Letter to the Editor
Late biliobronchial fistula
Romina Abelleiraa,
, María Elena Toubesa, Anxo Martínez de Alegríab, Luis Valdésa,c
Corresponding author
romina.abelleira.paris@sergas.es
Corresponding author. Pneumology Department. Hospital Clínico Universitario, Santiago de Compostela. Travesía da Choupana s/n. 15706 Santiago de Compostela, SPAIN. Tel.: +34 981 950 085
Corresponding author. Pneumology Department. Hospital Clínico Universitario, Santiago de Compostela. Travesía da Choupana s/n. 15706 Santiago de Compostela, SPAIN. Tel.: +34 981 950 085
a Pneumology Department, Hospital Clínico Universitario, Santiago de Compostela, SPAIN
b Radiology Department, Hospital Clínico Universitario, Santiago de Compostela, SPAIN
c Interdisciplinary Pneumology Research Group, Santiago de Compostela Health Research Institutions (Instituto de Investigaciones Sanitarias de Santiago de Compostela/IDIS), Santiago de Compostela, SPAIN
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class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "Luis" "apellidos" => "Valdés" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Pneumology Department, Hospital Clínico Universitario, Santiago de Compostela, SPAIN" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Radiology Department, Hospital Clínico Universitario, Santiago de Compostela, SPAIN" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Interdisciplinary Pneumology Research Group, Santiago de Compostela Health Research Institutions (<span class="elsevierStyleItalic">Instituto de Investigaciones Sanitarias de Santiago de Compostela/</span>IDIS), Santiago de Compostela, SPAIN" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author. Pneumology Department. Hospital Clínico Universitario, Santiago de Compostela. Travesía da Choupana s/n. 15706 Santiago de Compostela, SPAIN. Tel.: +34 981 950 085" ] ] ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 3388 "Ancho" => 2500 "Tamanyo" => 732986 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A: Axial cut computerized tomography. Pulmonary infiltrates patched with airborne bronchogram (thick arrow) and areas of tarnished glass predominantly right lower lobe (arrowhead).</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Figure 1B: Coronal cut computerized tomography. A small abscess is shown in the diaphragmatic region (thick arrow) and calcified hydatid cyst (arrowhead).</p> <p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Figure 1C: Axial cut computerized tomography. Abscess (thick arrow) between the posterior hepatic rim and the lower right lobe, with a small air bubble inside.</p> <p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Figure 1D: Coronal cut of hepatic magnetic resonance imaging in hepato-specific phase with bile duct contrast excretion at the same level as Figure 1B. Abscess (thick arrow) and fistulous path (thin arrow) are shown.</p> <p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Figure 1E: Axial cut of hepatic magnetic resonance imaging in hepato-specific phase with bile duct contrast excretion at the same level as Figure 1C. Fistulous tract (thin arrow) and abscess (thick arrow) leading to the anterobasal segment of the lower right lobe.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Biliobronchial fistula (BBF) is a rare condition characterized by communication between the bile duct and the bronchial Tree.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The first case was described by Peacok's in 1850 in a 20-year-old woman with hepatic echinococcosis.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Diagnosis is mainly clinical, with radiological or endoscopic support,<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> and therapeutic options range from conservative to invasive with highly variable results.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> We present the case of a patient admitted to our service with this unusual disorder.</p><p id="par0010" class="elsevierStylePara elsevierViewall">An 88-year-old male was hospitalized with fever, shortness of breath and increased expectoration in the previous month. Fourteen years earlier he had had a partial hepatectomy for a biliary fistula secondary to the removal of a hydatid cyst, with elevation of the right hemidiaphragm as a result of the surgery, and residual lesions to the ipsilateral lung base. He was diagnosed with bronchiectasis with chronic bronchial infection by <span class="elsevierStyleItalic">Pseudomonas aeruginosa</span> and treated with inhaled colistine. In the days prior arriving to the Emergency Department, he had been treated with tobramycin and intravenous amikacin (home hospitalization). On physical examination, he was tachypneic, afebrile, had bilious expectoration, and crackles and hoarseness could be heard throughout the right hemithorax. Blood tests showed leukocytosis (15.110/mm<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a>) with 