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Textbook outcome en colecistectomía. ¿Es útil esta herramienta en una intervención con baja tasa de morbilidad?
The textbook outcome for cholecystectomy: is it a good quality tool for a low-morbidity procedure?
David Hernández-Bermejoa,
Autor para correspondencia
david.hdezb@hotmail.com

Autor para correspondencia.
, Celia García-Vegaa, Juan Jesús Rubio-Garcíaa,b, Celia Villodre-Tudelaa,b,c, Silvia Carbonell-Morotea,b, José Manuel Ramiaa,b,c
a Departamento de Cirugía, Hospital General Universitario Dr. Balmis, Alicante, España
b ISABIAL: Instituto de Investigación Sanitaria y Biomédica, Alicante, España
c Departamento de Patología y Cirugía, Universidad Miguel Hernández, Campus Sant Joan, Alicante, España
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El abordaje laparosc&#243;pico se ha convertido en el patr&#243;n oro&#44; ya que es factible&#44; seguro&#44; con muy baja morbilidad y una mortalidad menor del 0&#44;1&#37;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">3</span></a>&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Hoy en d&#237;a&#44; existe una demanda creciente&#44; tanto en el sector sanitario como de la propia poblaci&#243;n&#44; de mejorar el conocimiento de los resultados&#44; la eficacia y la eficiencia de los centros sanitarios&#44; y saber qu&#233; hospitales ofrecen atenci&#243;n y resultados ejemplares&#46; En 2013 Kolfschoten et al&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">4</span></a> propusieron una nueva herramienta denominada <span class="elsevierStyleItalic">textbook outome</span> &#40;TO&#41;&#44; como un nuevo indicador de calidad asistencial&#46; Esta herramienta&#44; que principalmente se utiliza en la actualidad en procedimientos oncol&#243;gicos&#44; es obtenida al sumar varios par&#225;metros de resultados deseados a corto plazo en la atenci&#243;n posoperatoria&#58; que no existan complicaciones posoperatorias graves&#44; sin prolongaci&#243;n de la estancia hospitalaria posoperatoria&#44; sin mortalidad y sin reingresos&#46; Para conseguir ser clasificado como TO&#44; se deben cumplir todos los par&#225;metros citados&#44; obteniendo el porcentaje de pacientes para los que se han logrado todos los resultados posoperatorios sanitarios ideales<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">4</span></a>&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">El objetivo principal de este estudio es determinar el TO para colecistectom&#237;a global&#44; as&#237; como las caracter&#237;sticas y factores de riesgo que influyen en su consecuci&#243;n&#44; ya que existe muy escasa informaci&#243;n sobre la determinaci&#243;n en pacientes colecistectomizados&#46; Como objetivos secundarios hemos dividido la muestra seg&#250;n cirug&#237;a urgente y programada para estudiar las diferencias&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">M&#233;todos</span><p id="par0025" class="elsevierStylePara elsevierViewall">Estudio retrospectivo unic&#233;ntrico de pacientes intervenidos de colecistectom&#237;a entre enero de 2018 y diciembre 2020 en un hospital terciario&#46; Los datos de los pacientes se obtuvieron de los registros de informaci&#243;n y expedientes cl&#237;nicos hospitalarios&#46; La aprobaci&#243;n del estudio fue realizada por los comit&#233;s de investigaci&#243;n&#44; &#233;tica y bioseguridad del hospital&#46; &#40;CEIM PI2022-093&#41;&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Los criterios de inclusi&#243;n fueron&#58; pacientes sometidos a colecistectom&#237;a en el periodo de estudio&#46; Se consideraron criterios de exclusi&#243;n&#58; colecistectom&#237;a combinada con otros procedimientos quir&#250;rgicos&#44; enfermedad oncol&#243;gica activa de cualquier &#237;ndole en el momento de la intervenci&#243;n&#44; hallazgos de malignidad en la pieza quir&#250;rgica&#44; y reingresos programados en los primeros 90 d&#237;as posoperatorios por otras patolog&#237;as no relacionadas&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Se registraron diversas variables tras analizar las historias de los pacientes seleccionados&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">-</span><p id="par0040" class="elsevierStylePara elsevierViewall">Variables o datos preoperatorios&#44; se recogieron&#58; edad&#44; sexo y comorbilidades del paciente seg&#250;n la escala de la Asociaci&#243;n Americana de Anestesiolog&#237;a &#40;ASA&#41;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">5</span></a>&#44; tipo de patolog&#237;a biliar presente y colangiopancreatograf&#237;a retr&#243;grada endosc&#243;pica &#40;CPRE&#41; previa&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">-</span><p id="par0045" class="elsevierStylePara elsevierViewall">Datos quir&#250;rgicos&#44; se recogieron&#58; la patolog&#237;a biliar que precis&#243; la colecistectom&#237;a &#40;colelitiasis&#44; colecistitis&#44; pancreatitis de origen biliar&#44; colangitis de origen biliar&#44; coledocolitiasis simple&#44; p&#243;lipos vesiculares y otros&#41;&#44; la