Clinical case
Gastrocolic omental cyst in an adult: Case presentation and review of literature
Quiste omental gastrocólico en un adulto: presentación de un caso y revisión de la bibliografía
Pablo Serrano-Rodrígueza,
, Chirag Sureshchandra Desaib
Corresponding author
polserrano@yahoo.com
Corresponding author at: Rivera de Cupia 110-40, Col La Loma, 11700 Miguel Hidalgo, Mexico City, Mexico. Telephone: +52 55 5251 5974.
Corresponding author at: Rivera de Cupia 110-40, Col La Loma, 11700 Miguel Hidalgo, Mexico City, Mexico. Telephone: +52 55 5251 5974.
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Telephone: +52 55 5251 5974." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Quiste omental gastrocólico en un adulto: presentación de un caso y revisión de la bibliografía" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 762 "Ancho" => 950 "Tamanyo" => 85117 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Computed axial tomography showing the mesenteric cyst; a clear demarcation plane can be observed between the cyst and the liver.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Background</span><p id="par0005" class="elsevierStylePara elsevierViewall">Cystic lymphangioma is a rare, benign lesion, classified as a hamartoma. It is formed by a single layer of endothelial cells, connective tissue and smooth muscle fibres.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">1</span></a> It generally occurs in areas surrounded by connective tissue.</p><p id="par0010" class="elsevierStylePara elsevierViewall">They present most commonly in infancy, with an incidence of 1/20,000.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">2</span></a> Sixty-five percent are present at birth and 90% are diagnosed in children under 2 years of age. In adults, the incidence is between 1/100,000 and 1/250,000.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">3</span></a> Cystic lymphangioma can present in any part of the body, the neck being the most common (75%), the axillary region (20%) and the mediastinum, oesophagus, spleen, liver and other abdominal organs (4%).<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">4</span></a> They present in the mesentery in approximately 1% of cases, and within this group they are most commonly found in the small bowel (85%), mesocolon (10%) and retroperitoneum (5%).<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">5</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">In the adult population, cysts are generally asymptomatic, but they can present with different symptoms depending on their location, size and the organ affected. Paediatric patients present a clinical picture with a shorter duration and with more acute symptoms, and therefore they frequently require emergency surgery.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Because the most common location of cystic lymphangioma is the ileum, the main symptom is chronic abdominal pain and abdominal distension.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">6</span></a> However, cases have been described of acute pain and peritonitis due to rupture,<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">7</span></a> torsion, infection, due to a volvulus or intestinal obstruction secondary to the cyst.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">8</span></a> In a study by De Perrot et al.<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">9</span></a> the most common physical finding, present in up to 61% of patients, was a compressible abdominal mass.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Objective</span><p id="par0025" class="elsevierStylePara elsevierViewall">We present a case of a gastrocolic omental cyst in a male in the sixth decade of life.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Clinical case</span><p id="par0030" class="elsevierStylePara elsevierViewall">We present the case of a 67-year-old man, an African American war veteran with a previous history of exploratory laparotomy (37 years ago) for a liver injury secondary to a firearm wound in the upper right quadrant, for which a right subcostal incision was made. The patient did not know the details of this procedure, but stated that none of his abdominal organs had been resected.</p><p id="par0035" class="elsevierStylePara elsevierViewall">He consulted with increased abdominal volume, which he presented many years after the liver injury, accompanied by early satiety and a feeling of gastric fullness after small meals, progressing to nausea without vomiting or diarrhoea, and significant weight loss of 10<span class="elsevierStyleHsp" style=""></span>kg over 6 months. On physical examination the abdomen was soft, not painful and not distended. The increased volume was palpable in the upper right quadrant, below the subcostal incision. It had smooth edges and was not mobile on palpation. The laboratory tests that included viral hepatitis serology and alpha-fetoprotein were normal.</p><p id="par0040" class="elsevierStylePara elsevierViewall">An abdominal CT scan was performed which revealed a cystic lesion contiguous to the lower face of the left liver lobe. This was confirmed by MRI, which showed a cystic lesion with a clear plane between it and the liver. The cyst was in front of the head of pancreas and the duodenum, and therefore an endoscopic ultrasound was performed which confirmed that it was not in continuity with the pancreas or the pancreatic duct. We attempted to take a sample of the fluid during this procedure, but this was not possible. Most of the results confirmed the diagnosis of a benign cyst; we therefore decided to observe the patient over 6 weeks. During this time the patient's symptoms persisted, he was therefore scheduled for laparotomy (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>) due to the history of previous surgery to the right hypochondrium, near the lesion in question. We decided that laparotomy provided better access than laparoscopy due to the adhesions and because little was known about the previous procedure.