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Experience and Development of the Video-Assisted Thoracic Surgery Lobectomy Technique: Comparative Study With Conventional Surgery in Stage I Non-Small Cell Lung Cancer
Experiencia y desarrollo de la técnica de lobectomía por cirugía torácica videoasistida: estudio comparativo con cirugía convencional en estadio I de cáncer de pulmón no microcítico
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array:3 [ "entidad" => "Servicio de Cirugía Torácica, Hospital 12 de Octubre, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Cirugía General y Torácica, Hospital Universitario Virgen Macarena, Sevilla, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Experiencia y desarrollo de la técnica de lobectomía por cirugía torácica videoasistida: estudio comparativo con cirugía convencional en estadio <span class="elsevierStyleSmallCaps">I</span> de cáncer de pulmón no microcítico" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1085 "Ancho" => 1578 "Tamanyo" => 59651 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Comparison of the numbers of anatomical pulmonary resections performed using conventional surgery and using VATS.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">During the last decade, lung cancer has been the principal cause of cancer death throughout the world and remains one of the respiratory diseases with the highest mortality rates: every year, 900<span class="elsevierStyleHsp" style=""></span>000 new cases are diagnosed in males and 330<span class="elsevierStyleHsp" style=""></span>000 in females. In the European Union, lung cancer accounts for 21% of all cancers in males and causes 29% of all cancer deaths in that gender.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">In 1993, Roviaro et al.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> reported the first successful lobectomy carried out with video-assisted thoracic surgery (VATS), demonstrating that lung cancer could be appropriately treated in this way while describing the surgical technique employed.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Since then, various authors have reported high numbers of both lobectomies and pneumonectomies performed using this technique,<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3–6</span></a> with better immediate outcomes when compared to open surgery. Nevertheless, lobectomies by thoracotomy continue to be carried out in patients with early stage lung cancer. The primary aim of our study is to compare the two approaches for the surgical treatment of stage <span class="elsevierStyleSmallCaps">i</span>non-small cell lung cancer and to evaluate their outcomes, with the aim of defining the real advantages of VATS.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Materials and Methods</span><p id="par0020" class="elsevierStylePara elsevierViewall">This was a comparative, retrospective study in our centre, analysing the short and long-term outcomes of patients with a diagnosis of stage <span class="elsevierStyleSmallCaps">i</span> non-small cell lung cancer undergoing major anatomical lung resection with systematic lymph node dissection. The TNM classification (6th edition) for lung cancer was used in all cases. One hundred and sixty-one (161) major lung resections were performed using VATS and 142 were undertaken using conventional surgery. Twenty (12.4%) cases in the VATS group and 27 (19%) in the open surgery group were lost to follow-up.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The clinical variables studied were conversion rates, duration of the intervention, mortality, number of complications, hospital stay after surgery (complicated and non-complicated patients), local recurrence rates, distant metastases and 5-year survival. Pearson's <span class="elsevierStyleItalic">χ</span><span class="elsevierStyleSup">2</span>-test and the Mantel–Cox method were used for analysis, with a value of <span class="elsevierStyleItalic">P</span><.05 being considered statistically significant.</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Characteristics of the Two Groups</span><p id="par0030" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">-</span><p id="par0035" class="elsevierStylePara elsevierViewall">VATS group (n=141 patients; 102 men and 39 women). Mean age was 60.4 years (range 34–79 years). Histological types are listed in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>, squamous cell carcinoma being the most common (45.2%). The mean tumour size was 3.1<span class="elsevierStyleHsp" style=""></span>cm (range 1.1–6.2<span class="elsevierStyleHsp" style=""></span>cm). One hundred and thirty-eight (138) lobectomies and 3 bilobectomies were performed (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">-</span><p id="par0040" class="elsevierStylePara elsevierViewall">Conventional surgery group (n=115 patients; 88 men and 27 women). Mean age was 62.6 years (range 37–83 years). As in the VATS group, the most common histological type was squamous cell carcinoma (50.7%) (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). The mean tumour size was 3.6<span class="elsevierStyleHsp" style=""></span>cm (range 1.4–6.8<span class="elsevierStyleHsp" style=""></span>cm). One hundred and eight (108) lobectomies and 7 bilobectomies (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>) were performed.</p></li></ul></p><p id="par0045" class="elsevierStylePara elsevierViewall">Homogeneity between both groups was tested statistically with regard to sex, age, histological type, tumour size and resection type, using Snedecor's F distribution.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Selection Criteria</span><p id="par0050" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Inclusion criteria.</span> All patients with a diagnosis of stage <span class="elsevierStyleSmallCaps">i</span> non-small cell lung cancer (NSCLS) resected between 1 January 1993 and 31 December 2005; thus, all patients would be in follow-up for a minimum of 5 years.