cirug&#237;a realizada&#44; el tipo de cirug&#237;a &#40;urgente&#47;programada&#41;&#44; la v&#237;a de abordaje &#40;abierta&#47;laparosc&#243;pica&#47;conversi&#243;n&#41; y la dificultad t&#233;cnica de la cirug&#237;a recopilada del protocolo quir&#250;rgico realizado por el cirujano &#40;descripci&#243;n indicativa de una cirug&#237;a dif&#237;cil&#44; seg&#250;n la aparici&#243;n de uno o varios de los siguientes hallazgos intraoperatorios&#58; disecci&#243;n dificultosa de hilio hep&#225;tico&#44; ves&#237;cula escleroatr&#243;fica o gangrenosa&#44; plastr&#243;n o absceso perivesicular&#44; adherencias firmes&#44; no buena visualizaci&#243;n de las estructuras del tri&#225;ngulo hepatoc&#237;stico&#44; anatom&#237;a inusual del conducto c&#237;stico&#44; s&#237;ndrome de Mirizzi&#44; sangrado quir&#250;rgico con necesidad de uso de hemost&#225;ticos y&#47;o drenajes&#44; o cualquier otra caracter&#237;stica puntual del periodo intraoperatorio que aumentase el tiempo quir&#250;rgico o dificultad habituales&#41;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">-</span><p id="par0050" class="elsevierStylePara elsevierViewall">Resultados posquir&#250;rgicos&#44; se evaluaron&#58; las complicaciones posquir&#250;rgicas&#44; siguiendo la clasificaci&#243;n de Clavien-Dindo<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">6</span></a>&#59; los reingresos&#44; siguiendo la clasificaci&#243;n de Rana et al&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">7</span></a> &#40;causas quir&#250;rgicas biliares&#44; causas quir&#250;rgicas no biliares y causas no quir&#250;rgicas&#41; tomando como punto de corte los 90 d&#237;as&#59; y la mortalidad&#46;</p></li></ul></p><p id="par0055" class="elsevierStylePara elsevierViewall">Definimos como TO a los pacientes que cumplieron las siguientes premisas&#58; complicaciones menores de III seg&#250;n la clasificaci&#243;n de Clavien-Dindo &#40;definidas como&#58; cualquier complicaci&#243;n que requiera intervenci&#243;n quir&#250;rgica&#44; radiol&#243;gica o endosc&#243;pica&#59; complicaciones graves que requieran ingreso en Unidad de Cuidados Intensivos &#91;UCI&#93;&#59; o fallecimiento&#41;&#44; una estancia posquir&#250;rgica menor del percentil 75 &#40;&#60; 3 d&#237;as&#41; y no reingresos ni mortalidad en los primeros 90 d&#237;as tras la cirug&#237;a&#44; fijando como l&#237;mite los 90 d&#237;as&#44; para tener en cuenta las complicaciones y reingresos tard&#237;os&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">El an&#225;lisis estad&#237;stico se realiz&#243; con el programa Statistics IBM&#174; SPSS 25 &#40;IBM&#44; Armonk&#44; Nueva York&#44; Estados Unidos&#41;&#46; Se comprob&#243; la distribuci&#243;n no normal de las variables cuantitativas mediante la prueba de normalidad de Kolmogorov-Smirnov&#44; que se presentaron como mediana y rango intercuart&#237;lico &#40;IQR&#41;&#46; Para facilitar el an&#225;lisis estad&#237;stico&#44; las variables cuantitativas se recodificaron en variables cualitativas categ&#243;ricas&#44; utilizando como punto de corte la mediana&#46; En cuanto a las variables cualitativas&#44; se expresaron en forma de porcentajes&#46; Se crearon dos cohortes en cuanto a la consecuci&#243;n del TO&#46; Para la comparaci&#243;n de los grupos&#44; se utiliz&#243; la prueba estad&#237;stica <span class="elsevierStyleItalic">X</span><span class="elsevierStyleSup"><span class="elsevierStyleItalic">2</span></span> o el test <span class="elsevierStyleItalic">F</span> de Fisher&#44; mediante la creaci&#243;n de tablas de contingencia&#46; Por &#250;ltimo&#44; se realiz&#243; un an&#225;lisis de regresi&#243;n log&#237;stica &#40;an&#225;lisis univariado y multivariado&#41; para predecir el resultado de nuestras variables categ&#243;ricas en funci&#243;n de otras variables independientes o predictoras&#44; y as&#237; encontrar factores de riesgo o protectores de la probabilidad de ocurrencia de un evento&#44; que expresaremos en forma de <span class="elsevierStyleItalic">odds ratio</span> &#40;OR&#41; y sus correspondientes intervalos de confianza al 95&#37; &#40;IC 95&#37;&#41;&#46; Se consider&#243; como estad&#237;sticamente significativa un grado de significaci&#243;n &#40;p &#60;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#41;&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Resultados</span><p id="par0065" class="elsevierStylePara elsevierViewall">Se revisaron un total de 535 pacientes durante el periodo seleccionado&#46; Tras aplicar los criterios de exclusi&#243;n&#44; nuestra muestra cont&#243; finalmente con 475 pacientes&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">En cuanto a las caracter&#237;sticas de la muestra &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#41;&#44; est&#225; formada por 207 varones &#40;43&#44;6&#37;&#41; y 268 mujeres &#40;56&#44;4&#37;&#41;&#46; La mediana de edad de los pacientes fue de 63 a&#241;os &#40;IQR 50-73&#41;&#44; con una edad m&#237;nima de 17 a&#241;os y m&#225;xima de 93&#46; Seg&#250;n la escala de la ASA&#44; la