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">With the patient under general anaesthetic, we palpated the right hypochondrium where the edges of the cyst were palpable and easily delineated. We decided to start with an 8<span class="elsevierStyleHsp" style=""></span>cm incision in the midline.</p><p id="par0050" class="elsevierStylePara elsevierViewall">After extensive adhesiolysis, we observed a mobile, clearly translucent cystic lesion of 14<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleHsp" style=""></span>cm under the liver, anterior and lateral to the pylorus in the area of the gastrocolic mesentery. After careful dissection, we ligated the vessels of the omentum near the surface of the cyst. A sample of the fluid was taken, which was translucent, slightly yellow and had no subnatant matter and no bile, blood, pus or mucus were found. Haemostasis was performed, and we examined the mesentery of the transverse colon that was found to be intact. No reduction in colon perfusion was observed, which confirmed that the lesion was not in continuity with its mesentery. No lesions to the adjacent organs were observed either (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">The histopathological report showed that the cells covering the cystic spaces were positive for CD34, factor VIII, WT-1, CD31 and D2-40, and negative for cytokeratine-5/6, calretinin and HBME-1. Based on the results of immunohistochemical analysis, the definitive diagnosis was benign cystic lymphangioma. Venous cystic lesion and mesothelial inclusion cyst were ruled out as differential diagnoses.</p><p id="par0060" class="elsevierStylePara elsevierViewall">The patient recovered without incident after surgery. At 4 months’ follow-up he had recovered his appetite and gained weight.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0065" class="elsevierStylePara elsevierViewall">The aetiology of mesenteric cysts is not clear. Some of the accepted theories include a benign lymphatic proliferation, which does not communicate with the rest of the lymphatic system, or a fault in fusion of the mesenteric layers.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">10</span></a> The lesions can have blood or lymphatic vessels, and therefore can contain serous, haemorrhagic or lymphatic material.</p><p id="par0070" class="elsevierStylePara elsevierViewall">Traumatic or infectious cysts usually have a fibrous wall, foamy cells, cholesterol granuloma, and absence of epithelium and histologically they resemble pancreatic pseudocysts. They normally present within a couple of months to one year after traumatic injury. They can present through a mesenteric injury and cause a lymphatic vessel to rupture which will cause slow leakage of lymph fluid. In this case, the medical history of a firearm wound in the vicinity of the cyst made us consider trauma as the cause of the abdominal cyst formation, although the cyst formation time was much longer than that described in the literature.</p><p id="par0075" class="elsevierStylePara elsevierViewall">In the case we present, the cyst wall has specific features of a congenital cyst, since it did not show changes suggestive of a traumatic cyst and it presented in an elderly patient, when 80% of these cysts present in children under the age of 5.<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">11</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">Because the most common location is the mesentery of the ileum,<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">12</span></a> the principal symptom is chronic abdominal pain and abdominal distension, which subsequently causes a total or partial obstruction of the small bowel. The presentation of this case is unusual, since patients rarely complain of weight loss and early satiety. This patient's symptoms could be attributed to the cyst being located in the gastrocolic omentum and the increased size caused compression to the stomach, affecting its emptying, and as a result the patient's satiety. In our review of the literature we found no record of a cyst in this region and with these symptoms.</p><p id="par0085" class="elsevierStylePara elsevierViewall">Initially, the diagnosis was established in the operating theatre after exploratory laparotomy for non-specific symptoms. Preoperative imaging, ultrasound and computed axial tomography (CAT) are currently principally used to achieve a diagnosis. Ultrasound is useful for observing the content of the cyst. CAT is more sensitive in discerning cysts of neighbouring organs.<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">13</span></a> Magnetic resonance is an auxiliary procedure to distinguish mesenteric cysts from other abdominal cystic tumours, and is more sensitive than ultrasound in classifying their content.<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">14,15</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">The treatment of choice is enucleation of the lesion, which might require intestinal resection in specific cases when the cyst involves the intestinal mesenteric vasculature. An attempt at partial resection with marsupialisation of the cavity to avoid resection has been described in the literature, but in these cases this increases the possibility of a recurrence of the cyst.