\r\n\tb) how a concentrated attention focus on screens (i.e., tablets and smartphones) could result in a total activity absorption and a flow experience; \r\n\tc) teens' preference for media social interaction appears to be closely associated with impaired modes of mood regulation; \r\n\td) the web activities as factors of externalized and/or internalized risks; \r\n\te) the implementation of health promotion interventions by Internet Apps; finally, \r\n\tf) the cross-cultural differences and similarities about teen approaches to the web around the world.
\r\n
\r\n\tThis book intends to provide the reader with an overview of studies with a research topic that is crucial today: the need to integrate teens' use of the web into the processes contributing to determine adolescents' developmental trajectories and Quality of Life.
",isbn:"978-1-83969-594-0",printIsbn:"978-1-83969-593-3",pdfIsbn:"978-1-83969-595-7",doi:null,price:0,priceEur:0,priceUsd:0,slug:null,numberOfPages:0,isOpenForSubmission:!0,hash:"f005179bb7f6cd7c531a00cd8da18eaa",bookSignature:"Prof. Massimo Ingrassia and Prof. Loredana Benedetto",publishedDate:null,coverURL:"https://cdn.intechopen.com/books/images_new/10671.jpg",keywords:"Media Multitasking, Brain Development, Optimal-Experience Conditions, Digital Media Use, Mood Self-Regulation, Social Networking, Health Risk Behaviors, Internalizing/Externalizing Risk, Health Behaviors, Prevention, Cross-Cultural Research, Teen",numberOfDownloads:null,numberOfWosCitations:0,numberOfCrossrefCitations:null,numberOfDimensionsCitations:null,numberOfTotalCitations:null,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"February 25th 2021",dateEndSecondStepPublish:"March 24th 2021",dateEndThirdStepPublish:"May 23rd 2021",dateEndFourthStepPublish:"August 11th 2021",dateEndFifthStepPublish:"October 10th 2021",remainingDaysToSecondStep:"21 days",secondStepPassed:!1,currentStepOfPublishingProcess:2,editedByType:null,kuFlag:!1,biosketch:"Massimo Ingrassia is Director of the Post-graduate Advanced Studies in Palliative care and pain management for psychologists and a scientific advisor in research projects assessing psychological adjustment and therapeutic adherence in chronic illness. He was the author or co-author of several articles, and editor of the books on Parenting.",coeditorOneBiosketch:"Loredana Benedetto, Ph.D., is a psychologist and professor of Developmental and Educational Psychology at the Department of Clinical and Experimental Medicine, University of Messina. She was a scientific consultant for projects supporting families of the disabled and interventions in pediatric palliative care.",coeditorTwoBiosketch:null,coeditorThreeBiosketch:null,coeditorFourBiosketch:null,coeditorFiveBiosketch:null,editors:[{id:"193901",title:"Prof.",name:"Massimo",middleName:null,surname:"Ingrassia",slug:"massimo-ingrassia",fullName:"Massimo Ingrassia",profilePictureURL:"https://mts.intechopen.com/storage/users/193901/images/system/193901.png",biography:"Massimo Ingrassia, PsyD, is an Associate Professor of Developmental and Educational Psychology at Messina University, Italy, where he teaches graduate and postgraduate courses in Health Psychology. He is the Director of the postgraduate advanced studies in Palliative Care and Pain Management for Psychologists. His research interests include risk behaviors in adolescence and emerging adulthood, childhood development and digital technologies, pediatric palliative care and family resilience, and quality of life and chronic diseases. Dr. Ingrassia is also a scientific advisor for research projects assessing psychological adjustment and therapeutic adherence in chronic illness. He is the author or coauthor of several articles and books, including Growing Connected: Web’s Resources and Pitfalls",institutionString:"University of Messina",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"2",totalChapterViews:"0",totalEditedBooks:"0",institution:{name:"University of Messina",institutionURL:null,country:{name:"Italy"}}}],coeditorOne:{id:"193200",title:"Prof.",name:"Loredana",middleName:null,surname:"Benedetto",slug:"loredana-benedetto",fullName:"Loredana Benedetto",profilePictureURL:"https://mts.intechopen.com/storage/users/193200/images/system/193200.png",biography:"Loredana Benedetto, Ph.D., is a psychologist and Professor of Developmental and Educational Psychology at the Department of Clinical and Experimental Medicine, University of Messina, Italy. She teaches undergraduate and graduate courses in the areas of typical and atypical development, parent-child relationships, educational psychology, and family-based interventions. She has been a scientific consultant for projects supporting families of disabled children and interventions in pediatric palliative care. Her research interests focus on parenting assessment, self-efficacy and parental cognition, digital parenting and problematic use of the Internet in children, metacognition and childhood disorders, early intervention in autism and developmental disabilities, and behavioral parent training. She is the author or editor of several books, including Parenting: Empirical Advances and Intervention Resources (coedited with Massimo Ingrassia).",institutionString:"University of Messina",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"3",totalChapterViews:"0",totalEditedBooks:"2",institution:{name:"University of Messina",institutionURL:null,country:{name:"Italy"}}},coeditorTwo:null,coeditorThree:null,coeditorFour:null,coeditorFive:null,topics:[{id:"21",title:"Psychology",slug:"psychology"}],chapters:null,productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"},personalPublishingAssistant:{id:"205697",firstName:"Kristina",lastName:"Kardum Cvitan",middleName:null,title:"Ms.",imageUrl:"https://mts.intechopen.com/storage/users/205697/images/5186_n.jpg",email:"kristina.k@intechopen.com",biography:"As an Author Service Manager my responsibilities include monitoring and facilitating all publishing activities for authors and editors. From chapter submission and review, to approval and revision, copyediting and design, until final publication, I work closely with authors and editors to ensure a simple and easy publishing process. I maintain constant and effective communication with authors, editors and reviewers, which allows for a level of personal support that enables contributors to fully commit and concentrate on the chapters they are writing, editing, or reviewing. I assist authors in the preparation of their full chapter submissions and track important deadlines and ensure they are met. I help to coordinate internal processes such as linguistic review, and monitor the technical aspects of the process. As an ASM I am also involved in the acquisition of editors. Whether that be identifying an exceptional author and proposing an editorship collaboration, or contacting researchers who would like the opportunity to work with IntechOpen, I establish and help manage author and editor acquisition and contact."}},relatedBooks:[{type:"book",id:"6494",title:"Behavior Analysis",subtitle:null,isOpenForSubmission:!1,hash:"72a81a7163705b2765f9eb0b21dec70e",slug:"behavior-analysis",bookSignature:"Huei-Tse Hou and Carolyn S. Ryan",coverURL:"https://cdn.intechopen.com/books/images_new/6494.jpg",editedByType:"Edited by",editors:[{id:"96493",title:"Prof.",name:"Huei Tse",surname:"Hou",slug:"huei-tse-hou",fullName:"Huei Tse Hou"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"1591",title:"Infrared Spectroscopy",subtitle:"Materials Science, Engineering and Technology",isOpenForSubmission:!1,hash:"99b4b7b71a8caeb693ed762b40b017f4",slug:"infrared-spectroscopy-materials-science-engineering-and-technology",bookSignature:"Theophile Theophanides",coverURL:"https://cdn.intechopen.com/books/images_new/1591.jpg",editedByType:"Edited by",editors:[{id:"37194",title:"Dr.",name:"Theophanides",surname:"Theophile",slug:"theophanides-theophile",fullName:"Theophanides Theophile"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"3092",title:"Anopheles mosquitoes",subtitle:"New insights into malaria vectors",isOpenForSubmission:!1,hash:"c9e622485316d5e296288bf24d2b0d64",slug:"anopheles-mosquitoes-new-insights-into-malaria-vectors",bookSignature:"Sylvie Manguin",coverURL:"https://cdn.intechopen.com/books/images_new/3092.jpg",editedByType:"Edited by",editors:[{id:"50017",title:"Prof.",name:"Sylvie",surname:"Manguin",slug:"sylvie-manguin",fullName:"Sylvie Manguin"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"3161",title:"Frontiers in Guided Wave Optics and Optoelectronics",subtitle:null,isOpenForSubmission:!1,hash:"deb44e9c99f82bbce1083abea743146c",slug:"frontiers-in-guided-wave-optics-and-optoelectronics",bookSignature:"Bishnu Pal",coverURL:"https://cdn.intechopen.com/books/images_new/3161.jpg",editedByType:"Edited by",editors:[{id:"4782",title:"Prof.",name:"Bishnu",surname:"Pal",slug:"bishnu-pal",fullName:"Bishnu Pal"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"72",title:"Ionic Liquids",subtitle:"Theory, Properties, New Approaches",isOpenForSubmission:!1,hash:"d94ffa3cfa10505e3b1d676d46fcd3f5",slug:"ionic-liquids-theory-properties-new-approaches",bookSignature:"Alexander Kokorin",coverURL:"https://cdn.intechopen.com/books/images_new/72.jpg",editedByType:"Edited by",editors:[{id:"19816",title:"Prof.",name:"Alexander",surname:"Kokorin",slug:"alexander-kokorin",fullName:"Alexander Kokorin"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"1373",title:"Ionic Liquids",subtitle:"Applications and Perspectives",isOpenForSubmission:!1,hash:"5e9ae5ae9167cde4b344e499a792c41c",slug:"ionic-liquids-applications-and-perspectives",bookSignature:"Alexander Kokorin",coverURL:"https://cdn.intechopen.com/books/images_new/1373.jpg",editedByType:"Edited by",editors:[{id:"19816",title:"Prof.",name:"Alexander",surname:"Kokorin",slug:"alexander-kokorin",fullName:"Alexander Kokorin"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"57",title:"Physics and Applications of Graphene",subtitle:"Experiments",isOpenForSubmission:!1,hash:"0e6622a71cf4f02f45bfdd5691e1189a",slug:"physics-and-applications-of-graphene-experiments",bookSignature:"Sergey Mikhailov",coverURL:"https://cdn.intechopen.com/books/images_new/57.jpg",editedByType:"Edited by",editors:[{id:"16042",title:"Dr.",name:"Sergey",surname:"Mikhailov",slug:"sergey-mikhailov",fullName:"Sergey Mikhailov"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"371",title:"Abiotic Stress in Plants",subtitle:"Mechanisms and Adaptations",isOpenForSubmission:!1,hash:"588466f487e307619849d72389178a74",slug:"abiotic-stress-in-plants-mechanisms-and-adaptations",bookSignature:"Arun Shanker and B. Venkateswarlu",coverURL:"https://cdn.intechopen.com/books/images_new/371.jpg",editedByType:"Edited by",editors:[{id:"58592",title:"Dr.",name:"Arun",surname:"Shanker",slug:"arun-shanker",fullName:"Arun Shanker"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"878",title:"Phytochemicals",subtitle:"A Global Perspective of Their Role in Nutrition and Health",isOpenForSubmission:!1,hash:"ec77671f63975ef2d16192897deb6835",slug:"phytochemicals-a-global-perspective-of-their-role-in-nutrition-and-health",bookSignature:"Venketeshwer Rao",coverURL:"https://cdn.intechopen.com/books/images_new/878.jpg",editedByType:"Edited by",editors:[{id:"82663",title:"Dr.",name:"Venketeshwer",surname:"Rao",slug:"venketeshwer-rao",fullName:"Venketeshwer Rao"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"4816",title:"Face Recognition",subtitle:null,isOpenForSubmission:!1,hash:"146063b5359146b7718ea86bad47c8eb",slug:"face_recognition",bookSignature:"Kresimir Delac and Mislav Grgic",coverURL:"https://cdn.intechopen.com/books/images_new/4816.jpg",editedByType:"Edited by",editors:[{id:"528",title:"Dr.",name:"Kresimir",surname:"Delac",slug:"kresimir-delac",fullName:"Kresimir Delac"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}}]},chapter:{item:{type:"chapter",id:"69623",title:"Laparoscopic Pancreatoduodenectomy",doi:"10.5772/intechopen.89228",slug:"laparoscopic-pancreatoduodenectomy",body:'
1. Introduction
Minimally invasive techniques in pancreatic surgery were initially used only for diagnostic and stadiative purposes, palliative procedures, or the drainage of cysts and the enucleation of small solid lesions [1, 2]. In the last 10 years, with advances in technology and surgical techniques, there has been a growing application of minimally invasive surgery for the treatment of benign and malignant pancreatic neoplasms [3], and complex operations such as distal pancreatectomy (DP) and pancreaticoduodenectomy (PD) have started to be performed [2]. Laparoscopic distal pancreatectomy (LDP) does not require the execution of anastomosis, resulting in quite easy performance and achieving worldwide acceptance. On the other hand, the laparoscopic pancreaticoduodenectomy (LPD) has obtained a marginal acceptance until now, raising doubts about its safety and reproducibility, due to its technical complexity and prolonged operating time [3].
Although the first LPD was performed by Gagner and Pomp more than 20 years ago for the treatment of a chronic pancreatitis involving the pancreatic head [4], the procedure had a slow diffusion [5], especially in comparison to the other applications of minimally invasive surgery in the field of oncological treatment [3].
This slow diffusion can be explained by three main reasons.
The first one is the technical complexity of LPD, especially due to the retroperitoneal position of the pancreas and the proximity to the duodenum and surrounding vascular structures; the fashioning of the laparoscopic anastomoses; and the laparoscopic dissection of the uncinate process from the large vessels [6, 7, 8].
The second one is the high complication rate of PD, heavily affecting postoperative recovery; this represents a limit to the potential advantages of mini-invasiveness [9].
Finally, there is a lack of international consensus about the benefits regarding the feasibility and oncological efficacy of LPD [10].
However, in the last decade, the growing number of publications about laparoscopic pancreatic surgery seems to assess its feasibility and safety [3], especially if performed in highly experienced centers [11].
2. Indications
In all the cases where PD is indicated, laparoscopic approach can be theoretically applied:
pancreatic adenocarcinoma
symptomatic chronic pancreatitis
neuroendocrine pancreatic tumors: functioning tumors, tumors with resectable metastases, tumors with diameters >2 cm, symptomatic nonfunctioning tumors, G3 with Ki67 > 20%, and neuroendocrine carcinoma
cystic pancreatic tumors
IPMN with high-risk stigmata (dilation of the Wirsung ≥10 mm, contrast-enhancing solid intracystic component ≥5 mm, causing obstructive jaundice, with positive cytology)
malignant tumors of the distal common bile duct
malignant tumors of the ampulla of Vater
malignant tumors of the duodenum
Since the learning curve for LPD is long, patients should be adequately selected. As reported in the literature [12], it is preferable to start with patients with low BMI and small ampullary tumors, duodenal adenocarcinomas, or tumors of the distal biliary tract and avoid ductal pancreatic adenocarcinomas because of their infiltrative nature.
