Funduplicatura con disección extensa de la unión esofagogástrica: lecciones aprendidas y resultados tras 178 pacientes consecutivos

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la aparici&#243;n de anemia o hemorragia digestiva alta<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">5</span></a>&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Los inhibidores de la bomba de protones &#40;IBP&#41; son la base del tratamiento m&#233;dico<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">6&#44;7</span></a>&#44; aunque un alto porcentaje de los pacientes con pirosis<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">8</span></a> y regurgitaci&#243;n<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">9</span></a> no responden al mismo&#46; La cirug&#237;a es el &#250;nico abordaje eficaz ante el fracaso de los IBP<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">10&#44;11</span></a>&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Desde que en 1937 Rudolph Nissen<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">12</span></a> realiz&#243; la primera funduplicatura&#44; se han propuesto muchas alternativas de la t&#233;cnica para controlar los s&#237;ntomas de la ERGE y minimizar las complicaciones derivadas del procedimiento<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">13</span></a>&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">En 1988&#44; Rossetti et al&#46; describieron una variante t&#233;cnica para tratar a pacientes con ERGE y &#250;lcera gastroduodenal asociada o esofagitis grave&#44; en la cual realizaban una disecci&#243;n de la uni&#243;n esofagog&#225;strica &#40;UEG&#41; y una vagotom&#237;a proximal selectiva vinculada a la funduplicatura<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">14</span></a>&#46; Un a&#241;o m&#225;s tarde&#44; a&#241;adieron una modificaci&#243;n situando este procedimiento entre la UEG y la parte proximal de la curvatura menor y los troncos vagales para mejorar su anclaje y disminuir el riesgo de deslizamiento<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">15</span></a>&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Dada la ausencia de informaci&#243;n en la literatura acerca los resultados a medio y largo plazo de dicha modificaci&#243;n t&#233;cnica&#44; sistematizamos en nuestra unidad la disecci&#243;n extensa de la UEG previa a la confecci&#243;n de una funduplicatura que queda anclada entre los troncos vagales y el es&#243;fago distal&#46; Esto puede aportar una serie de ventajas&#58; la ganancia de longitud adicional de es&#243;fago intrabdominal&#44; evitar el malposicionamiento de las valvas&#44; una disminuci&#243;n en la aparici&#243;n o recidiva de una hernia de hiato &#40;HH&#41; al obstaculizar el deslizamiento del <span class="elsevierStyleItalic">fundus</span> sobre la funduplicatura &#40;telescopaje&#41;&#44; y la identificaci&#243;n y preservaci&#243;n de los nervios vagos&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">El objetivo de este estudio fue evaluar los resultados cl&#237;nicos&#44; la recidiva herniaria&#44; la calidad de vida y el grado de satisfacci&#243;n a uno y tres a&#241;os en pacientes sometidos a una funduplicatura con disecci&#243;n extensa de la UEG&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">M&#233;todos</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Pacientes y t&#233;cnica quir&#250;rgica</span><p id="par0035" class="elsevierStylePara elsevierViewall">Fueron incluidos todos aquellos pacientes intervenidos entre 2015-2020 con diagn&#243;stico confirmado de ERGE sintom&#225;tico con o sin HH&#44; aquellos con HH tipos I-IV sintom&#225;tica a los que se les efectu&#243; una funduplicatura como t&#233;cnica antirreflujo y las cirug&#237;as de revisi&#243;n en las que se inclu&#237;a la realizaci&#243;n de una funduplicatura como parte del procedimiento&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Se consideraron criterios de exclusi&#243;n&#58; pacientes menores de 18 a&#241;os&#44; aquellos con resecciones g&#225;stricas previas&#44; sujetos con dos o m&#225;s cirug&#237;as antirreflujo anteriores o algunas que requirieron conversi&#243;n a abordaje abierto&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">El estudio fue aprobado por el comit&#233; &#233;tico institucional&#46;</p><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">T&#233;cnica quir&#250;rgica</span><p id="par0050" class="elsevierStylePara elsevierViewall">No se utilizaron sondas nasog&#225;strica&#44; de calibraci&#243;n esof&#225;gica&#44; ni urinaria durante la cirug&#237;a&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">La disecci&#243;n extensa de la UEG comienza en el tercio proximal de la curvatura menor&#46; Se diseca y rechaza posteriormente la almohadilla grasa &#40;<span class="elsevierStyleItalic">fat pad</span>&#41; y se identifican y lateralizan ambos troncos vagales &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">Los vasos cortos son seccionados y&#44; posteriormente&#44; se realiza una hiatorrafia con puntos sueltos irreabsorbibles&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Finalmente&#44; en pacientes con trastorno motor severo&#44; se efectu&#243; una funduplicatura parcial tipo Toupet 270&#176;&#46; En aquellos con motilidad conservada&#44; se confeccion&#243; una funduplicatura modificada consistente en la fijaci&#243;n anterior de ambas valvas con un punto sobre el es&#243;fago distal y la UEG&#44; y la sutura de cada una de las mismas a la cara anterolateral del es&#243;fago&#46; Esta