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Factores de mal pronóstico en 113 pacientes sometidos a duodenopancreatectomía cefálica por colangiocarcinoma distal
Prognostic risk factors in 113 patients undergoing cephalic duodenopancreatectomy for distal cholangiocarcinoma
Juli Busquetsa,b,c,◊,
Autor para correspondencia
jbusquets@bellvitgehospital.cat

Autor para correspondencia.
, Luís Secanellaa,c,d,◊, Paula Cifrea,b, María Sorribasa,c, Teresa Serranoe, Laura Martínez-Carnicerof, David Leivaf, Berta Laquenteg, Silvia Salordc,h, Nuria Peláeza,c, Juan Fabregata,c
a Unitat de Cirurgia Hepatobiliopancreàtica, Servei de Cirurgia General i Digestiva, Hospital Universitari de Bellvitge, Barcelona, España
b Departament de Ciències Clíniques, Facultat de Medicina i Ciències de la Salut, Universitat de Barcelona (UB), Barcelona, España
c Research Group of Hepato-biliary and Pancreatic Diseases, Institut d’Investigació Biomèdica de Bellvitge - IDIBELL, L’Hospitalet de Llobregat, Barcelona, España
d Departament d’Infermeria Fonamental i Medicoquirúrgica, Facultat de Medicina i Ciències de la Salut, Universitat de Barcelona (UB), Barcelona, España
e Servei de Anatomia Patològica, Hospital Universitari de Bellvitge, Barcelona, España
f Servei de Radiodiagnòstic, Hospital Universitari de Bellvitge, Barcelona, Spain
g Servei d’Oncologia Mèdica, Instituto Catalán de Oncología. Institut d’Investigació Biomèdica de Bellvitge - IDIBELL, L’Hospitalet de Llobregat, Barcelona, España
h Servei de Gastroenterologia, Hospital Universitari de Bellvitge, Barcelona, España
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          "es" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">supervivencia a largo plazo tras duodenopancreatectom&#237;a cef&#225;lica&#44; seg&#250;n aparici&#243;n de f&#237;stula biliar postoperatoria&#46; 1991-2021&#46; OS&#58; <span class="elsevierStyleItalic">overall survival</span> &#40;supervivencia&#44; meses&#41;&#46; COMPL&#95;FB&#44; f&#237;stula biliar&#46; 0&#44; no&#59; 1&#44; s&#237;&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Introducci&#243;n</span><p id="par0005" class="elsevierStylePara elsevierViewall">Los tumores malignos de la v&#237;a biliar representan el segundo c&#225;ncer hepatobiliar en todo el mundo&#46; Su incidencia var&#237;a entre 0&#44;53 a 2 casos por cada 100&#46;000 personas&#47;a&#241;o en el mundo&#44; con una mayor frecuencia en los pa&#237;ses asi&#225;ticos<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">1</span></a>&#46; Se clasifican en colangiocarcinoma intrahep&#225;tico y colangiocarcinoma extrahep&#225;tico dependiendo de la ubicaci&#243;n del tumor&#44; y este &#250;ltimo a su vez se subdivide en tumor hiliar &#40;PHC&#41; y distal &#40;dCC&#41;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">2</span></a>&#46; El dCC se origina en las c&#233;lulas epiteliales del conducto biliar caudal al conducto c&#237;stico y representa el 30-40&#37; de las neoplasias de la v&#237;a biliar<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">3&#44;4</span></a>&#46; La resecci&#243;n quir&#250;rgica sigue siendo el principal tratamiento curativo<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">5&#8211;7</span></a> con una supervivencia a los 5 a&#241;os entorno al 20-50&#37;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">3&#44;7</span></a>&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Diversas variables han sido identificadas como factores de mal pron&#243;stico tras la resecci&#243;n del dCC como la extensi&#243;n tumoral&#44; la afectaci&#243;n de los m&#225;rgenes de resecci&#243;n quir&#250;rgicos&#44; la invasi&#243;n perineural y la afectaci&#243;n adenop&#225;tica por el tumor<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">6&#44;8&#44;9</span></a>&#46; Otros marcadores oncol&#243;gicos definidos en otros tumores est&#225;n siendo investigados en el dCC como la ratio plaquetas&#47;linfocitos&#44; neutr&#243;filo&#47;linfocitos&#44; y el &#237;ndice de inflamaci&#243;n sist&#233;mica<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">6&#44;7&#44;10&#44;11</span></a>&#46; Se ha demostrado una correlaci&#243;n entre un estado nutricional preoperatorio deteriorado o hiperbilirrubinemia preoperatoria y un peor pron&#243;stico tras la resecci&#243;n del adenocarcinoma pancre&#225;tico&#46; Sin embargo&#44; dichos hallazgos no han podido ser demostrados tras la resecci&#243;n por dCC<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">7</span></a>&#46; El objetivo principal de este estudio es analizar los factores de riesgo de mortalidad y recidiva del colangiocarcinoma distal de los pacientes resecados en nuestro centro&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Material y m&#233;todos</span><p id="par0015" class="elsevierStylePara elsevierViewall">Hemos recogido la experiencia en el tratamiento quir&#250;rgico del colangiocarcinoma distal en nuestro centro&#44; mediante duodenopancreatectom&#237;a cef&#225;lica &#40;DPC&#41; desde el a&#241;o 1990 hasta el a&#241;o 2021&#46; Hemos registrado de forma prospectiva los datos demogr&#225;ficos&#44; anatomopatol&#243;gicas y de seguimiento&#44; haciendo un an&#225;lisis sobre factores de riesgo de mortalidad y recidiva de la enfermedad&#46; Hemos recibido la autorizaci&#243;n del Comit&#233; de &#201;tica de nuestro centro&#44; n&#250;mero registro PR230&#47;22&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Estudio preoperatorio</span><p id="par0020" class="elsevierStylePara elsevierViewall">El algoritmo del paciente con ictericia en nuestro centro se basa en la anamnesis&#44; exploraci&#243;n&#44; anal&#237;tica de sangre y ecograf&#237;a de abdomen&#46; En un paciente con ictericia indolora y dilataci&#243;n de la v&#237;a biliar intra y extrahep&#225;tica&#44; sospechamos neoplasia periampular&#46; El estudio por TC evidenciar&#225; una hipercaptaci&#243;n a la v&#237;a biliar