</p><p id="par0055" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Exclusion criteria.</span> Minor lung resections (atypical resection or segmentectomy) or major anatomical resection with pneumonectomy, sleeve lobectomy, bronchoplasty or broncho-angioplasty. Cases in the VATS group which required conversion to conventional surgery (24) once dissection had begun were also excluded.</p><p id="par0060" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Selection of approach.</span> The choice of an open approach or VATS was a decision made individually by each surgeon after exploratory video-assisted thoracoscopy, although since that time the criteria in our department have been unified. For lung resection to be performed using VATS, the cases had to meet the following criteria:<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">1.</span><p id="par0065" class="elsevierStylePara elsevierViewall">Tumour <4<span class="elsevierStyleHsp" style=""></span>cm. This is the ideal size, although in our study, tumours of up to 6<span class="elsevierStyleHsp" style=""></span>cm were successfully resected, as there is usually no problem if the location is sufficiently peripheral.</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">2.</span><p id="par0070" class="elsevierStylePara elsevierViewall">The tumour had to be peripheral, and never in the lobar bronchi, or at least 2<span class="elsevierStyleHsp" style=""></span>cm from the interlobar carina.</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">3.</span><p id="par0075" class="elsevierStylePara elsevierViewall">Open fissure, although this is now in question. On the right side, the minor fissure does not present any problem in upper, mid and lower lobectomies, and fused major fissure is not a problem, neither for an upper lobectomy nor for a lower lobectomy, where the bronchus must be done before the artery. On the left side, the major fissure must be open, although in cases where the fissure is fused, the lobar bronchus may be done first, as on the right side.</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">4.</span><p id="par0080" class="elsevierStylePara elsevierViewall">Pleural adhesions are a relative contraindication for VATS, since they only represent a real obstacle when they are firm and extensive; otherwise they can generally be completely freed.</p></li></ul></p></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Results</span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Feasibility</span><p id="par0085" class="elsevierStylePara elsevierViewall">In our study, anatomical lung resections were performed in 256 patients with stage <span class="elsevierStyleSmallCaps">i</span> non-small cell lung cancer. If the number of VATS lung resections carried out in the first six years (1993–1999) is compared with the last five years of the study (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>), a significant increase can be observed in the number of VATS lobectomies (37.5%) compared to lobectomies by conventional surgery. This rise can be attributed to our surgical team overcoming the learning curve and a reduction in the number of contraindications for VATS as our experience grew. For example, at the beginning, pleural adhesions were a contraindication for this type of surgery, but now open surgery is undertaken in only a small number of cases. The rate of conversion to open surgery in our study is 14.5% (n=24). The reason for conversion was due to controlled bleeding in 13 cases and in the others it due to technical difficulties (multiple and/or firm adhesions, calcified lymph nodes, oncological reasons, anaesthetists could not achieve adequate lung collapse). Notwithstanding, on examining the number of conversions in the last 5 years, the conversion rate has fallen to 7.6%.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">It is also important to determine the time required for a VATS lung resection and if this impacts on the development of complications. If surgical time is taken as the time from making the first port incision until closure, the mean duration in the VATS group was 138.3<span class="elsevierStyleHsp" style=""></span>min (median 92<span class="elsevierStyleHsp" style=""></span>min). When surgical time is correlated with development or non-development of complications, using Pearson's <span class="elsevierStyleItalic">χ</span><span class="elsevierStyleSup">2</span> test, a prevalence ratio of 2.42 (95% CI, 1.09–5.36, <span class="elsevierStyleItalic">P</span>=.043) is obtained, showing that surgical time is a risk factor for the development of post-operative complications (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>). The mean duration of conventional surgery was 126.6<span class="elsevierStyleHsp" style=""></span>min (median 123<span class="elsevierStyleHsp" style=""></span>min).</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Morbidity and Mortality</span><p id="par0095" class="elsevierStylePara elsevierViewall">Let us first examine mortality in the first 30 days (<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>). Pearson's <span class="elsevierStyleItalic">χ</span><span class="elsevierStyleSup">2</span> test gave a <span class="elsevierStyleItalic">P</span>-value of .88, showing that the risk of death after conventional thoracotomy is no greater than with VATS.</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0100" class="elsevierStylePara elsevierViewall">The overall number of complications that emerged in our series was 64, of which the most frequent were pulmonary (48; 75%), followed by cardiovascular (10; 15.6%), surgical wound problems (5; 7.8%) and cerebrovascular accident (1; 1.6%).</p><p id="par0105" class="elsevierStylePara elsevierViewall">Overall morbidity in the conventional surgery group was greater than in the VATS group (<a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>), due to greater trauma to the chest wall and the lung caused by thoracotomy. In view of these data, a Pearson's <span class="elsevierStyleItalic">χ</span><span class="elsevierStyleSup">2</span>-test was performed on the number of patients who underwent resection in order to determine whether the approach adopted affected the development of complications in the post-operative period. The <span class="elsevierStyleItalic">P</span>-value was .0001, with a prevalence ratio of 0.55 (95% CI, 0.39–0.79), showing a significant association between the approach used and the rate of complications.