mayor&#237;a de los pacientes &#40;48&#37;&#41; presentan un ASA II&#44; y hasta el 75&#44;2&#37; un ASA menor de III&#46; La patolog&#237;a m&#225;s frecuente por la que se indic&#243; la colecistectom&#237;a fue la colecistitis &#40;46&#44;1&#37;&#41;&#44; seguida de la colelitiasis &#40;30&#44;7&#37;&#41;&#46; El tipo de cirug&#237;a fue en un 52&#37; de las ocasiones realizada de forma electiva&#46; El abordaje m&#225;s frecuentemente utilizado fue el laparosc&#243;pico&#44; en un 86&#44;5&#37; de las intervenciones&#46; La tasa de conversi&#243;n total fue del 6&#44;1&#37;&#46; A 53 &#40;11&#44;2&#37;&#41; se les realiz&#243; una CPRE previa a la colecistectom&#237;a&#46; Del total&#44; 160 pacientes &#40;33&#44;7&#37;&#41; presentaron una colecistectom&#237;a dif&#237;cil seg&#250;n nuestra clasificaci&#243;n&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">En cuanto a resultados posoperatorios&#44; 43 pacientes &#40;9&#44;1&#37;&#41; presentaron complicaciones mayores Clavien-Dindo &#8805; IIIa&#46; El percentil 75 de la estancia posquir&#250;rgica fue de tres d&#237;as&#44; consiguiendo una estancia menor de tres d&#237;as el 78&#44;1&#37; de los pacientes&#46; La tasa de reingresos a los 90 d&#237;as fue del 13&#44;1&#37;&#44; presentando una tasa de mortalidad del 1&#44;3&#37;&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">En nuestra serie&#44; conseguimos clasificar como TO a 342 pacientes &#40;72&#37;&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>&#41;&#46; Como podemos observar&#44; los pacientes m&#225;s propensos a conseguir estos objetivos son aquellos de sexo femenino &#40;59&#44;6&#37; mujeres vs&#46; 40&#44;4&#37; hombres&#41;&#44; con una edad menor de 63 a&#241;os &#40;54&#44;1&#37;&#41; y con un ASA &#60;<span class="elsevierStyleHsp" style=""></span>III &#40;81&#44;6&#37;&#41;&#46; Con respecto al motivo de indicaci&#243;n de la cirug&#237;a&#44; vemos que la mayor diferencia la encontramos en cuanto a la colecistitis aguda&#44; en el que el 62&#44;4&#37; de los pacientes que no consiguieron un TO fueron intervenidos por dicha indicaci&#243;n&#46; Por otro lado&#44; la cirug&#237;a realizada de manera urgente influye en la no consecuci&#243;n de un TO &#40;40&#44;4&#37; TO vs&#46; 59&#44;6&#37; TO en cirug&#237;a programada&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">En cuanto a las variables intraoperatorias&#44; la v&#237;a de abordaje laparosc&#243;pica se utiliz&#243; en el 93&#44;6&#37; de los TO&#44; y en cuanto a nuestra clasificaci&#243;n de colecistectom&#237;a dif&#237;cil&#44; cuando se calificaba la intervenci&#243;n como dif&#237;cil&#44; el porcentaje de TO solo lo consegu&#237;a el 23&#44;1&#37; de los pacientes&#46; La &#250;nica variable en la que no se encontraron diferencias estad&#237;sticamente significativas entre ambos grupos fue la realizaci&#243;n de una CPRE previa a la intervenci&#243;n&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Cuando analizamos estas variables pre e intraoperatorias mediante la realizaci&#243;n de una regresi&#243;n log&#237;stica &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a>&#41; para establecer cu&#225;les son factores de riesgo o protectores a la hora de conseguir un resultado TO&#44; vemos c&#243;mo en un primer an&#225;lisis univariante&#44; el sexo femenino&#44; la menor edad&#44; el ASA &#60;<span class="elsevierStyleHsp" style=""></span>III&#44; la cirug&#237;a electiva&#44; el abordaje laparosc&#243;pico y la presencia de una colecistectom&#237;a &#171;no dif&#237;cil&#187;&#44; son factores protectores para conseguir este resultado ideal&#44; o lo que es lo mismo&#44; estas caracter&#237;sticas hacen m&#225;s proclives a conseguir el TO&#46; Sin embargo&#44; cuando correlacionamos estos coeficientes entre s&#237; mediante la realizaci&#243;n de un an&#225;lisis multivariante para eliminar posibles factores confusores&#44; vemos que el sexo y la edad no resultan finalmente ser factores independientes para la consecuci&#243;n de este TO&#46; No obstante&#44; se identificaron como factores independientes el ASA &#60;<span class="elsevierStyleHsp" style=""></span>III &#40;OR 2&#44;39 IC 95&#37; 1&#44;37&#8211;4&#44;16&#41;&#44; la cirug&#237;a electiva &#40;OR 2&#44;77 IC 95&#37; 1&#44;64-4&#44;67&#41;&#44; el abordaje laparosc&#243;pico &#40;OR 5&#44;71 IC 95&#37; 2&#44;89-11&#44;30&#41;&#44; y la colecistectom&#237;a &#171;no dif&#237;cil&#187; &#40;OR 0&#44;42 IC 95&#37; 0&#44;259-0&#44;71&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">Si dividimos la muestra seg&#250;n cirug&#237;a programada y urgente &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#41;&#44; vemos c&#243;mo el TO resulta 82&#44;6&#37; y 60&#44;5&#37;&#44; respectivamente&#46; Tras aplicar el an&#225;lisis multivariante &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">tabla 3</a>&#41;&#44; en la cirug&#237;a programada resultan factores independientes para la consecuci&#243;n de este TO el abordaje laparosc&#243;pico y la colecistectom&#237;a &#171;no dif&#237;cil&#187;&#46; En