Accurate selection of patients is essential to decrease the rate of conversion and avoid unnecessary laparoscopic attempts, which would only increase the operative time and the risk of intraoperative complications.
Suggested contraindications to LPD are significant comorbidities [1, 2, 13, 14, 15], previous upper-mesocolic abdominal surgeries [1, 14, 16, 17], and high BMI [17, 18].
On the contrary, age does not seem to be a contraindication. A study by Buchs et al. [13] compared LPD in patients younger and older than 70 years: post-operative outcomes in the two groups were similar, showing that age alone may not be a selection criterion for LPD.
Current studies about LPD are subject to high selection bias, since most centers are still in the learning curve and selecting only ideal candidates for the procedures.
A recent review by Wang et al. [19] analyzed studies that evaluated inclusion and exclusion criteria for mini-invasive PD, reporting 14 studies that only mentioned inclusion criteria, 20 that only mentioned exclusion ones, and 13 that reported both. This review showed that patients selected for LPD had small peri-ampullary tumors and low BMI. The most frequent contraindications were vascular invasion, previous upper-mesocolic procedures, and severe cardiovascular disease.
Indications and contraindications to LPD also depend on the experience of the surgical team [12]; with increased experience, it may also be performed for the treatment of tumors involving surrounding organs or vascular structures, and almost all contraindications to LPD may become relative. In this scenario, some pioneering groups have also started performing venous resections during LPDs [7, 8].
However, the majority of authors consider as exclusion criteria: large tumors [1, 16], chronic pancreatitis, tumors involving the superior mesenteric-portal vein confluence, the superior mesenteric artery or the hepatic artery [12, 13], and neoadjuvant radio-chemotherapy [20, 21], due to the local fibrosis caused by radiotherapy.
Many algorithms have been developed to help with LPD patient selection [22, 23].
3. Surgical technique
Currently, there is no consensus on the best surgical option for LPD, neither for the demolitive phase nor for the reconstructive one.
Differences in the surgical technique concern as follows:
Preparatory phase: trocar placement, type of trocar used, access technique to peritoneum.
Demolitive phase: surgical steps, devices and materials, pylorus preservation or not.
Reconstructive phase: type of suture, anastomosis technique, surgical specimen extraction, drainages, stent placement in pancreatic duct to protect the pancreatico-jejunal anastomosis.
3.1 Preparatory phase
The number, type, and placement of trocars for LPD vary greatly throughout the literature. Most authors use 5 trocars (52.1%) [1, 24, 25]; some use 6 (30.4%) [26, 27]; more rarely, 4 [28, 29] or 7 [16] are used.
Pneumoperitoneum is usually induced using the “open” technique according to Hasson in periumbilical or supra-umbilical position [20, 24, 26, 28, 30], while rarely the “closed” technique with the Veress needle is used [1, 16, 27, 29].
Trocar placement varies between series, especially concerning the optic port and the port for the hepatic retractor. The optic port is more commonly placed in the umbilical region (41.7%). The port for the hepatic retractor is, in many cases, placed along the midline in the subxiphoid region, while in some cases, it is placed along the right anterior axillary line, just under the hepatic ridge.
3.2 Demolitive phase
Boggi et al. [31] published a systematic review that analyzed various aspects of the demolitive phase. Their results are summarized in this section.
Concerning materials, the majority of authors used energy devices (678 patients, 90.8% of cases). Some authors used a single energy device (in 10 cases ultrasonic shears, in 4 cases radiofrequency), while 8 used a dual energy device (6 ultrasound and radiofrequency, 1 ultrasound and bipolar, 1 ultrasound and monopolar).
The section of the pancreatic neck can be done using the ultrasonic shears, the electrocautery (104 patients, 15.9%), the stapler or ultrasonic shears (100 patients, 15.3%), electrocautery or ultrasonic shears (65 patients, 9.9%), only stapler (12 patients 1.8%), or only radiofrequency (6 patients, 0.9%) (Figures 1–3).
Figure 1.
Retropancreatic tunnel.
Figure 2.
Pancreatic neck section using ultrasonic shears.
Figure 3.
Pancreatic neck section using ultrasonic scissors.
The method used to section the gastroduodenal artery is another relevant technical aspect, since the arterial stump is a frequent site of bleeding in case of pancreatic fistula.
In the majority of cases (274 patients, 54.5%), the use of clips was reported, while some authors (100 patients, 19.9%) reported only ligature. Other options are vascular stapler plus suture (1 article, 50 patients, 9.9%), clips plus suture (1 article, 35 patients, 6.9%), vascular stapler only (1 article, 24 patients, 2.7%), and radiofrequency only (1 article, 11 patients, 2.1%) (Figures 4 and 5).
Figure 4.
Gastroduodenal artery closure using clips.
Figure 5.
Gastroduodenal artery closure using vascular stapler.
The specimen is often extracted via an umbilical (42.2%), supra-pubic (15.7%), or subxiphoid (15%) mini-laparotomy; other sites for extraction are sub-umbilical (8.9%), the right inferior quadrant (8.8%), or supraumbilical (4.9%) one.
Finally, the surgeon must decide whether to preserve the pylorus (Traverso-Longmire intervention) or resect the gastric antrum (classic Whipple procedure).
Pylorus-preserving surgery is more commonly performed (55%) than gastric antrum resection among 21 authors (636 patients), 6 always preserve the pylorus (262 patients, 41.1%), 8 always section the gastric antrum (13 patients, 17.7%), while 7 used both techniques (261 patients, 41%).
Pylorus preservation in oncological cases is a controversial topic; it was compared with the Whipple technique without significant differences between the two techniques in terms of overall survival (p = 0.11), in-hospital mortality (p = 0.18) and morbidity (p = 0.69), incidence of postoperative pancreatic fistula (POPF; p = 0.63), biliary leakage (BL; p = 0.82), post-pancreatectomy hemorrage (PPH; p = 0.53), or delayed gastric emptying (DGE; p = 0.16) [32]. Pylorus-preservation was associated with a shorter operative time (p = 0.0004) and a reduced intraoperative blood loss (p = 0.00001).
There is a lack of data about laparoscopic “artery first approach” to PD and total mesopancreas excision (TMpE), because no details about this important topics were reported in the literature.
3.3 Reconstructive phase
Great variability in the reconstructive phase is reported in the literature, both in materials (type of suture) and in fashioning anastomoses.
The management of the pancreatic stump represents one of the most important steps of the entire procedure [33, 34], especially when dealing with a soft gland, as it is one of the main risk factors for the development of a POPF [35, 36].
Pancreaticojejunostomy (PJ; 84% of cases; Figures 6 and 7) and pancreaticogastrostomy (PG; 9.8% of cases) are the most commonly performed anastomoses; on the other hand, the duct occlusion has mostly been abandoned (6.8% of cases) [31].
Figure 6.
Duct-to-mucosa anastomosis.
Figure 7.
Pancreato-jejunal anastomosis.
In order to reduce the risk of POPF, the majority of the authors (72.8%) positioned a stent in the Wirsung, either routinely or selectively; the pancreatic anastomosis was in most cases performed with a double layer (90.6%) and interrupted sutures (74.6%).
The gastro/duodenal-jejunal (GJ/DJ) anastomosis was antecolic in 76.3% of cases (Figure 8), retromesenteric in 13.4% of cases, and retrocolic in 10.2% of cases.
Figure 8.
Antecolic gastro-jejunal anastomosis.
The majority of GJ and DJ anastomoses were handsewn (n = 491/566; 86.7%); mechanical anastomoses using stapler were performed in only 13.2% of cases and always to perform GJ anastomosis.
In a randomized multicentric study on 440 patients, Keck et al. [37] compared the outcomes of PG vs. PJ: although POPF rate was 20%, without significant differences between the two techniques, the rate of anastomotic bleeding was higher for PG.
Surprisingly in a meta-analysis [38] based on 676 patients underwent to PD, a significantly lower rate of POPF was found in favor of PG, while there were no differences in the incidence of BL, PPH, or DGE between the two anastomoses.
4. Postoperative outcomes
4.1 Short-term outcomes
Despite the technical and technological progress made in recent years, postoperative morbidity for PD remains high (30–50%) [39].
The most frequent postoperative complications for PD are DGE (19–23% of cases), POPF (9–18%), intra-abdominal abscess (9–10%), and intra-abdominal or GI bleeding (1–8%) [40].
Many authors questioned the possibility to improve postoperative outcomes through the use of mini-invasiveness.
Compared to open PD, LPD has been found to require longer operative time [30, 41, 42, 43] (Tables 1 and 2); however, it leads to
reduce intraoperative blood loss and the need for transfusions [6, 26, 30, 41, 43, 44, 45]
Thirty-day mortality and morbidity, including POPF, DGE, PPH, BL, and surgical site infection (SSI), are comparable between laparoscopic and open PD [30, 42, 43, 44, 45, 46, 47].
Author
Year
No of patients
Operative time (min)
Intraop blood loss (ml)
Postop LOS (days)
30-days mortality
VL
Op
VL
Op
VL
Op
VL
Op
VL
Op
Stauffer
2016
58
193
375
518
250
600
6
9
—
—
Sharpe
2015
384
4037
nr
nr
nr
nr
10
12
5.2
3.7
Song
2015
104
576
482
348
570
609
14
19
—
—
Speicher
2014
25
84
381
326
200
425
8
10
—
1.2
Dokmak
2014
46
46
342
264
368
293
23
25
2
—
Croome
2014
108
214
379
387
492
866
6
9
1
2
Mesleh
2013
75
nr
551
nr
nr
nr
7
nr
—
nr
Asbun
2012
53
215
541
401
195
1032
8
12
5.7
8.8
Table 1.
Postoperative outcomes: comparison between laparoscopic and open PD.
Regarding oncological radicality, laparoscopic PD appears to be at least noninferior to open PD.
Considering tumors of similar size and histological type, the number of harvested lymph nodes and the rate of negative resection margins have been found to be either comparable [20, 30, 45, 46, 48] between laparoscopic and open PD or superior in laparoscopic PD [6, 26, 41, 42, 43].
Overall survival between laparoscopic and open PD is comparable [6, 30, 45]. However, the reduction in postoperative pain and physical impairment, paired with the reduced rate of surgical site complications, may allow for a broader access to adjuvant chemotherapy and an earlier start of treatment in patients who underwent laparoscopic PD [11, 49].
Current studies comparing laparoscopic PD vs. open PD have been criticized because they may suffer from selection bias, as many of them excluded patients with vascular involvement, high intraoperative risk, and multiple previous abdominal operations, all of which have higher chances of undergoing an open procedure.
However, the results from Croome et al. [6] and the review from Wang et al. [43] showed promising results also in complex cases, which required vascular resections.
5. Learning curve
The learning curve for LPD is particularly steep and represents an obstacle to a more widespread use of the procedure; it seems that learning curve can be shortened with specific training strategies, e.g., ex vivo training, proctoring, and simulation in loco.
The majority of studies about surgical learning curves define it as the number of procedures needed to achieve a decrease in operative time and blood loss and in the number of conversions.
With increased experience in those kinds of procedures, the surgeon is also able to deal laparoscopically with more technical complex situations, such as vascular resections (portal, mesenteric, and arterial), without increasing postoperative complications.
As shown in the review published by De Rooij et al. [12], there are three strategies to learn how to carry out PD completely laparoscopically (i.e., not only the demolitive phase, which is more commonly performed laparoscopically, but also the reconstructive one, which represents a considerable obstacle for some).
The first strategy consists of tutoring. The second one is a hybrid approach, i.e., performing the demolitive phase through laparoscopy and the reconstructive phase through a service minilaparotomy. The third one is also a hybrid approach, but the reconstructive phase is carried out robotically.
Each strategy has its own learning curve and needs to be performed only in specialized centers with high volumes of pancreatic surgeries to avoid unnecessarily high rates of morbidity and mortality. Recent studies suggest that using hybrid techniques before performing the procedure completely laparoscopically might be useful. A cut off of 10 hybrid procedures is considered enough to start with full laparoscopy, although 50 hybrid procedures are required for significant improvements in operative outcomes to appear/significant improvements in operative outcomes appear after 50 hybrid procedures.
A study by Speicher et al. [41] shows that laparoscopic PD’s learning curve goes through a slow and difficult initial phase (first 10 cases), a much faster improvement phase (10–20 cases), and finally a plateau with a slow but steady improvement with time (after 50 cases).
However, these considerations can only be applied to surgeons with great expertise in open PD and in advanced laparoscopic surgery; it is often difficult to satisfy both conditions, as many centers with high volumes of pancreatic surgeons do not have high volumes of laparoscopic surgery and vice versa.
Many years are required to overcome the learning curve and reach an adequate outcome level [50]. Pancreatic surgery should be centralized in dedicated centers, as this has been shown in many studies to improve outcomes [51, 52].
A review by Gumbs et al. [53] that analyzed 285 LPDs shows that the length of hospital stay and the operative time for the procedure decrease proportionally to the higher volume of cases of the center.
Different studies show that, as one moves along the learning curve, there is a decrease in operative time, blood loss, morbidity, and open conversions, resulting in a reduced length of hospital stay.
Kim et al. [24] analyzed 100 consecutive cases of pylorus-preserving LPD, of which all performed by the same surgeon and divided them in three time periods. With increased experience, operative time decreased from 9.8 hours in the first-time period to 6.6 in the third. Length of hospital stay went from 20.4 to 11.5 days. Morbidity, including pancreatic fistula, intraoperative bleeding, delayed gastric emptying, and ileus, decreased from 33.3 to 17.6%.
Similar results, demonstrating an improvement in the surgical outomes increasing the learning curve, also reported by Speicher et al. [41], with diminished operative time and blood loss with increased experience, and Song et al. [30].
Song et al. divided LPD’s cases into two cohorts (the first 47 consecutive cases vs. the next 50 cases). The second cohort had decreased operative time (399.4 vs. 566.5 minutes, p < 0.0001), decreased intraoperative blood loss (503 vs. 685 cc, p = 0.018), and decreased length of hospitals stay (11.2 days vs. 17.3, p < 0.001).
Another cohort study shows that rates of postoperative pancreatic fistulas diminished from 36 to 18% after only 11 LPDs [1]. Other study also confirmed that morbidity is inversely proportional to the number of procedures performed in a single center [9, 20, 30].
