylinders obtained and the percentage of adequate biopsies&#59; safety was analysed in terms of the percentage of complications&#44; which were classified as major or minor&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">We included 295 biopsies in 278 patients &#40;median age&#44; 69 years&#59; 64&#46;1&#37; male&#59; 44&#46;7&#37; had prior neoplasms&#41;&#46; In 61&#46;4&#37;&#44; the biopsy was indicated for the initial diagnosis&#59; 82&#46;4&#37; of biopsies were done in hospitalised patients&#44; and 65&#37; of the lesions were located in the right liver lobe&#46;</p><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">The median number of cylinders obtained was 3 &#40;range 1&#8211;6&#41;&#59; 91&#46;2&#37; of the biopsies were adequate and 92&#46;2&#37; were considered clinically useful&#46; These percentages did not differ significantly according to the presence of risk factors&#46; Complications occurred in 10 &#40;3&#46;4&#37;&#41; patients&#46; Complications were considered major in 3 &#40;0&#46;9&#37;&#41; patients &#40;2 &#40;0&#46;6&#37;&#41; bleeding complications and 1 &#40;0&#46;3&#37;&#41; infectious complication&#41; and minor in 7 &#40;2&#46;4&#37;&#41;&#46; The percentage of complications was significantly higher in patients who did not cooperate during the procedure &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;04&#41;&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Ultrasound-guided percutaneous liver biopsy is an efficacious and safe technique for the histological diagnosis of space-occupying liver lesions&#46; Our results confirm the increased rate of complications when patients fail to cooperate during the procedure&#46;</p></span>"
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            "titulo" => "Introduction"
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            "titulo" => "Material and methods"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducci&#243;n</span><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">La biopsia hep&#225;tica percut&#225;nea ecoguiada se considera la t&#233;cnica de elecci&#243;n para el diagn&#243;stico histol&#243;gico de las lesiones ocupantes de espacio &#40;LOE&#41;&#44; dada su elevada seguridad y rentabilidad diagn&#243;stica&#46; Sin embargo&#44; al tratarse de una t&#233;cnica de diagn&#243;stico invasiva&#44; no se encuentra exenta de complicaciones&#46; Diversos par&#225;metros cl&#237;nico-radiol&#243;gicos han sido analizados como factores relacionados con la eficacia o complicaciones&#44; con resultados contradictorios&#46; Por todo ello&#44; el objetivo de nuestro estudio es evaluar el impacto de diversos factores de riesgo en la eficacia y complicaciones de la biopsia hep&#225;tica percut&#225;nea ecoguiada en el diagn&#243;stico de LOE&#44; en el &#225;mbito de la pr&#225;ctica cl&#237;nica habitual&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y m&#233;todos</span><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Llevamos a cabo un estudio observacional&#44; retrospectivo&#44; unic&#233;ntrico de pacientes sometidos a biopsia hep&#225;tica percut&#225;nea ecoguiada en tiempo real con t&#233;cnica de manos libres para el diagn&#243;stico de LOE&#44; realizadas en el Servicio de Radiodiagn&#243;stico del Hospital Cl&#237;nico Universitario de Santiago de Compostela entre diciembre 2012 y febrero 2018&#46; Seleccionamos como factores de riesgo&#58; la localizaci&#243;n de la LOE en los segmentos hep&#225;ticos superiores &#40;II&#44; IVa&#44; VII y VIII&#41;&#44; la proximidad a la c&#225;psula hep&#225;tica&#44; la distancia entre piel y LOE mayor de 100<span class="elsevierStyleHsp" style=""></span>mm&#44; la interposici&#243;n de estructuras &#243;seas o vasculares&#44; la incapacidad para atravesar par&#233;nquima sano o la falta de colaboraci&#243;n del paciente durante el procedimiento&#46; La eficacia fue analizada en t&#233;rminos de n&#250;mero de cilindros extra&#237;dos y porcentaje de biopsias satisfactorias&#59; y la seguridad&#44; en t&#233;rminos de porcentaje de complicaciones presentadas&#44; clasific&#225;ndolas&#44; a su vez&#44; en complicaciones mayores y menores&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Se incluyeron 295 biopsias de 278 pacientes&#46; La mediana de edad fue de 69 a&#241;os&#44; el 64&#44;1&#37; eran varones y el 44&#44;7&#37; ten&#237;a una neoplasia previa&#46; El 61&#44;4&#37; de las biopsias se indicaron para el diagn&#243;stico inicial&#44; el 82&#44;4&#37; se realizaron con el paciente ingresado y el 65&#37; de las lesiones se localizaban en el l&#243;bulo hep&#225;tico derecho&#46;</p><p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">La mediana de cilindros extra&#237;dos fue de 3 &#40;rango 1&#8211;6&#41;&#46; El 91&#44;2&#37; de las biopsias fueron satisfactorias&#44; sin diferencias en funci&#243;n de la presencia de factores de riesgo&#44; y el 92&#44;2&#37; fueron clasificadas como &#250;tiles desde el punto de vista cl&#237;nico&#46; Diez &#40;3&#44;4&#37;&#41; pacientes presentaron complicaciones&#44; en 3 &#40;0&#44;9&#37;&#41; fueron complicaciones mayores&#44; en 2 &#40;0&#44;6&#37;&#41; complicaciones hemorr&#225;gicas y en 1 &#40;0&#44;3&#37;&#41; complicaciones infecciosas&#59; y los 7 restantes &#40;2&#44;4&#37;&#41;&#44; complicaciones menores&#46; Se observ&#243; un porcentaje significativamente superior de complicaciones en pacientes no colaboradores durante el procedimiento &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;04&#41;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">La biopsia hep&#225;tica percut&#225;nea ecoguiada es una t&#233;cnica eficaz y segura para el diagn&#243;stico histol&#243;gico de LOE&#46; Se confirma el impacto en el desarrollo de complicaciones en el paciente no colaborador durante el procedimiento de biopsia&#46;</p></span>"
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">189 &#40;64&#46;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Female&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">106 &#40;35&#46;9&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " colspan="2" 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-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Previous neoplasia</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Yes&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">132 &#40;44&#46;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>No&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">163 &#40;55&#46;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " colspan="2" 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-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Indication for biopsy</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Initial diagnosis&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">182 &#40;61&#46;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Confirmation of metastasis&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">105 &#40;35&#46;6&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Molecular study&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;2&#46;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " colspan="2" 