cuanto a la cirug&#237;a urgente&#44; resultan estad&#237;sticamente significativas el ASA &#60;<span class="elsevierStyleHsp" style=""></span>III&#44; el abordaje laparosc&#243;pico y la colecistectom&#237;a &#171;no dif&#237;cil&#187;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Discusi&#243;n</span><p id="par0100" class="elsevierStylePara elsevierViewall">Cada vez es m&#225;s frecuente la utilizaci&#243;n del TO como herramienta para medir la calidad asistencial de las intervenciones&#46; Hasta el momento&#44; se est&#225; utilizando sobre todo en cirug&#237;as oncol&#243;gicas con alta morbimortalidad<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">8</span></a>&#46; Sin embargo&#44; es un indicador que re&#250;ne los principales resultados medidos tras una intervenci&#243;n quir&#250;rgica &#40;complicaciones mayores&#44; estancia posquir&#250;rgica&#44; reingresos y mortalidad&#41;&#44; y es por ello f&#225;cilmente extrapolable a otras intervenciones con menor morbimortalidad&#44; como es la colecistectom&#237;a&#44; y puede ser un marcador f&#225;cil de entender por la poblaci&#243;n general&#46; Este nuevo marcador de calidad asistencial no solo servir&#237;a a los pacientes para basar la elecci&#243;n de un hospital para su patolog&#237;a&#44; representando sus posibilidades para el mejor resultado posible&#44; sino tambi&#233;n para los propios facultativos e investigadores&#44; recabando informaci&#243;n sobre la frecuencia en la que sus tratamientos quir&#250;rgicos y sus t&#233;cnicas son exitosas&#44; y con ello poder impulsar la mejor&#237;a para la gesti&#243;n hospitalaria&#44; ya que pueden utilizarla para aplicar una contrataci&#243;n selectiva&#44; y para los inspectores sanitarios&#44; ya que puede guiar los programas de vigilancia&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">En cuanto a lo descrito en la literatura actual acerca del TO en la colecistectom&#237;a&#44; vemos concordancia en cuanto a ciertos factores que resultan desfavorables para clasificar un TO&#44; como la edad&#44; descrita en el art&#237;culo de Iseda et al&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">9</span></a>&#44; en cuyo caso ser&#237;a<span class="elsevierStyleHsp" style=""></span>&#62; 70 a&#241;os&#44; siete a&#241;os superior a nuestros resultados&#59; y tambi&#233;n la clasificaci&#243;n ASA&#44; como en el art&#237;culo de Lucocq et al&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">10</span></a> en cuyo caso a mayor clasificaci&#243;n ASA menor consecuci&#243;n de un resultado TO&#44; compar&#225;ndolo con nuestro estudio donde&#44; sobre todo los ASA &#8805; III son los que consiguen menos TO&#46; En este &#250;ltimo art&#237;culo&#44; tambi&#233;n se describe la indicaci&#243;n de colecistectom&#237;a por colecistitis aguda como factor desfavorable&#44; lo que concuerda con nuestros resultados&#44; sin embargo&#44; tambi&#233;n parece influir la realizaci&#243;n de una CPRE previa&#44; en contraposici&#243;n a nuestro an&#225;lisis&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">En otro art&#237;culo del mismo autor<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">11</span></a>&#44; donde se analiza la morbilidad tras una colecistectom&#237;a urgente vs&#46; electiva&#44; se demuestra que la colecistectom&#237;a laparosc&#243;pica de urgencia se relaciona positivamente con la aparici&#243;n de resultados adversos&#44; en comparaci&#243;n con la colecistectom&#237;a laparosc&#243;pica programada&#44; dato que concuerda con nuestra serie donde la cirug&#237;a programada consigue mayor porcentaje de TO&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">En cuanto al sexo&#44; no hay art&#237;culos que relacionen causalidad&#44; no obstante&#44; en nuestra serie el sexo femenino en un primer an&#225;lisis univariante result&#243; ser favorable a la consecuci&#243;n de TO&#46; Por otro lado&#44; la v&#237;a de abordaje en nuestro estudio se ha estudiado como factor a analizar&#44; si bien&#44; en los dos art&#237;culos mencionados<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">9&#44;10</span></a>&#44; la v&#237;a de abordaje es un criterio de la propia definici&#243;n de TO&#44; donde necesariamente tiene que ser una &#171;<span class="elsevierStyleItalic">colecistectom&#237;a laparosc&#243;pica sin conversi&#243;n a cirug&#237;a abierta</span>&#187; para ser clasificado como TO&#46; En nuestro estudio&#44; tras analizar esta variable&#44; vemos que efectivamente la v&#237;a laparosc&#243;pica es m&#225;s propensa a conseguir un TO&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Por &#250;ltimo&#44; son muchos los grupos quir&#250;rgicos que han intentado definir lo que se considera una colecistectom&#237;a dif&#237;cil en los &#250;ltimos a&#241;os&#46; Dos ejemplos de los m&#225;s recientes son&#58; el proyecto Delphi realizado en 2021<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">12</span></a> por expertos espa&#241;oles&#44; donde se intent&#243; llegar a un consenso sobre qu&#233; factores