</p><elsevierMultimedia ident="tbl0025"></elsevierMultimedia><p id="par0110" class="elsevierStylePara elsevierViewall">The last important point in this comparison concerns the mean post-operative hospital stay after both procedures, which is basically determined by morbidity. To this end, the mean number of days of the post-operative stay were evaluated according to the approach used, by complicated and non-complicated patients (<a class="elsevierStyleCrossRef" href="#tbl0030">Table 6</a>). The Pearson's <span class="elsevierStyleItalic">χ</span><span class="elsevierStyleSup">2</span> test was applied, giving a highly significant <span class="elsevierStyleItalic">P</span>-value (<span class="elsevierStyleItalic">P</span>=.0001) and a prevalence ratio of 0.21 (95% CI, 0.15–0.31).</p><elsevierMultimedia ident="tbl0030"></elsevierMultimedia></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Survival</span><p id="par0115" class="elsevierStylePara elsevierViewall">The 5-year survival rate after the intervention was 68.1% in the VATS group and 63.8% in the conventional surgery group. A Mantel–Cox non-parametric test that accepted censored data was used to compare both survival curves (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). No statistically significant differences were observed in overall survival (log-rank test, <span class="elsevierStyleItalic">P</span>=.735).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Recurrence Rate and Distant Metastases</span><p id="par0120" class="elsevierStylePara elsevierViewall">No statistically significant differences (<span class="elsevierStyleItalic">P</span>=.84) were observed when the recurrence rates of patients who underwent resection using conventional surgery and VATS were compared (<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>). The relationship between the development of distant metastases and the approach is not statistically significant (<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>), according to a Pearson's <span class="elsevierStyleItalic">χ</span><span class="elsevierStyleSup">2</span> test (<span class="elsevierStyleItalic">P</span>=.82).</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Discussion</span><p id="par0125" class="elsevierStylePara elsevierViewall">The first successful lobectomy with VATS was carried out in 1993.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Several advantages of this technique over conventional surgery have been subsequently demonstrated. In our study, in order to make a comparison between the two approaches and to assess the outcomes, patients with stage <span class="elsevierStyleSmallCaps">i</span> (TNM) lung cancer were selected to undergo lobectomy/bilobectomy by VATS or open surgery. Mean tumour size in both groups was practically the same (VATS: 3.1<span class="elsevierStyleHsp" style=""></span>cm; open surgery group: 3.6<span class="elsevierStyleHsp" style=""></span>cm) and the mean age of both groups was similar. Accordingly, any influence derived from the stage, tumour size, type of resection or age of the patients on surgical outcomes and long-term survival was avoided.</p><p id="par0130" class="elsevierStylePara elsevierViewall">As in other studies,<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,7</span></a> morbidity in the VATS group (15.6%) was lower than that in the open surgery group (36.52%) (<span class="elsevierStyleItalic">P</span>=.0001). However, in a study<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> comparing 122 patients undergoing VATS lobectomy with 122 undergoing conventional surgery, no statistically significant differences were observed when the different types of complications were analysed individually. This is probably because in that study the groups were classified by sex and age, without taking into account other characteristics including stage, tumour size, etc. These factors were included in the series published by Villamizar et al.,<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> in which 284 VATS patients were compared with 284 conventional surgery patients on the basis of 13 perioperative variables. There were fewer complications in the VATS group (21%) than in the conventional surgery group (49%). In our series, pulmonary complications were the most common, and only 1.4% of the VATS group and 2.6% of the thoracotomy group experienced atrial fibrillation in the post-operative period. Morbidity was lower because VATS is less aggressive to the chest wall and lung and has less impact on the breathing mechanism, unlike thoracotomy, which produces more cases of atelectasis, pneumonia, prolonged air leak, etc.</p><p id="par0135" class="elsevierStylePara elsevierViewall">Obviously, the lower rate of complications in the VATS group will impact positively on the mean hospital stay; in our study the difference between the two approaches was highly significant (<span class="elsevierStyleItalic">P</span>=.0001), both in the group of complicated patients and in the patients without complications. This reduction in the length of hospital stay in the VATS group has been described in other studies,<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,7,9</span></a> and attributed to less post-operative pain or the early withdrawal of pleural drainage.</p><p id="par0140" class="elsevierStylePara elsevierViewall">As in the larger series published,<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,6–13</span></a> which show mortality ranging between 0.4% and 3.7%, in our study the mortality rate in the first 30 days post-surgery in the VATS group was very low. Similarly to our series, no differences were found between the two groups in the first 30 days post-surgery in the prospective study performed by Villamizar et al.,<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> showing that VATS did not increase the risk of death.