modificaci&#243;n descrita por Luketich<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">16</span></a>&#44; a la que denominaremos en lo sucesivo funduplicatura 320&#176;&#44; tiene como prop&#243;sito minimizar el riesgo de disfagia asociado a los procedimientos completos de 360&#176;&#44; manteniendo un correcto control del reflujo &#40;<a class="elsevierStyleCrossRef" href="#fig0010">fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Evaluaci&#243;n preoperatoria y seguimiento</span><p id="par0070" class="elsevierStylePara elsevierViewall">De manera basal&#44; se llev&#243; a cabo una evaluaci&#243;n cl&#237;nica&#44; una endoscopia digestiva alta &#40;EDA&#41;&#44; tr&#225;nsito esofagogastroduodenal &#40;TEGD&#41; y un estudio funcional esof&#225;gico con manometr&#237;a y pHmetr&#237;a de 24 horas&#46; Despu&#233;s de un mes&#44; se realiz&#243; una reevaluaci&#243;n cl&#237;nica y TEGD&#44; y al a&#241;o y a los tres siguientes de la cirug&#237;a se llev&#243; a cabo una nueva valoraci&#243;n&#44; EDA&#44; TEGD y un estudio funcional a aquellos pacientes con sospecha cl&#237;nica de recidiva&#46; Las complicaciones posoperatorias fueron recogidas y clasificadas seg&#250;n los grados de la escala Clavien-Dindo<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">17</span></a>&#46; Asimismo&#44; se documentaron las reintervenciones quir&#250;rgicas y los reingresos no programados a 30 y 90 d&#237;as&#46;</p><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Evaluaci&#243;n de los s&#237;ntomas</span><p id="par0075" class="elsevierStylePara elsevierViewall">El seguimiento de los pacientes fue realizado por tres cirujanos <span class="elsevierStyleItalic">senior</span> de la Unidad de Cirug&#237;a Esofagog&#225;strica mediante una entrevista presencial o telef&#243;nica en la que se evaluaron los s&#237;ntomas posoperatorios&#44; la toma de IBP y la calidad de vida mediante la escala para s&#237;ntomas y calidad de vida &#40;<span class="elsevierStyleItalic">Gastro Esophageal Reflux Disease-Health Related Quality of Life</span> &#91;GERD-HRQL&#93;&#41; descrita por Velanovich<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">18</span></a> que incluye 10 preguntas acerca de la pirosis&#44; disfagia&#44; o la toma de medicaci&#243;n otorgando una puntuaci&#243;n de entre 0 y 45&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Los s&#237;ntomas t&#237;picos&#44; at&#237;picos y otros como la disnea o el dolor abdominal fueron evaluados como variables cuantitativas dicot&#243;micas&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">La disfagia se catalog&#243; bas&#225;ndose en la clasificaci&#243;n de Visick en&#58; 1&#41; leve &#40;grado II de Visick&#41;&#44; 2&#41; moderada &#40;Visick III&#41; y 3&#41; severa &#40;Visick IV y V&#41;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">19</span></a> &#40;<a class="elsevierStyleCrossRef" href="#fig0015">fig&#46; 3</a>&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Endoscopia y estudio radiol&#243;gico</span><p id="par0090" class="elsevierStylePara elsevierViewall">Se realizaron EDA y TEGD&#44; preoperatoriamente y durante el seguimiento&#44; para el estudio de la esofagitis&#44; el es&#243;fago de Barrett y la presencia o recidiva de HH&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Para evaluar la esofagitis y el es&#243;fago de Barrett se emplearon la clasificaci&#243;n de Los &#193;ngeles<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">20</span></a> y la de Praga<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">21</span></a>&#44; respectivamente&#46; La toma de biopsias en el es&#243;fago de Barrett se realiz&#243; seg&#250;n el protocolo de Seattle<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">22</span></a>&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">La evaluaci&#243;n radiol&#243;gica fue llevada a cabo por dos miembros del Servicio de Radiolog&#237;a&#46; Se defini&#243; la recidiva de la HH como el ascenso de la c&#225;mara g&#225;strica por encima del nivel del diafragma&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Estudio funcional</span><p id="par0105" class="elsevierStylePara elsevierViewall">La presencia de reflujo patol&#243;gico se defini&#243; como una puntuaci&#243;n &#62; 14&#44;72 seg&#250;n la escala descrita por Johnson et al&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">23</span></a>&#46; Se realiz&#243; una manometr&#237;a convencional en el periodo 2015-2016 y una manometr&#237;a de alta resoluci&#243;n &#40;HRM&#41; entre 2017-2020&#44; para detectar trastornos de la motilidad esof&#225;gica&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">A los pacientes con trastornos severos de la motilidad&#44; definidos como tal por el informe de la manometr&#237;a o con una integral de contractilidad distal<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>450 en la HRM&#44; se les practic&#243; una funduplicatura parcial tipo Toupet 270&#176;&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">An&#225;lisis estad&#237;stico</span><p id="par0115" class="elsevierStylePara elsevierViewall">Las variables cualitativas se expresan como porcentajes y las cuantitativas como valores medios con desviaci&#243;n est&#225;ndar &#40;DE&#41; en el caso de distribuci&#243;n normal&#44; utiliz&#225;ndose la mediana con el rango intercuart&#237;lico &#40;IQR&#41; para la variable de calidad de vida&#46; Las cualitativas se compararon mediante la prueba <span class="elsevierStyleItalic">X</span><span class="elsevierStyleSup"><span