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Características clínicas y resultados postoperatorios de los pacientes con antecedentes de enfermedad por coronavirus (COVID-19) sometidos a intervenciones quirúrgicas torácicas
Clinical features and postoperative outcomes of patients with history of COVID-19 undergoing thoracic surgery
María Teresa Gómez Hernándeza,b,c,
Autor para correspondencia
mtgh@usal.es

Autor para correspondencia.
, Clara Forcada Barredaa, Nuria M. Novoa Valentína,b,c, Marta G. Fuentes Gagoa,b,c, Marcelo F. Jiménez Lópeza,b,c
a Servicio de Cirugía Torácica, Hospital Universitario de Salamanca, Salamanca, España
b Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, España
c Universidad de Salamanca, Salamanca, España
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Varios estudios han demostrado un mayor riesgo de la mortalidad y de las complicaciones respiratorias postoperatorias en pacientes tratados mediante intervenciones quir&#250;rgicas en el contexto de una infecci&#243;n perioperatoria por coronavirus tipo 2 causante del s&#237;ndrome respiratorio severo &#40;SARS-CoV-2&#41;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1-3</span></a>&#46; En el caso de resecciones pulmonares anat&#243;micas por c&#225;ncer&#44; Gonfiotti et al&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> describieron una morbilidad postoperatoria del 60&#37; y una mortalidad del 40&#37; tras analizar los resultados de 5 pacientes intervenidos de forma concomitante con la infecci&#243;n por SARS-CoV-2&#46; Sin embargo&#44; no existen datos sobre los resultados postoperatorios de los pacientes tratados mediante intervenciones quir&#250;rgicas tor&#225;cicas tras haber superado la infecci&#243;n&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Nuestro estudio tiene como objetivo describir las caracter&#237;sticas cl&#237;nicas y los resultados postoperatorios de los pacientes con antecedentes de infecci&#243;n por SARS-CoV-2 documentada tratados mediante intervenciones quir&#250;rgicas tor&#225;cicas&#46; Para ello&#44; se realiz&#243; una revisi&#243;n retrospectiva de los registros de todos los pacientes consecutivos tratados mediante intervenciones quir&#250;rgicas tor&#225;cicas entre abril del 2020 y julio del 2021 &#40;16 meses&#41; en nuestro centro&#46; Durante el per&#237;odo de estudio fueron intervenidos un total de 653 pacientes&#44; de los que un 7&#37; &#40;46 pacientes&#41; ten&#237;an antecedentes de enfermedad por coronavirus &#40;COVID-19&#41; documentada mediante PCR y resuelta en el momento de la cirug&#237;a&#46; En la <a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a> se detallan las caracter&#237;sticas cl&#237;nico-demogr&#225;ficas y los resultados postoperatorios de estos pacientes&#46; El tiempo m&#237;nimo transcurrido entre el diagn&#243;stico de la infecci&#243;n y la cirug&#237;a en casos sintom&#225;ticos intervenidos de forma programada fue de 65 d&#237;as&#46; En el 39&#44;1&#37; de los pacientes intervenidos&#44; el hallazgo de la lesi&#243;n tor&#225;cica subsidiaria de cirug&#237;a fue incidental debido a los estudios realizados en el contexto de la infecci&#243;n por SARS-CoV-2&#46; Sin embargo&#44; si consideramos &#250;nicamente los pacientes con infecci&#243;n sintom&#225;tica por SARS-CoV-2&#44; el porcentaje aumenta al 47&#44;2&#37; &#40;17&#47;36&#41;&#46; Siete pacientes requirieron una intervenci&#243;n quir&#250;rgica urgente derivada de la COVID-19 por neumot&#243;rax con fuga a&#233;rea prolongada&#44; empiema&#44; estenosis traqueal y hematoma de pared&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Por otro lado&#44; dado que el SARS-CoV-2 puede ocasionar un importante da&#241;o pulmonar y que la severidad de dicho da&#241;o est&#225; directamente relacionada con la gravedad de la infecci&#243;n<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a>&#44; se llev&#243; a cabo un an&#225;lisis del subgrupo de pacientes con antecedente de COVID-19 tratados mediante resecciones pulmonares electivas por sospecha o diagn&#243;stico de neoplasia&#46; Se analizaron 26 pacientes&#44; de los que 12 requirieron ingreso hospitalario &#40;10 en &#225;reas de hospitalizaci&#243;n y 2 en unidades de Cuidados Intensivos&#41; para el tratamiento de la infecci&#243;n&#46; En la <a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a> se describen las principales caracter&#237;sticas cl&#237;nicas y los resultados postoperatorios de este grupo de pacientes&#46; El tiempo m&#237;nimo transcurrido entre el diagn&#243;stico de la infecci&#243;n en pacientes sintom&#225;ticos y la cirug&#237;a fue de 66 d&#237;as&#46; En 12 de los 20 pacientes tratados mediante resecci&#243;n pulmonar tras COVID-19 sintom&#225;tica&#44; los estudios realizados en el contexto de la infecci&#243;n llevaron al hallazgo incidental de una lesi&#243;n pulmonar indicativa de malignidad&#44; que result&#243; ser un carcinoma pulmonar en 10 casos&#46; Ocho pacientes presentaron adherencias intensas en la cirug&#237;a&#46; El an&#225;lisis histol&#243;gico final no mostr&#243; alteraciones relacionadas con la COVID-19 en ning&#250;n caso&#46; Siete