distal&#46; En caso de que la imagen no sea concluyente&#44; realizamos colangiopancreatograf&#237;a por resonancia nuclear magn&#233;tica&#44; a&#241;adiendo el estudio por ecoendoscopia en los casos dudosos&#46; Los criterios de irresecabilidad en nuestro centro han estado la presencia de met&#225;stasis&#44; invasi&#243;n arteria &#40;arteria mesent&#233;rica superior o tronco cel&#237;aco&#41;&#44; obliteraci&#243;n venosa o invasi&#243;n de otros &#243;rganos por contig&#252;idad &#40;excepto duodeno&#41;&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">T&#233;cnica quir&#250;rgica</span><p id="par0025" class="elsevierStylePara elsevierViewall">La intervenci&#243;n quir&#250;rgica se inicia con una laparoscopia exploradora&#44; y exploraci&#243;n minuciosa y sistem&#225;tica de la cavidad abdominal&#46; En caso de evidenciar signos de extensi&#243;n de la enfermedad se realiza biopsia preoperatoria&#44; contraindicando la resecci&#243;n en caso de positividad&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Todos los pacientes de la serie fueron resecados con intenci&#243;n curativa&#44; extirpando la enfermedad macrosc&#243;pica en el momento de la intervenci&#243;n&#46; La t&#233;cnica realizada fue la DPC&#44; con una linfadenectom&#237;a est&#225;ndar &#40;tejido linf&#225;tico peri pancre&#225;tico y peri duodenal&#41;&#46; A todos los pacientes los realizamos antrectom&#237;a desde 2011&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">La cirug&#237;a se inici&#243; con colecistectom&#237;a&#44; linfadenectom&#237;a del hilio hep&#225;tico y secci&#243;n de la v&#237;a biliar&#46; A continuaci&#243;n&#44; se remiti&#243; una secci&#243;n de margen del conducto hep&#225;tico proximal para estudio en fresco&#46; La afectaci&#243;n de este oblig&#243; a ampliar la resecci&#243;n de la v&#237;a biliar&#44; con un nuevo an&#225;lisis y resecci&#243;n de conducto hep&#225;tico hasta la bifurcaci&#243;n de la v&#237;a biliar&#46; Los casos con colangiocarcinoma de tercio medio de v&#237;a biliar han sido excluidos del estudio&#46; El estudio anatomopatol&#243;gico fue realizado por una misma pat&#243;loga en todos los casos&#46; La inclusi&#243;n de la pieza de resecci&#243;n sigue un estricto protocolo de los m&#225;rgenes de resecci&#243;n&#44; con an&#225;lisis del margen retro- peritoneal y del margen de secci&#243;n del cuello pancre&#225;tico&#44; as&#237; como el an&#225;lisis de los territorios ganglionares&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">La reconstrucci&#243;n se practic&#243; en todos los casos con una &#250;nica asa intestinal a la cual se anastomos&#243; el p&#225;ncreas&#44; v&#237;a biliar y duodeno&#44; consecutivamente&#46; La anastomosis pancr&#225;tico-yeyunal realizada fue ducto-mucosa t&#233;rmino-lateral como primera elecci&#243;n&#44; y t&#233;rmino-terminal introducida en caso de presentar ducto fino&#46; Hasta el a&#241;o 2011 se colocaron 3 drenajes aspirativos&#46; A partir de entonces&#44; se colocan 2 drenajes aspirativos cercanos a la anastomosis pancre&#225;tico-yeyunal&#46; A partir del a&#241;o 2011&#44; el paciente es remitido a la sala de reanimaci&#243;n postquir&#250;rgica sin sonda nasog&#225;strica&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Tratamiento adyuvante</span><p id="par0045" class="elsevierStylePara elsevierViewall">En nuestro centro&#44; el tratamiento adyuvante se indic&#243; en los pacientes con factores histol&#243;gicos de mal pron&#243;stico&#44; como presencia de tumores con adenopat&#237;as afectas&#44; invasi&#243;n perineural&#44; invasi&#243;n vascular o invasi&#243;n venosa&#46; El tratamiento se estandariz&#243; a partir del a&#241;o 2011&#44; administrando quimioterapia con gemcitabina &#40;dosis 1&#46;000<span class="elsevierStyleHsp" style=""></span>mg&#47;m<span class="elsevierStyleSup">2</span> d&#237;as 1&#44;8 y 15 cada 28 d&#237;as&#47;durante 6 meses<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">12</span></a>&#41;&#46; A partir del a&#241;o 2019&#44; se utiliz&#243; capecitabina como terapia adyuvante 6 meses a todos los pacientes con c&#225;ncer de v&#237;as biliares resecado y de quimiorradioterapia en caso de margen afecto&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Definiciones</span><p id="par0050" class="elsevierStylePara elsevierViewall">Se consider&#243; morbilidad postoperatoria la aparecida durante el ingreso postoperatorio o hasta los 30 d&#237;as de la cirug&#237;a hasta el a&#241;o 2011<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">13</span></a>&#46; A partir del a&#241;o 2011&#44; se consider&#243; la morbilidad aparecida hasta los 90 d&#237;as de la intervenci&#243;n&#46; En cuanto a las complicaciones postoperatorias propias de la DPC &#40;vaciamiento g&#225;strico lento&#44; f&#237;stula pancre&#225;tica&#44; hemorragia postoperatoria&#41; se definieron de acuerdo con el consenso internacional &#40;ISGPS&#41; a su publicaci&#243;n<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">14&#8211;16</span></a>&#46; Se defini&#243; ducto pancre&#225;tico fino el inferior a 3<span class="elsevierStyleHsp" style=""></span>mm de di&#225;metro&#44; y ancho el igual o superior a 3<span class="elsevierStyleHsp" style=""></span>mm&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Estudio estad&#237;stico</span><p id="par0055" class="elsevierStylePara elsevierViewall">Se realiz&#243; un an&#225;lisis descriptivo seg&#250;n medidas de tendencia central &#40;media&#41; y de dispersi&#243;n &#40;desviaci&#243;n t&#237;pica&#41; seg&#250;n criterios de normalidad &#40;test de Kolmogorov-Smirnov&#41;&#46; Posteriormente&#44; se realiz&#243; un estudio comparativo entre variables cualitativas seg&#250;n Chi-cuadrado de Pearson o Fisher&#46; Se realiz&#243; un an&#225;lisis de Kaplan-Meier para determinar la supervivencia global y sus factores predictores&#44; y aquellas variables que mostraron una