class="elsevierStyleItalic">2</span></span> de Pearson con correcci&#243;n de continuidad o la prueba <span class="elsevierStyleItalic">F</span> de Fisher cuando al menos 25&#37; de los valores mostraban una frecuencia esperada inferior a 5&#46; Se emple&#243; el test de la mediana para comparar la calidad de vida seg&#250;n la t&#233;cnica&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Los an&#225;lisis estad&#237;sticos se realizaron con el software inform&#225;tico paquete estad&#237;stico para las ciencias sociales &#40;SPSS Statistics Base para Windows Versi&#243;n 17&#46;0&#41;&#44; versi&#243;n 17&#46;0&#46; Se asumi&#243; un nivel de significaci&#243;n de 5&#37; &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#41;&#46;</p></span></span></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Resultados</span><p id="par0125" class="elsevierStylePara elsevierViewall">Un total de 229 pacientes fueron sometidos a cirug&#237;a antirreflujo en nuestro centro entre octubre de 2015 y diciembre de 2020&#46; De ellos&#44; a 178 &#40;77&#44;7&#37;&#41; se les realiz&#243; una funduplicatura con disecci&#243;n extensa de la UEG&#46; Todos los casos se efectuaron por v&#237;a laparosc&#243;pica&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">La edad media de los pacientes fue de 53&#44;3 a&#241;os y 52&#44;2&#37; fueron mujeres&#46; Las caracter&#237;sticas demogr&#225;ficas se encuentran reflejadas en la <a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0135" class="elsevierStylePara elsevierViewall">Hab&#237;an sido intervenidos previamente de cirug&#237;a antirreflujo siete pacientes y cuatro presentaron un telescopaje de la funduplicatura&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">En el momento del diagn&#243;stico&#44; 166 sujetos &#40;93&#44;3&#37;&#41; presentaban pirosis&#44; 127 &#40;71&#44;3&#37;&#41; regurgitaci&#243;n y 24 &#40;13&#44;5&#37;&#41; disfagia&#44; 16 leve &#40;Visick II&#41;&#44; cinco moderada &#40;Visick III&#41; y tres severa &#40;Visick IV-V&#41;&#46; Refer&#237;an laringitis 22 &#40;12&#44;4&#37;&#41; y 12 &#40;6&#44;7&#37;&#41; disnea secundaria a una HH grande&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">La mediana &#40;IQR&#41; de la escala GERD-HRQL preoperatoria fue 27&#40;15&#41;&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Todos los pacientes tomaban IBP&#46; De ellos&#44; 48&#37; no respond&#237;a al tratamiento y 39&#44;3&#37; presentaba respuesta parcial&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">La pHmetr&#237;a fue patol&#243;gica en 156 personas &#40;87&#44;6&#37;&#41;&#46; La manometr&#237;a esof&#225;gica revel&#243; un trastorno moderado o severo de la motilidad en 36&#37; de los casos&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Se realiz&#243; un TEGD preoperatorio en 154 pacientes&#44; mostrando una HH en 85 &#40;55&#44;1&#37;&#41;&#44; siendo la m&#225;s frecuente la de tipo I en 56 &#40;36&#44;6&#37;&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#41;&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">Se efectuaron 174 EDA &#40;97&#44;7&#37;&#41;&#46; Presentaron esofagitis grado A como alteraci&#243;n m&#225;s frecuente 20 pacientes &#40;11&#44;5&#37;&#41;&#44; evidenci&#225;ndose es&#243;fago de Barrett en 18 casos &#40;10&#44;1&#37;&#41;&#46; Dos sujetos padecieron displasia de bajo grado &#40;DBG&#41;&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">La t&#233;cnica m&#225;s frecuente fue la funduplicatura tipo Toupet en 105 casos &#40;58&#44;9&#37;&#41; seguida de la 320&#176; &#40;73 casos&#44; 41&#44;1&#37;&#41;&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">Durante el periodo posoperatorio&#44; seis pacientes &#40;3&#44;3&#37;&#41; presentaron complicaciones m&#233;dicas&#44; siendo las m&#225;s frecuentes las respiratorias en tres casos &#40;1&#44;8&#37;&#44; Clavien-Dindo I y II&#41; y cardiovasculares en dos casos &#40;1&#44;2&#37;&#44; Clavien-Dindo II&#41;&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">Se observaron complicaciones quir&#250;rgicas en siete &#40;3&#44;9&#37;&#41; pacientes&#44; siendo las m&#225;s habituales la hemorragia en dos casos &#40;1&#44;2&#37;&#44; Clavien-Dindo II&#41; y la infecci&#243;n del sitio quir&#250;rgico en dos sujetos &#40;1&#44;2&#37;&#44; Clavien-Dindo I&#41;&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">Un paciente mostr&#243; una evisceraci&#243;n que requiri&#243; cirug&#237;a durante el ingreso &#40;Clavien-Dindo IIIb&#41;&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">Se registr&#243; un reingreso a 30 d&#237;as por una volvulaci&#243;n aguda que necesit&#243; reintervenci&#243;n urgente en otro centro &#40;Clavien-Dindo IVa&#41;&#46; No se registraron otros reingresos a 90 d&#237;as&#46;</p><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Seguimiento al a&#241;o de la cirug&#237;a</span><p id="par0195" class="elsevierStylePara elsevierViewall">Se obtuvo el seguimiento de 160 &#40;89&#37;&#41; pacientes&#46; De ellos&#44; 10 &#40;7&#44;5&#37;&#41; presentaron pirosis&#44; seis &#40;3&#44;7&#37;&#41; regurgitaci&#243;n y tres &#40;1&#44;9&#37;&#41; laringitis&#46; Refer&#237;an disfagia seis &#40;3&#44;7&#37;&#41;&#44; en cinco casos fue leve &#40;Visick II&#41; y en uno moderada &#40;Visick III&#41;&#46; En 14 &#40;8&#44;8&#37;&#41; se observaron s&#237;ntomas relacionados con el s&#237;ndrome <span class="elsevierStyleItalic">gas-bloat</span> &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0200" class="elsevierStylePara elsevierViewall">Se realiz&#243; pHmetr&#237;a