perioperatorios se consideran de dificultad en esta intervenci&#243;n&#59; y la &#171;<span class="elsevierStyleItalic">Nassar scale</span>&#187;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">13</span></a> como escala preoperatoria para predecir una colecistectom&#237;a dif&#237;cil&#46; Sin embargo&#44; encontramos una falta de consenso y estudios en la literatura actual que relacionen individualmente cada posible variable predictora de dificultad&#44; con los resultados posoperatorios&#46; Creemos&#44; aun as&#237;&#44; que es un par&#225;metro que debe incluirse en cualquier estudio sobre resultados en colecistectom&#237;a&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Una limitaci&#243;n del estudio&#44; al ser retrospectivo&#44; es que la recopilaci&#243;n de ciertos par&#225;metros&#44; como las complicaciones menores&#44; son sensibles al sesgo y dif&#237;ciles de registrar de forma correcta si no son recogidas de forma prospectiva&#46; En nuestro caso&#44; son registradas sistem&#225;ticamente en el informe de alta de hospitalizaci&#243;n&#46; Por otro lado&#44; nuestra variable &#171;colecistectom&#237;a dif&#237;cil&#187; si bien puede resultar una variable subjetiva y cirujano dependiente&#44; la revisi&#243;n exhaustiva de los partes de quir&#243;fanos para clasificar la intervenci&#243;n como tal&#44; la realiz&#243; una &#250;nica persona para evitar cualquier tipo de sesgo&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">En conclusi&#243;n&#44; en nuestra serie el porcentaje de TO de colecistectom&#237;a fue del 72&#37; &#40;82&#44;6&#37; en cirug&#237;a programada y 60&#44;5&#37; en cirug&#237;a urgente&#41;&#46; Los factores que nos llevan a su consecuci&#243;n seg&#250;n el an&#225;lisis estad&#237;stico realizado fueron el sexo femenino&#44; la edad menor de 63 a&#241;os&#44; un riesgo ASA &#60;<span class="elsevierStyleHsp" style=""></span>III&#44; la cirug&#237;a electiva y por v&#237;a de abordaje laparosc&#243;pica&#44; y la colecistectom&#237;a en la que no se encontraron hallazgos intraoperatorios relacionados con una intervenci&#243;n dif&#237;cil&#44; seg&#250;n nuestra clasificaci&#243;n&#46; Creemos que el TO es una herramienta de calidad asistencial sencilla de realizar&#44; f&#225;cilmente interpretable y &#250;til para evaluar la calidad en la atenci&#243;n sanitaria y comparar centros&#44; aplicable no solo en procedimientos oncol&#243;gicos&#44; sino tambi&#233;n en la colecistectom&#237;a&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Financiaci&#243;n</span><p id="par0140" class="elsevierStylePara elsevierViewall">Este trabajo no ha recibido ning&#250;n tipo de financiaci&#243;n</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conflicto de intereses</span><p id="par0145" class="elsevierStylePara elsevierViewall">Los autores declaran no tener ning&#250;n conflicto de intereses&#46;</p></span></span>"
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              "identificador" => "abst0030"
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              "titulo" => "Methods"
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            2 => array:2 [
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              "titulo" => "Results"
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          "titulo" => "M&#233;todos"
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          "titulo" => "Resultados"
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          "identificador" => "sec0020"
          "titulo" => "Discusi&#243;n"
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          "identificador" => "sec0030"
          "titulo" => "Financiaci&#243;n"
        ]
        10 => array:2 [
          "identificador" => "sec0025"
          "titulo" => "Conflicto de intereses"
        ]
        11 => array:1 [
          "titulo" => "Bibliograf&#237;a"
        ]
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    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2024-03-13"
    "fechaAceptado" => "2024-05-23"
    "PalabrasClave" => array:2 [
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        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
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          "palabras" => array:6 [
            0 => "Colecistectom&#237;a"
            1 => "<span class="elsevierStyleItalic">Textbook outcome</span>"
            2 => "Complicaciones posoperatorias"
            3 => "Resultados"
            4 => "Reingresos"
            5 => "Mortalidad"
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          "clase" => "keyword"
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            0 => "Cholecystectomy"
            1 => "Textbook outcome"
            2 => "Postoperative complications"
            3 => "Outcomes"
            4 => "Readmissions"
            5 => "Mortality"
          ]
        ]
      ]
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    "resumen" => array:2 [