asociaci&#243;n estad&#237;sticamente significativa en el test de <span class="elsevierStyleItalic">log-rank</span> &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#41; sin interacci&#243;n fueron consideradas en un modelo de regresi&#243;n de COX&#46; Aquellas variables que mostraron asociaci&#243;n con p valor &#60;<span class="elsevierStyleHsp" style=""></span>0&#44;10 y que no presentaron interacci&#243;n entre ellas fueron consideradas en un modelo de regresi&#243;n log&#237;stica binaria siendo la variable dependiente morbilidad o mortalidad postoperatoria&#46; Diversas variables continuas &#40;edad&#44; bilirrubina&#44; creatinina&#44; albumina&#44; periodo&#41; fueron categorizadas para facilitar su comparaci&#243;n&#46; Se utiliz&#243; el paquete estad&#237;stico SPSSS&#174; 12&#46;0 y el valor estad&#237;sticamente significativo considerado fue de p valor &#60;<span class="elsevierStyleHsp" style=""></span>0&#44;05 en todos los casos&#46;</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Resultados</span><p id="par0060" class="elsevierStylePara elsevierViewall">Entre los a&#241;o 1990 y 2021 se realizaron 113 DPC por colangiocarcinoma distal&#44; 30&#37; con DPCPP&#46; Un 30&#37; de los pacientes eran mayores de 70 a&#241;os&#44; y un 45&#44;9&#37; fueron ASA II &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#41;&#46; Un 77&#37; de pacientes tuvieron complicaciones postoperatorias&#44; destacando un 33&#37; de vaciamiento g&#225;strico lento &#40;VGL&#41;&#44; el 27&#37; f&#237;stula pancre&#225;tica y el 6&#37; f&#237;stula biliar&#46; La mortalidad postoperatoria fue del 13&#37; siendo superior durante el primer per&#237;odo del estudio&#44; a pesar de no alcanzar la significaci&#243;n estad&#237;stica &#40;19 vs&#46; 7&#37;&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;06&#41;&#46; El estudio histol&#243;gico de las piezas quir&#250;rgicas evidenci&#243; que el tumor resecado presentaba un tama&#241;o medio de 18<span class="elsevierStyleHsp" style=""></span>mm y en el 63&#37; de los casos&#44; med&#237;a m&#225;s de 12<span class="elsevierStyleHsp" style=""></span>mm &#40;pT3&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">tabla 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">Durante el seguimiento se contabilizaron 88 muertos &#40;59&#37;&#41;&#44; estando vivos al cierre de 3ste&#44; 46 pacientes &#40;41&#37;&#41;&#46; El 68&#37; de los pacientes estuvieron libres de enfermedad &#40;68&#37;&#41; vs&#46; 32&#37; de ellos&#44; que recidivaron &#40;32&#37;&#41;&#46; El estudio bivariante evidenci&#243; peor evoluci&#243;n entre los pacientes con edad avanzada &#40;mayores de 60 a&#241;os&#41;&#44; a pesar de que las diferencias no fueron estad&#237;sticamente significativas&#46; Tampoco se demostraron diferencias estad&#237;sticamente significativas entre los pacientes dependiendo de la situaci&#243;n anal&#237;tica preoperatoria&#44; aunque entre los enfermos con bilirrubina superior a 200&#44; el porcentaje de fallecidos era superior al de los enfermos sin colestasis&#46; La presencia de adenopat&#237;as afectas &#40;pT2&#41; se asoci&#243; a una mayor mortalidad a largo plazo&#44; sin ser diferencias estad&#237;sticamente significativas&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">En cuanto a la regresi&#243;n log&#237;stica univariante&#44; solo se encontraron factores de riesgo de mortalidad a la pN &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;04&#41;&#44; con un <span class="elsevierStyleItalic">odds ratio</span> &#40;OR&#41; de 2 y la presencia de recidiva &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;002&#41; con un OR de 5&#46; En el estudio multivariante la variable de tener recidiva &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;016&#41; tiene un OR de 3&#44;7&#46; En cuanto al multivariante sin tener en cuenta la recidiva tumoral&#44; la variable pN &#40;0&#44;044&#41; presenta un OR de 1&#44;9 &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">tabla 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">La supervivencia actual media es de 56&#44;23 meses con una desviaci&#243;n t&#237;pica de 64&#44;43 y el tiempo libre de enfermedad de 61&#44;11 meses con una desviaci&#243;n t&#237;pica de 63&#44;6&#46; La supervivencia actuarial media fue de 100 meses &#40;76-124&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">fig&#46; 1</a>&#41;&#46; La comparaci&#243;n de curvas Kaplan-Meier demostr&#243; que los pacientes con recidiva presentan peor supervivencia &#40;p<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;01&#41;&#46; De la misma forma&#44; los pacientes con afectaci&#243;n adenop&#225;tica presentan peor supervivencia a largo plazo &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;007&#44; <a class="elsevierStyleCrossRef" href="#fig0010">fig&#46; 2</a>&#41;&#46; Al comparar variables perioperatorias demostramos una peor supervivencia en los pacientes que presentaron fistula biliar postoperatoria &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;002&#59; <a class="elsevierStyleCrossRef" href="#fig0015">fig&#46; 3</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Discusi&#243;n</span><p id="par0080" class="elsevierStylePara elsevierViewall">La met&#225;stasis en n&#243;dulos linf&#225;ticos&#44; la diferenciaci&#243;n tumoral&#44; el factor T avanzado&#44; la invasi&#243;n linf&#225;tica&#44; venosa&#44; pancre&#225;tica y peri neural son factores conocidos de mal pron&#243;stico tras la resecci&#243;n del colangiocarcinoma distal<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">6&#44;8</span></a>&#46; Adem&#225;s&#44; la afectaci&#243;n de los m&#225;rgenes quir&#250;rgicos comporta mayor recurrencia y una supervivencia inferior<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">17</span></a>&#46; En nuestro estudio&#44; hemos corroborado la importancia de la afectaci&#243;n adenop&#225;tica y evidenciado