Mortality also decreased with an increase in experience [54]; analyzing a national database with over 7000 patients who underwent PD from 2010 to 2011, higher 30-day mortality with LPD than with open PD was found. However, this result only applied to those centers with less than 10 LPDs in 2 years, where 30-day mortality was twice that of open PD. In centers with more than 10 LPDs, 30-day mortality was similar in laparoscopic and open procedures.
The dramatic improvement shown by these authors as they progress along the learning curve is encouraging and may bring much more surgeons to perform PD laparoscopically.
6. Costs
Most of the financial benefit of laparoscopic vs. open PD is attributed to the reduced length of hospital stay [15, 17, 20, 30]. However, laparoscopy significantly increases operative time (usually by 2 hours) [30] and requires expensive materials with an increase in cost of 35%, p < 0.0001, both of which lead to increased costs [30].
Speicher et al. and Mesleh et al. compared open vs. laparoscopic PD costs [41, 44]. They concluded that total costs were comparable. According to Speicher et al. [41], laparoscopic PD costs 24,590 dollars vs. 19,720 dollars in open technique (p = 0.19).
According to Mesleh et al. [44], laparoscopic PD is significantly more expensive (p < 0.0001) than open PD, due to the cost of the surgical material and the increased operative time (551 vs. 355 minutes).
Morbidity and postoperative length of hospital stay were comparable and did not influence the overall cost. However, the post-operative management for open PD is slightly more expensive than laparoscopic PD when single categories are taken into account (expenses for nursing, anaesthesia, drugs, labs, and imaging).
As recovery expenses represent 65–70% of the overall cost, the decreased postoperative cost of laparoscopic PD balances out its increased intra-operative cost when compared to open PD.
7. Conclusions
LPD is a safe, standardizable, and oncologically adequate surgical technique, but only if performed by surgeons with extensive experience both in pancreatic surgery and in laparoscopy and, at least at the beginning of the learning curve, on appropriately selected cases.
\n',keywords:"mini-invasive pancreaticoduodenectomy, laparoscopic pancreaticoduodenectomy, advanced laparoscopic surgery, pancreatic surgery",chapterPDFUrl:"https://cdn.intechopen.com/pdfs/69623.pdf",chapterXML:"https://mts.intechopen.com/source/xml/69623.xml",downloadPdfUrl:"/chapter/pdf-download/69623",previewPdfUrl:"/chapter/pdf-preview/69623",totalDownloads:236,totalViews:0,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,dateSubmitted:"February 7th 2019",dateReviewed:"August 17th 2019",datePrePublished:"October 21st 2019",datePublished:"March 11th 2020",dateFinished:null,readingETA:"0",abstract:"In recent years, total laparoscopic pancreaticoduodenectomy (TLPD) has been introduced as a feasible alternative to open pancreaticoduodenectomy (OPD) when performed by experienced surgeons in laparoscopic and pancreatic surgery. Its application has been gradually increased, but its safety, reproducibility, and oncological outcomes are still debated due to its technical complexity and prolonged operating time. We performed a systematic analysis of the more relevant aspects of TLPD. In this chapter, we report a general overview of the different experiences present in the literature regarding indications, surgical techniques, postoperative outcomes, benefits and limitations of this approach, oncological results, learning curve, and costs. There is no standardized surgical technique for TLPD. Different techniques exist for both the demolitive stage and the reconstructive stage. We summarized the different aspects of the surgical technique based on the various experiences reported by different authors. Compared to OPD, TLPD provides the advantages of laparoscopy, i.e., reduced blood loss, decreased postoperative pain, and shorter length of hospital stay, without increasing the rate of postoperative complications or compromising oncological outcomes. An appropriate patient selection is crucial at the beginning of the learning curve. With increased experience, more challenging cases may also be approached with this technique, including those requiring major vascular resections or multi-visceral resections.",reviewType:"peer-reviewed",bibtexUrl:"/chapter/bibtex/69623",risUrl:"/chapter/ris/69623",book:{slug:"advanced-endoscopy"},signatures:"Michele Mazzola, Lorenzo Morini, Marianna Maspero, Camillo Leonardo Bertoglio, Sara Andreani, Carmelo Magistro, Paolo De Martini and Giovanni Ferrari",authors:[{id:"39890",title:"Dr.",name:"Michele",middleName:null,surname:"Mazzola",fullName:"Michele Mazzola",slug:"michele-mazzola",email:"micmazzola@gmail.com",position:null,institution:null},{id:"306694",title:"Dr.",name:"Lorenzo",middleName:null,surname:"Morini",fullName:"Lorenzo Morini",slug:"lorenzo-morini",email:"lorenzo.morini@ospedaleniguarda.it",position:null,institution:null},{id:"306695",title:"Dr.",name:"Sara",middleName:null,surname:"Andreani",fullName:"Sara Andreani",slug:"sara-andreani",email:"sara.andreani@ospedaleniguarda.it",position:null,institution:{name:"Ospedale Niguarda Ca' Granda",institutionURL:null,country:{name:"Italy"}}},{id:"306698",title:"Dr.",name:"Marianna",middleName:null,surname:"Maspero",fullName:"Marianna Maspero",slug:"marianna-maspero",email:"marianna.maspero@ospedaleniguarda.it",position:null,institution:{name:"Ospedale Niguarda Ca' Granda",institutionURL:null,country:{name:"Italy"}}},{id:"306699",title:"Dr.",name:"Camillo Leonardo",middleName:null,surname:"Bertoglio",fullName:"Camillo Leonardo Bertoglio",slug:"camillo-leonardo-bertoglio",email:"camilloleonardo.bertoglio@ospedaleniguarda.it",position:null,institution:{name:"Ospedale Niguarda Ca' Granda",institutionURL:null,country:{name:"Italy"}}},{id:"306700",title:"Dr.",name:"Carmelo",middleName:null,surname:"Magistro",fullName:"Carmelo Magistro",slug:"carmelo-magistro",email:"carmelo.magistro@ospedaleniguarda.it",position:null,institution:{name:"Ospedale Niguarda Ca' Granda",institutionURL:null,country:{name:"Italy"}}},{id:"306701",title:"Dr.",name:"Paolo",middleName:null,surname:"De Martini",fullName:"Paolo De Martini",slug:"paolo-de-martini",email:"paolo.demartini@ospedaleniguarda.it",position:null,institution:{name:"Ospedale Niguarda Ca' Granda",institutionURL:null,country:{name:"Italy"}}},{id:"306702",title:"Dr.",name:"Giovanni",middleName:null,surname:"Ferrari",fullName:"Giovanni Ferrari",slug:"giovanni-ferrari",email:"giovanni.ferrari@ospedaleniguarda.it",position:null,institution:{name:"Ospedale Niguarda Ca' Granda",institutionURL:null,country:{name:"Italy"}}}],sections:[{id:"sec_1",title:"1. Introduction",level:"1"},{id:"sec_2",title:"2. Indications",level:"1"},{id:"sec_3",title:"3. Surgical technique",level:"1"},{id:"sec_3_2",title:"3.1 Preparatory phase",level:"2"},{id:"sec_4_2",title:"3.2 Demolitive phase",level:"2"},{id:"sec_5_2",title:"3.3 Reconstructive phase",level:"2"},{id:"sec_7",title:"4. Postoperative outcomes",level:"1"},{id:"sec_7_2",title:"4.1 Short-term outcomes",level:"2"},{id:"sec_8_2",title:"4.2 Oncological outcomes",level:"2"},{id:"sec_10",title:"5. Learning curve",level:"1"},{id:"sec_11",title:"6. Costs",level:"1"},{id:"sec_12",title:"7. Conclusions",level:"1"}],chapterReferences:[{id:"B1",body:'Corcione F et al. Laparoscopic pancreaticoduodenectomy: Experience of 22 cases. Surgical Endoscopy and Other Interventional Techniques. 2013;27(6):2131-2136'},{id:"B2",body:'Palanivelu C, Jani K, Senthilnathan P, Parthasarathi R, Rajapandian S, Madhankumar MV. Laparoscopic pancreaticoduodenectomy: Technique and outcomes. Journal of the American College of Surgeons. 2007;205(2):222-230'},{id:"B3",body:'Ammori BJ, Ayiomamitis GD. Laparoscopic pancreaticoduodenectomy and distal pancreatectomy: A UK experience and a systematic review of the literature. Surgical Endoscopy and Other Interventional Techniques. 2011;25(7):2084-2099'},{id:"B4",body:'Gagner M, Palermo M. Laparoscopic whipple procedure: Review of the literature. Journal of Hepato-Biliary-Pancreatic Surgery. 2009;16(6):726-730'},{id:"B5",body:'Merkow J, Paniccia A, Edil BH. Laparoscopic pancreaticoduodenectomy: A descriptive and comparative review. Chinese Journal of Cancer Research. 2015;27(4):368-375'},{id:"B6",body:'Croome KP et al. Pancreaticoduodenectomy with major vascular resection: A comparison of laparoscopic versus open approaches. Journal of Gastrointestinal Surgery. 2014;19(1):189-194'},{id:"B7",body:'Kendrick ML, Sclabas GM. Major venous resection during total laparoscopic pancreaticoduodenectomy. HPB. 2011;13(7):454-458'},{id:"B8",body:'Khatkov IE, Izrailov RE, Khisamov AA, Tyutyunnik PS, Fingerhut A. Superior mesenteric–portal vein resection during laparoscopic pancreatoduodenectomy. Surgical Endoscopy and Other Interventional Techniques. 2017;31(3):1488-1495'},{id:"B9",body:'Wang M et al. Learning curve for laparoscopic pancreaticoduodenectomy: A CUSUM analysis. Journal of Gastrointestinal Surgery. 2016;20(5):924-935'},{id:"B10",body:'Kantor O et al. Laparoscopic pancreaticoduodenectomy for adenocarcinoma provides short-term oncologic outcomes and long-term overall survival rates similar to those for open pancreaticoduodenectomy. American Journal of Surgery. 2017;213(3):512-515'},{id:"B11",body:'Dai R, Turley RS, Blazer DG. Contemporary review of minimally invasive pancreaticoduodenectomy. World Journal of Gastrointestinal Surgery. 2016;8(12):784'},{id:"B12",body:'de Rooij T, Klompmaker S, Hilal MA, Kendrick ML, Busch OR, Besselink MG. Laparoscopic pancreatic surgery for benign and malignant disease. Nature Reviews. Gastroenterology and Hepatology. 2016;13(4):227-238'},{id:"B13",body:'Buchs NC, Addeo P, Bianco FM, Gangemi A, Ayloo SM, Giulianotti PC. Outcomes of robot-assisted pancreaticoduodenectomy in patients older than 70 years: A comparative study. World Journal of Surgery. 2010;34(9):2109-2114'},{id:"B14",body:'Lee JS et al. Laparoscopic pancreaticoduodenectomy assisted by mini-laparotomy. Surgical Laparoscopy Endoscopy and Percutaneous Techniques. 2013;23(3):98-102'},{id:"B15",body:'Wellner UF et al. Hybrid laparoscopic versus open pylorus-preserving pancreatoduodenectomy: Retrospective matched case comparison in 80 patients. Langenbeck’s Archives of Surgery. 2014;399(7):849-856'},{id:"B16",body:'Palanivelu C et al. Evolution in techniques of laparoscopic pancreaticoduodenectomy: A decade long experience from a tertiary center. Journal of Hepato-Biliary-Pancreatic Surgery. 2009;16(6):731-740'},{id:"B17",body:'Langan RC et al. Laparoscopic-assisted versus open pancreaticoduodenectomy: Early favorable physical quality-of-life measures. Surgery. (United States). 2014;156(2):379-384'},{id:"B18",body:'Boggi U et al. Feasibility of robotic pancreaticoduodenectomy. The British Journal of Surgery. 2013;100(7):917-925'},{id:"B19",body:'Liao CH et al. Systemic review of the feasibility and advantage of minimally invasive pancreaticoduodenectomy. World Journal of Surgery. 2016;40(5):1218-1225'},{id:"B20",body:'Dokmak S et al. Laparoscopic pancreaticoduodenectomy should not be routine for resection of periampullary tumors. Journal of the American College of Surgeons. 2015;220(5):831-838'},{id:"B21",body:'Delitto D et al. Oncologic and perioperative outcomes following selective application of laparoscopic pancreaticoduodenectomy for periampullary malignancies. Journal of Gastrointestinal Surgery. 2016;20(7):1343-1349'},{id:"B22",body:'Cho CS et al. Laparoscopic versus open left pancreatectomy: Can preoperative factors indicate the safer technique? Annals of Surgery. 2011;253(5):975-980'},{id:"B23",body:'Magge D et al. Comparative effectiveness of minimally invasive and open distal pancreatectomy for ductal adenocarcinoma. JAMA Surgery. 2013;148(6):525-531'},{id:"B24",body:'Kim SC et al. Short-term clinical outcomes for 100 consecutive cases of laparoscopic pylorus-preserving pancreatoduodenectomy: Improvement with surgical experience. Surgical Endoscopy and Other Interventional Techniques. 2013;27(1):95-103'},{id:"B25",body:'Gumbs AA, Gayet B. The laparoscopic duodenopancreatectomy: The posterior approach. Surgical Endoscopy and Other Interventional Techniques. 2008;22(2):539-540'},{id:"B26",body:'Asbun HJ, Stauffer JA. Laparoscopic vs open pancreaticoduodenectomy: Overall outcomes and severity of complications using the accordion severity grading system. Journal of the American College of Surgeons. 2012;215(6):810-819'},{id:"B27",body:'Zureikat AH, Breaux JA, Steel JL, Hughes SJ. Can laparoscopic pancreaticoduodenectomy be safely implemented? Journal of Gastrointestinal Surgery. 2011;15(7):1151-1157'},{id:"B28",body:'Lei Z et al. Pancreaticojejunostomy sleeve reconstruction after pancreaticoduodenectomy in laparoscopic and open surgery. Journal of the Society of Laparoendscopic Surgeons. 2013;17(1):68-73'},{id:"B29",body:'Azagra JS, Arru L, Estévez S, Silviu-Tiberiu M-P, Poulain V, Goergen M. Pure laparoscopic pancreatoduodenectomy with initial approach to the superior mesenteric artery. Videosurgery and Other Miniinvasive Techniques. 2015;3:450-457'},{id:"B30",body:'Song KB et al. Matched case-control analysis comparing laparoscopic and open pylorus-preserving pancreaticoduodenectomy in patients with periampullary tumors. Annals of Surgery. 2015;262(1):146-155'},{id:"B31",body:'Boggi U et al. Laparoscopic pancreaticoduodenectomy: A systematic literature review. Surgical Endoscopy and Other Interventional Techniques. 