Letter to the Editor
Pulmonary aspergillomas management: A 26-years case series of surgical therapy
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Meira, L. Mendonça Almeida, A. Luísa Pereira, C. Damas, A. Amorim" "autores" => array:5 [ 0 => array:2 [ "nombre" => "L." "apellidos" => "Meira" ] 1 => array:2 [ "nombre" => "L. Mendonça" "apellidos" => "Almeida" ] 2 => array:2 [ "nombre" => "A. Luísa" "apellidos" => "Pereira" ] 3 => array:2 [ "nombre" => "C." "apellidos" => "Damas" ] 4 => array:2 [ "nombre" => "A." 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"apellidos" => "Vieira" "email" => array:1 [ 0 => "analuisapvieira@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "P." "apellidos" => "Fernandes" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "S." "apellidos" => "Lareiro" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "M." "apellidos" => "Guerra" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 4 => array:3 [ "nombre" => "J." "apellidos" => "Miranda" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 5 => array:3 [ "nombre" => "L." "apellidos" => "Vouga" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Pulmonology, Hospital de Braga, Braga, Portugal" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Cardiothoracic Surgery, Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Department of Surgery and Physiology, Cardiovascular R&D Unit, Faculty of Medicine, University of Porto, Portugal" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Among the clinical syndromes caused by the fungus <span class="elsevierStyleItalic">Aspergillus</span> spp., aspergillomas are the most common form of pulmonary involvement. This non-invasive form of aspergillosis consists of a fungus ball – formed by fungal hyphae, inflammatory cells and tissue debris – and usually develops in pre-existing lung cavities.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1,2</span></a> Although aspergillomas resolve spontaneously in up to 10% of the patients, they tend to remain stable in most cases.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1,2</span></a> They can present with haemoptysis or, less commonly, cough, dyspnoea and/or fever. However, there is no consensus on the best treatment approach: whereas medical management has yielded limited results, surgical removal seems to be the only long-term efficient treatment but is overshadowed by a relatively high rate of post-operative complications.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1,2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">This study consisted of a 26-years (January 1990–December 2015) retrospective assessment of pulmonary aspergilloma surgical interventions in a single centre in the north of Portugal (Centro Hospitalar de Vila Nova de Gaia/Espinho). A previous clinical series, encompassing 60 cases that occurred between 1990 and 2004, has been published.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> We updated and extended that series, focusing on surgery-related morbidity, mortality, follow-up and clinical relapses.</p><p id="par0015" class="elsevierStylePara elsevierViewall">During the period considered, 88 patients were submitted to pulmonary aspergilloma surgical intervention: 72.7% of them were male, their average age was 46.5 years, and almost half of them (46.6%) were or had been smokers (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). Tuberculosis was the most common underlying lung pathology, being present in 73.6% of the patients, whereas bronchiectasis and chronic obstructive pulmonary disease (COPD) were present in 19.0% and 13.6%, respectively. Seven patients (8.0%) had been diagnosed with diabetes and two patients suffered from chronic kidney disease. Aspergillomas were equally distributed by side (51.1% in the right lung and 48.9% in the left lung), and more commonly located in the upper lobes (78.0%). In respect to symptomatology, the majority of the patients presented haemoptysis (84.1% of all patients), whereas 68.2% and 14% presented with chronic cough and bronchorrhea, respectively (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). Most patients (56.8%) had normal respiratory function.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">All surgeries were done under general anaesthesia and patients were intubated with a double-lumen endotracheal tube to allow selective lung ventilation. A posterolateral thoracotomy approach was employed, and the type of resection was selected in each case in order to minimize the resected tissue without compromising the disease elimination: a lobectomy was performed in most patients (75.0%), whereas a pneumonectomy, a wedge resection or a segmentectomy and a bilobectomy were performed in 11.4%, 10.2% and 3.4% of all patients, respectively (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). The majority (59.1%) of the aspergillomas had a complex morphology, according to the definition of Belcher and Plummer.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> Six patients (6.8%) required a subsequent surgical intervention because of wound dehiscence (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>2), haemothorax (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>1), broncopleural fistula (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>2) and empyema (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>1).</p><p id="par0025" class="elsevierStylePara elsevierViewall">Patients’ chest tubes were removed in median five days (interquartile range 7–17) after surgery, while patients’ discharge took place in median 11 days (interquartile range 4–11) after the intervention. Four patients (4.5%) died within 30 days of surgery, and 38 (43.1%) presented some type of post-surgical complication (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). An air leak for a period more than 5 days was the most common complication, affecting 31.8% of the patients. Moreover, 10.2% patients presented with empyema, 7.9% developed a nosocomial pneumoniae, and 5.0% maintained haemoptysis. Patient follow-up lasted for nine months on average (±17) and the overall global mortality was 7%. Two patients had a contralateral relapse.</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">The incidence of post-operative morbidity increased more than 2.5-fold (16.3% in the 1990–2004 period to 42.9% in the 2005–2016 period). This may be related with the higher frequency of aspergillomas with a complex morphology: in fact, 64.0% of all aspergillomas between 2005 and 2016 were considered to be complex versus 56.7% between 1990 and 2004. A complex morphology is indeed a poor prognosis factor for aspergilloma surgical removal.