84% of segmented and 7% of stems; creatinine 1.18<span class="elsevierStyleHsp" style=""></span>mg/dL; Na 129 mmol/L; GGT 83 UI/L; FAL 303 UI/L; total proteins 5.7<span class="elsevierStyleHsp" style=""></span>g/dL; C-reactive protein 24.2<span class="elsevierStyleHsp" style=""></span>mg/dL and procalcitonin 1.32 ng/mL; PaO<span class="elsevierStyleInf">2</span> 56<span class="elsevierStyleHsp" style=""></span>mm Hg. Bronchofibroscopy showed, from the larynx and throughout the right bronchial tree, abundant yellowish bilious-looking fluid, compatible with bilioptisis, with an inflammatory mucosa of the lower right bronchus lobe without endobronchial lesions. In CT we observed pulmonary infiltrates patched with airborne bronchogram, areas of tarnished glass predominating in the right lower lobe (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>A), a peridiaphragmatic cystic lesion at the base of the right lung with a small air bubble and post-operative liver changes with peripheral calcification in the caudate lobe suggesting a healing hydatid cyst (<a class="elsevierStyleCrossRef" href="#fig0005">Figures 1B and 1C</a>). Liver ultrasound showed right hepatectomy with hypertrophy of the left hepatic lobe without biliary lithiasis. Liver MRI and cholangio-MRI scans showed a fistulous tract and subdiaphragmatic abscesses (<a class="elsevierStyleCrossRef" href="#fig0005">Figures 1D and 1E</a>). A plastic biliary stent was placed by endoscopic retrograde cholangiography. We also performed a sphincterotomy for biliary decompression. At the same time, the subdiaphragmatic collections in which <span class="elsevierStyleItalic">Pseudomona aeruginosa</span> was cultivated were drained. During the course of antibiotic treatment (ceftazidime and tobramycin), <span class="elsevierStyleItalic">Sthaphylococcus haemolyticus</span> bacteremia occurred, forcing the addition of vancomycin. The patient worsened progressively with renal function deterioration, dying a few days later.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Biliobronchial fistula is a rare condition for which diagnosis is established from the presence of bilioptisis and is confirmed by techniques such as bronchofibroscopy or various imaging studies. It may be congenital or secondary to trauma (most common, including bile duct surgery), liver disease (hydatid cyst and amoebic liver abscess), or bile duct obstruction. A frequent complication in chronic stages, as in our case, is the presence of bronchiectasis in the pulmonary segment involved.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Occasionally, there may be recurrent pneumonia and ipsilateral pleural effusion, with secondary sepsis, probably caused by chemical pneumonitis that produces bile in the bronchial mucosa. Imaging studies used to confirm the diagnosis (CT scan, ultrasound, hepatic nuclear magnetic resonance, nuclear magnetic resonance, percutaneous cholangiography, and endoscopic retrograde cholangiopancreatography) must demonstrate the fistulous tract.</p><p id="par0020" class="elsevierStylePara elsevierViewall">There is no general agreement on how to deal with BBFs. Ong et al used subcutaneous octreotide and succeeded in reducing bilious cough in a patient and speeding up the closure of the fistula, but its use is limited and is not effective if there is underlying infection, neoplasia or obstruction.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> The definitive treatment is surgical fistulectomy with soft tissue reconstruction, but due to its significant morbidity and mortality and the frequent re-operations it leads to, more conservative interventions have also been proposed aimed at reducing pressure in the biliary tract, such as endoscopic retrograde biliary drainage or percutaneous transhepatic biliary drainage. Depending on the size and location of the BBF, another conservative option would be to try to close the fistula through bronchofibroscopy. The sealing material used should achieve an inflammatory reaction of the mucous membrane that causes the permanent closure of the fistula. There is a wide range of synthetic substances and biological derivatives that can be applied through the flexible bronchoscope.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">What can be learned from this case is that faced with a patient with a history of a traumatic process in the hepatobiliary tract (even if it is old), bilious sputum and bronchiectasis in the right lung, this condition should be suspected.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Author's Contributions</span><p id="par0030" class="elsevierStylePara elsevierViewall">RA, MET, AMdeA and LV were responsible for the conception and design of the study, and wrote and edited the manuscript. All authors read and approved the final manuscript.