2015;29(1):9-23'},{id:"B32",body:'Diener MK, Knaebel HP, Heukaufer C, Antes G, Büchler MW, Seiler CM. A systematic review and meta-analysis of pylorus-preserving versus classical pancreaticoduodenectomy for surgical treatment of periampullary and pancreatic carcinoma. Annals of Surgery. 2007;245(2):187-200'},{id:"B33",body:'Paye F. The pancreatic stump after pancreatoduodenectomy: The Achille’s heel revisited. Journal of Visceral Surgery. 2010;147(1):e13-e20'},{id:"B34",body:'Kleespies A, Albertsmeier M, Obeidat F, Seeliger H, Jauch KW, Bruns CJ. The challenge of pancreatic anastomosis. Langenbeck’s Archives of Surgery. 2008;393(4):459-471'},{id:"B35",body:'Berger AC et al. Does type of pancreaticojejunostomy after pancreaticoduodenectomy decrease rate of pancreatic fistula? A randomized, prospective, dual-institution trial. Journal of the American College of Surgeons. 2009;208(5):738-747'},{id:"B36",body:'Hosotani R, Doi R, Imamura M. Duct-to-mucosa pancreaticojejunostomy reduces the risk of pancreatic leakage after pancreatoduodenectomy. World Journal of Surgery. 2002;26(1):99-104'},{id:"B37",body:'Keck T et al. Pancreatogastrostomy versus pancreatojejunostomy for RECOnstruction after PANCreatoduodenectomy (RECOPANC, DRKS 00000767): Perioperative and long-term results of a multicenter randomized controlled trial. Annals of Surgery. 2016;263(3):440-449'},{id:"B38",body:'Hallet J et al. The impact of pancreaticojejunostomy versus pancreaticogastrostomy reconstruction on pancreatic fistula after pancreaticoduodenectomy: Meta-analysis of randomized controlled trials. HPB. 2015;17(2):113-122'},{id:"B39",body:'Wente MN et al. Delayed gastric emptying (DGE) after pancreatic surgery: A suggested definition by the International Study Group of Pancreatic Surgery (ISGPS). Surgery. 2007;142(5):761-768'},{id:"B40",body:'Wente MN et al. Postpancreatectomy hemorrhage (PPH)-an international study group of pancreatic surgery (ISGPS) definition. Surgery. 2007;142(1):20-25'},{id:"B41",body:'Speicher PJ et al. Defining the learning curve for team-based laparoscopic pancreaticoduodenectomy. Annals of Surgical Oncology. 2014;21(12):4014-4019'},{id:"B42",body:'Stauffer JA et al. Laparoscopic versus open pancreaticoduodenectomy for pancreatic adenocarcinoma: Long-term results at a single institution. Surgical Endoscopy. 2017;31(5):2233-2241'},{id:"B43",body:'Wang M et al. Minimally invasive pancreaticoduodenectomy: A comprehensive review. International Journal of Surgery. 2016;35:139-146'},{id:"B44",body:'Mesleh MG, Stauffer JA, Bowers SP, Asbun HJ. Cost analysis of open and laparoscopic pancreaticoduodenectomy: A single institution comparison. Surgical Endoscopy. 2013;27(12):4518-4523'},{id:"B45",body:'Croome KP et al. Total laparoscopic pancreaticoduodenectomy for pancreatic ductal adenocarcinoma oncologic advantages over open approaches? The Annals of Surgery. 2014;260(4):633-640'},{id:"B46",body:'Sharpe SM et al. Early national experience with laparoscopic pancreaticoduodenectomy for ductal adenocarcinoma: A comparison of laparoscopic pancreaticoduodenectomy and open pancreaticoduodenectomy from the National Cancer Data Base. Journal of the American College of Surgeons. 2015;221(1):175-184'},{id:"B47",body:'Kendrick ML et al. Minimally invasive pancreatoduodenectomy. HPB. 2017;19(3):215-224'},{id:"B48",body:'Nussbaum DP et al. Minimally invasive pancreaticoduodenectomy does not improve use or time to initiation of adjuvant chemotherapy for patients with pancreatic adenocarcinoma. Annals of Surgical Oncology. 2016;23(3):1026-1033'},{id:"B49",body:'Jacobs MJ, Kamyab A. Total laparoscopic pancreaticoduodenectomy. Journal of the Society of Laparoendscopic Surgeons. 2013;17(2):188-193'},{id:"B50",body:'Boone BA et al. Assessment of quality outcomes for robotic pancreaticoduodenectomy: Identification of the learning curve. JAMA Surgery. 2015;150(5):416-422'},{id:"B51",body:'Topal B, Van De Sande S, Fieuws S, Penninckx F. Effect of centralization of pancreaticoduodenectomy on nationwide hospital mortality and length of stay. The British Journal of Surgery. 2007;94(11):1377-1381'},{id:"B52",body:'De Wilde RF et al. Impact of nationwide centralization of pancreaticoduodenectomy on hospital mortality. The British Journal of Surgery. 2012;99(3):404-410'},{id:"B53",body:'Gumbs AA, Rodriguez Rivera AM, Milone L, Hoffman JP. Laparoscopic pancreatoduodenectomy: A review of 285 published cases. Annals of Surgical Oncology. 2011;18(5):1335-1341'},{id:"B54",body:'Abdelgadir Adam M et al. Minimally invasive versus open pancreaticoduodenectomy for cancer: Practice patterns and short-term outcomes among 7061 patients. Annals of Surgery. 2015;262(2):372-377'}],footnotes:[],contributors:[{corresp:"yes",contributorFullName:"Michele Mazzola",address:"micmazzola@gmail.com",affiliation:'
Division of Minimally-invasive Surgical Oncology, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
Division of Minimally-invasive Surgical Oncology, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
'}],corrections:null},book:{id:"7869",title:"Advanced Endoscopy",subtitle:null,fullTitle:"Advanced Endoscopy",slug:"advanced-endoscopy",publishedDate:"March 11th 2020",bookSignature:"Qiang Yan and Xu Sun",coverURL:"https://cdn.intechopen.com/books/images_new/7869.jpg",licenceType:"CC BY 3.0",editedByType:"Edited by",editors:[{id:"247970",title:"Prof.",name:"Qiang",middleName:null,surname:"Yan",slug:"qiang-yan",fullName:"Qiang Yan"}],productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"},chapters:[{id:"70736",title:"Introductory Chapter: Endoscopy and ERAS",slug:"introductory-chapter-endoscopy-and-eras",totalDownloads:233,totalCrossrefCites:0,signatures:"Qiang Yan",authors:[{id:"247970",title:"Prof.",name:"Qiang",middleName:null,surname:"Yan",fullName:"Qiang Yan",slug:"qiang-yan"}]},{id:"68473",title:"Multimodal Optical Imaging by Microendoscope",slug:"multimodal-optical-imaging-by-microendoscope",totalDownloads:203,totalCrossrefCites:0,signatures:"Lin Huang and Zhen Qiu",authors:[{id:"229868",title:"Dr.",name:"Zhen",middleName:null,surname:"Qiu",fullName:"Zhen Qiu",slug:"zhen-qiu"},{id:"303368",title:"Dr.",name:"Lin",middleName:null,surname:"Huang",fullName:"Lin Huang",slug:"lin-huang"}]},{id:"69623",title:"Laparoscopic Pancreatoduodenectomy",slug:"laparoscopic-pancreatoduodenectomy",totalDownloads:236,totalCrossrefCites:0,signatures:"Michele Mazzola, Lorenzo Morini, Marianna Maspero, Camillo Leonardo Bertoglio, Sara Andreani, Carmelo Magistro, Paolo De Martini and Giovanni Ferrari",authors:[{id:"39890",title:"Dr.",name:"Michele",middleName:null,surname:"Mazzola",fullName:"Michele Mazzola",slug:"michele-mazzola"},{id:"306694",title:"Dr.",name:"Lorenzo",middleName:null,surname:"Morini",fullName:"Lorenzo Morini",slug:"lorenzo-morini"},{id:"306695",title:"Dr.",name:"Sara",middleName:null,surname:"Andreani",fullName:"Sara Andreani",slug:"sara-andreani"},{id:"306698",title:"Dr.",name:"Marianna",middleName:null,surname:"Maspero",fullName:"Marianna Maspero",slug:"marianna-maspero"},{id:"306699",title:"Dr.",name:"Camillo Leonardo",middleName:null,surname:"Bertoglio",fullName:"Camillo Leonardo Bertoglio",slug:"camillo-leonardo-bertoglio"},{id:"306700",title:"Dr.",name:"Carmelo",middleName:null,surname:"Magistro",fullName:"Carmelo Magistro",slug:"carmelo-magistro"},{id:"306701",title:"Dr.",name:"Paolo",middleName:null,surname:"De Martini",fullName:"Paolo De Martini",slug:"paolo-de-martini"},{id:"306702",title:"Dr.",name:"Giovanni",middleName:null,surname:"Ferrari",fullName:"Giovanni Ferrari",slug:"giovanni-ferrari"}]},{id:"68061",title:"Endoscopic Management of Leaks and Fistula in Gastrointestinal Tract",slug:"endoscopic-management-of-leaks-and-fistula-in-gastrointestinal-tract",totalDownloads:289,totalCrossrefCites:0,signatures:"Mahesh Kumar Goenka, Gajanan Ashokrao Rodge and Usha Goenka",authors:[{id:"292494",title:"Dr.",name:"Mahesh",middleName:null,surname:"Goenka",fullName:"Mahesh Goenka",slug:"mahesh-goenka"},{id:"292496",title:"Dr.",name:"Gajanan",middleName:null,surname:"Rodge",fullName:"Gajanan Rodge",slug:"gajanan-rodge"},{id:"292497",title:"Dr.",name:"Usha",middleName:null,surname:"Goenka",fullName:"Usha Goenka",slug:"usha-goenka"}]},{id:"68014",title:"EUS-Guided Biliary Drainage",slug:"eus-guided-biliary-drainage",totalDownloads:398,totalCrossrefCites:0,signatures:"Takeshi Ogura and Kazuhide Higuchi",authors:[{id:"291491",title:"Dr.",name:"Takehsi",middleName:null,surname:"Ogura",fullName:"Takehsi Ogura",slug:"takehsi-ogura"},{id:"301705",title:"Prof.",name:"Kazuhide",middleName:null,surname:"Higuchi",fullName:"Kazuhide Higuchi",slug:"kazuhide-higuchi"}]},{id:"68554",title:"Stents in Gastrointestinal Diseases",slug:"stents-in-gastrointestinal-diseases",totalDownloads:419,totalCrossrefCites:0,signatures:"Eduardo Aimore Bonin, Bruno Verschoor, Fernanda Hoffmann Silva, Kelly Cristina Vieira and Susan Kakitani Takata",authors:[{id:"301234",title:"Ph.D.",name:"Eduardo",middleName:null,surname:"Aimore Bonin",fullName:"Eduardo Aimore Bonin",slug:"eduardo-aimore-bonin"},{id:"301241",title:"Ms.",name:"Susan Louise",middleName:null,surname:"Kakitani Takata",fullName:"Susan Louise Kakitani Takata",slug:"susan-louise-kakitani-takata"},{id:"301242",title:"Mr.",name:"Bruno",middleName:null,surname:"Verschoor",fullName:"Bruno Verschoor",slug:"bruno-verschoor"},{id:"301243",title:"Mrs.",name:"Kelly Cristina",middleName:null,surname:"Vieira",fullName:"Kelly Cristina Vieira",slug:"kelly-cristina-vieira"},{id:"306494",title:"Mrs.",name:"Fernanda",middleName:null,surname:"Hoffmann Silva",fullName:"Fernanda Hoffmann Silva",slug:"fernanda-hoffmann-silva"}]}]},relatedBooks:[{type:"book",id:"6692",title:"Medical and Biological Image Analysis",subtitle:null,isOpenForSubmission:!1,hash:"e75f234a0fc1988d9816a94e4c724deb",slug:"medical-and-biological-image-analysis",bookSignature:"Robert Koprowski",coverURL:"https://cdn.intechopen.com/books/images_new/6692.jpg",editedByType:"Edited by",editors:[{id:"50150",title:"Dr.",name:"Robert",surname:"Koprowski",slug:"robert-koprowski",fullName:"Robert Koprowski"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"},chapters:[{id:"60741",title:"Image Segmentation",slug:"image-segmentation",signatures:"Kumaravel Subramaniam Tamilselvan and Govindasamy\nMurugesan",authors:[{id:"232687",title:"Dr.",name:"K.S",middleName:null,surname:"Tamilselvan",fullName:"K.S Tamilselvan",slug:"k.s-tamilselvan"},{id:"245153",title:"Dr.",name:"G",middleName:null,surname:"Murugesan",fullName:"G Murugesan",slug:"g-murugesan"}]},{id:"59741",title:"Active Contour Based Segmentation Techniques for Medical Image Analysis",slug:"active-contour-based-segmentation-techniques-for-medical-image-analysis",signatures:"R.J. Hemalatha, T.R. Thamizhvani, A. Josephin Arockia Dhivya,\nJosline Elsa Joseph, Bincy Babu and R. Chandrasekaran",authors:[{id:"238868",title:"Prof.",name:"Hemalatha",middleName:null,surname:"R.J",fullName:"Hemalatha R.J",slug:"hemalatha-r.j"},{id:"242385",title:"Dr.",name:"Chandrasekaran",middleName:null,surname:"R",fullName:"Chandrasekaran R",slug:"chandrasekaran-r"},{id:"242386",title:"Ms.",name:"Thamizhvani",middleName:null,surname:"T.R",fullName:"Thamizhvani T.R",slug:"thamizhvani-t.r"},{id:"242388",title:"Dr.",name:"Josephin Arockia Dhivya",middleName:null,surname:"A",fullName:"Josephin Arockia Dhivya A",slug:"josephin-arockia-dhivya-a"},{id:"242389",title:"Ms.",name:"Josline Elsa",middleName:null,surname:"Joseph",fullName:"Josline Elsa Joseph",slug:"josline-elsa-joseph"},{id:"242390",title:"Ms.",name:"Bincy",middleName:null,surname:"Babu",fullName:"Bincy Babu",slug:"bincy-babu"}]},{id:"60362",title:"Medical and Biological Image Analysis",slug:"medical-and-biological-image-analysis",signatures:"Abdelkader Moumen",authors:[{id:"233918",title:"Dr.",name:"Abdelkader",middleName:null,surname:"Moumen",fullName:"Abdelkader Moumen",slug:"abdelkader-moumen"}]},{id:"60853",title:"Bioinformatics Solutions for Image Data Processing",slug:"bioinformatics-solutions-for-image-data-processing",signatures:"Pietro Cinaglia, Luciano Caroprese, Giuseppe Lucio Cascini,\nFrancesco Dattola, Pasquale Iaquinta, Miriam Iusi, Pierangelo Veltri\nand Ester Zumpano",authors:[{id:"236617",title:"Prof.",name:"Ester",middleName:null,surname:"Zumpano",fullName:"Ester Zumpano",slug:"ester-zumpano"},{id:"248312",title:"Dr.",name:"Pietro",middleName:null,surname:"Cinaglia",fullName:"Pietro Cinaglia",slug:"pietro-cinaglia"},{id:"248313",title:"Dr.",name:"Luciano",middleName:null,surname:"Caroprese",fullName:"Luciano Caroprese",slug:"luciano-caroprese"},{id:"248316",title:"Prof.",name:"Giueppe Lucio",middleName:null,surname:"Cascini",fullName:"Giueppe Lucio Cascini",slug:"giueppe-lucio-cascini"},{id:"248317",title:"Dr.",name:"Francesco",middleName:null,surname:"Dattola",fullName:"Francesco Dattola",slug:"francesco-dattola"},{id:"248319",title:"Dr.",name:"Pasquale",middleName:null,surname:"Iaquinta",fullName:"Pasquale Iaquinta",slug:"pasquale-iaquinta"},{id:"248320",title:"Dr.",name:"Miriam",middleName:null,surname:"Iusi",fullName:"Miriam Iusi",slug:"miriam-iusi"},{id:"248321",title:"Prof.",name:"Pierangelo",middleName:null,surname:"Veltri",fullName:"Pierangelo Veltri",slug:"pierangelo-veltri"}]},{id:"60152",title:"Abnormal Tissue Zone Detection and Average Active Stress Estimation in Patients with LV Dysfunction",slug:"abnormal-tissue-zone-detection-and-average-active-stress-estimation-in-patients-with-lv-dysfunction",signatures:"Sareh Behdadfar, Laurent