que la aparici&#243;n de complicaciones postoperatorias como la presencia de f&#237;stula biliar se asocian a una peor evoluci&#243;n del paciente tras la resecci&#243;n de dCC&#44; cuesti&#243;n que no hab&#237;a sido demostrada hasta el momento actual&#46; Por &#250;ltimo&#44; el an&#225;lisis presentado es el estudio unic&#233;ntrico nacional m&#225;s extenso publicado hasta el momento&#44; con experiencia acumulada de m&#225;s de 30 a&#241;os de cirug&#237;a del colangiocarcinoma distal&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">El estadio de la enfermedad a la presentaci&#243;n es el determinante de m&#225;s peso en el pron&#243;stico del paciente<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">18&#8211;20</span></a>&#46; Hasta el momento&#44; el sistema de estadificaci&#243;n m&#225;s utilizado es el TNM &#40;8&#46;&#170; edici&#243;n&#41; de la American Joint Comission on Cancer &#40;AJCC&#41;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">5</span></a>&#46; As&#237;&#44; el estado de los n&#243;dulos linf&#225;ticos ha demostrado ser un fuerte predictor de peores resultados oncol&#243;gicos<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">9</span></a>&#46; Algunos autores han demostrado que la tasa de n&#243;dulos linf&#225;ticos positivos sobre el total de n&#243;dulos linf&#225;ticos resecados &#40;LNR&#41; est&#225; relacionada con los resultados oncol&#243;gicos de los pacientes con malignidad pancreaticobiliar&#44; y que puede ser un factor pronostico m&#225;s determinante comparado con el TNM<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">21</span></a>&#46; En nuestra experiencia&#44; el estudio de regresi&#243;n log&#237;stica univariante y multivariante rebel&#243; de forma estad&#237;sticamente significativa que la presencia de adenopat&#237;as afectadas duplica el riesgo de mortalidad en los pacientes intervenidos &#40;OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>2&#41;&#46; El an&#225;lisis de Kaplan-Meier objetiva una peor supervivencia para estos pacientes &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;003&#41;&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">En cuanto a las complicaciones postoperatorias&#44; no hemos conseguido demostrar que fuesen un factor de riesgo de presentar una peor evoluci&#243;n a largo plazo&#44; al contrario que otros grupos<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">22</span></a>&#46; Ahora bien&#44; de forma remarcable&#44; un 85&#37; de los enfermos con una f&#237;stula biliar fallecieron durante el seguimiento &#40;6&#47;7&#41; vs&#46; 57&#37; en los pacientes sin f&#237;stula biliar &#40;60&#47;105&#41;&#44; diferencias estad&#237;sticamente no significativas&#46; Hemos evidenciado una relaci&#243;n de los pacientes con f&#237;stula biliar y un peor pron&#243;stico de la enfermedad seg&#250;n la comparaci&#243;n de curvas de Kaplan-Meier&#46; Posiblemente&#44; la presencia de f&#237;stula biliar influye negativamente en la evoluci&#243;n de la enfermedad&#44; cuesti&#243;n que deber&#225; ser investigada en un futuro y para la que no tenemos explicaci&#243;n&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">El estudio multivariante que incluye la presencia de recidiva ha rebelado un incremento del riesgo de mortalidad 3&#44;7 veces superior vs&#46; los que no lo hacen &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;016&#41;&#46; El tratamiento con quimioterapia en enfermos con tumores de la v&#237;a biliar tras la cirug&#237;a tiene como objetivo disminuir la recidiva tumoral&#46; Ahora bien&#44; la literatura actual no consigue demostrar un efecto claro del tratamiento m&#233;dico postoperatorio en la supervivencia del enfermo a largo plazo<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">6&#44;23</span></a>&#46; Los estudios de tratamiento adyuvante en tumores de v&#237;as biliares han sido hist&#243;ricamente peque&#241;os&#44; retrospectivos y no aleatorizados&#44; e incluyen una combinaci&#243;n de pacientes con tumores de ves&#237;cula biliar&#44; ampulomas&#44; y otros tumores del tracto biliar&#46; Con esta escasa evidencia cient&#237;fica las recomendaciones de las gu&#237;as de pr&#225;ctica cl&#237;nica se han basado principalmente en el consenso de expertos&#46; A partir de 2011&#44; los pacientes se trataron con quimioterapia con gemcitabina &#40;dosis de 1&#46;000<span class="elsevierStyleHsp" style=""></span>mg&#47;m<span class="elsevierStyleSup">2</span> d&#237;as 1&#44;8 y 15&#47;cada 28 d&#237;as&#47;durante 6 meses bas&#225;ndonos en los resultados del metaan&#225;lisis publicado por Horgan et al&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">12</span></a>&#46; En &#233;l se objetivaba un beneficio no significativo en la supervivencia de los pacientes con tumores de v&#237;as biliares resecados y tratados posteriormente con quimioterapia adyuvante&#46; Recientemente&#44; se han publicado los resultados de ensayos prospectivos&#44; multic&#233;ntricos y aleatorizados de quimioterapia adyuvante en tumores del tracto biliar<a class="elsevierStyleCrossRefs" href="#bib0260"><span class="elsevierStyleSup">24&#8211;26</span></a> y de un ensayo de quimio-radioterapia adyuvante<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">27</span></a>&#46; En base a estos estudios&#44; la Sociedad Americana de Oncolog&#237;a M&#233;dica &#40;ASCO&#41; convoc&#243; un panel de expertos para llevar a cabo una revisi&#243;n sistem&#225;tica de la literatura y proporcionar unas recomendaciones terap&#233;uticas basadas en la evidencia para esta poblaci&#243;n de pacientes<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">28</span></a>&#46; Se emitieron dos recomendaciones&#58; la indicaci&#243;n de capecitabina por un per&#237;odo de 6 meses como terapia adyuvante a todos los pacientes con c&#225;ncer de v&#237;as biliares resecado y la posibilidad de quimiorradioterapia en el caso de