en 41 &#40;25&#44;6&#37;&#41; pacientes siendo patol&#243;gica en seis&#46; Manten&#237;an tratamiento con IBP 16&#44;2&#37;&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">Se efectu&#243; EDA a 40 personas &#40;25&#37;&#41;&#46; En 84&#44;6&#37; de los casos desapareci&#243; la esofagitis y en 16&#44;6&#37; la metaplasia&#46; Un paciente desarroll&#243; DBG <span class="elsevierStyleItalic">de novo</span> que remiti&#243; en un control a los tres meses tras un tratamiento intensivo con IBP&#46;</p><p id="par0210" class="elsevierStylePara elsevierViewall">A 153 &#40;85&#44;6&#37;&#41; sujetos se les realiz&#243; el TEGD mostrando recidiva herniaria en 12 &#40;7&#44;8&#37;&#41;&#46;</p><p id="par0215" class="elsevierStylePara elsevierViewall">La mediana &#40;IQR&#41; de la escala de calidad de vida GERD-HRQL fue 2 &#40;5&#41;&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Seguimiento a los tres a&#241;os</span><p id="par0220" class="elsevierStylePara elsevierViewall">Fueron evaluados 158 pacientes &#40;88&#44;7&#37;&#41;&#46; De ellos&#44; 17 &#40;10&#44;7&#37;&#41; refer&#237;an pirosis&#44; 12 &#40;7&#44;6&#37;&#41; regurgitaci&#243;n y dos &#40;1&#44;2&#37;&#41; laringitis&#46; Se llev&#243; a cabo una pHmetr&#237;a a 34 &#40;21&#44;5&#37;&#41; siendo patol&#243;gica en nueve&#46; Presentaban disfagia 12 &#40;7&#44;6&#37;&#41;&#59; en dos casos era moderada &#40;Visick III&#41; y en uno severa &#40;Visick IV-V&#41;&#44; requiriendo dilataciones endosc&#243;picas con buen resultado cl&#237;nico&#46;</p><p id="par0225" class="elsevierStylePara elsevierViewall">Se realizaron 49 EDA &#40;31&#37;&#41;&#46; En 85&#44;7&#37; desapareci&#243; la esofagitis y 83&#44;4&#37; manten&#237;an la metaplasia&#46; Ning&#250;n caso present&#243; displasia y no se registr&#243; esofagitis <span class="elsevierStyleItalic">de novo</span>&#46; Un total de 22&#44;7&#37; continu&#243; el tratamiento con IBP&#46;</p><p id="par0230" class="elsevierStylePara elsevierViewall">Se efectuaron 142 &#40;89&#44;8&#37;&#41; TEGD revelando HH en 14 &#40;9&#44;8&#37;&#41;&#46; La mediana &#40;IQR&#41; de la escala GERD-HRQL fue 0 &#40;2&#41;&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Resultados en funci&#243;n del tipo de funduplicatura</span><p id="par0235" class="elsevierStylePara elsevierViewall">En nuestro estudio existe una diferencia cl&#237;nicamente relevante&#44; sin alcanzar significaci&#243;n estad&#237;stica&#44; en la mayor aparici&#243;n de pirosis a los tres a&#241;os en aquellos pacientes a los que se les realiz&#243; una funduplicatura parcial &#40;5&#44;6 vs&#46; 14&#44;9&#37;&#59; p &#61; 0&#44;060&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">tabla 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0240" class="elsevierStylePara elsevierViewall">No se encontr&#243; diferencia estad&#237;sticamente significativa en la respuesta a los IBP&#44; el estudio de calidad de vida&#44; o recidiva de la HH&#46;</p></span></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Discusi&#243;n</span><p id="par0245" class="elsevierStylePara elsevierViewall">Mediante la correcta localizaci&#243;n de la UEG y el anclaje de las valvas que aporta la funduplicatura con disecci&#243;n extensa de la misma hemos obtenido a los tres a&#241;os de seguimiento&#44; &#237;ndices de pirosis en torno a 10&#37;&#44; regurgitaci&#243;n 7&#44;6&#37; y cl&#237;nica at&#237;pica menor a 5&#37;&#44; manteniendo las tasas de disfagia alrededor de 7&#37;&#46; La tasa de recidiva de HH fue de 9&#44;8&#37; y en m&#225;s de 80&#37; de los casos ha desaparecido la esofagitis previa&#44; mejorando todo ello la calidad de vida de los pacientes lo que queda evidenciado en una disminuci&#243;n en la mediana en la escala GERD-HRQL de 27 a 0&#46; No hemos encontrado diferencias estad&#237;sticamente significativas comparando las distintas variantes de funduplicatura&#46;</p><p id="par0250" class="elsevierStylePara elsevierViewall">El correcto posicionamiento de la funduplicatura ha contribuido a lograr bajas tasas de recidiva cl&#237;nica de reflujo&#46; Dallemagne et al&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">24</span></a>&#44; reflejan tasas de &#233;xito del control del reflujo de 93&#37; tras la funduplicatura de Nissen y 82&#37; despu&#233;s de la de Toupet&#46; En la misma l&#237;nea&#44; Luketich et al&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">25</span></a> reportan&#44; en 18 meses de seguimiento&#44; pirosis persistente en 23 y 27&#44;6&#37; y regurgitaci&#243;n en 8&#44;8 y 10&#37; de los pacientes sometidos a funduplicatura de Nissen y Toupet&#44; respectivamente&#46;</p><p id="par0255" class="elsevierStylePara elsevierViewall">Por otro lado&#44; en diversas series<a class="elsevierStyleCrossRefs" href="#bib0305"><span class="elsevierStyleSup">26&#44;27</span></a> se reportan tasas de resoluci&#243;n de la sintomatolog&#237;a at&#237;pica tras la cirug&#237;a antirreflujo menores a 50&#37;&#46;</p><p id="par0260" class="elsevierStylePara elsevierViewall">La conformaci&#243;n de la funduplicatura con las valvas ancladas entre los troncos vagales y el es&#243;fago ha contribuido probablemente a la baja tasa de HH a los tres a&#241;os de seguimiento&#46;</p><p id="par0265" class="elsevierStylePara elsevierViewall">Las altas tasas de recidiva herniaria descritas en la literatura siguen siendo poco conocidas variando entre 5 y 59&#37;<a class="elsevierStyleCrossRefs" href="#bib0315"><span class="elsevierStyleSup">28&#8211;30</span></a> y contin&#250;a siendo uno de los problemas