Navarro, Joakim Sundnes, Molly\nMaleckar, Hans Henrik Odland and Stephane Avril",authors:[{id:"53776",title:"Dr.",name:"Laurent",middleName:null,surname:"Navarro",fullName:"Laurent Navarro",slug:"laurent-navarro"},{id:"233287",title:"Prof.",name:"Stephane",middleName:null,surname:"Avril",fullName:"Stephane Avril",slug:"stephane-avril"},{id:"243118",title:"Dr.",name:"Sareh",middleName:null,surname:"Behdadfar",fullName:"Sareh Behdadfar",slug:"sareh-behdadfar"},{id:"243119",title:"Dr.",name:"Mary M",middleName:null,surname:"Maleckar",fullName:"Mary M Maleckar",slug:"mary-m-maleckar"},{id:"243120",title:"Dr.",name:"Hans Henrik",middleName:null,surname:"Odland",fullName:"Hans Henrik Odland",slug:"hans-henrik-odland"},{id:"243121",title:"Prof.",name:"Joakim",middleName:null,surname:"Sundnes",fullName:"Joakim Sundnes",slug:"joakim-sundnes"}]},{id:"58652",title:"Non-Conventional Radiotherapy for Total Body Irradiation: Antecedents, Current Research and Perspectives",slug:"non-conventional-radiotherapy-for-total-body-irradiation-antecedents-current-research-and-perspectiv",signatures:"Francisco Mesa-Linares",authors:[{id:"233671",title:"Dr.",name:"Francisco",middleName:null,surname:"Mesa-Linares",fullName:"Francisco Mesa-Linares",slug:"francisco-mesa-linares"}]},{id:"60729",title:"Automatic Image Analysis and Recognition for Ultrasound Diagnosis and Treatment in Cardiac, Obstetrics and Radiology",slug:"automatic-image-analysis-and-recognition-for-ultrasound-diagnosis-and-treatment-in-cardiac-obstetric",signatures:"Zisheng Li, Peifei Zhu, Takashi Toyomura and Yoshimi Noguchi",authors:[{id:"237293",title:"Ph.D.",name:"Zisheng",middleName:null,surname:"Li",fullName:"Zisheng Li",slug:"zisheng-li"},{id:"246858",title:"Ms.",name:"Peifei",middleName:null,surname:"Zhu",fullName:"Peifei Zhu",slug:"peifei-zhu"},{id:"246859",title:"Mr.",name:"Takashi",middleName:null,surname:"Toyomura",fullName:"Takashi Toyomura",slug:"takashi-toyomura"},{id:"246860",title:"Mr.",name:"Yoshimi",middleName:null,surname:"Noguchi",fullName:"Yoshimi Noguchi",slug:"yoshimi-noguchi"}]}]}]},onlineFirst:{chapter:{type:"chapter",id:"64339",title:"Postural Imbalance in the Elderly: Main Aspects",doi:"10.5772/intechopen.79830",slug:"postural-imbalance-in-the-elderly-main-aspects",body:'\n
\n
1. Aging of population
\n
The aging of the population is an unprecedented world phenomenon. The projections of the World Health Organization indicate that by 2050, all ages will increase by 35%, people aged 65–84 will increase by 164%, older people aged 85–99 will increase by 301% and centenarians will grow by 746% [1].
\n
Increasing longevity also contributes to an aging population. Globally, life expectancy at birth is projected to increase from 69 years in 2005–2010 to 76 years in 2045–2050 and to 82 years in 2095–2100 [1] (Figures 1 and 2).
\n
Figure 1.
Total population by broad age group. Courtesy: World Health Organization.
\n
Figure 2.
Life expectancy at birth by sex. Courtesy: World Health Organization.
\n
Physiological changes are observed with aging, increasing the risks of developing chronic diseases and dependence care. Auditory, visual, and movement problems may be present in people 60 years or older. In addition, some conditions such as dementia, heart disease, stroke, respiratory disorders, diabetes, and musculoskeletal conditions (osteoarthritis and back pain) are more frequent in this age group [2].
\n
One of the most common situations for the elderly is postural imbalance and, consequently, the occurrence of falls, representing a significant health problem in older adults. Each year, approximately 30% of community-dwelling older people fall at least once and 10–20% fall twice or more [3]. The incidence among institutionalized older people is even higher, with a mean percentage of residents who fall each year of over 40% [4].
\n
\n
\n
2. Postural balance
\n
Balancing is the process of controlling the body’s center of mass with respect to its base of support, whether in a static or dynamic situation. It depends on the integration of sensory systems with the CNS. Sensory information from somatosensory, visual, and vestibular systems must be integrated to interpret complex sensory environments. Each system interacts with each other to maintain balance in a closed loop, with an interrelation of cause and effect. When the sensory environment is changed, the CNS needs to re-weigh the contribution of each of the senses in postural balance. In an environment with good lighting and a firm surface, the contribution of somatosensory information is 70%, the visual information is 10%, and the vestibular information is 20% [5].
\n
Each system is prone to deterioration with advancing age, and this is influenced by age-related diseases and use of some types of medications, in addition to polypharmacy [6]. Systems can partially compensate for each other’s deterioration. Failing compensation strategies may eventually result in impaired balance, which may result in falls [7].
\n
\n
2.1 Vision and postural balance
\n
The role of central and peripheral vision information in the control of movements and posture was examined in some studies [8, 9]. These authors suggested that peripheral vision is used for postural control and most particularly for stabilization of fore-aft sways, while the central vision is more often used for foot trajectory planning, targeting, obstacle avoidance, and stabilization of lateral sways.
\n
Visual impairment is an important health problem and a major cause of injury in the elderly. Cataract, glaucoma, age-related macular degeneration, and diabetic retinopathy are the most common diseases related to the elderly and can interfere with the postural balance.
\n
\n
2.1.1 Cataract
\n
Cataract, affecting mainly visual acuity and contrast sensitivity, contributes to about 50% of visual impairments in the elderly [10, 11]. The consequences include decreased ability to perform activities of daily living (such as reading, watching television, driving, and interacting socially), depression, increased number of falls, and increased mortality [10, 12]. The impact on patients is comparable with that of major systemic conditions including stroke, diabetes, and arthritis. In a study in patients with cataract, Pasma et al. found a higher proprioceptive weight compared with healthy elderly participants, which means that the elderly with cataract rely more on their proprioceptive information [7].
\n
\n
\n
2.1.2 Glaucoma
\n
Glaucoma is a progressive optic neuropathy characterized by degeneration of retinal ganglion cells and their axons with consequent vision loss and blindness. This condition leads to a characteristic reduction in the visual field (VF), with good central visual acuity. Previous studies have reported a higher risk of falling in patients with glaucoma compared to normal subjects [13, 14, 15]. In the study by Black et al., a cohort of glaucoma subjects was examined to assess body displacement of the trunk and the results showed that the worse the visual field defect, the greater the body sway [16].
\n
\n
\n
2.1.3 Age-related macular degeneration
\n
Age-related macular degeneration (AMD) is a disease that affects the macula (central vision), altering the accuracy of vision necessary for “direct” and fine activities, and may interfere with activities of daily living [17].
\n
Wood et al. studied postural balance in older adults with AMD and showed that diminution of contrast sensitivity and visual field loss lead to postural instability and mobility difficulties in these patients [18]. Chatard et al., studying 10 elderly unilateral AMD subjects, 10 elderly bilateral AMD subjects, and 10 healthy age-matched control subjects, showed that bilateral AMD subjects had a surface area and an antero-posterior displacement of the CoP higher than healthy elderly. Unilateral AMD subjects had more antero-posterior displacement of the CoP than healthy elderly [19]. The authors conclude that because of aging, AMD subjects could have poor postural adaptive mechanisms which increase instability and risk of falls.
\n
\n
\n
2.1.4 Diabetic retinopathy
\n
Diabetic retinopathy (DR) is a common and potentially blinding microvascular complication of diabetes [20]. In a study, Gupta et al. found that diabetes per se was not a risk factor for falls. However, the authors found an association between diabetic patients with DR and risk of falling [20], suggesting a relation between DR and postural balance.
\n
The greater tendency to fall in patients with mild-to-moderate DR can be explained by a reduction in the components of the visual function system, such as contrast, sensitivity, stereo acuity, and color perception [21, 22].
\n
Figure 3 summarizes the normal vision and main eye disorders that can interfere with the postural balance described above.
\n
Figure 3.
The main vision impairments that interfere with balance. Courtesy: National Eye Institute, National Institutes of Health (NEI/NIH).
\n
Thus, it is important to evaluate visual function when we propose to work with postural balance in the elderly.
\n
\n
\n
\n
2.2 Vestibular system and postural balance
\n
Through its sensory functions, the vestibular system detects the position and movement of the head in space relative to gravity, and helps to stabilize vision and balance [23].
\n
The vestibular system has structures similar to miniaturized accelerometers, which report continuous information to the cerebral cortex, cerebellum, and somatic sensory cortices on the movements and position of the head and body. The vestibular nuclei make connections with structures of the brainstem and cerebellum and also innervate the motor neurons that control extraocular, cervical, and postural muscles [23] (Figure 4).
\n
Figure 4.
Postural balance and the vestibular system responses. From Wikimedia Commons, https://commons.wikimedia.org/wiki/File:1410_Equilibrium_and_Semicircular_Canals.jpg.
\n
Impaired function of the vestibular system causes vertigo, loss of balance, and loss of gaze fixation during movement, often accompanied by dizziness and nausea [24].
\n
Vestibular dysfunction is typically characterized by vertigo (i.e., an illusory sense of motion) and imbalance owing to disturbances in gaze and postural stability [25], which can culminate in falls [26].
\n
So, the evaluation of the vestibular system is indispensable when the patients have a impaired balance control.
\n
\n
\n
2.3 Somatosensory system and postural balance
\n
People rely primarily on the proprioceptive and cutaneous input to maintain normal quiet stance and to safely accomplish the majority of activities of daily living [27].
\n
The proprioceptive information depends on muscle spindles, the Golgi tendon organ (GTO), and articular receptors. The first provide the nervous system with information about the muscle’s length and velocity of contraction, thus contributing to the individual’s ability to discern joint movement and position sense [28]. Besides, the muscle spindles provide afferent feedback that translates stimuli to appropriate reflexive and voluntary movements. The GTO relays information about tensile forces, and is sensitive to very slight changes [28], and when it is activated, the afferent neuron synapses in the spinal cord interneurons, which inhibit the muscle alpha motoneuron, resulting in decreased tension in muscle and tendon. Articular or joint proprioceptors respond to mechanical deformation of the joint capsule and ligaments.
\n
On a slippery or dry floor surface, people show different gait parameters, including step length, required coefficient of friction, and heel contact velocity, evidencing the importance of the sensorimotor system in balance control [29].
\n
Sensorimotor impairments occur with aging and are believed to contribute to the increased likelihood of imbalance and falling [30]. Damage to joint and muscular proprioception, strength (capacity of muscle strength), and reaction time may contribute to the increase in the probability of fall [30].
\n
Some diseases can affect muscles and joints. Studies have shown that, in patients with knee osteoarthritis (AO), postural balance is impaired due to reduced quadriceps function and decreased proprioception [31, 32]. Among elderly individuals, the prevalence of knee OA is approximately 12.2%, with a higher prevalence in women (14.9%) than in men (8.7%) [33].
\n
Patients with neuromuscular diseases (NMDs), usually characterized by muscle weakness, appear to fall regularly. Aging causes a loss of muscle mass with a preferential decline in type II fibers [34], besides decrements in force production, power, specific tension, and fatigability [35], increasing the risk of falls.
\n\n
Key points
\n
\n
Elderly population is increasing.
Postural imbalance and falling are serious problems faced by the older population.
Postural control is based on the interpretation by central nervous system of convergent sensory information from somatosensory, vestibular, and visual systems.
Impairments in these systems lead directly to functional loss, such as the inability to walk safely, to climb stairs, and dress independently, increasing the risk of falls.
\n\n
\n
\n
\n
3. Approach to the patient with a balance problem
\n
\n
3.1 Physical examination
\n
As with any good clinical evaluation, a detailed history and a thorough physical examination are essential. As the postural balance depends on several systems, it is essential to evaluate the visual system, the vestibular and auditory system, and the sensorimotor system.