margen afecto&#46; En nuestro centro y en el periodo de a&#241;os de la serie presentada&#44; los pacientes fueron tratados con los esquemas recomendados descritos&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Entre las limitaciones del estudio debemos resaltar que se trata de un an&#225;lisis retrospectivo de una serie unic&#233;ntrica&#44; por lo que debemos tener en cuenta un sesgo de selecci&#243;n&#44; as&#237; como el sesgo aparecido al ser una serie que abarca un gran per&#237;odo de tiempo&#46; Como hemos detallado&#44; el tratamiento sist&#233;mico durante estos a&#241;os se ha modificado siguiendo la evidencia cient&#237;fica del momento&#44; cuesti&#243;n puede ser una limitaci&#243;n y podr&#237;a modificar los resultados a largo plazo&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Conclusiones</span><p id="par0105" class="elsevierStylePara elsevierViewall">De acuerdo con nuestros resultados&#44; la presencia de afectaci&#243;n adenop&#225;tica&#44; adem&#225;s de la presencia de recidiva tumoral&#44; son factores de riesgo de mal pron&#243;stico a largo plazo&#46; La aparici&#243;n de f&#237;stula biliar durante el postoperatorio del colangiocarcinoma distal podr&#237;a agravar los resultados a largo plazo&#44; hallazgo que debe ser reafirmado en futuros estudios&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">A vista de nuestros resultados&#44; creemos que los esfuerzos deber&#237;an centrarse en la prevenci&#243;n&#44; identificaci&#243;n de factores de riesgo individuales y promoci&#243;n del diagn&#243;stico y tratamientos adecuados&#46; Es de vital importancia evitar o hacer un buen control de aquellas variables que comporten un mayor riesgo para el desarrollo de este tumor&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Financiaci&#243;n</span><p id="par0125" class="elsevierStylePara elsevierViewall">Este estudio recibi&#243; el apoyo del Institut de Investigaci&#243; Biom&#232;dica de Bellvitge &#40;Fundaci&#243;n IDIBELL&#41;&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Conflicto de intereses</span><p id="par0120" class="elsevierStylePara elsevierViewall">Los autores declaran no tener ning&#250;n conflicto de intereses&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introducci&#243;n</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">El colangiocarcinoma distal es una neoplasia epitelial maligna que afecta a los conductos biliares extrahep&#225;ticos&#44; per debajo del conducto c&#237;stico&#46; Existe poca evidencia sobre la relaci&#243;n entre factores perioperatorios y peor evoluci&#243;n a largo plazo tras la resecci&#243;n quir&#250;rgica&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Objetivo</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Analizar los factores de riesgo de mortalidad y recidiva a largo plazo del colangiocarcinoma distal de los pacientes resecados&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Material y m&#233;todos</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Se ha analizado una base de datos prospectiva unic&#233;ntrica de pacientes intervenidos por colangiocarcinoma distal entre los a&#241;os 1990 y 2021 con la finalidad de investigar los factores de mortalidad y recidiva&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Resultados</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Se han intervenido 113 pacientes&#44; con una supervivencia actuarial media de 100&#44;2 &#40;76-124&#41; meses tras la resecci&#243;n&#46; El estudio bivariante no evidenci&#243; diferencias entre los pacientes dependiendo de la edad o variables preoperatorias estudiadas&#46; La presencia de adenopat&#237;as afectadas fue un factor de riesgo de mortalidad a largo plazo en el estudio multivariante&#46; La presencia de adenopat&#237;as afectadas&#44; la recidiva tumoral y la f&#237;stula biliar durante el postoperatorio implicaron peor supervivencia actuarial al comparar las curvas de Kaplan-Meier&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conclusiones</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La presencia de adenopat&#237;as afectadas influyen en el pron&#243;stico de la enfermedad&#46; La aparici&#243;n de f&#237;stula biliar durante el postoperatorio del colangiocarcinoma distal podr&#237;a agravar los resultados a largo plazo&#44; hallazgo que debe ser reafirmado en futuros estudios&#46;</p></span>"
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        "resumen" => "<span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Introduction</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Distal cholangiocarcinoma is a malignant epithelial neoplasia that affects the extrahepatic bile ducts&#44; below the cystic duct&#46; No relevant relationship between perioperative factors and worse long-term outcome has been proved&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Objective</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">To analyze the risk factors for mortality and long-term recurrence of distal cholangiocarcinoma in resected patients&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Materials and methods</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">A single-center prospective database of patients operated on for distal cholangiocarcinoma between 1990 and 2021 was analyzed in order to investigate mortality and recurrence factors&#46;</p></span> <span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Results</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">One hundred and thirteen patients have undergone surgery&#44; with mean actuarial survival of 100&#46;2 &#40;76&#8211;124&#41; months after resection&#46; The bivariate study did not show differences between patients depending on age or preoperative variables studied&#46; When multivariate analysis was performed&#44; the presence of affected adenopathy was a risk factor for long-term mortality&#46; The presence of affected lymph nodes&#44; tumor recurrence&#44; and biliary fistula during the postoperative period implied worse actuarial survival when comparing the Kaplan&#8211;Meier curves&#46;</p></span> <span id="abst0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conclusions</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">The presence of affected lymph nodes influence the prognosis of the disease&#46; The occurrence of biliary fistula during postoperative cholangiocarcinoma distal could aggravate long-term outcomes&#44; a finding that should be reaffirmed in future studies&#46;</p></span>"