      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Introducci&#243;n</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">La colelitiasis es el diagn&#243;stico hospitalario m&#225;s com&#250;n del sistema digestivo&#44; y su tratamiento&#44; si es sintom&#225;tica&#44; es la colecistectom&#237;a laparosc&#243;pica&#46; Existe una necesidad creciente de una determinaci&#243;n exhaustiva de los resultados posoperatorios y la eficiencia de los centros sanitarios&#46; El <span class="elsevierStyleItalic">textbook outome</span> &#40;TO&#41; es un indicador de calidad asistencial utilizado habitualmente en procedimientos oncol&#243;gicos&#44; obtenido al sumar varios par&#225;metros posoperatorios&#44; que informa si se ha obtenido un resultado perfecto&#46; El objetivo principal de este estudio es determinar el TO para colecistectom&#237;a&#44; y ver los factores que influyen en su consecuci&#243;n&#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 unic&#233;ntrico de cohorte retrospectivo sobre pacientes intervenidos de colecistectom&#237;a entre 2018 y 2020&#46; Definimos TO como aquellos pacientes que cumplieron las siguientes premisas&#58; complicaciones Clavien-Dindo<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>III&#44; estancia posquir&#250;rgica menor del percentil 75 &#40;&#60; 3 d&#237;as&#41;&#44; y no reingresos ni mortalidad en los primeros 90 d&#237;as&#46; Se analizaron las caracter&#237;sticas perioperatorias&#44; dividiendo los pacientes en dos grupos seg&#250;n la consecuci&#243;n o no de TO&#46; Definimos unos criterios de colecistectom&#237;a dif&#237;cil seg&#250;n el informe operatorio&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Resultados</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">El porcentaje de TO global fue de 72&#37; &#40;342&#47;475&#41; &#40;82&#44;6&#37; en cirug&#237;a programada y 60&#44;5&#37; en cirug&#237;a urgente&#41;&#46; El an&#225;lisis univariante demostr&#243; que los siguientes factores se asocian a la consecuci&#243;n de TO&#58; sexo femenino&#44; edad &#60;<span class="elsevierStyleHsp" style=""></span>63 a&#241;os&#44; riesgo seg&#250;n la Asociaci&#243;n Americana de Anestesiolog&#237;a &#40;ASA&#41; &#60;<span class="elsevierStyleHsp" style=""></span>III&#44; cirug&#237;a electiva&#44; abordaje laparosc&#243;pico y no ser colecistectom&#237;a dif&#237;cil&#46; Tras el an&#225;lisis multivariante se mantiene significativo el riesgo ASA &#60;<span class="elsevierStyleHsp" style=""></span>III &#40;<span class="elsevierStyleItalic">odds ratio</span> &#91;OR&#93; 2&#44;39 IC 95&#37; 1&#44;37&#8211;4&#44;16&#41;&#44; la cirug&#237;a electiva &#40;OR 2&#44;77 IC 95&#37; 1&#44;64-4&#44;67&#41;&#44; el abordaje laparosc&#243;pico &#40;OR 5&#44;71 IC 95&#37; 2&#44;89-11&#44;30&#41; y no ser colecistectom&#237;a dif&#237;cil &#40;OR 0&#44;42 IC 95&#37; 0&#44;259-0&#44;71&#41;&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conclusiones</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">El TO es una herramienta de calidad asistencial sencilla de realizar&#44; f&#225;cilmente interpretable y &#250;til para evaluar la calidad en la atenci&#243;n sanitaria y comparar centros&#44; aplicable no solo en procedimientos oncol&#243;gicos&#44; sino tambi&#233;n en la colecistectom&#237;a&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Introducci&#243;n"
          ]
          1 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "M&#233;todos"
          ]
          2 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Resultados"
          ]
          3 => array:2 [
            "identificador" => "abst0025"
            "titulo" => "Conclusiones"
          ]
        ]
      ]
      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Introduction</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Cholelithiasis is the most common hospital diagnosis of the digestive system&#44; and its treatment&#44; if symptomatic&#44; is laparoscopic cholecystectomy&#46; There is a growing need for comprehensive determination of postoperative outcomes and the efficiency of healthcare facilities&#46; The &#8220;textbook outcome&#8221;&#40;TO&#41; indicates the quality of care commonly used in oncological procedures&#44; obtained by adding several postoperative parameters&#44; which informs whether a perfect result has been obtained&#46; The main objective of this study is to determine the TO for cholecystectomy and to see the factors that influence its achievement&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Methods</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Retrospective observational unicentric cohort study on patients who underwent cholecystectomy between 2018-2020&#46; We defined TO as those patients who met the following premises&#58; Clavien-Dindo complications &#60;<span class="elsevierStyleHsp" style=""></span>III&#44; postsurgical stay less than the 75th percentile &#40;&#60;3 days&#41;&#44; and no readmissions or mortality in the first ninety days&#46; Perioperative characteristics were analyzed&#44; and the patients were divided into two groups