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Funding</span><p id="par0035" class="elsevierStylePara elsevierViewall">This study was undertaken without funding</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Conflicts Of Interest</span><p id="par0040" class="elsevierStylePara elsevierViewall">We wish to confirm that there are no known conflicts of interest associated with this publication. This study did not receive any financial support for this work that could have influenced its outcome. We confirm that the manuscript has been read and approved by all named authors and there are no other persons who satisfied the criteria for authorship who are not listed. We further confirm that the order of authors listed in the manuscript has been approved by all of us. We confirm that we have given due consideration to the protection of intellectual property associated with this work and that there are no impediments to publication, including the timing of publication, with respect to intellectual property. We confirm that we have followed the regulations of our institutions concerning intellectual property.</p><p id="par0045" class="elsevierStylePara elsevierViewall">We understand that the Corresponding Author is the sole contact for the Editorial process (including Editorial manager and direct communications with the office). She is responsible for communicating with the other authors about progress, submissions of revisions and final approval of proofs. We confirm that we have provided a current, correct email address which is accessible by the Corresponding Author and which has been configured to accept e-mail from: romina.abelleira.paris@sergas.es</p><p id="par0050" class="elsevierStylePara elsevierViewall">We confirm that the manuscript is not published elsewhere, in any language, and is not under simultaneous consideration by any other journal. Signed by all authors as follows:</p><p id="par0055" class="elsevierStylePara elsevierViewall">Romina Abelleira, María E. Toubes, Anxo Martínez de Alegría and Luis Valdés.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:5 [ 0 => array:2 [ "identificador" => "xpalclavsec1033645" "titulo" => "Abbreviations" ] 1 => array:2 [ "identificador" => "sec0005" "titulo" => "Author's Contributions" ] 2 => array:2 [ "identificador" => "sec0010" "titulo" => "Funding" ] 3 => array:2 [ "identificador" => "sec0015" "titulo" => "Conflicts Of Interest" ] 4 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "PalabrasClave" => array:1 [ "en" => array:1 [ 0 => array:4 [ "clase" => "abr" "titulo" => "Abbreviations" "identificador" => "xpalclavsec1033645" "palabras" => array:2 [ 0 => "BBF" 1 => "CT" ] ] ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 3388 "Ancho" => 2500 "Tamanyo" => 732986 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A: Axial cut computerized tomography. Pulmonary infiltrates patched with airborne bronchogram (thick arrow) and areas of tarnished glass predominantly right lower lobe (arrowhead).</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Figure 1B: Coronal cut computerized tomography. A small abscess is shown in the diaphragmatic region (thick arrow) and calcified hydatid cyst (arrowhead).</p> <p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Figure 1C: Axial cut computerized tomography. Abscess (thick arrow) between the posterior hepatic rim and the lower right lobe, with a small air bubble inside.</p> <p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Figure 1D: Coronal cut of hepatic magnetic resonance imaging in hepato-specific phase with bile duct contrast excretion at the same level as Figure 1B. Abscess (thick arrow) and fistulous path (thin arrow) are shown.</p> <p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Figure 1E: Axial cut of hepatic magnetic resonance imaging in hepato-specific phase with bile duct contrast excretion at the same level as Figure 1C. Fistulous tract (thin arrow) and abscess (thick arrow) leading to the anterobasal segment of the lower right lobe.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:7 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A biliobronchial fistula in a patient with hepatocellular carcinoma treated with chemoembolization diagnosed by hepatobiliary iminodiacetic acid scan and managed by endoscopic retrograde Cholangiopancreatography" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "Y. Nassar" 1 => "S. Hida" 2 => "S. Richter" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Gastroenterol Res" "fecha" => "2017" "volumen" => "10" "paginaInicial" => "383" "paginaFinal" => "385" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Case in which hydatids were expectorated and one of suppuration of hydatid cyst of the liver communicating with the lungs" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "T.B. Peacock" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Edin Med J" "fecha" => "1850" "volumen" => "74" "paginaInicial" => "33" "paginaFinal" => "46" ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A