</p><p id="par0145" class="elsevierStylePara elsevierViewall">The mean duration of a VATS lobectomy in a clinical trial performed by the American College of Surgeons Oncology Group Z0030<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> was 117<span class="elsevierStyleHsp" style=""></span>minutes, and 171<span class="elsevierStyleHsp" style=""></span>minutes by lateral thoracotomy (<span class="elsevierStyleItalic">P</span>=.001). However, in the study of Subroto et al.,<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> centred on the Society of Thoracic Surgeons database, the duration of a VATS lobectomy (173<span class="elsevierStyleHsp" style=""></span>min) was greater than that by the conventional method (143<span class="elsevierStyleHsp" style=""></span>min), with a statistically significant difference (<span class="elsevierStyleItalic">P</span>=.0001). In our series, the duration of a VATS lobectomy (median: 92<span class="elsevierStyleHsp" style=""></span>min) did not involve longer surgery time or more time under anaesthesia. In addition, if surgical time is compared with the development or non-development of complications, the duration of the intervention (>140<span class="elsevierStyleHsp" style=""></span>min) is found to be a risk factor for development of post-operative complications (<span class="elsevierStyleItalic">P</span>=.043). These results suggest that although the aggression to the chest wall and the resulting repercussions on post-operative progress after one approach or another are factors to be taken into account, the length of time in surgery must also be taken into consideration.</p><p id="par0150" class="elsevierStylePara elsevierViewall">Despite the advantages offered by anatomical lung resections with video-assisted surgery, its use in the treatment of lung cancer continues to be controversial. The defenders of the technique, including our team, maintain that in a VATS lung resection all the principles of oncological surgery are respected, including complete resection (R0) and complete lymph node dissection. Although the role of VATS in performing complete lymph node dissection has been questioned, in our experience all lymph node stations are equally or more accessible using this technique when compared to thoracotomy, and is therefore perfectly valid and safe for this purpose. In the randomised study by Kirby and Rice,<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> no statistically significant differences were observed between the total number of lymph nodes obtained in the two approaches (total number of lymph nodes from VATS: 9.5<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>3.6; from thoracotomy: 9.3<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>4.3). In another study by Sagawa et al.,<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> in which a thoracotomy was performed after VATS lobectomy in order to verify whether complete lymph node dissection had been achieved, the number of remnant nodes after a VATS lymphadenectomy was between 2% and 3% (on the right side an average of 1.3 nodes of a mean total of 40.3 nodes was found, and on the left side, 1.2 of a mean total of 37.3).</p><p id="par0155" class="elsevierStylePara elsevierViewall">Detractors of VATS point to another randomised study in which no particular advantage was seen for this technique, since the patients had similar hospital stays and post-operative morbidities with both approaches.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> They also point out that most of the series published in favour of VATS were retrospective case-control studies.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> However, the prospective, randomised, multicentre study carried out by Scott et al.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> with a scoring system for obtaining two groups with similar baseline characteristics, showed a shorter hospital stay and a lower number of complications in the VATS group. Similarly, the morbidity rate in the VATS group in our series was lower than in the open surgery group (<span class="elsevierStyleItalic">P</span>=.0001), as was the mean post-operative stay in complicated and non-complicated patients (<span class="elsevierStyleItalic">P</span>=.0001).</p><p id="par0160" class="elsevierStylePara elsevierViewall">Another aspect showing that VATS complies with the principles of oncological surgery is the recurrence rate and overall survival. In our study, follow-up was at least 5 years and no statistically significant differences were found in overall survival (log-rank test, <span class="elsevierStyleItalic">P</span>=.735), although our results suggested a slight increase in survival in the VATS group. Similarly, no statistically significant differences were observed in the number of recurrences and distant metastases on comparing the two approaches (<span class="elsevierStyleItalic">P</span>=.82). As in our results, the recent meta-analysis of 21 studies by Yan et al.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> found the same rate of recurrence after VATS lobectomies as after conventional surgery (RR: 0.64; 95% CI, 0.35–1.35; <span class="elsevierStyleItalic">P</span>=.24). The authors suggest that VATS lobectomies for lung cancer treatment are associated with a low rate of systemic recurrences (RR: 0.57; 95% CI 0.3–0.95; <span class="elsevierStyleItalic">P</span>=.03) and a better 5-year survival rate (RR: 0.66; 95% CI, 0.45–0.97; <span class="elsevierStyleItalic">P</span>=.04).