\n
\n
\n
3.2 Functional performance tests
\n
A comprehensive assessment of balance is important for both diagnostic and therapeutic reasons in clinical practice.
\n
The tests can be divided between single-task measures and multiple-task measures [36]. These tests often can be done very quickly and with relatively little equipment and training.
\n
\n
3.2.1 Single-task measures
\n
\n
3.2.1.1 Single-leg stance test
\n
The single leg-stance test (SLS) is simple, has high reliability and low cost, and is widely used for diagnosis and follow-up of patients in research and clinical settings. In this test, the participant remains supported on one leg, with arms resting on the hips, and the time (in seconds) that the patient remains in the position without unbalance is verified [37]. Decreased eyes-open SLS time is associated with an increased risk for falls [38].
\n
\n
\n
3.2.1.2 Functional reach test
\n
The functional reach test (FRT) is an easy and inexpensive test in which the patient flexes the trunk, extending the arms horizontally and keeping the feet in contact with the ground. The score is obtained by measuring the distance between the initial and the final positions of the fingertip [39]. Displacements less than 15 cm indicate postural balance problems and increased risk of falls [40].
\n
\n
3.2.1.3 Gait speed test
\n
The gait speed test gives an easy, inexpensive, reliable measure of functional capacity [41], with high interrater and test-retest reliability [42]; does not require laboratory equipment; is not limited to a specific health care discipline [43]; and may be done quickly in clinical settings. The test may vary according to the pace (usual or maximal speed), whether static or moving start, and the distance walked (ranging from 4 to 500 m) [44].
\n
\n
\n
\n
\n
3.2.2 Multiple-task measures
\n
\n
3.2.2.1 Berg Balance Scale
\n
The Berg Balance Scale (BBS) consists of a battery of 14 tasks common to the activities of daily living, which quantitatively evaluate the risk of falls, through observations undertaken by the examiner [45]. The score on the test ranges from 0 to 56 and the performance on each task is measured on a five-point scale ranging from 0 to 4 (0 = unable to perform, 4 = independent). Scores of 48 or less indicate inability to walk independently and safely in activities of daily living and, consequently, increased risk of falls [46].
\n
\n
\n
3.2.2.2 Short physical performance battery
\n
The short physical performance battery (SPPB) is designed to measure functional status and physical performance, assessing walking speed, standing balance, and sit-to-stand performance [47]. The scores range from 0 (worst performance) to 12 (best performance). In a study, Veronese et al. demonstrated that SPPB scores ≤6 are associated with a higher fall rate in old people [48].
\n
\n
\n
3.2.2.3 Timed up and go
\n
The Timed up and go (TUG) test was developed in 1991 [49]. The test consists of finding the time the patient takes to get up from a chair (height about 46 cm), walk the distance of 3 m at a comfortable and safe step, turn around and go back to the chair, and sit down again. The subject wears his regular footwear and uses his customary walking aid (cane or walker) if necessary [49]. A faster time indicates a better functional performance [50].
\n\n
Key points
\n
\n
A good clinical evaluation, a detailed history, and a thorough physical examination are essential to evaluate postural balance.
The tests can be divided between single-task and multiple-task measures.
Assessment of balance is important for both diagnostic and therapeutic reasons in clinical practice.
\n\n
\n
\n
\n
\n
\n
4. Improvement of the postural balance
\n
Falls are a public health problem. The risk of falling increases with age for many reasons, for example overall weakness and frailty, balance problems, cognitive problems, vision problems, some medications and polypharmacy, acute illness, and other environmental hazards. Because of this, multifactorial interventions should include an initial assessment of modifiable risk factors for falls and subsequent customized interventions for each patient based on issues identified in the initial assessment.
\n
One type of treatment to improve balance is physical exercise. Figure 5 presents a summary of best practice recommendations to use for improving postural balance and, consequently, fall prevention.
\n
Figure 5.
Recommendations to guide the use of exercise for falls prevention.
\n
\n
4.1 Types of exercises
\n
Any physical exercise that overloads the balance systems without putting the patient at risk is recommended. It is possible, for example, to make a training circuit, with different stimuli for the elderly [51]. In the circuit, exercises such as one-legged support (both sides), gait on unstable surface, tandem gait, among others can be done, always increasing the level of difficulty.
\n
Another possibility is to join two modalities of exercises: video games and muscle strengthening, for example. In a study, Prata and Scheicher found improvement in fear of falling and in mobility after 12 weeks of video game and muscle strength training in older women with a history of falls [52].
\n
\n
4.1.1 Video games
\n
Postural balance training involving new technologies can promote more challenging situations for the elderly, increasing patient motivation and adherence to the program [53]. The use of video games provides immediate visual feedback, allowing users to make changes in motion according to the situations of the games and thus to develop strategies to restore and/or maintain postural balance, and may therefore be effective for the prevention of falls [54].
\n
Carvalho et al. showed an increase in gait speed and a decrease in the TUG time in elderly female fallers after 12 weeks of training (two sessions per week) with commercialized games of Wii Fit by Nintendo® in sync with the Wii Balance Board® [55]. Three different games were used for postural balance training: Penguin Slide, where the participants had to catch fish while balanced on a piece of ice by shifting their weight from side to side; Table Tilt, where participants move their bodies in various directions to put balls into holes; and Tightrope, where participants walk on a tightrope with several vertical jumps to avoid obstacles.
\n
\n
\n
4.1.2 Treadmill exercise
\n
In the last decade, the use of the treadmill in the rehabilitation of gait in Parkinson’s disease patients, stroke patients, and cerebral palsy (CP) patients has been studied. Some studies explain the reasons for improving postural balance patterns with treadmill training. One of them explains that treadmill training has the capacity to promote motor re-learning and, consequently, improve locomotor capacity during walking [56]. It has also been suggested that training, through repetitive movements generated by the treadmill, activates locomotor patterns of functional movements, sensory inputs, and circuits of the central nervous system [57]. In addition, it has been hypothesized that repetitive movements associated with cutaneous and proprioceptive impulses may induce activation of central movement patterns and, in the long term, potentiate the motor cortex, facilitating motor learning [58].
\n
Toole et al. and Frenkel-Toledo et al. showed an improvement in the gait and balance in Parkinson’s patients that participated in a six-week treadmill walking program [59, 60]. Herman et al. showed an enhancement in the gait rhythmicity and several improvements in motor signs, the latter remaining significantly better 4 weeks after the training was stopped [61].
\n
Training on a treadmill to fight the stroke-related disabilities resulted in valuable results: fatigue resistance [62], endurance performance improvement [63], and the development of motor function [64]. A study in chronic non-ambulatory hemiparetic subjects revealed that partial body weight–supported treadmill training was superior to conventional physiotherapy with regard to restoration of gait and improvement of ground walking velocity [65]. In this study, during one 30-min session of treadmill training, patients could practice up to 1000 gait cycles as compared with a median of less than 50 gait cycles during one regular physiotherapy session.
\n
Bjornson et al. studied the effect of short-burst interval locomotor treadmill training on walking capacity and performance in cerebral palsy and concluded that this training may improve short-term walking capacity and performance [66]. In another study, Mattern-Baxter et al. concluded that home-based treadmill training accelerates the attainment of walking skills and decreases the amount of support used for walking in young children with CP [67].
\n
In healthy elderly with falls history, there are few studies that evaluated the responses of the postural balance with the treadmill training. Dorfman et al. found that after 6 weeks of treadmill plus dual-task training program, elderly fallers demonstrated improved scores on tests of mobility, functional performance tasks, and cognition [68]. In another study, van Ooijen et al., using a treadmill training with visual context, found improvement in walking ability and reduced risk of falls and fear of falling in older adults with a recent fall-related hip fracture [69].
\n\n
Key points
\n
\n
Any physical exercise that overloads the balance systems without putting the patient at risk is recommended.
Postural balance training involving new technologies can promote more challenging situations for the elderly, increasing patient motivation and adherence to the program.
Treadmill training is another form of exercise to challenge the postural control system.
\n\n
\n
\n
\n
\n
5. Conclusion
\n
It is necessary to consider the various facets of the postural balance system when a patient presents a problem related to this. Evaluating these facets is important in prescribing the correct treatment for each situation. There are many types of training that can improve postural balance. Physical exercises, when performed with a moderate or high challenge to the balance system, are a type of treatment that can help reduce the risk of falls in the elderly.
\n
\n
Conflict of interest
The authors declare no conflicts of interest.
\n',keywords:"aging, postural balance, sensory systems",chapterPDFUrl:"https://cdn.intechopen.com/pdfs/64339.pdf",chapterXML:"https://mts.intechopen.com/source/xml/64339.xml",downloadPdfUrl:"/chapter/pdf-download/64339",previewPdfUrl:"/chapter/pdf-preview/64339",totalDownloads:617,totalViews:0,totalCrossrefCites:0,dateSubmitted:"March 13th 2018",dateReviewed:"June 28th 2018",datePrePublished:"November 7th 2018",datePublished:"December 4th 2019",dateFinished:null,readingETA:"0",abstract:"The aging of the population is an unprecedented world phenomenon. Numerous physiological changes occur with aging, and one of the most common situations is postural imbalance and, consequently, the occurrence of falls. Balancing is the process of controlling the body’s center of mass with respect to its base of support and depends on the integration of sensory systems (visual, vestibular, and somatosensory) with the central nervous system (CNS). Each system is prone to deterioration with advancing age and is influenced by age-related diseases and use of some types of medications and polypharmacy. As with any good clinical evaluation, a detailed history and a thorough physical examination are essential to evaluate postural balance. The evaluation of balance must be done with tests that are quick and with relatively little equipment and training. The improvement of postural balance can be done in many ways, and exercises are a type of this treatment and can be done with video games or a treadmill, for example.",reviewType:"peer-reviewed",bibtexUrl:"/chapter/bibtex/64339",risUrl:"/chapter/ris/64339",signatures:"Natália Moya Rodrigues Pereira and Marcos Eduardo Scheicher",book:{id:"7837",title:"Geriatric Medicine and Gerontology",subtitle:null,fullTitle:"Geriatric Medicine and Gerontology",slug:"geriatric-medicine-and-gerontology",publishedDate:"December 4th 2019",bookSignature:"Edward T. Zawada Jr.",coverURL:"https://cdn.intechopen.com/books/images_new/7837.jpg",licenceType:"CC BY 3.0",editedByType:"Edited by",editors:[{id:"16344",title:"Dr.",name:"Edward T.",middleName:null,surname:"Zawada Jr.",slug:"edward-t.-zawada-jr.",fullName:"Edward T. Zawada Jr."}],productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"}},authors:[{id:"250221",title:"Associate Prof.",name:"Marcos Eduardo",middleName:null,surname:"Scheicher",fullName:"Marcos Eduardo Scheicher",slug:"marcos-eduardo-scheicher",email:"marcos.scheicher@unesp.br",position:null,institution:null},{id:"260902",title:"MSc.",name:"Natália Moya Rodrigues",middleName:null,surname:"Pereira",fullName:"Natália Moya Rodrigues Pereira",slug:"natalia-moya-rodrigues-pereira",email:"nanamoya@hotmail.com",position:null,institution:null}],sections:[{id:"sec_1",title:"1. Aging of population",level:"1"},{id:"sec_2",title:"2. Postural balance",level:"1"},{id:"sec_2_2",title:"2.1 Vision and postural balance",level:"2"},{id:"sec_2_3",title:"2.1.1 Cataract",level:"3"},{id:"sec_3_3",title:"2.1.2 Glaucoma",level:"3"},{id:"sec_4_3",title:"2.1.3 Age-related macular degeneration",level:"3"},{id:"sec_5_3",title:"2.1.4 Diabetic retinopathy",level:"3"},{id:"sec_7_2",title:"2.2 Vestibular system and postural balance",level:"2"},{id:"sec_8_2",title:"2.3 Somatosensory system and postural balance",level:"2"},{id:"sec_10",title:"3. Approach to the patient with a balance problem",level:"1"},{id:"sec_10_2",title:"3.1 Physical examination",level:"2"},{id:"sec_11_2",title:"3.2 Functional performance tests",level:"2"},{id:"sec_11_3",title:"3.2.1 Single-task measures",level:"3"},{id:"sec_11_4",title:"3.2.1.1 Single-leg stance test",level:"4"},{id:"sec_12_4",title:"3.2.1.2 Functional reach test",level:"4"},{id:"sec_12_5",title:"3.2.1.3 Gait speed test",level:"5"},{id:"sec_15_3",title:"3.2.2 Multiple-task measures",level:"3"},{id:"sec_15_4",title:"3.2.2.1 Berg Balance Scale",level:"4"},{id:"sec_16_4",title:"3.2.2.2 Short physical performance battery",level:"4"},{id:"sec_17_4",title:"3.2.2.3 Timed up and go",level:"4"},{id:"sec_21",title:"4. Improvement of the postural balance",level:"1"},{id:"sec_21_2",title:"4.1 Types of exercises",level:"2"},{id:"sec_21_3",title:"4.1.1 Video games",level:"3"},{id:"sec_22_3",title:"4.1.2 Treadmill exercise",level:"3"},{id:"sec_25",title:"5. Conclusion",level:"1"},{id:"sec_29",title:"Conflict of interest",level:"1"}],chapterReferences:[{id:"B1",body:'United Nations. World population prospects: The 2012 revision. Highlights and advance tables. Population and Development Review. 