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">There was a slight reduction in the mortality rate (5.0% in the 1990–2004 period and 3.6% in the 2005–2016 period). The post-operative mortality of aspergilloma patients is considered to be relatively high, with some series reporting up to 44%.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> However, contemporaneous series tend to present lower values, similar to the one reported here.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Overall, the clinical characteristics, symptomatology and outcomes of this case series, the largest one described in Portugal, overlap those previously published in the literature, and support an early surgical intervention as the most effective option for aspergilloma patients. In fact, taking into account that more than half of the patients with an aspergilloma will eventually develop haemoptysis, and up to 20% will have a fatal haemorrhage, the risks of surgery are largely justified.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> Moreover, aspergilloma surgical removal attenuates or eliminates the symptomatology, increasing patients’ quality of life and life expectation.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Authors’ contribution</span><p id="par0045" class="elsevierStylePara elsevierViewall">Ana Luísa Vieira drafted the manuscript, Susana Laeiro and Pedro Fernandes supported data collection, Miguel Guerra conceived and designed the study and all authors revised the manuscript and approved its final version.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Conflicts of interest</span><p id="par0050" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Authors’ contribution" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Conflicts of interest" ] 2 => array:2 [ "identificador" => "xack370394" "titulo" => "Acknowledgments" ] 3 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:2 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "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=""><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Demographic variables</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Male sex (<span class="elsevierStyleItalic">n</span>/%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">64 (72.7%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Age (average<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>SD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">46.5<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>12.1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Smokers and ex-smokers (<span class="elsevierStyleItalic">n</span>/%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">41 (46.6%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Cigarettes’ pack-years (average<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>SD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">43<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>23 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Previous lung pathologies</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Tuberculosis (<span class="elsevierStyleItalic">n</span>/%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">64 (73.6%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Bronchiectasis (<span class="elsevierStyleItalic">n</span>/%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">16 (19.0%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>COPD (<span class="elsevierStyleItalic">n</span>/%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12 (13.8%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Other clinical conditions</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Diabetes (<span class="elsevierStyleItalic">n</span>/%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7 (8.0%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Chronic kidney disease (<span class="elsevierStyleItalic">n</span>/%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2 (2.3%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Symptomatology</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Haemoptysis (<span class="elsevierStyleItalic">n</span>/%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">74 (84.1%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Chronic cough (<span class="elsevierStyleItalic">n</span>/%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">58 (68.2%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Bronchorrhea (<span class="elsevierStyleItalic">n</span>/%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12 (14%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Aspergilloma morphology</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Simple (<span class="elsevierStyleItalic">n</span>/%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">36 (40.9%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Complex (<span class="elsevierStyleItalic">n</span>/%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">52 (59.1%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Surgical procedure</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Lobectomy (<span class="elsevierStyleItalic">n</span>/%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">66 (75.0%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Pneumonectomy (<span class="elsevierStyleItalic">n</span>/%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10 (11.4%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Wedge resection/segmentectomy (<span class="elsevierStyleItalic">n</span>/%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">9 (10.2%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Bilobectomy (<span class="elsevierStyleItalic">n</span>/%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3 (3.4%) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1864376.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Cohort characterization.