</p><p id="par0165" class="elsevierStylePara elsevierViewall">Although our study shows that video-assisted surgery is a safe and appropriate approach in patients with stage <span class="elsevierStyleSmallCaps">i</span> NSCLC that complies with the principles of oncological surgery, the results should be evaluated with caution. Although the aim was to select a sample with similar clinical characteristics in both groups (age, sex, tumour size, TNM), this is a retrospective study, so there could be a risk of bias in the collection of the clinical data. Despite this, the use of this technique in the surgical treatment of NSCLC continues to increase, as demonstrated by the results obtained in the series published by Subroto et al.,<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> Villamizar et al.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> and Scott et al.,<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> who conclude that VATS lung resection for the treatment of NSCLC is a safe and effective treatment with fewer complications than open surgery and better outcomes with regard to hospital stay and aesthetic appearance. Long-term survival with both techniques is similar, although as surgeons’ experience increases and the number of cases of resection continues to rise, it seems that survival in the VATS group may be longer.</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Conflict of Interests</span><p id="par0170" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflict of interests.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:2 [ "identificador" => "xres315529" "titulo" => array:5 [ 0 => "Abstract" 1 => "Background" 2 => "Materials and methods" 3 => "Results" 4 => "Conclusions" ] ] 1 => array:2 [ "identificador" => "xpalclavsec298253" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres315528" "titulo" => array:5 [ 0 => "Resumen" 1 => "Objetivo" 2 => "Material y métodos" 3 => "Resultados" 4 => "Conclusiones" ] ] 3 => array:2 [ "identificador" => "xpalclavsec298254" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Materials and Methods" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Characteristics of the Two Groups" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Selection Criteria" ] ] ] 6 => array:3 [ "identificador" => "sec0025" "titulo" => "Results" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0030" "titulo" => "Feasibility" ] 1 => array:2 [ "identificador" => "sec0035" "titulo" => "Morbidity and Mortality" ] 2 => array:2 [ "identificador" => "sec0040" "titulo" => "Survival" ] 3 => array:2 [ "identificador" => "sec0045" "titulo" => "Recurrence Rate and Distant Metastases" ] ] ] 7 => array:2 [ "identificador" => "sec0050" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0055" "titulo" => "Conflict of Interests" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2013-02-10" "fechaAceptado" => "2013-05-22" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec298253" "palabras" => array:4 [ 0 => "Video-assisted thoracic surgery" 1 => "Thoracotomy" 2 => "Non-small cell lung carcinoma" 3 => "Surgery" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec298254" "palabras" => array:4 [ 0 => "Cirugía torácica videoasistida" 1 => "Toracotomía" 2 => "Carcinoma no microcítico de pulmón" 3 => "Cirugía" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0010">Background</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Surgical treatment of stage <span class="elsevierStyleSmallCaps">I</span> non-small cell lung cancer (NSCLC) can be performed either by thoracotomy or by employing video-assisted thoracic surgery (VATS). The aim of this study was to compare long- and short-term results of conventional surgery (CS) vs VATS lobectomy in the treatment of stage <span class="elsevierStyleSmallCaps">I</span> NSCLC.</p> <span class="elsevierStyleSectionTitle" id="sect0015">Materials and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">We performed a retrospective, analytical study of patients undergoing surgery for stage <span class="elsevierStyleSmallCaps">I</span> NSCLC during the period January 1993 to December 2005. The variables analysed were overall survival, recurrence, distant metastasis, morbidity, mortality and hospital stay. During this period, 256 anatomic lung resections were performed: 141 by CS and 115 by VATS.</p> <span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">There were statistically significant differences in: (i) mean hospital stay in patients with no complications (VATS group: 4.3 days vs CS group: 8.7 days, <span class="elsevierStyleItalic">P</span>=.0001); (ii) mean hospital stay in patients with complications (VATS: 7.2 days vs CS: 13.7 days, <span class="elsevierStyleItalic">P</span>=.0001), and (iii) morbidity (VATS: 15.6% vs CS: 36.52%, <span class="elsevierStyleItalic">P</span>=.0001). No statistically significant differences were found in: (i) mortality (VATS: 2.17% vs CS: 1.7%, <span class="elsevierStyleItalic">P</span>=.88); (ii) 5-year overall survival (VATS: 68.1% vs CS: 63.8%), and (iii) local recurrence and distant metastasis (<span class="elsevierStyleItalic">P</span>=.82).</p> <span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">VATS lobectomy is a safe and effective approach, with a shorter hospital stay and lower morbidity than CS; no statistically significant differences were observed in survival in patients undergoing surgery for stage <span class="elsevierStyleSmallCaps">I</span> NSCLC.</p>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Analizar nuestra experiencia con la cirugía torácica videoasistida (VATS) y comparar sus resultados a corto y a largo plazo con la lobectomía por cirugía convencional, en el tratamiento quirúrgico del cáncer de pulmón no microcítico (CPNM) en estadio <span class="elsevierStyleSmallCaps">I</span>.</p> <span class="elsevierStyleSectionTitle" id="sect0040">Material y métodos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Se realizó un estudio retrospectivo y analítico de los pacientes intervenidos de cáncer de pulmón no microcítico en estadio <span class="elsevierStyleSmallCaps">I</span> durante el periodo de enero de 1993 a diciembre de 2005. Las variables analizadas fueron: supervivencia global, recidiva, metástasis a distancia, morbimortalidad y estancia hospitalaria. Durante este periodo se realizaron 256<span class="elsevierStyleHsp" style=""></span>resecciones pulmonares anatómicas: 141 por VATS y 115 por cirugía convencional.