pacientes presentaron complicaciones postoperatorias consistentes en&#58; neumon&#237;a &#40;un caso&#41;&#44; derrame pleural &#40;un caso&#41;&#44; neumot&#243;rax &#40;2 casos&#41;&#44; arritmia &#40;un caso&#41;&#44; insuficiencia renal &#40;un caso&#41; y hemot&#243;rax &#40;2 casos&#41;&#59; estos 2<span class="elsevierStyleHsp" style=""></span>&#250;ltimos precisaron reintervenci&#243;n quir&#250;rgica&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Nuestro estudio estim&#243; una prevalencia de antecedentes de COVID-19 en pacientes tratados mediante cirug&#237;as tor&#225;cicas del 7&#37;&#46; Sin embargo&#44; dado el elevado porcentaje de pacientes con infecci&#243;n asintom&#225;tica por el virus<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a>&#44; es muy probable que esta prevalencia sea considerablemente m&#225;s alta&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">En nuestra serie&#44; el tiempo m&#237;nimo transcurrido entre el diagn&#243;stico de la infecci&#243;n y la cirug&#237;a programada en pacientes con COVID-19 sintom&#225;tica fue de 65 d&#237;as &#40;&#8776; 9 semanas&#41;&#46; Las recomendaciones actuales establecen una demora m&#237;nima de la cirug&#237;a de al menos 7 semanas desde el diagn&#243;stico de la infecci&#243;n<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a>&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Por otro lado&#44; uno de los resultados m&#225;s relevantes del presente estudio es que en el 47&#44;2&#37; de los pacientes operados tras la infecci&#243;n sintom&#225;tica por el virus&#44; el hallazgo de la lesi&#243;n objeto de la cirug&#237;a fue incidental debido a los estudios realizados en el contexto de la COVID-19&#46; En este sentido&#44; Kilsdonk et al&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> describen una frecuencia de hallazgos incidentales del 54&#37; en pacientes a los que se les realiz&#243; una tomograf&#237;a computarizada como herramienta de triaje de la infecci&#243;n por COVID-19&#46; En un 3&#37; de los casos de su serie&#44; el hallazgo incidental consisti&#243; en n&#243;dulos pulmonares&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">El an&#225;lisis histol&#243;gico de las piezas de resecci&#243;n pulmonar no mostr&#243; alteraciones significativas relacionadas con la COVID-19&#44; indicando que es posible una completa recuperaci&#243;n tras la infecci&#243;n&#46; Estos hallazgos son similares a los descritos por Diaz et al&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> que no encontraron cambios histopatol&#243;gicos que sugirieran da&#241;o pulmonar permanente tras analizar las piezas de resecci&#243;n de 11 pacientes tratados mediante resecci&#243;n pulmonar electiva tras recuperarse de la infecci&#243;n por SARS-CoV-2&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Finalmente&#44; los resultados postoperatorios de la serie global muestran una prevalencia de efectos adversos postoperatorios aceptable&#44; con nula mortalidad y una prevalencia de complicaciones pulmonares postoperatorias del 13&#37; en la serie global y del 15&#44;4&#37; en los pacientes tratados mediante resecci&#243;n pulmonar&#44; inferior a la descrita en grandes series nacionales<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a>&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Financiaci&#243;n</span><p id="par0045" class="elsevierStylePara elsevierViewall">Los autores declaran que no han recibido ning&#250;n tipo de financiaci&#243;n en relaci&#243;n con el contenido del presente manuscrito&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Autor&#237;a</span><p id="par0050" class="elsevierStylePara elsevierViewall">Concepci&#243;n del estudio y dise&#241;o&#58; MTGH&#44; MFJL&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Adquisici&#243;n de los datos&#58; MTGH&#44; MFJL&#44; MGFG&#44; NMNV&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">An&#225;lisis e interpretaci&#243;n de los datos&#58; MTGH&#44; MFJL&#44; NMNV&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Redacci&#243;n del manuscrito y revisi&#243;n cr&#237;tica del contenido&#58; MTGH&#44; NMNV&#44; MFJL&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Aprobaci&#243;n final del manuscrito&#58; MTGH&#44; CF&#44; NMNV&#44; MGFG&#44; MFJL&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflicto de intereses</span><p id="par0075" class="elsevierStylePara elsevierViewall">Los autores declaran que no existe ning&#250;n conflicto de inter&#233;s en relaci&#243;n con el contenido del presente manuscrito&#46;</p></span></span>"
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                  \t\t\t\t">29 &#40;63&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">10 &#40;21&#44;7&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Cribado preoperatorio&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">14&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
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                  \t\t\t\t">10&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">13&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