according to whether or not they achieved TO&#46; We defined criteria for difficult cholecystectomy according to the operative report&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Results</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">The percentage of TO was 72&#37; &#40;342&#47;475&#41; &#40;82&#46;6&#37; in elective surgery and 60&#46;5&#37; in urgent surgery&#41;&#46; The univariate analysis showed that the following factors are associated with achieving TO&#58; female sex&#44; age &#60;<span class="elsevierStyleHsp" style=""></span>63 years&#44; ASA risk &#60;<span class="elsevierStyleHsp" style=""></span>III&#44; elective surgery&#44; laparoscopic approach&#44; and not difficult cholecystectomy&#46; After multivariate analysis<span class="elsevierStyleCrossOut">&#44;</span> ASA&#60;<span class="elsevierStyleHsp" style=""></span>III &#40;OR 2&#46;39 CI95&#37; 1&#46;37-4&#46;16&#41;&#44; elective surgery &#40;OR 2&#46;77 CI95&#37; 1&#46;64-4&#46;67&#41;&#44; laparoscopic approach &#40;OR 5&#46;71 CI95&#37; 2&#46;89-11&#46;30&#41; and not to be difficult cholecystectomy &#40;OR 0&#46;42 CI95&#37; 0&#46;259-0&#46;71&#41; remained statistically significant&#46;</p></span> <span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Conclusions</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">The TO is a healthcare quality tool that is simple to perform&#44; easily interpretable&#44; and helpful for evaluating quality in healthcare and comparing centers&#46; It applies not only to oncological procedures but also to cholecystectomy&#46;</p></span>"
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          0 => array:2 [
            "identificador" => "abst0030"
            "titulo" => "Introduction"
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          1 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Methods"
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          2 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Results"
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          3 => array:2 [
            "identificador" => "abst0045"
            "titulo" => "Conclusions"
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        "etiqueta" => "Figura 1"
        "tipo" => "MULTIMEDIAFIGURA"
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        "descripcion" => array:1 [
          "es" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Gr&#225;fica TO&#46; Perdemos seis pacientes &#40;1&#44;3&#37;&#41; por mortalidad&#46; TO acumulado tras complicaciones mayores&#58; 90&#44;9&#37; &#40;perdemos 33 pacientes m&#225;s&#44; un 7&#44;8&#37;&#41;&#46; TO acumulado tras no reingresos a 90 d&#237;as&#58; 86&#44;2&#37; &#40;perdemos 22 pacientes m&#225;s&#44; un 4&#44;7&#37;&#41;&#46; TO acumulado tras no estancia prolongada&#58; 72&#37; &#40;perdemos 67 pacientes m&#225;s&#44; un 14&#44;2&#37;&#41;&#46; TO&#58; <span class="elsevierStyleItalic">textbook outome</span>&#46;</p>"
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          "leyenda" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">ASA&#58; Asociaci&#243;n Americana de Anestesiolog&#237;a&#59; CPRE&#58; colangiopancreatograf&#237;a retr&#243;grada endosc&#243;pica&#59; IQR&#58; rango intercuart&#237;lico&#59; TO&#58; <span class="elsevierStyleItalic">textbook outome</span>&#46;</p>"
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">Textbook outcome</span> para colecistectom&#237;a</th></tr><tr title="table-row"><th class="td" title="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t" scope="col">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t" scope="col">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="3" align="center" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Colecistectom&#237;a global</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="3" align="center" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Colecistectom&#237;a programada</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="3" align="center" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Colecistectom&#237;a urgente</th></tr><tr title="table-row"><th class="td-with-role" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">Variable&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">Total&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">TO S&#237;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col">TO No&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="" 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  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">TO S&#237;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">TO No&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="" 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  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">TO S&#237;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">TO No&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="" 