</p> <span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Se encontraron diferencias estadísticamente significativa en: a) estancia media postoperatoria en pacientes que no tuvieron complicaciones (grupo VATS: 4,3<span class="elsevierStyleHsp" style=""></span>días; grupo de cirugía convencional: 8,7<span class="elsevierStyleHsp" style=""></span>días; p<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0,0001); b) estancia media postoperatoria en pacientes que tuvieron complicaciones (VATS: 7,2 días; cirugía convencional: 13,7 días; p<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0,0001), y c) morbilidad (VATS: 15,6%; cirugía abierta: 36,52%; p<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0,0001). No se encontraron diferencias estadísticamente significativas en: a) mortalidad (VATS: 2,17%; cirugía convencional: 1,7%; p<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0,88); b) supervivencia global a 5<span class="elsevierStyleHsp" style=""></span>años (VATS: 68,1%; cirugía convencional: 63,8%); c) recidiva local y metástasis a distancia (p<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0,82).</p> <span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La lobectomía VATS es una técnica segura y eficaz, con una menor estancia hospitalaria y morbilidad que la cirugía convencional, sin que se observen diferencias estadísticamente significativas en la supervivencia en pacientes intervenidos por cáncer de pulmón no microcítico en estadio<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleSmallCaps">i</span>.</p>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Triviño A, Congregado M, Loscertales J, Jiménez-Merchán R, Pinos-Vélez N, Cózar F, et al. Experiencia y desarrollo de la técnica de lobectomía por cirugía torácica videoasistida: estudio comparativo con cirugía convencional en estadio I de cáncer de pulmón no microcítico. Arch Bronconeumol. 2014;50:57–61.</p>" ] ] "multimedia" => array:8 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1085 "Ancho" => 1578 "Tamanyo" => 59651 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Comparison of the numbers of anatomical pulmonary resections performed using conventional surgery and using VATS.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1245 "Ancho" => 1597 "Tamanyo" => 73141 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Survival curves of patients with stage <span class="elsevierStyleSmallCaps">i</span> lung cancer in group 1 (VATS group) and group 2 (conventional surgery group).</p>" ] ] 2 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td 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" style="border-bottom: 2px solid black">Histology \t\t\t\t\t\t\n \t\t\t\t</td><td 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" style="border-bottom: 2px solid black">VATS (n=141) \t\t\t\t\t\t\n \t\t\t\t</td><td 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" style="border-bottom: 2px solid black">Thoracotomy (n=115) \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><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">Squamous cell carcinoma \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">64 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">58 \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 " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Adenocarcinoma \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">53 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">38 \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 " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Large cell carcinoma \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">14 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 \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 " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Adenosquamous carcinoma \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \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 " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Carcinosarcoma \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \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 " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Undifferentiated carcinoma \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \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 " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Mixed squamous and giant cell carcinoma \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \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 " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Undifferentiated carcinoma \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \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 " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Intermediate cell carcinoma \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab464088.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Histological Types.</p>" ] ] 3 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td 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" style="border-bottom: 2px solid black">Lung resections \t\t\t\t\t\t\n \t\t\t\t</td><td 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" style="border-bottom: 2px solid black">VATS (n=141) \t\t\t\t\t\t\n \t\t\t\t</td><td 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" style="border-bottom: 2px solid black">Thoracotomy (n=115) \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><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">ULL \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">25 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">32 \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 " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">LLL \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">28 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 \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 " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Bilobectomy \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 \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 " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">RUL \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">55 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">43 \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 " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">RLL \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">22 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">17 \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 " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">ML \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab464086.