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          "leyenda" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">DE&#58; desviaci&#243;n est&#225;ndar&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
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                  \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">Datos preoperatorios&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">N&#46;&#176;&#47;&#37;&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="elsevierStyleBold">Edad &#40;a&#241;os&#59; media</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleBold">&#177; DE&#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">66&#44;30 &#40;&#177;8&#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="elsevierStyleBold">Sexo&#58; Var&#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">83&#47;75&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="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">ASA</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><span class="elsevierStyleItalic">I</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">21&#47;19&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">II</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">51&#47;46&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">III</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">36&#47;32&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="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">Anal&#237;tica preoperatoria</span>&#42;</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">Bilirrubina &#40;&#956;mol&#47;l&#59; media</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#177;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">DE&#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">154<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>162&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">Creatinina &#40;&#956;mol&#47;l&#59; media</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#177;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">DE&#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">78<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>30&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">Alb&#250;mina &#40;g&#47;l&#59; media</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#177;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">DE&#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">37<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>6&#44;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">CA 19&#46;9 &#40;media</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#177;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">DE&#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">282<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>697&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">Bilirrubina &#62;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">200</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#956;mol&#47;l</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">14&#47;35&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">Creatinina &#62;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">100</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#956;mol&#47;l</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">9&#47;25&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">Alb&#250;mina &#60;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">35</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">g&#47;l</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">12&#47;30&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="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">Detalles de la t&#233;cnica quir&#250;rgica</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><span class="elsevierStyleItalic">Tiempo &#40;minutos&#59; media</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#177;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">DE&#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">420<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>348&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="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Anastomosis pancre&#225;tica</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><span class="elsevierStyleHsp" style=""></span>Ducto-mucosa&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">59&#47;54&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>A toda boca&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">24&#47;22&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>Introducida&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">23&#47;21&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>Blumgart&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&#47;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
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>Tutor en la sutura pancre&#225;tica&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">30&#47;27&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">Resecci&#243;n vascular</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">4&#47;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