<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">16</span></a> In a study by Prakash et al.<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">17</span></a> 41% of cases were completely enucleated, 2% required intestinal resection and marsupialisation was performed in 35%. In this case, we were able to enucleate the cyst completely, without damaging any of the surrounding structures.</p><p id="par0095" class="elsevierStylePara elsevierViewall">Very many reports have been written on laparoscopic resection of a mesenteric cyst.<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">18</span></a> In this case we decided to take an open approach because of the patient's prior surgery to the area and the scant information that we had about that procedure.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conclusions</span><p id="par0100" class="elsevierStylePara elsevierViewall">Mesenteric cysts are rare and usually present early in life if they are congenital, or shortly after trauma. However they should be considered as a differential diagnosis in adults when the patient presents a clinical picture with increased abdominal volume and a history of abdominal trauma or with symptoms of increased volume causing compression.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Ethical disclosures</span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Protection of human and animal subjects</span><p id="par0110" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study.</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Confidentiality of data</span><p id="par0115" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their work center on the publication of patient data.</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Right to privacy and informed consent</span><p id="par0120" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article.</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Conflict of interests</span><p id="par0105" class="elsevierStylePara elsevierViewall">The authors have no conflict of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:3 [ "identificador" => "xres778288" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Objective" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Clinical case" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec778311" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres778289" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Antecedentes" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Objetivo" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Caso clínico" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec778312" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Background" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Objective" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Clinical case" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conclusions" ] 9 => array:3 [ "identificador" => "sec0035" "titulo" => "Ethical disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0040" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0045" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0050" "titulo" => "Right to privacy and informed consent" ] ] ] 10 => array:2 [ "identificador" => "sec0030" "titulo" => "Conflict of interests" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2015-02-04" "fechaAceptado" => "2015-06-19" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec778311" "palabras" => array:3 [ 0 => "Lymphangioma" 1 => "Mesenteric" 2 => "Tumour" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec778312" "palabras" => array:3 [ 0 => "Linfagioma" 1 => "Mesentérico" 2 => "Tumor" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Background</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Mesenteric lymphangioma are rare tumours. They usually present early on in life, if congenital, or soon after trauma. The usual sites of presentation of lymphangiomas are in the neck, and axillae. In the abdomen they are more common in the mesentery, primarily of the ileum, or retroperitoneal.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Objective</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A rare case is presented of a mesenteric lymphangioma.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Clinical case</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">It involves an elderly African-American male, many years after trauma, and characterised with early satiety, causing weight loss, but without gastric outlet obstruction or vomiting. Its diagnosis, management and review of literature are presented.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Mesenteric cysts are rare tumours that should be included as differential diagnosis in elderly patients with a history of previous abdominal trauma.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Objective" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Clinical case" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Antecedentes</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Los linfangiomas mesentéricos son tumores poco frecuentes que suelen presentarse temprano en la vida, si son congénitos, o poco después de un trauma. Los sitios habituales de presentación son en el cuello, en la axila o en la cavidad abdominal; dentro de esta, el sitio más común es en el mesenterio, principalmente del íleon, o retroperitoneal.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Objetivo</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Mostramos este caso clínico poco frecuente de un linfangioma mesentérico.