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">5&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
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                  \t\t\t\t"><span class="elsevierStyleBold">Cirug&#237;a urgente&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">7 &#40;15&#44;2&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Neumot&#243;rax</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">3&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
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \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  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8 &#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
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleBold">Intervalo de tiempo entre el diagn&#243;stico de infecci&#243;n por SARS-CoV-2 y la cirug&#237;a&#44; mediana &#40;RIQ&#41;&#44; d&#237;as</span>&nbsp;\t\t\t\t\t\t\n
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                  \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><span class="elsevierStyleHsp" style=""></span>Cribado preoperatorio&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&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><span class="elsevierStyleHsp" style=""></span>Rastreo de contactos&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&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><span class="elsevierStyleItalic">COVID-19</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">20 &#40;76&#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><span class="elsevierStyleHsp" style=""></span>Manejo ambulatorio&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&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><span class="elsevierStyleHsp" style=""></span>Ingreso hospitalario&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&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><span class="elsevierStyleHsp" style=""></span>Ingreso en UCI&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&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="elsevierStyleBold">Tipo de cirug&#237;a&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \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><span class="elsevierStyleItalic">Neumonectom&#237;a</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;7&#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><span class="elsevierStyleItalic">Bilobectom&#237;a</span>&nbsp;\t\t\t\t\t\t\n
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                  \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;3&#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="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Lobectom&#237;a</span>&nbsp;\t\t\t\t\t\t\n
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                  \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&#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><span class="elsevierStyleItalic">Segmentectom&#237;a</span>&nbsp;\t\t\t\t\t\t\n
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                  \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;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><span class="elsevierStyleItalic">Wedge</span>&nbsp;\t\t\t\t\t\t\n
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                  \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;26&#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
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                  \t\t\t\t"><span class="elsevierStyleBold">Diagn&#243;stico&#44; n &#40;&#37;&#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
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                  \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><span class="elsevierStyleItalic">Carcinoma de pulm&#243;n</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">16 &#40;61&#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><span class="elsevierStyleItalic">Met&#225;stasis pulmonar</span>&nbsp;\t\t\t\t\t\t\n
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                  \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;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><span class="elsevierStyleItalic">Otros</span>&nbsp;\t\t\t\t\t\t\n
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                  \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;26&#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="elsevierStyleBold">Mortalidad a 30 d&#237;as&#44; n &#40;&#37;&#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">0 &#40;0&#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="elsevierStyleBold">Morbilidad postoperatoria&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \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;26&#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="elsevierStyleBold">Complicaciones respiratorias&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \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&#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="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Neumon&#237;a</span>&nbsp;\t\t\t\t\t\t\n