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></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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">475&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">342&#47;475 &#40;72&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">133&#47;475 &#40;28&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Valor 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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">204&#47;247 &#40;82&#44;6&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">43&#47;247 &#40;17&#44;4&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Valor 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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">138&#47;228 &#40;60&#44;5&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">90&#47;228 &#40;39&#44;5&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Valor p&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"><span class="elsevierStyleItalic">Sexo</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><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><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">0&#44;970 &#8211; 1&#44;004&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2&#44;011 - 4850&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Ref&#46;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Ref&#46;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Ref&#46;&nbsp;\t\t\t\t\t\t\n
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                  \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><td class="td" title="\n
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                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " colspan="7" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Colecistectom&#237;a dif&#46;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>No&nbsp;\t\t\t\t\t\t\n
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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">Ref&#46;&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
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;125 &#8211; 0&#44;296&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\ttop\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#44;429&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&#44;259 &#8211; 0&#44;710&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&#44;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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                  <table border="0" frame="\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="7" align="center" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Regresi&#243;n log&#237;stica <span class="elsevierStyleItalic">textbook outcome</span> s&#237; cirug&#237;a programada</th></tr><tr title="table-row"><th class="td" title="\n
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                  \t\t\t\t\ttop\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Valor p&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">OR ajust&#46;&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" scope="col" style="border-bottom: 2px solid black">IC 95&#37;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Valor p&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">Ref&#46;&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
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                  \t\t\t\t\ttable-entry\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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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&#44;258&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\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\ttable-entry\n
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                  \t\t\t\t\ttop\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">Ref&#46;&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
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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
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;010&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
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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">0&#44;272 &#8211; 1&#44;728&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&#44;424&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="7" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="7" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Colecistectom&#237;a dif&#46;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Ref&#46;&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
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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><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  """
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Información del artículo
ISSN: 0009739X
Idioma original: Español
DOI:10.1016/j.ciresp.2024.05.011
Datos actualizados diariamente
año/Mes Html Pdf Total
2024 Noviembre 2 2 4
2024 Octubre 10 6 16

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