2013;36:775-801. Available from: http://esa.un.org/unpd/wpp/Documentation/publications.htm\n\n'},{id:"B2",body:'World Health Organization. Integrated Care for Older People [Internet]. Geneva; 2017. 46 p. Available from: http://apps.who.int/iris/bitstream/10665/258981/1/9789241550109-eng.pdf?ua=1\n\n'},{id:"B3",body:'Graafmans WC, Ooms ME, Hofstee HMA, Bezemer PD, Bouter LM, Lips P. Falls in the elderly: A prospective study of risk factors and risk profiles. American Journal of Epidemiology. 1996;143(11):1129-1136. Available from: https://academic.oup.com/aje/article-lookup/doi/10.1093/oxfordjournals.aje.a008690\n\n'},{id:"B4",body:'Rubenstein LZ, Josephson KR. The epidemiology of falls and sincope. Clinics in Geriatric Medicine. 2002;18:141-158\n'},{id:"B5",body:'Peterka RJ. Sensorimotor integration in human postural control. Journal of Neurophysiology. 2002;88:1097-1118\n'},{id:"B6",body:'Maki B, McIlroy W. Postural control in the older adult. Clinics in Geriatric Medicine. 1996;12(4):635-658\n'},{id:"B7",body:'Pasma JH, Engelhart D, Maier AB, Schouten AC, van der Kooij H, Meskers CGM. Changes in sensory reweighting of proprioceptive information during standing balance with age and disease. Journal of Neurophysiology. 2015;114(6):3220-3233. Available from: http://jn.physiology.org/lookup/doi/10.1152/jn.00414.2015\n\n'},{id:"B8",body:'Berencsi A, Ishihara M, Imanaka K. The functional role of central and peripheral vision in the control of posture. Human Movement Science. 2005;24(5–6):689-709\n'},{id:"B9",body:'Marigold DS, Patla AE. Visual information from the lower visual field is important for walking across multi-surface terrain. Experimental Brain Research. 2008;188(1):23-31\n'},{id:"B10",body:'Desapriya E, Subzwari S, Scime-Beltrano G, Samayawardhena LA, Pike I. Vision improvement and reduction in falls after expedited cataract surgery. Systematic review and metaanalysis. Journal of Cataract & Refractive Surgery. 2010;36(1):13-19. DOI: 10.1016/j.jcrs.2009.07.032\n'},{id:"B11",body:'Chew M, Chiang PPC, Zheng Y, Lavanya R, Wu R, Saw SM, et al. The impact of cataract, cataract types, and cataract grades on vision-specific functioning using rasch analysis. American Journal of Ophthalmology. 2012;154(1):29-38\n'},{id:"B12",body:'Polack S, Kuper H, Wadud Z, Fletcher A, Foster A. Quality of life and visual impairment from cataract in Satkhira district, Bangladesh. British Journal of Ophthalmology. 2008;92(8):1026-1030\n'},{id:"B13",body:'Wood JM, Lacherez P, Black AA, Cole MH, Boon MY, Kerr GK. Risk of falls, injurious falls, and other injuries resulting from visual impairment among older adults with age-related macular degeneration. Investigative Ophthalmology & Visual Science. 2018;52(8):5088-5092\n'},{id:"B14",body:'Black AA, Wood JM, Lovie-Kitchin JE. Inferior field loss increases rate of falls in older adults with glaucoma. Optometry and Vision Science. 2011;88(11):1275-1282\n'},{id:"B15",body:'Coleman AL, Stone K, Ewing SK, Nevitt M, Cummings S, Cauley JA, et al. Higher risk of multiple falls among elderly women who lose visual acuity. Ophthalmology. 2004;111(5):857-862\n'},{id:"B16",body:'Black AA, Wood JM, Lovie-Kitchin JE, Newman BM. Visual impairment and postural sway among older adults with glaucoma. Optometry and Vision Science. 2008;85(6):489-497\n'},{id:"B17",body:'National Eye Institute. Age-Related Macular Degeneration (AMD) [Internet]. [cited 2018 Jun 26]. Available from: https://nei.nih.gov/health/maculardegen\n\n'},{id:"B18",body:'Wood JM, Lacherez PF, Black AA, Cole MH, Boon MY, Kerr GK. Postural stability and gait among older adults with age-related maculopathy. Investigative Ophthalmology and Visual Science. 2009;50(1):482-487\n'},{id:"B19",body:'Chatard H, Tepenier L, Jankowski O, Aussems A, Allieta A, Beydoun T, et al. Effects of age-related macular degeneration on postural sway. Frontiers in Human Neuroscience. 2017;11(March):1-9. Available from: http://journal.frontiersin.org/article/10.3389/fnhum.2017.00158/full\n\n'},{id:"B20",body:'Gupta P, Aravindhan A, Gan ATL, Man REK, Fenwick EK, Mitchell P, et al. Association between the severity of diabetic retinopathy and falls in an Asian population with diabetes the Singapore epidemiology of eye diseases study. JAMA Ophthalmology. 2017;135(12):1410-1416\n'},{id:"B21",body:'Lord SR, Clark RD, Webster IW. Visual acuity and contrast sensitivity in relation to falls in an elderly population. Age Ageing. 1991;20(3):175-181. Available from: https://academic.oup.com/ageing/article-lookup/doi/10.1093/ageing/20.3.175\n\n'},{id:"B22",body:'Lord SR, Menz HB. Visual contributions to postural stability in older adults. Gerontology. 2000;46(6):306-310\n'},{id:"B23",body:'Purves D, Augustine GJ, Fitzpatrick D, Hall WC, Lamantia A-S, Mcnamara JO, et al. The Vestibular System. In: Purves D, Augustine GJ, Fitzpatrick D, Hall WC, Lamantia A-S, Mcnamara JO, et al., editors. Neuroscience. 3rd ed. Sunderland: Sinauer Associates; 2004. p. 315?335\n'},{id:"B24",body:'Sedó-Cabezón L, Boadas-Vaello P, Soler-Martín C, Llorens J. Vestibular damage in chronic ototoxicity: A mini-review. Neurotoxicology. 2014;43:21-27\n'},{id:"B25",body:'Tian JR, Shubayev I, Baloh RW, Demer JL. Impairments in the initial horizontal vestibulo-ocular reflex of older humans. Experimental Brain Research. 2001;137(3–4):309-322\n'},{id:"B26",body:'Gazzola JM, Ganança FF, Aratani MC, Perracini MR, Ganança MM. Clinical evaluation of elderly people with chronic vestibular disorder. Brazilian Journal of Otorhinolaryngology. 2006;72(4):515-522\n'},{id:"B27",body:'Grace Gaerlan M, Alpert PT, Cross C, Louis M, Kowalski S. Postural balance in young adults: The role of visual, vestibular and somatosensory systems. Journal of the American Academy of Nurse Practitioners. 2012;24(6):375-381\n'},{id:"B28",body:'Shaffer SW, Harrison AL. Aging of the somatosensory system: A translational perspective. Physical Therapy. 2007;87(2):193-207. Available from: https://academic.oup.com/ptj/ptj/article/2742177/Aging\n\n'},{id:"B29",body:'Lockhart TE, Spaulding JM, Park SH. Age-related slip avoidance strategy while walking over a known slippery floor surface. Gait & Posture. 2007;26(1):142-149\n'},{id:"B30",body:'Lord S, Ward J. Age-associated differences in sensori-motor function and balance in community dwelling women. Age and Ageing. 1994;23(6):452-460\n'},{id:"B31",body:'Turcot K, Sagawa Y, Hoffmeyer P, Suvà D, Armand S. Multi-joint postural behavior in patients with knee osteoarthritis. Knee. 2015;22(6):517-521. DOI: 10.1016/j.knee.2014.09.001\n'},{id:"B32",body:'Walker CRC, Myles C, Nutton R, Rowe P. Movement of the knee in osteoarthritis. Journal of Bone and Joint Surgery. British Volume. 2001;83(2):195-198\n'},{id:"B33",body:'Quintana JM, Arostegui I, Escobar A, Azkarate J, Goenaga JI, Lafuente I. Prevalence of knee and hip osteoarthritis and the appropriateness of joint replacement in an older population. Archives of Internal Medicine. 2008;168(14):1576-1584\n'},{id:"B34",body:'Barry BK, Carson RG. The consequences of resistance training for movement control in older adults. Journals of Gerontology. Series A, Biological Sciences and Medical Sciences. 2004;59(7):730-754. Available from: papers://5a68cd75-9e27-4626-8d94-057f1df96060/Paper/p43\n'},{id:"B35",body:'Orr R. Contribution of muscle weakness to postural instability in the elderly. A systematic review. European Journal of Physical and Rehabilitation Medicine. 2010;46(2):183-220\n'},{id:"B36",body:'Persad C, Cook S, Giordani B. Assessing falls in the elderly: Should we use simple screening tests or a comprehensive fall risk evaluation? European Journal of Physical and Rehabilitation Medicine. 2010;46(2):249-259\n'},{id:"B37",body:'Hatton AL, Rome K, Dixon J, Martin DJ, McKeon PO. Footwear interventions: A review of their sensorimotor and mechanical effects on balance performance and gait in older adults. Journal of the American Podiatric Medical Association. 2013;103(6):516-533. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24297988\n\n'},{id:"B38",body:'Springer BA, Marin R, Cyhan T, Roberts H, Gill NW. Normative values for the unipedal stance test with eyes open and closed. Journal of Geriatric Physical Therapy [Internet]. 2007;30(1):8-15. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19839175\n'},{id:"B39",body:'de Waroquier-Leroy L, Bleuse S, Serafi R, Watelain E, Pardessus V, Tiffreau AV, et al. The Functional Reach Test: Strategies, performance and the influence of age. Annals of Physical and Rehabilitation Medicine. 2014;57(6):452-464. DOI: 10.1016/j.rehab.2014.03.003\n'},{id:"B40",body:'Duncan PW, Weiner DK, Chandler J, Studenski S. Functional reach: A new clinical measure of balance. Journals of Gerontology. 1990;45(6):M192-M197. Available from: https://academic.oup.com/geronj/article-lookup/doi/10.1093/geronj/45.6.M192\n\n'},{id:"B41",body:'Cesari M, Kritchevsky SB, Penninx BWHJ, Nicklas BJ, Simonsick EM, Newman AB, et al. Prognostic value of usual gait speed in well-functioning older people—Results from the health, aging and body composition study. Journal of the American Geriatrics Society. 2005;53(10):1675-1680\n'},{id:"B42",body:'Studenski S, Perera S, Wallace D, Chandler JM, Duncan PW, Rooney E, et al. Physical performance measures in the clinical setting. Journal of the American Geriatrics Society. 2003;51(3):314-322. Available from: http://www.ncbi.nlm.nih.gov/pubmed/12588574\n\n'},{id:"B43",body:'Graham J, Ostir G. Assessing walking speed in clinical research: A systematic review. Journal of Evaluation in Clinical Practice. 2008;14(4):552-562. Available from: http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2753.2007.00917.x/full\n\n'},{id:"B44",body:'Graham JE, Ostir GV, Kuo YF, Fisher SR, Ottenbacher KJ. Relationship between test methodology and mean velocity in timed walk tests: A review. Archives of Physical Medicine and Rehabilitation. 2008;89(5):865-872\n'},{id:"B45",body:'Berg K. Measuring balance in the elderly: Preliminary development of an instrument. Physiotherapy Canada. 1989;41(6):304-311. Available from: https://utpjournals.press/doi/10.3138/ptc.41.6.304\n\n'},{id:"B46",body:'Santos GM, Souza ACS, Virtuoso JF, Tavares GMS, Mazo GZ. Valores preditivos para o risco de queda em idosos praticantes e não praticantes de atividade física por meio do uso da escala de equilíbrio de berg. Revista Brasileira de Fisioterapia. 2011;15(2):95-101\n'},{id:"B47",body:'Guralnik JM, Simonsick EM, Ferrucci L, Glynn RJ, Berkman LF, Blazer DG, et al. A short physical performance battery assessing lower extremity function: Association with self-reported disability and prediction of mortality and nursing home admission. Journals of Gerontology. 1994;49(2):M85-M94. Available from: https://academic.oup.com/geronj/article-lookup/doi/10.1093/geronj/49.2.M85\n\n'},{id:"B48",body:'Veronese N, Bolzetta F, Toffanello ED, Zambon S, De Rui M, Perissinotto E, et al. Association between short physical performance battery and falls in older people: The Progetto Veneto Anziani Study. Rejuvenation Research. 2014;17(3):276-284. Available from: http://online.liebertpub.com/doi/abs/10.1089/rej.2013.1491\n\n'},{id:"B49",body:'Podsiadlo D, Richadson S. The timed “Up and Go” test: A test of basic functional mobility for frail elderly persons. Journal of the American Geriatrics Society. 1991;39(2):142-148\n'},{id:"B50",body:'Rose D, Jones C, Lucchese N. Predicting the probability of falls in community-residing older adults using the 8-foot up- and-go: A new measure of functional mobility. Journal of Aging and Physical Activity. 2002;10(4):466-475\n'},{id:"B51",body:'Costa J, Gonçalves C, Rodrigues G, de Paula A, Pereira M, Safons M. Exercícios multisensoriais no equilíbrio e na prevenção de quedas em idosos [Internet]. 2009. Available from: http://www.efdeportes.com/efd135/exercicios-multisensoriais-em-idosos.htm\n\n'},{id:"B52",body:'Prata MG, Scheicher ME. Effects of strength and balance training on the mobility, fear of falling and grip strength of elderly female fallers, Journal of Bodywork and Movement Therapies. 2015;19(4):646-650. DOI: 10.1016/j.jbmt.2014.11.013\n'},{id:"B53",body:'Gil-Gómez JA, Lloréns R, Alcñiz M, Colomer C. Effectiveness of a Wii balance board-based system (eBaViR) for balance rehabilitation: A pilot randomized clinical trial in patients with acquired brain injury. Journal of NeuroEngineering and Rehabilitation. 2011;8(1):30 Available from: http://www.jneuroengrehab.com/content/8/1/30\n\n'},{id:"B54",body:'Clark RA, Bryant AL, Pua Y, McCrory P, Bennell K, Hunt M. Validity and reliability of the Nintendo Wii Balance Board for assessment of standing balance. Gait Posture. 2010;31(3):307-310. Available from: https://www.sciencedirect.com/science/article/pii/S096663620900664X?via%3Dihub\n\n'},{id:"B55",body:'Carvalho IF, Leme GLM, Scheicher ME. The influence of video game training with and without subpatelar bandage in mobility and gait speed on elderly female fallers. Journal of Aging Research [Internet]. 2018;2018:9415093. Published 2018 Mar 26. DOI: 10.1155/2018/9415093\n'},{id:"B56",body:'Visintin M, Barbeau H. The effects of body weight support on the locomotor pattern of spastic paretic patients. Canadian Journal of Neurological Sciences. 1989;16(3):315-325\n'},{id:"B57",body:'Dietz V. Spinal cord pattern generators for locomotion. Clinical Neurophysiology. 2003;114(8):1379-1389\n'},{id:"B58",body:'Asanuma H, Keller A. Neuronal mechanisms of motor learning in mammals. Neuroreport. 1991;2:217-224\n'},{id:"B59",body:'Toole T, Maitland C, Warren E, Hubmann M, Panton L. The effects of loading and unloading treadmill walking on balance, gait, fall risk, and daily function in Parkinsonism. NeuroRehabilitation. 