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Caso clínico</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Masculino afroamericano que presentó aumento de volumen muchos años después de un traumatismo, caracterizándose clínicamente por: saciedad temprana y pérdida de peso, pero sin obstrucción de la salida gástrica, náuseas o vómitos. Exponemos su diagnóstico, manejo y revisión de la bibliografía.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Los quistes mesentéricos son poco frecuentes; sin embargo, deben tenerse en cuenta como diagnóstico diferencial cuando un paciente presenta un cuadro clínico con aumento de volumen e historia de un trauma abdominal previo.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Antecedentes" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Objetivo" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Caso clínico" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Serrano-Rodríguez P, Desai CS. Quiste omental gastrocólico en un adulto: presentación de un caso y revisión de la bibliografía. Cir Cir. 2016;84:509–512.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 762 "Ancho" => 950 "Tamanyo" => 85117 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Computed axial tomography showing the mesenteric cyst; a clear demarcation plane can be observed between the cyst and the liver.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 615 "Ancho" => 950 "Tamanyo" => 120964 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Image taken during surgery showing the cyst free from adhesions, prior to its resection.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:18 [ 0 => array:3 [ "identificador" => "bib0095" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Intra-abdominal cystic lymphangioma and mesenteric cysts as a cause of abdominal discomfort" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "J. 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Rider" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/S1072-7515(02)01755-6" "Revista" => array:6 [ "tituloSerie" => "J Am Coll Surg" "fecha" => "2003" "volumen" => "196" "paginaInicial" => "598" "paginaFinal" => "603" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12691938" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/24440507/0000008400000006/v1_201612211125/S2444050716300821/v1_201612211125/en/main.assets" "Apartado" => array:4 [ "identificador" => "44602" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Clinical Cases" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/24440507/0000008400000006/v1_201612211125/S2444050716300821/v1_201612211125/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2444050716300821?idApp=UINPBA00004N" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 October | 17 | 3 | 20 |
| 2024 September | 30 | 8 | 38 |
| 2024 August | 19 | 5 | 24 |
| 2024 July | 25 | 4 | 29 |
| 2024 June | 25 | 5 | 30 |
| 2024 May | 7 | 4 | 11 |
| 2024 April | 31 | 2 | 33 |
| 2024 March | 18 | 7 | 25 |
| 2024 February | 20 | 2 | 22 |
| 2024 January | 63 | 7 | 70 |
| 2023 December | 49 | 9 | 58 |
| 2023 November | 48 | 6 | 54 |
| 2023 October | 52 | 5 | 57 |
| 2023 September | 35 | 6 | 41 |
| 2023 August | 23 | 5 | 28 |
| 2023 July | 35 | 9 | 44 |
| 2023 June | 43 | 4 | 47 |
| 2023 May | 48 | 2 | 50 |
| 2023 April | 54 | 1 | 55 |
| 2023 March | 62 | 6 | 68 |
| 2023 February | 45 | 4 | 49 |
| 2023 January | 44 | 3 | 47 |
| 2022 December | 43 | 7 | 50 |
| 2022 November | 31 | 20 | 51 |
| 2022 October | 32 | 6 | 38 |
| 2022 September | 33 | 18 | 51 |
| 2022 August | 30 | 10 | 40 |
| 2022 July | 26 | 9 | 35 |
| 2022 June | 29 | 7 | 36 |
| 2022 May | 26 | 13 | 39 |
| 2022 April | 25 | 8 | 33 |
| 2022 March | 33 | 14 | 47 |
| 2022 February | 40 | 4 | 44 |
| 2022 January | 91 | 13 | 104 |
| 2021 December | 49 | 11 | 60 |
| 2021 November | 48 | 9 | 57 |
| 2021 October | 40 | 9 | 49 |
| 2021 September | 43 | 12 | 55 |
| 2021 August | 60 | 6 | 66 |
| 2021 July | 35 | 10 | 45 |
| 2021 June | 31 | 4 | 35 |
| 2021 May | 28 | 13 | 41 |
| 2021 April | 65 | 14 | 79 |
| 2021 March | 35 | 15 | 50 |
| 2021 February | 8 | 7 | 15 |
| 2021 January | 20 | 8 | 28 |
| 2020 December | 11 | 11 | 22 |
| 2020 November | 14 | 13 | 27 |
| 2020 October | 7 | 11 | 18 |
| 2020 September | 16 | 10 | 26 |
| 2020 August | 23 | 6 | 29 |
| 2020 July | 15 | 9 | 24 |
| 2020 June | 13 | 6 | 19 |
| 2020 May | 10 | 5 | 15 |
| 2020 April | 10 | 2 | 12 |
| 2020 March | 12 | 2 | 14 |
| 2020 February | 18 | 12 | 30 |
| 2020 January | 6 | 5 | 11 |
| 2019 December | 11 | 6 | 17 |
| 2019 November | 11 | 5 | 16 |
| 2019 October | 12 | 3 | 15 |
| 2019 September | 14 | 3 | 17 |
| 2019 August | 7 | 4 | 11 |
| 2019 July | 9 | 24 | 33 |
| 2019 June | 28 | 19 | 47 |
| 2019 May | 66 | 29 | 95 |
| 2019 April | 31 | 5 | 36 |
| 2019 March | 4 | 1 | 5 |
| 2019 February | 7 | 4 | 11 |
| 2019 January | 6 | 6 | 12 |
| 2018 December | 3 | 3 | 6 |
| 2018 November | 11 | 3 | 14 |
| 2018 October | 8 | 3 | 11 |
| 2018 September | 20 | 0 | 20 |
| 2018 August | 4 | 0 | 4 |
| 2018 July | 4 | 1 | 5 |
| 2018 June | 2 | 1 | 3 |
| 2018 May | 5 | 3 | 8 |
| 2018 April | 15 | 5 | 20 |
| 2018 March | 6 | 0 | 6 |
| 2018 February | 8 | 0 | 8 |
| 2018 January | 11 | 1 | 12 |
| 2017 December | 9 | 3 | 12 |
| 2017 November | 7 | 3 | 10 |
| 2017 October | 17 | 10 | 27 |
| 2017 September | 13 | 3 | 16 |
| 2017 August | 6 | 0 | 6 |
| 2017 July | 7 | 1 | 8 |
| 2017 June | 19 | 2 | 21 |
| 2017 May | 6 | 10 | 16 |
| 2017 April | 5 | 5 | 10 |
| 2017 March | 11 | 38 | 49 |
| 2017 February | 11 | 1 | 12 |
| 2017 January | 9 | 4 | 13 |
| 2016 December | 6 | 2 | 8 |
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