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                  \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&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><span class="elsevierStyleItalic">Neumot&#243;rax</span>&nbsp;\t\t\t\t\t\t\n
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                  \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&nbsp;\t\t\t\t\t\t\n
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                  \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><span class="elsevierStyleItalic">Derrame pleural</span>&nbsp;\t\t\t\t\t\t\n
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                  \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&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="elsevierStyleBold">Reintervenci&#243;n&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \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&#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><span class="elsevierStyleItalic">Hemot&#243;rax</span>&nbsp;\t\t\t\t\t\t\n
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                  \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&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="elsevierStyleBold">Estancia postoperatoria&#44; mediana &#40;RIQ&#41;&#44; d&#237;as</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">3 &#40;2-4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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        "descripcion" => array:1 [
          "es" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Caracter&#237;sticas cl&#237;nicas y demogr&#225;ficas&#44; contexto diagn&#243;stico de la infecci&#243;n y resultados postoperatorios de los pacientes con antecedentes de COVID-19 sometidos a resecci&#243;n pulmonar programada</p>"
        ]
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      "titulo" => "Bibliograf&#237;a"
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        0 => array:2 [
          "identificador" => "bibs0015"
          "bibliografiaReferencia" => array:10 [
            0 => array:3 [
              "identificador" => "bib0055"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:1 [
                  "referenciaCompleta" => "Cardiothoracic Interdisciplinary Research Network and COVID Surg Collaborative&#46; Early outcomes and complications following cardiac surgery in patients testing positive for coronavirus disease 2019&#58; An international cohort study&#46; J Thorac Cardiovasc Surg&#46; 2021&#59;162&#40;2&#41;&#58;e355-372&#46;"
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              "identificador" => "bib0060"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Perioperative SARS-CoV-2 infections increase mortality&#44; pulmonary complications&#44; and thromboembolic events&#58; A Dutch&#44; multicenter&#44; matched-cohort clinical study"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "P&#46;K&#46;C&#46; Jonker"
                            1 => "W&#46;Y&#46; van der Plas"
                            2 => "P&#46;J&#46; Steinkamp"
                            3 => "R&#46; Poelstra"
                            4 => "M&#46; Emous"
                            5 => "W&#46; van der Meij"
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                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Surgery&#46;"
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              "identificador" => "bib0065"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:1 [
                  "referenciaCompleta" => "COVID Surg Collaborative&#46; Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection&#58; An international cohort study&#46; Lancet Lond Engl&#46; 2020&#59;396&#40;10243&#41;&#58;27-38&#46;"
                ]
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            3 => array:3 [
              "identificador" => "bib0070"
              "etiqueta" => "4"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Clinical courses and outcomes of five patients with primary lung cancer surgically treated while affected by severe acute respiratory syndrome coronavirus 2"
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "A&#46; Gonfiotti"
                            1 => "L&#46; Gatteschi"
                            2 => "A&#46; Salvicchi"
                            3 => "S&#46; Bongiolatti"
                            4 => "F&#46; Lavorini"
                            5 => "L&#46; Voltolini"
                          ]
                        ]
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                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Eur J Cardio-Thorac Surg Off J Eur Assoc Cardio-Thorac Surg&#46;"
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                      ]
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                      "titulo" => "Pulmonary pathology and COVID-19&#58; Lessons from autopsy&#46; The experience of European Pulmonary Pathologists"
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                          "etal" => true
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