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-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Biopsy context</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Inpatient&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">243 &#40;82&#46;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Outpatient&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">52 &#40;17&#46;6&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " colspan="2" 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-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Puncture technique</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Direct&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">142 &#40;48&#46;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Coaxial&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">153 &#40;51&#46;9&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " colspan="2" 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-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Liver lobe</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Right&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">192 &#40;65&#46;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Left&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">103 &#40;35&#46;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " colspan="2" 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-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Liver segment</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>I&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">3 &#40;1&#46;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>II&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">18 &#40;6&#46;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>III&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">29 &#40;9&#46;8&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>IVa&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;15&#46;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>IVb&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;4&#46;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>V&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">61 &#40;20&#46;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>VI&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">52 &#40;17&#46;6&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>VII&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">28 &#40;9&#46;5&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>VIII&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;15&#46;6&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
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        ]
      ]
      3 => array:8 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0020"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:1 [
              "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"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Final utility of biopsies&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">N<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1295 &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Initial diagnosis&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">133 &#40;45&#46;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Confirmation of metastatic disease&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">58 &#40;19&#46;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Identification of second neoplasm&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">15 &#40;5&#46;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Determination of the origin of metastasis in a patient with more than 2 previous neoplasms&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;2&#46;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Ruling out malignancy&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">28 &#40;9&#46;5&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Molecular study&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">2 &#40;0&#46;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Inconclusive&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">23 &#40;7&#46;8&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Final utility of biopsies&#46;</p>"
        ]
      ]
      4 => array:8 [
        "identificador" => "tbl0015"
        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0025"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:1 [
              "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"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Complications&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">N<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>10 &#40;3&#46;4&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Major complications&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">3 &#40;0&#46;9&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Bleeding&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">2 &#40;0&#46;6&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;0&#46;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Minor complications&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">7 &#40;2&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Pain&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">7 &#40;2&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Complications&#46;</p>"
        ]
      ]
      5 => array:8 [
        "identificador" => "tbl0020"
        "etiqueta" => "Table 4"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0030"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:1 [
              "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"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Risk factors&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Total N<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>295&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Satisfactory N<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>269&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Failed&#47;Insufficient N<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>26&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">P</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Complications&#58; No N<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>285&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Complications&#58; Yes N<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">P</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " colspan="8" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Age</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#62;70 years&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">133 &#40;45&#46;1&#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">120 &#40;44&#46;6&#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">13 &#40;50&#46;0&#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">&#46;681&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">127 &#40;44&#46;6&#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">6 &#40;60&#46;0&#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">&#46;355&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#60;70 years&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">162 &#40;54&#46;9&#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">149 &#40;55&#46;4&#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">13 &#40;50&#46;0&#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">&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">158 &#40;55&#46;4&#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">4 &#40;40&#46;0&#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">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " colspan="8" 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-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " colspan="8" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Liver segment</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Upper &#40;II&#44; IVa&#44; VII&#44; VIII&#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">134 &#40;45&#46;5&#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">123 &#40;45&#46;7&#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">11 &#40;42&#46;3&#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">&#46;838&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">129 &#40;45&#46;3&#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">5 &#40;50&#46;0&#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">&#46;995&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Lower &#40;I&#44; III&#44; IVb&#44; V&#44; VI&#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">161 &#40;54&#46;5&#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">146 &#40;54&#46;3&#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">15 &#40;57&#46;7&#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">&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">156 &#40;54&#46;7&#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">5 &#40;50&#46;0&#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">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " colspan="8" 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-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " colspan="8" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Proximity to the capsule</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Yes&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">205 &#40;69&#46;5&#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">183 &#40;68&#46;0&#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;84&#46;6&#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">&#46;116&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">198 &#40;69&#46;5&#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">7 &#40;70&#46;0&#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">&#46;995&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>No&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">90 &#40;30&#46;5&#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">86 &#40;32&#46;0&#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">4 &#40;15&#46;4&#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">&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">87 &#40;30&#46;5&#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">3 &#40;30&#46;0&#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">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " colspan="8" 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-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " colspan="8" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Interposition of vascular or bone structures</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Yes&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">25 &#40;8&#46;5&#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">23 &#40;8&#46;6&#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">2 &#40;7&#46;7&#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">&#46;995&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">24 &#40;8&#46;4&#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">1 &#40;10&#46;0&#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">&#46;989&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>No&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">270 &#40;91&#46;5&#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">246 &#40;91&#46;5&#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">24 &#40;92&#46;3&#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">&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">261 &#40;91&#46;6&#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">9 &#40;90&#46;0&#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">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " colspan="8" 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-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " colspan="8" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Distance between skin and lesion</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#62;100<span class="elsevierStyleHsp" style=""></span>mm&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">42 &#40;14&#46;2&#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">38 &#40;12&#46;5&#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">4 &#40;15&#46;4&#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">&#46;774&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">40 &#40;14&#46;0&#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">2 &#40;20&#46;0&#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">&#46;630&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>&#60;100<span class="elsevierStyleHsp" style=""></span>mm&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">253 &#40;85&#46;8&#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">231 &#40;87&#46;5&#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;84&#46;6&#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">&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">245 &#40;86&#46;0&#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">8 &#40;80&#46;0&#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">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " colspan="8" 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-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " colspan="8" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Collaborating patient</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>No&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">10 &#40;3&#46;4&#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">8 &#40;3&#46;0&#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">2 &#40;7&#46;7&#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">&#46;217&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;2&#46;8&#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">2 &#40;20&#46;0&#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">&#46;040&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t">285 &#40;96&#46;6&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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