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Wirsung fi &#40;&#60;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">4</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">mm&#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">77&#47;70&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">P&#225;ncreas de consistencia blanda</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">41&#47;37&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">Transfusi&#243;n postoperatoria</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">42&#47;37&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">Nutrici&#243;n parenteral</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">65&#47;59&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 postoperatorias</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
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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>G3 &#40;Pobremente diferenciado&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 13&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="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Afectaci&#243;n adenop&#225;tica &#40;pN&#41;</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>0 &#40;no afectaci&#243;n ganglionar&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">65&#47;60&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>1 &#40;1-3 ganglios regionales&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">35&#47;32&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>2 &#40;&#8805;<span class="elsevierStyleHsp" style=""></span>4 ganglios regionales&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9&#47;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="elsevierStyleItalic">Adenopat&#237;as resecadas &#40;media</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#177;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">DE&#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">20&#44;35<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>8&#44;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="elsevierStyleItalic">Adenopat&#237;as afectas &#40;media</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#177;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">DE&#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">1&#44;20<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#44;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Adenopat&#237;as regionales &#40;media</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#177;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">DE&#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">1&#44;17<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#44;04&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
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " colspan="2" align="center" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Univariante</th><th class="td" title="\n
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                  \t\t\t\t  " colspan="2" align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">MultivarianteIncluyendo recidiva</th></tr><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">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" style="border-bottom: 2px solid black">OR &#40;IC 95&#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">P valor&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">OR &#40;IC 95&#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">P valor&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">OR &#40;IC 95&#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">P valor&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">Edad 70 &#40;a&#241;os&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#44;065 &#40;0&#44;466-2&#44;436&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;881&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&#44;524 &#40;0&#44;651-3&#44;570&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;331&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&#44;592 &#40;0&#44;649-5&#44;046&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;341&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">Sexo &#40;var&#243;n&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;773 &#40;0&#44;477-2&#44;707&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;605&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&#44;340 &#40;0&#44;535-3&#44;353&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;582&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&#44;809 &#40;0&#44;649-5&#44;046&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;257&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">Alb&#250;mina &#706;<span class="elsevierStyleHsp" style=""></span>35<span class="elsevierStyleHsp" style=""></span>g&#47;l&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;556 &#40;0&#44;141-2&#44;187&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;401&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
                  \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></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">Bilirrubina &#707;<span class="elsevierStyleHsp" style=""></span>300<span class="elsevierStyleHsp" style=""></span>&#956;mol&#47;l&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;0&#44;232-4&#44;310&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&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
                  \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></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">Creatinina &#62;<span class="elsevierStyleHsp" style=""></span>100<span class="elsevierStyleHsp" style=""></span>&#956;mol&#47;l&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;643 &#40;0&#44;136-3&#44;35&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;578&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