lethal complication after transarterial chemoembolization with drug-eluting beads for hepatocellular Carcinoma" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A. Toro" 1 => "G. Bertino" 2 => "M.C. Arcerito" 3 => "M. Mannino" 4 => "A. Ardiri" 5 => "D. Patane" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1155/2015/873601" "Revista" => array:5 [ "tituloSerie" => "Case Rep Surg" "fecha" => "2015" "volumen" => "2015" "paginaInicial" => "873601" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25802793" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Bronchobiliary fistula treated with histoacryl embolization under bronchoscopic guidance: A case report" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "J.H. Kim" 1 => "M.D. Kim" 2 => "Y.K. Lee" 3 => "S.G. Hwang" 4 => "J.H. Lee" 5 => "E.K. Kim" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Respir Med CME" "fecha" => "2008" "volumen" => "1" "paginaInicial" => "164" "paginaFinal" => "468" ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Bonchobiliary fistula successfully treated surgically" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "C.F. Chong" 1 => "V.H. Chong" 2 => "A. Jalihal" 3 => "L. Mathews" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Singapore Med J" "fecha" => "2008" "volumen" => "49" "paginaInicial" => "e208" "paginaFinal" => "e211" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18756335" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0030" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Octreotide in bronchobiliary fistula management" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "M. Ong" 1 => "K. Moozar" 2 => "L.B. Cohen" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.athoracsur.2003.10.137" "Revista" => array:6 [ "tituloSerie" => "Ann Thorac Surg" "fecha" => "2004" "volumen" => "78" "paginaInicial" => "1512" "paginaFinal" => "1513" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15464539" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0035" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Bronchopleural fistula: an update for intensivists" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "K. Shekar" 1 => "C. Foot" 2 => "J. Fraser" 3 => "M. Ziegenfuss" 4 => "P. Hopkins" 5 => "M. Windsor" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jcrc.2009.05.007" "Revista" => array:6 [ "tituloSerie" => "J Crit Care" "fecha" => "2010" "volumen" => "25" "paginaInicial" => "47" "paginaFinal" => "55" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19592205" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/25310437/0000002400000005/v1_201810040621/S2531043718301156/v1_201810040621/en/main.assets" "Apartado" => array:4 [ "identificador" => "72880" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letters to the Editor" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/25310437/0000002400000005/v1_201810040621/S2531043718301156/v1_201810040621/en/main.pdf?idApp=UINPBA00004E&text.app=https://journalpulmonology.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2531043718301156?idApp=UINPBA00004E" ]
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| 2023 July | 29 | 30 | 59 |
| 2023 June | 31 | 15 | 46 |
| 2023 May | 54 | 23 | 77 |
| 2023 April | 45 | 23 | 68 |
| 2023 March | 95 | 25 | 120 |
| 2023 February | 44 | 26 | 70 |
| 2023 January | 35 | 15 | 50 |
| 2022 December | 42 | 33 | 75 |
| 2022 November | 61 | 40 | 101 |
| 2022 October | 56 | 34 | 90 |
| 2022 September | 23 | 39 | 62 |
| 2022 August | 41 | 36 | 77 |
| 2022 July | 28 | 45 | 73 |
| 2022 June | 24 | 24 | 48 |
| 2022 May | 31 | 40 | 71 |
| 2022 April | 24 | 30 | 54 |
| 2022 March | 39 | 43 | 82 |
| 2022 February | 45 | 28 | 73 |
| 2022 January | 54 | 39 | 93 |
| 2021 December | 30 | 35 | 65 |
| 2021 November | 39 | 34 | 73 |
| 2021 October | 42 | 46 | 88 |
| 2021 September | 26 | 37 | 63 |
| 2021 August | 21 | 24 | 45 |
| 2021 July | 27 | 16 | 43 |
| 2021 June | 32 | 26 | 58 |
| 2021 May | 37 | 44 | 81 |
| 2021 April | 47 | 44 | 91 |
| 2021 March | 39 | 39 | 78 |
| 2021 February | 32 | 21 | 53 |
| 2021 January | 38 | 17 | 55 |
| 2020 December | 19 | 16 | 35 |
| 2020 November | 37 | 22 | 59 |
| 2020 October | 44 | 31 | 75 |
| 2020 September | 44 | 27 | 71 |
| 2020 August | 35 | 21 | 56 |
| 2020 July | 42 | 26 | 68 |
| 2020 June | 40 | 21 | 61 |
| 2020 May | 41 | 32 | 73 |
| 2020 April | 29 | 10 | 39 |
| 2020 March | 23 | 22 | 45 |
| 2020 February | 26 | 23 | 49 |
| 2020 January | 34 | 25 | 59 |
| 2019 December | 40 | 21 | 61 |
| 2019 November | 27 | 15 | 42 |
| 2019 October | 30 | 18 | 48 |
| 2019 September | 37 | 22 | 59 |
| 2019 August | 71 | 25 | 96 |
| 2019 July | 59 | 20 | 79 |
| 2019 June | 66 | 24 | 90 |
| 2019 May | 70 | 33 | 103 |
| 2019 April | 59 | 34 | 93 |
| 2019 March | 70 | 24 | 94 |
| 2019 February | 67 | 38 | 105 |
| 2019 January | 68 | 46 | 114 |
| 2018 December | 25 | 12 | 37 |
| 2018 November | 1 | 0 | 1 |
Show all