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Lung Resections Performed in the Two Groups.</p>" ] ] 4 => array:7 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td 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" style="border-bottom: 2px solid black">Duration \t\t\t\t\t\t\n \t\t\t\t</td><td 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" style="border-bottom: 2px solid black">Complications \t\t\t\t\t\t\n \t\t\t\t</td><td 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" style="border-bottom: 2px solid black">No complications \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><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"><140<span class="elsevierStyleHsp" style=""></span>min \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">68 \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 " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">>140<span class="elsevierStyleHsp" style=""></span>min \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">14 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">41 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab464090.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Number of Complications by Surgical Time in the VATS Group.</p>" ] ] 5 => array:7 [ "identificador" => "tbl0020" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td 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" style="border-bottom: 2px solid black">Approach \t\t\t\t\t\t\n \t\t\t\t</td><td 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" style="border-bottom: 2px solid black">Recurrence \t\t\t\t\t\t\n \t\t\t\t</td><td 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" style="border-bottom: 2px solid black">Metastasis \t\t\t\t\t\t\n \t\t\t\t</td><td 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" style="border-bottom: 2px solid black">Death \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><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">VATS \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 (4.2%) \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">11 (7.80%) \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 (2.1%) \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 " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Conventional surgery \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 (5.2%) \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9 (7.82%) \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 (1.7%) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab464089.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Recurrence Rates, Metastases and Death in the First 30 Days in the Two Groups.</p>" ] ] 6 => array:7 [ "identificador" => "tbl0025" "etiqueta" => "Table 5" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td 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" style="border-bottom: 2px solid black">Complications \t\t\t\t\t\t\n \t\t\t\t</td><td 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" style="border-bottom: 2px solid black">VATS (n=22) 15.6% \t\t\t\t\t\t\n \t\t\t\t</td><td 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" style="border-bottom: 2px solid black">Conventional surgery (n=42) 36.52% \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><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">Prolonged air leak \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10 \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 " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Atelectasis \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 \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 " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Apical airspace \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \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 " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Respiratory failure \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \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 " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Pneumonia \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \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 " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Bronchial fistula \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \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 " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Haemothorax \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \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 " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Atrial fibrillation \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \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 " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Pulmonary embolism \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \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 " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Myocardial infarction \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \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 " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Cerebrovascular accident \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \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 " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Wound infection \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab464085.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Morbidity in the Two Groups.