sin resolver de esta patolog&#237;a&#46;</p><p id="par0270" class="elsevierStylePara elsevierViewall">Ning&#250;n paciente de nuestro estudio ha presentado telescopaje o malposicionamiento de la funduplicatura durante el seguimiento&#46;</p><p id="par0275" class="elsevierStylePara elsevierViewall">Horgan et al&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">31</span></a> describen hasta 16&#37; de pacientes con telescopaje &#40;hernia tipo Ib de la clasificaci&#243;n de fallos anat&#243;micos&#41; y de 6&#44;4&#37; de sujetos con malposici&#243;n &#40;hernia tipo III&#41;&#46; Pennathur et al&#46;<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">32</span></a> reflejan un malposicionamiento de las valvas sobre el cuerpo g&#225;strico en 13&#44;8&#37; de los casos en una serie de 80 cirug&#237;as de revisi&#243;n&#46;</p><p id="par0280" class="elsevierStylePara elsevierViewall">No se ha evidenciado sintomatolog&#237;a relacionada con lesiones vagales durante el seguimiento&#44; como diarrea cr&#243;nica sin otra causa comprobada o cl&#237;nica derivada del retraso en el vaciado g&#225;strico&#46;</p><p id="par0285" class="elsevierStylePara elsevierViewall">Lindeboom et al&#46;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">33</span></a> reportan lesiones del nervio vago hasta en 10&#37;&#44; aunque no siempre asociado a un retraso en el vaciado g&#225;strico&#46; Van Rijn et al&#46;<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">34</span></a> observaron&#44; del mismo modo&#44; lesiones iatrog&#233;nicas del nervio vago en 20&#37; de una serie de 125 pacientes&#44; con un retraso significativo del vaciado g&#225;strico posoperatorio en el grupo con lesi&#243;n vagal&#46;</p><p id="par0290" class="elsevierStylePara elsevierViewall">Entre las limitaciones del estudio&#44; cabe se&#241;alar&#44; en primer lugar&#44; que la recurrencia del reflujo se evalu&#243; bas&#225;ndose en la evoluci&#243;n cl&#237;nica&#44; realiz&#225;ndose pruebas funcionales de control &#250;nicamente en pacientes con sospecha cl&#237;nica de recidiva&#46; Sin embargo&#44; como se&#241;alaron Morgenthal et al&#46;<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">35</span></a>&#44; la evoluci&#243;n cl&#237;nica de los sujetos parece ser un m&#233;todo &#250;til y fiable en el seguimiento&#44; ya que &#250;nicamente 22 a 29&#37; de los sintom&#225;ticos presentaban una pHmetr&#237;a patol&#243;gica&#46;</p><p id="par0295" class="elsevierStylePara elsevierViewall">El periodo de seguimiento establecido a tres a&#241;os puede suponer otra limitaci&#243;n&#46; No obstante&#44; los estudios que eval&#250;an el &#233;xito en t&#233;rminos de control del reflujo y complicaciones de la funduplicatura sugieren que estos resultados a largo plazo se asemejan a los mostrados tres a&#241;os despu&#233;s de la cirug&#237;a<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">36</span></a>&#46;</p><p id="par0300" class="elsevierStylePara elsevierViewall">Finalmente&#44; representa una limitaci&#243;n la no utilizaci&#243;n de cuestionarios validados para la evaluaci&#243;n de los s&#237;ntomas t&#237;picos o at&#237;picos&#46; L&#243;gicamente&#44; al no usar estos&#44; no se ha podido describir con detalle las caracter&#237;sticas de la recidiva cl&#237;nica&#44; aunque s&#237; su impacto en la calidad de vida mediante el cuestionario GERD-HRQL&#46; No se emplearon&#44; asimismo&#44; herramientas espec&#237;ficas para la valoraci&#243;n de la disfagia&#46;</p><p id="par0305" class="elsevierStylePara elsevierViewall">Como conclusi&#243;n&#44; la disecci&#243;n extensa de la UEG contribuye al correcto posicionamiento y a un mejor anclaje de la funduplicatura&#44; obteni&#233;ndose tasas bajas de recidiva herniaria y de reflujo en este estudio&#46; Ninguno de los pacientes present&#243; telescopaje de la funduplicatura ni s&#237;ntomas que sugirieran lesi&#243;n vagal&#46; Nuevos estudios con un mayor n&#250;mero de participantes y un seguimiento m&#225;s prolongado nos permitir&#225;n obtener hallazgos m&#225;s s&#243;lidos y concretos acerca de los resultados de la t&#233;cnica&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Financiaci&#243;n</span><p id="par0310" class="elsevierStylePara elsevierViewall">Este trabajo no ha recibido ning&#250;n tipo de financiaci&#243;n&#46;</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Conflicto de inter&#233;s</span><p id="par0315" class="elsevierStylePara elsevierViewall">Los autores declaran no tener ning&#250;n conflicto de intereses&#46;</p></span></span>"
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            1 => "Hiatal hernia"
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    "resumen" => array:2 [