                  \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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                  \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">Complicaciones postoperatorias&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
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                  \t\t\t\t">0&#44;444 &#40;0&#44;169-1&#44;165&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#44;090&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">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \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 ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">F&#237;stula biliar&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">4&#44;500 &#40;0&#44;523-38&#44;709&#41;&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">0&#44;171&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">0&#44;230 &#40;0&#44;026-2&#44;012&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#44;159&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
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                  \t\t\t\t">0&#44;221 &#40;0&#44;023-2&#44;082&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#44;187&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">Grado diferenciaci&#243;n tumoral &#40;alto grado&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#44;587 &#40;0&#44;304-1&#44;132&#41;&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">0&#44;112&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \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 ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">pT&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
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                  \t\t\t\t">1&#44;588 &#40;0&#44;925-2&#44;726&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#44;093&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
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \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 ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">pN&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
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                  \t\t\t\t">2&#44;010 &#40;1&#44;034-3&#44;910&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#44;040&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
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                  \t\t\t\t">1&#44;991 &#40;1&#44;017-3&#44;896&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#44;044&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
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                  \t\t\t\t">1&#44;376 &#40;0&#44;646-2&#44;931&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#44;911&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
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                  \t\t\t\t">Recidiva&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&#44;093 &#40;1&#44;825-14&#44;207&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#44;002&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
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                  \t\t\t\t">3&#44;770 &#40;1&#44;276-11&#44;143&#41;&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">0&#44;016&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "es" => "<p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">Factores de riesgo de mortalidad a largo plazo&#46; Regresi&#243;n log&#237;stica univariante&#44; y multivariante <span class="elsevierStyleItalic">&#40;forward conditional&#41;</span></p>"
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
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                      "Revista" => array:6 [
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                        "volumen" => "24"
                        "paginaInicial" => "115"
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                        "link" => array:1 [
                          0 => array:2 [
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                    0 => array:2 [
                      "doi" => "10.3390/cancers12051237"
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                0 => array:2 [
                  "contribucion" => array:1 [
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                    0 => array:2 [
                      "doi" => "10.1097/01.sla.0000251366.62632.d3"
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                      "titulo" => "Cancer review&#58; Cholangiocarcinoma"
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                            0 => "W&#46; Zhou"
                            1 => "L&#46; Qian"
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                            3 => "W&#46;Y&#46; Jin"
                            4 => "Z&#46; Xu"
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                0 => array:2 [
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                      "titulo" => "It is the lymph node ratio that determines survival and recurrence patterns in resected distal cholangiocarcinoma&#46; A multicenter international study"
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                            1 => "Y&#46;X&#46; Koh"
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                            3 => "K&#46; Chin"
                            4 => "F&#46; Burdio"
                            5 => "P&#46; Sanchez-Velazquez"
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                    0 => array:2 [
                      "doi" => "10.1016/j.ejso.2022.02.008"
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                        "tituloSerie" => "Eur J Surg Oncol"
                        "fecha" => "2022"
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Información del artículo
ISSN: 02105705
Idioma original: Español
DOI:10.1016/j.gastrohep.2023.09.009
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