</p>" ] ] 7 => array:7 [ "identificador" => "tbl0030" "etiqueta" => "Table 6" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td 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" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td><td 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" style="border-bottom: 2px solid black">VATS Group, mean stay \t\t\t\t\t\t\n \t\t\t\t</td><td 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" style="border-bottom: 2px solid black">Open surgery group, mean stay \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><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">Non-complicated patient \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4.3 days (n=119) \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8.7 days (n=73) \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 " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Complicated \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7.2 days (n=22) \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">13.7 days (n=42) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab464087.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Mean Post-operative Hospital Stay in the Two Groups for Complicated and Non-complicated Patients.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:13 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Epidemiology of lung cancer" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "H. Skuladottir" 1 => "J.H. Olsen" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Eur Respir Mon" "fecha" => "2001" "volumen" => "17" "paginaInicial" => "1" "paginaFinal" => "12" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Videoendoscopic thoracic surgery" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "G.C. Roviaro" 1 => "C. Rebuffat" 2 => "F. Varoli" 3 => "C. Vergani" 4 => "C. Maciocco" 5 => "F. Grignani" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:3 [ "tituloSerie" => "Int Surg" "fecha" => "1993" "paginaInicial" => "78" ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The role of video-assisted thoracic surgery for carcinoma of the lung: wedge resection to lobectorny by simultaneous individual stapling" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "R.I. Lewis" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Ann Thorac Surg" "fecha" => "1993" "volumen" => "56" "paginaInicial" => "762" "paginaFinal" => "768" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8379790" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:1 [ "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "J. Loscertales" 1 => "R. Jimenez-Merchan" 2 => "M. Congregado" 3 => "F.J. Ayarra" 4 => "G. Gallardo" 5 => "A. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 6 | 5 | 11 |
| 2024 October | 49 | 25 | 74 |
| 2024 September | 47 | 14 | 61 |
| 2024 August | 60 | 41 | 101 |
| 2024 July | 54 | 26 | 80 |
| 2024 June | 71 | 18 | 89 |
| 2024 May | 66 | 29 | 95 |
| 2024 April | 38 | 31 | 69 |
| 2024 March | 46 | 13 | 59 |
| 2024 February | 32 | 23 | 55 |
| 2023 March | 7 | 1 | 8 |
| 2023 February | 25 | 19 | 44 |
| 2023 January | 33 | 22 | 55 |
| 2022 December | 48 | 34 | 82 |
| 2022 November | 44 | 23 | 67 |
| 2022 October | 53 | 34 | 87 |
| 2022 September | 38 | 22 | 60 |
| 2022 August | 41 | 30 | 71 |
| 2022 July | 39 | 37 | 76 |
| 2022 June | 30 | 32 | 62 |
| 2022 May | 41 | 32 | 73 |
| 2022 April | 43 | 20 | 63 |
| 2022 March | 51 | 36 | 87 |
| 2022 February | 44 | 39 | 83 |
| 2022 January | 31 | 34 | 65 |
| 2021 December | 28 | 39 | 67 |
| 2021 November | 52 | 32 | 84 |
| 2021 October | 39 | 40 | 79 |
| 2021 September | 36 | 44 | 80 |
| 2021 August | 49 | 29 | 78 |
| 2021 July | 43 | 39 | 82 |
| 2021 June | 53 | 26 | 79 |
| 2021 May | 45 | 49 | 94 |
| 2021 April | 99 | 78 | 177 |
| 2021 March | 42 | 26 | 68 |
| 2021 February | 38 | 19 | 57 |
| 2021 January | 66 | 11 | 77 |
| 2020 December | 37 | 9 | 46 |
| 2020 November | 35 | 18 | 53 |
| 2020 October | 22 | 20 | 42 |
| 2020 September | 76 | 9 | 85 |
| 2020 August | 90 | 14 | 104 |
| 2020 July | 119 | 19 | 138 |
| 2020 June | 23 | 5 | 28 |
| 2020 May | 63 | 17 | 80 |
| 2020 April | 67 | 25 | 92 |
| 2020 March | 32 | 13 | 45 |
| 2020 February | 45 | 19 | 64 |
| 2020 January | 33 | 26 | 59 |
| 2019 December | 46 | 16 | 62 |
| 2019 November | 30 | 14 | 44 |
| 2019 October | 34 | 9 | 43 |
| 2019 September | 42 | 16 | 58 |
| 2019 August | 46 | 6 | 52 |
| 2019 July | 27 | 21 | 48 |
| 2019 June | 31 | 13 | 44 |
| 2019 May | 48 | 9 | 57 |
| 2019 April | 44 | 18 | 62 |
| 2019 March | 49 | 16 | 65 |
| 2019 February | 40 | 18 | 58 |
| 2019 January | 47 | 27 | 74 |
| 2018 December | 62 | 19 | 81 |
| 2018 November | 68 | 22 | 90 |
| 2018 October | 94 | 23 | 117 |
| 2018 September | 36 | 14 | 50 |
| 2018 May | 10 | 1 | 11 |
| 2018 April | 35 | 6 | 41 |
| 2018 March | 24 | 3 | 27 |
| 2018 February | 30 | 7 | 37 |
| 2018 January | 154 | 9 | 163 |
| 2017 December | 181 | 3 | 184 |
| 2017 November | 47 | 5 | 52 |
| 2017 October | 23 | 10 | 33 |
| 2017 September | 17 | 9 | 26 |
| 2017 August | 42 | 10 | 52 |
| 2017 July | 31 | 6 | 37 |
| 2017 June | 53 | 12 | 65 |
| 2017 May | 45 | 5 | 50 |
| 2017 April | 37 | 5 | 42 |
| 2017 March | 40 | 3 | 43 |
| 2017 February | 28 | 3 | 31 |
| 2017 January | 17 | 10 | 27 |
| 2016 December | 39 | 11 | 50 |
| 2016 November | 45 | 13 | 58 |
| 2016 October | 38 | 12 | 50 |
| 2016 September | 41 | 12 | 53 |
| 2016 August | 32 | 8 | 40 |
| 2016 July | 28 | 8 | 36 |
| 2016 March | 1 | 0 | 1 |
| 2016 February | 1 | 0 | 1 |
| 2015 December | 3 | 0 | 3 |
| 2015 October | 49 | 2 | 51 |
| 2015 September | 40 | 7 | 47 |
| 2015 August | 39 | 10 | 49 |
| 2015 July | 43 | 20 | 63 |
| 2015 June | 24 | 6 | 30 |
| 2015 May | 39 | 7 | 46 |
| 2015 April | 19 | 11 | 30 |
| 2015 March | 31 | 7 | 38 |
| 2015 February | 27 | 10 | 37 |
| 2015 January | 41 | 4 | 45 |
| 2014 December | 23 | 7 | 30 |
| 2014 November | 22 | 4 | 26 |
| 2014 October | 30 | 9 | 39 |
| 2014 September | 35 | 13 | 48 |
| 2014 August | 28 | 15 | 43 |
| 2014 July | 30 | 6 | 36 |
| 2014 June | 43 | 18 | 61 |
| 2014 May | 40 | 11 | 51 |
| 2014 March | 0 | 2 | 2 |
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