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Introducci&#243;n</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">La cirug&#237;a antirreflujo se asocia con frecuencia a tasas significativas de recurrencia y complicaciones&#44; habi&#233;ndose propuesto varias t&#233;cnicas quir&#250;rgicas para minimizarlas&#46; El objetivo del estudio es evaluar los resultados a tres a&#241;os de una funduplicatura con disecci&#243;n extensa de la uni&#243;n esofagog&#225;strica &#40;UEG&#41;&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">M&#233;todos</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Estudio observacional retrospectivo que incluy&#243; a 178 pacientes con enfermedad por reflujo gastroesof&#225;gico &#40;ERGE&#41; o hernia de hiato &#40;HH&#41; a los que se les realiz&#243; una funduplicatura con disecci&#243;n extensa de la UEG entre 2015 y 2020&#46; La recidiva herniaria&#44; los s&#237;ntomas y la calidad de vida al primer a&#241;o y a los tres siguientes de la cirug&#237;a fueron evaluados mediante tr&#225;nsito baritado&#44; endoscopia y cuestionarios para s&#237;ntomas y calidad de vida &#40;<span class="elsevierStyleItalic">Gastro Esophageal Reflux Disease-Health Related Quality of Life</span> &#91;GERD-HRQL&#93;&#41;&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Resultados</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">La tasa de pirosis fue de 7&#44;5 y 10&#44;7&#37; al a&#241;o y a los tres siguientes&#44; respectivamente&#44; regurgitaci&#243;n de 3&#44;8 y 6&#44;9&#37; y disfagia de 3&#44;7 y 7&#44;6&#37;&#46; La presencia de hernia hiatal se evidenci&#243; preoperatoriamente en 55&#44;1&#37; y en 7&#44;8 y 9&#44;6&#37; en el seguimiento y la mediana de la escala GERD-HRQL fue de 27&#44; 2 y 0&#44; respectivamente&#46; No aparecieron casos de telescopaje de la funduplicatura ni s&#237;ntomas que sugieran lesi&#243;n vagal&#46; No se encontraron diferencias al comparar los distintos tipos de funduplicatura en t&#233;rminos de recidiva del reflujo&#44; complicaciones o recurrencia de la hernia&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conclusiones</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La funduplicatura con disecci&#243;n extensa de la UEG contribuye a su correcto posicionamiento y mejor anclaje&#44; lo que asocia bajas tasas de recidiva herniaria y del reflujo&#44; as&#237; como disminuye la posibilidad de telescopaje y lesi&#243;n vagal&#46;</p></span>"
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        "resumen" => "<span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Introduction</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Antireflux surgery is commonly associated with significant recurrence and complication rates&#44; and several surgical techniques have been proposed to minimize them&#46; The aim of this study is to evaluate the results of a fundoplication with extensive dissection of the esophagogastric junction 1 and 3 years after the procedure&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Methods</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Retrospective observational study including 178 patients with gastroesophageal reflux disease or hiatal hernia who underwent fundoplication with extensive dissection of the esophagogastric junction between 2015 and 2020&#46; Hernia recurrence&#44; symptoms and quality of life at 1 and 3 years after surgery were assessed by barium transit&#44; endoscopy and questionnaires for symptoms and quality of life &#40;GERD-HRQL&#41;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Results</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Heartburn rate was 7&#46;5&#37; and 10&#46;7&#37; at 1 and 3 years respectively&#44; regurgitation 3&#46;8&#37; and 6&#46;9&#37; and dysphagia was 3&#46;7&#37; and 7&#46;6&#37;&#46; The presence of hiatal hernia was evident preoperatively in 55&#46;1&#37; and in 7&#46;8&#37; and 9&#46;6&#37; at follow-up and the median GERD-HRQL scale was 27&#44; 2 and 0&#44; respectively&#46; There were no cases of slippage of the fundoplication or symptoms suggestive of vagal injury&#46; No differences were found when comparing the different types of fundoplication in terms of reflux and recurrence or complications&#46;</p></span> <span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Conclusions</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Fundoplication with extensive dissection of the esophagogastric junction contributes to correct positioning and better anchorage of the fundoplication&#44; which is associated with low rates of hiatal hernia and reflux recurrence&#44; as well as absence of slippage and lower possibility of vagal injury&#46;</p></span>"
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                  \t\t\t\t\tvoid\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">n &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Edad</span><a class="elsevierStyleCrossRef" href="#tblfn0005">&#42;</a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">53&#44;5 &#40;14&#44;2&#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="elsevierStyleItalic">Sexo &#40;femenino&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">93 &#40;52&#44;2&#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="elsevierStyleItalic">EPOC</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 &#40;1&#44;7&#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="elsevierStyleItalic">Alcohol</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7 &#40;3&#44;9&#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