</p>" ] ] 1 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "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"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">n</span> (%) \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Mortality (within 30 days of surgery) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 (4.5%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Prolonged air leak (>5 days) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">28 (31.8%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Empyema \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9 (10.2%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Nosocomial pneumoniae \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 (7.9%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Haemoptysis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 (5.0%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Wound dehiscence \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 (3.4%) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1864377.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Post-operative morbidity and mortality.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Aspergilloma and the surgeon" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "L. Moodley" 1 => "J. Pillay" 2 => "K. Dheda" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.3978/j.issn.2072-1439.2013.12.40" "Revista" => array:6 [ "tituloSerie" => "J Thorac Dis" "fecha" => "2014" "volumen" => "6" "paginaInicial" => "202" "paginaFinal" => "209" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24624284" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0035" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pulmonary aspergillosis: a clinical review" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "M. Kousha" 1 => "R. Tadi" 2 => "A.O. Soubani" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1183/09059180.00001011" "Revista" => array:6 [ "tituloSerie" => "Eur Respir Rev" "fecha" => "2011" "volumen" => "20" "paginaInicial" => "156" "paginaFinal" => "174" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21881144" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0040" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Surgical management of pulmonary aspergilloma" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "M. Guerra" 1 => "N. Santos" 2 => "J. Miranda" 3 => "J. Carlos Mota" 4 => "F. Leal" 5 => "L. Vouga" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Rev Port Cir Cardiotorac Vasc" "fecha" => "2008" "volumen" => "15" "paginaInicial" => "135" "paginaFinal" => "138" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19116677" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0045" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Surgery in broncho-pulmonary aspergillosis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "B.Y.J.R. Belcher" 1 => "S. Plummer" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/S0007-0971(60)80067-8" "Revista" => array:5 [ "tituloSerie" => "Brit J Dis Chest" "fecha" => "1960" "volumen" => "54" "paginaInicial" => "335" "paginaFinal" => "341" ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0050" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pulmonary aspergilloma. Clinical aspects and surgical treatment outcome" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "E. Passera" 1 => "A. Rizzi" 2 => "M. Robustellini" 3 => "G. Rossi" 4 => "C. Della Pona" 5 => "F. Massera" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.thorsurg.2012.04.001" "Revista" => array:6 [ "tituloSerie" => "Thorac Surg Clin" "fecha" => "2012" "volumen" => "22" "paginaInicial" => "345" "paginaFinal" => "361" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22789598" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] "agradecimientos" => array:1 [ 0 => array:4 [ "identificador" => "xack370394" "titulo" => "Acknowledgments" "texto" => "<p id="par0055" class="elsevierStylePara elsevierViewall">Ana Luísa Vieira would like to thank Catarina L. Santos for medical writing advice.</p>" "vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/25310437/0000002400000004/v2_201810040624/S2531043718300746/v2_201810040624/en/main.assets" "Apartado" => array:4 [ "identificador" => "72881" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Research Letters" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/25310437/0000002400000004/v2_201810040624/S2531043718300746/v2_201810040624/en/main.pdf?idApp=UINPBA00004E&text.app=https://journalpulmonology.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2531043718300746?idApp=UINPBA00004E" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 6 | 2 | 8 |
| 2024 October | 27 | 32 | 59 |
| 2024 September | 33 | 27 | 60 |
| 2024 August | 33 | 36 | 69 |
| 2024 July | 26 | 30 | 56 |
| 2024 June | 33 | 18 | 51 |
| 2024 May | 31 | 32 | 63 |
| 2024 April | 40 | 29 | 69 |
| 2024 March | 30 | 22 | 52 |
| 2024 February | 29 | 19 | 48 |
| 2024 January | 16 | 23 | 39 |
| 2023 December | 12 | 22 | 34 |
| 2023 November | 36 | 44 | 80 |
| 2023 October | 33 | 37 | 70 |
| 2023 September | 22 | 33 | 55 |
| 2023 August | 18 | 22 | 40 |
| 2023 July | 27 | 26 | 53 |
| 2023 June | 15 | 17 | 32 |
| 2023 May | 40 | 30 | 70 |
| 2023 April | 25 | 18 | 43 |
| 2023 March | 33 | 23 | 56 |
| 2023 February | 32 | 24 | 56 |
| 2023 January | 16 | 20 | 36 |
| 2022 December | 23 | 23 | 46 |
| 2022 November | 42 | 34 | 76 |
| 2022 October | 46 | 44 | 90 |
| 2022 September | 20 | 33 | 53 |
| 2022 August | 35 | 44 | 79 |
| 2022 July | 33 | 56 | 89 |
| 2022 June | 18 | 40 | 58 |
| 2022 May | 38 | 48 | 86 |
| 2022 April | 24 | 36 | 60 |
| 2022 March | 35 | 41 | 76 |
| 2022 February | 30 | 48 | 78 |
| 2022 January | 38 | 44 | 82 |
| 2021 December | 28 | 35 | 63 |
| 2021 November | 33 | 35 | 68 |
| 2021 October | 34 | 59 | 93 |
| 2021 September | 37 | 39 | 76 |
| 2021 August | 17 | 26 | 43 |
| 2021 July | 24 | 17 | 41 |
| 2021 June | 23 | 40 | 63 |
| 2021 May | 30 | 34 | 64 |
| 2021 April | 52 | 84 | 136 |
| 2021 March | 47 | 37 | 84 |
| 2021 February | 20 | 19 | 39 |
| 2021 January | 24 | 19 | 43 |
| 2020 December | 19 | 13 | 32 |
| 2020 November | 29 | 18 | 47 |
| 2020 October | 31 | 30 | 61 |
| 2020 September | 31 | 43 | 74 |
| 2020 August | 32 | 29 | 61 |
| 2020 July | 38 | 38 | 76 |
| 2020 June | 22 | 19 | 41 |
| 2020 May | 33 | 24 | 57 |
| 2020 April | 36 | 17 | 53 |
| 2020 March | 32 | 22 | 54 |
| 2020 February | 25 | 13 | 38 |
| 2020 January | 35 | 21 | 56 |
| 2019 December | 33 | 26 | 59 |
| 2019 November | 29 | 15 | 44 |
| 2019 October | 27 | 24 | 51 |
| 2019 September | 39 | 18 | 57 |
| 2019 August | 34 | 24 | 58 |
| 2019 July | 44 | 23 | 67 |
| 2019 June | 34 | 35 | 69 |
| 2019 May | 30 | 23 | 53 |
| 2019 April | 45 | 34 | 79 |
| 2019 March | 24 | 16 | 40 |
| 2019 February | 27 | 16 | 43 |
| 2019 January | 26 | 33 | 59 |
| 2018 December | 11 | 12 | 23 |
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