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                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">31 &#40;17&#44;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"><span class="elsevierStyleItalic">Diabetes</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">15 &#40;8&#44;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"><span class="elsevierStyleItalic">HTA</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">39 &#40;21&#44;9&#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="elsevierStyleItalic">Insuficiencia cardiaca</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;1&#44;1&#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="elsevierStyleItalic">Cardiopat&#237;a isqu&#233;mica</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5 &#40;2&#44;8&#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="elsevierStyleItalic">IMC</span><a class="elsevierStyleCrossRef" href="#tblfn0005">&#42;</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">26&#44;4 &#40;3&#44;6&#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="elsevierStyleItalic">Obesidad &#40;SEEDO&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" 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 " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Sobrepeso&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">85 &#40;48&#44;6&#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>Obesidad grado 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">35 &#40;20&#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>Obesidad grado 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">1 &#40;0&#44;6&#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="elsevierStyleItalic">Clasificaci&#243;n ASA&#58;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" 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 " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>ASA 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">44 &#40;24&#44;7&#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>ASA 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">111 &#40;62&#44;3&#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>ASA 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">23 &#40;12&#44;9&#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="elsevierStyleItalic">Hernia de hiato&#58;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" 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 " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Tipo 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">56 &#40;36&#44;3&#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>Tipo 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">2 &#40;1&#44;3&#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>Tipo 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">25 &#40;16&#44;2&#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>Tipo IV&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;1&#44;3&#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>Recidiva herniaria&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;4&#44;5&#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="elsevierStyleItalic">Esofagitis&#58;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" 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 " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Grado A&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">20 &#40;11&#44;5&#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>Grado B&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">19 &#40;10&#44;9&#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>Grado C&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;2&#44;2&#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>Grado D&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;1&#44;1&#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>Es&#243;fago de Barrett&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;10&#44;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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              "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Expresado como media &#40;desviaci&#243;n est&#225;ndar&#41;</p>"
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          ]
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          "es" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Caracter&#237;sticas demogr&#225;ficas de los pacientes</p>"
        ]
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        "etiqueta" => "Tabla 2"
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          0 => array:3 [
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            0 => array:2 [
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                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">Sintomatolog&#237;a&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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Pre &#40;n &#61; 178&#41;n &#40;&#37;&#41;&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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Mes &#40;n &#61; 178&#41;n &#40;&#37;&#41;&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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">A&#241;o &#40;n &#61; 160&#41;n &#40;&#37;&#41;&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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">3 a&#241;os &#40;n &#61; 158&#41;n &#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">Disfagia&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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">24 &#40;13&#44;5&#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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">36 &#40;20&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6 &#40;3&#44;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12 &#40;7&#44;6&#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">Pirosis&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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">166 &#40;93&#44;3&#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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10 &#40;5&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12 &#40;7&#44;5&#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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">17 &#40;10&#44;7&#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">Regurgitaci&#243;n&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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">127 &#40;71&#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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;1&#44;2&#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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6 &#40;3&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12 &#40;6&#44;9&#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">Laringitis&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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">22 &#40;12&#44;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 &#40;1&#44;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 &#40;1&#44;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;1&#44;2&#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">Tos&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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">17 &#40;9&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 &#40;1&#44;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;1&#44;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8 &#40;5&#44;1&#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="elsevierStyleItalic">Gas bloat</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" 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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16 &#40;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14 &#40;8&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">18 &#40;11&#44;3&#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">Disnea&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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12 &#40;6&#44;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;0&#44;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">19 &#40;10&#44;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&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">Dolor abdominal&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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">33 &#40;18&#44;5&#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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6 &#40;3&#44;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10 &#40;6&#44;3&#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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">21 &#40;13&#44;2&#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">Dolor tor&#225;cico&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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13 &#40;7&#44;3&#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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5 &#40;2&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 &#40;1&#44;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4 &#40;2&#44;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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                0 => "xTab3436192.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "es" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">S&#237;ntomas presentados preoperatoriamente&#44; al primer mes&#44; al a&#241;o y a los 3 a&#241;os de seguimiento</p>"
        ]
      ]
      5 => array:8 [
        "identificador" => "tbl0015"
        "etiqueta" => "Tabla 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at3"
            "detalle" => "Tabla "
            "rol" => "short"
          ]
        ]
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">&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  " colspan="3" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Preoperatorio &#40;n &#61; 178&#41;n &#40;&#37;&#41;</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="3" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">1 a&#241;o &#40;n &#61; 160&#41;n &#40;&#37;&#41;</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="3" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">3 a&#241;os &#40;n &#61; 158&#41;n &#40;&#37;&#41;</th></tr><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">320&#176;&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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Toupet&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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">p&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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">320&#176;&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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Toupet&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="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">p&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="center" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">320&#176;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Toupet&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">89 &#40;91&#44;8&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">67 &#40;94&#44;4&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">71 &#40;97&#44;2&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">3 &#40;3&#44;2&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Laringitis&#58;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Tos cr&#243;nica&#58;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">69 &#40;97&#44;2&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>S&#237;&nbsp;\t\t\t\t\t\t\n
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