2005;20(4):302-322\n'},{id:"B60",body:'Frenkel-Toledo S, Giladi N, Peretz C, Herman T, Gruendlinger L, Hausdorff JM. Treadmill walking as an external pacemaker to improve gait rhythm and stability in Parkinson’s disease. Movement Disorders. 2005;20(9):1109-1114\n'},{id:"B61",body:'Herman T, Giladi N, Gruendlinger L, Hausdorff JM. Six weeks of intensive treadmill training improves gait and quality of life in patients with Parkinson’s disease: A pilot study. Archives of Physical Medicine and Rehabilitation. 2007;88(9):1154-1158\n'},{id:"B62",body:'Abbasian S, Rastegar MMM. Is the intensity or duration of treadmill training important for stroke patients? A meta-analysis. Journal of Stroke & Cerebrovascular Diseases. 2018;27(1):32-43. DOI: 10.1016/j.jstrokecerebrovasdis.2017.09.061\n'},{id:"B63",body:'Sullivan KJ, Brown DA, Klassen T, Mulroy S, Ge T, Azen SP, et al. Effects of task-specific locomotor and strength training in adults who were ambulatory after stroke: Results of the STEPS randomized clinical trial. Physical Therapy. 2007;87(12):1580-1602. Available from: https://academic.oup.com/ptj/article-lookup/doi/10.2522/ptj.20060310\n\n'},{id:"B64",body:'Barbeau H, Visintin M. Optimal outcomes obtained with body-weight support combined with treadmill training in stroke subjects. Archives of Physical Medicine and Rehabilitation. 2003;84(10):1458-1465\n'},{id:"B65",body:'Hesse S. Treadmill training with partial body weight support after stroke: A review. NeuroRehabilitation. 2008;23(1):55-65\n'},{id:"B66",body:'Bjornson KF, Moreau N, Bodkin AW. Short-burst interval treadmill training walking capacity and performance in cerebral palsy: A pilot study. Developmental Neurorehabilitation. 2018;16:1-8. Available from: https://www.tandfonline.com/doi/full/10.1080/17518423.2018.1462270\n\n'},{id:"B67",body:'Mattern-Baxter K, McNeil S, Mansoor JK. Effects of home-based locomotor treadmill training on Gross Motor Function in young children with cerebral palsy: A quasi-randomized controlled trial. Archives of Physical Medicine and Rehabilitation. 2013;94(11):2061-2067. DOI: 10.1016/j.apmr.2013.05.012\n'},{id:"B68",body:'Dorfman M, Herman T, Brozgol M, Shema S, Weiss A, Hausdorff J, et al. Dual-task training on a treadmill to improve gait and cognitive function in elderly idiopathic fallers. Journal of Neurologic Physical Therapy. 2014;38(4):246-253\n'},{id:"B69",body:'van Ooijen MW, Roerdink M, Trekop M, Visschedijk J, Janssen TW, Beek PJ. Functional gait rehabilitation in elderly people following a fall-related hip fracture using a treadmill with visual context: Design of a randomized controlled trial. BMC Geriatrics. 2013;13:34\n'}],footnotes:[],contributors:[{corresp:null,contributorFullName:"Natália Moya Rodrigues Pereira",address:null,affiliation:'
Physiotherapy and Occupational Therapy Department, UNESP, Brazil
'}],corrections:null},book:{id:"7837",title:"Geriatric Medicine and Gerontology",subtitle:null,fullTitle:"Geriatric Medicine and Gerontology",slug:"geriatric-medicine-and-gerontology",publishedDate:"December 4th 2019",bookSignature:"Edward T. Zawada Jr.",coverURL:"https://cdn.intechopen.com/books/images_new/7837.jpg",licenceType:"CC BY 3.0",editedByType:"Edited by",editors:[{id:"16344",title:"Dr.",name:"Edward T.",middleName:null,surname:"Zawada Jr.",slug:"edward-t.-zawada-jr.",fullName:"Edward T. Zawada Jr."}],productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"}}},profile:{item:{id:"121895",title:"Dr.",name:"Isabelle",middleName:null,surname:"Virlogeux-Payant",email:"ipayant@tours.inra.fr",fullName:"Isabelle Virlogeux-Payant",slug:"isabelle-virlogeux-payant",position:null,biography:null,institutionString:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",totalCites:0,totalChapterViews:"0",outsideEditionCount:0,totalAuthoredChapters:"1",totalEditedBooks:"0",personalWebsiteURL:null,twitterURL:null,linkedinURL:null,institution:null},booksEdited:[],chaptersAuthored:[{title:"The Different Strategies Used by Salmonella to Invade Host Cells",slug:"the-different-strategies-used-by-salmonella-to-invade-host-cells",abstract:null,signatures:"Rosselin Manon, Abed Nadia, Namdari Fatemeh, Virlogeux-Payant Isabelle, Velge Philippe and Wiedemann Agnes",authors:[{id:"80202",title:"Dr.",name:"Agnes",surname:"Wiedemann",fullName:"Agnes Wiedemann",slug:"agnes-wiedemann",email:"awiedemann@tours.inra.fr"},{id:"84523",title:"Dr.",name:"Manon",surname:"Rosselin",fullName:"Manon Rosselin",slug:"manon-rosselin",email:"mrosselin@tours.inra.fr"},{id:"84525",title:"Dr.",name:"Nadia",surname:"Abed",fullName:"Nadia Abed",slug:"nadia-abed",email:"nabed@tours.inra.fr"},{id:"84526",title:"Dr.",name:"Philippe",surname:"Velge",fullName:"Philippe Velge",slug:"philippe-velge",email:"velge@tours.inra.fr"},{id:"121895",title:"Dr.",name:"Isabelle",surname:"Virlogeux-Payant",fullName:"Isabelle Virlogeux-Payant",slug:"isabelle-virlogeux-payant",email:"ipayant@tours.inra.fr"},{id:"121896",title:"Ms.",name:"Fatémeh",surname:"Namdari",fullName:"Fatémeh Namdari",slug:"fatemeh-namdari",email:"fatemeh.namdari@tours.inra.fr"}],book:{title:"Salmonella",slug:"salmonella-distribution-adaptation-control-measures-and-molecular-technologies",productType:{id:"1",title:"Edited Volume"}}}],collaborators:[{id:"73055",title:"Dr.",name:"Hussein",surname:"Abulreesh",slug:"hussein-abulreesh",fullName:"Hussein Abulreesh",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Umm al-Qura University",institutionURL:null,country:{name:"Saudi Arabia"}}},{id:"78256",title:"Prof.",name:"Ana",surname:"Carvajal",slug:"ana-carvajal",fullName:"Ana Carvajal",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Universidad de León",institutionURL:null,country:{name:"Mexico"}}},{id:"78439",title:"Dr.",name:"Anita",surname:"Mikolajczyk",slug:"anita-mikolajczyk",fullName:"Anita Mikolajczyk",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"University of Warmia and Mazury in Olsztyn",institutionURL:null,country:{name:"Poland"}}},{id:"78565",title:"Dr.",name:"Florence",surname:"Dubois-Brissonnet",slug:"florence-dubois-brissonnet",fullName:"Florence Dubois-Brissonnet",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Agro ParisTech",institutionURL:null,country:{name:"France"}}},{id:"79956",title:"Dr.",name:"Adil Ali",surname:"El-Hussein",slug:"adil-ali-el-hussein",fullName:"Adil Ali El-Hussein",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"University of Khartoum",institutionURL:null,country:{name:"Sudan"}}},{id:"82596",title:"Dr.",name:"Pongsak",surname:"Rattanachaikunsopon",slug:"pongsak-rattanachaikunsopon",fullName:"Pongsak Rattanachaikunsopon",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Ubon Ratchathani University",institutionURL:null,country:{name:"Thailand"}}},{id:"82627",title:"Dr.",name:"Parichat",surname:"Phumkhachorn",slug:"parichat-phumkhachorn",fullName:"Parichat Phumkhachorn",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Ubon Ratchathani University",institutionURL:null,country:{name:"Thailand"}}},{id:"83489",title:"Mr.",name:"Henrique",surname:"Bastos",slug:"henrique-bastos",fullName:"Henrique Bastos",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:null},{id:"84514",title:"Dr.",name:"Paul",surname:"McKeown",slug:"paul-mckeown",fullName:"Paul McKeown",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Health Protection Surveillance Centre",institutionURL:null,country:{name:"Ireland"}}},{id:"89250",title:"Prof.",name:"Mohamed Elanwar",surname:"Osman",slug:"mohamed-elanwar-osman",fullName:"Mohamed Elanwar Osman",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Tanta University",institutionURL:null,country:{name:"Egypt"}}}]},generic:{page:{slug:"open-access-funding-funders-list",title:"List of Funders by Country",intro:"
If your research is financed through any of the below-mentioned funders, please consult their Open Access policies or grant ‘terms and conditions’ to explore ways to cover your publication costs (also accessible by clicking on the link in their title).
\n\n
IMPORTANT: You must be a member or grantee of the listed funders in order to apply for their Open Access publication funds. Do not attempt to contact the funders if this is not the case.
",metaTitle:"List of Funders by Country",metaDescription:"If your research is financed through any of the below-mentioned funders, please consult their Open Access policies or grant ‘terms and conditions’ to explore ways to cover your publication costs (also accessible by clicking on the link in their title).",metaKeywords:null,canonicalURL:"/page/open-access-funding-funders-list",contentRaw:'[{"type":"htmlEditorComponent","content":"
UK Research and Innovation (former Research Councils UK (RCUK) - including AHRC, BBSRC, ESRC, EPSRC, MRC, NERC, STFC.) Processing charges for books/book chapters can be covered through RCUK block grants which are allocated to most universities in the UK, which then handle the OA publication funding requests. It is at the discretion of the university whether it will approve the request.)
UK Research and Innovation (former Research Councils UK (RCUK) - including AHRC, BBSRC, ESRC, EPSRC, MRC, NERC, STFC.) Processing charges for books/book chapters can be covered through RCUK block grants which are allocated to most universities in the UK, which then handle the OA publication funding requests. It is at the discretion of the university whether it will approve the request.)
Wellcome Trust (Funding available only to Wellcome-funded researchers/grantees)
\n
\n'}]},successStories:{items:[]},authorsAndEditors:{filterParams:{sort:"featured,name"},profiles:[{id:"6700",title:"Dr.",name:"Abbass A.",middleName:null,surname:"Hashim",slug:"abbass-a.-hashim",fullName:"Abbass A. Hashim",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/6700/images/1864_n.jpg",biography:"Currently I am carrying out research in several areas of interest, mainly covering work on chemical and bio-sensors, semiconductor thin film device fabrication and characterisation.\nAt the moment I have very strong interest in radiation environmental pollution and bacteriology treatment. The teams of researchers are working very hard to bring novel results in this field. I am also a member of the team in charge for the supervision of Ph.D. students in the fields of development of silicon based planar waveguide sensor devices, study of inelastic electron tunnelling in planar tunnelling nanostructures for sensing applications and development of organotellurium(IV) compounds for semiconductor applications. I am a specialist in data analysis techniques and nanosurface structure. I have served as the editor for many books, been a member of the editorial board in science journals, have published many papers and hold many patents.",institutionString:null,institution:{name:"Sheffield Hallam University",country:{name:"United Kingdom"}}},{id:"54525",title:"Prof.",name:"Abdul Latif",middleName:null,surname:"Ahmad",slug:"abdul-latif-ahmad",fullName:"Abdul Latif Ahmad",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:null},{id:"20567",title:"Prof.",name:"Ado",middleName:null,surname:"Jorio",slug:"ado-jorio",fullName:"Ado Jorio",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Universidade Federal de Minas Gerais",country:{name:"Brazil"}}},{id:"47940",title:"Dr.",name:"Alberto",middleName:null,surname:"Mantovani",slug:"alberto-mantovani",fullName:"Alberto Mantovani",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:null},{id:"12392",title:"Mr.",name:"Alex",middleName:null,surname:"Lazinica",slug:"alex-lazinica",fullName:"Alex Lazinica",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/12392/images/7282_n.png",biography:"Alex Lazinica is the founder and CEO of IntechOpen. After obtaining a Master's degree in Mechanical Engineering, he continued his PhD studies in Robotics at the Vienna University of Technology. Here he worked as a robotic researcher with the university's Intelligent Manufacturing Systems Group as well as a guest researcher at various European universities, including the Swiss Federal Institute of Technology Lausanne (EPFL). During this time he published more than 20 scientific papers, gave presentations, served as a reviewer for major robotic journals and conferences and most importantly he co-founded and built the International Journal of Advanced Robotic Systems- world's first Open Access journal in the field of robotics. Starting this journal was a pivotal point in his career, since it was a pathway to founding IntechOpen - Open Access publisher focused on addressing academic researchers needs. Alex is a personification of IntechOpen key values being trusted, open and entrepreneurial. Today his focus is on defining the growth and development strategy for the company.",institutionString:null,institution:{name:"TU Wien",country:{name:"Austria"}}},{id:"19816",title:"Prof.",name:"Alexander",middleName:null,surname:"Kokorin",slug:"alexander-kokorin",fullName:"Alexander Kokorin",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/19816/images/1607_n.jpg",biography:"Alexander I. Kokorin: born: 1947, Moscow; DSc., PhD; Principal Research Fellow (Research Professor) of Department of Kinetics and Catalysis, N. Semenov Institute of Chemical Physics, Russian Academy of Sciences, Moscow.\r\nArea of research interests: physical chemistry of complex-organized molecular and nanosized systems, including polymer-metal complexes; the surface of doped oxide semiconductors. He is an expert in structural, absorptive, catalytic and photocatalytic properties, in structural organization and dynamic features of ionic liquids, in magnetic interactions between paramagnetic centers. The author or co-author of 3 books, over 200 articles and reviews in scientific journals and books. He is an actual member of the International EPR/ESR Society, European Society on Quantum Solar Energy Conversion, Moscow House of Scientists, of the Board of Moscow Physical Society.",institutionString:null,institution:{name:"Semenov Institute of Chemical Physics",country:{name:"Russia"}}},{id:"62389",title:"PhD.",name:"Ali Demir",middleName:null,surname:"Sezer",slug:"ali-demir-sezer",fullName:"Ali Demir Sezer",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/62389/images/3413_n.jpg",biography:"Dr. Ali Demir Sezer has a Ph.D. from Pharmaceutical Biotechnology at the Faculty of Pharmacy, University of Marmara (Turkey). He is the member of many Pharmaceutical Associations and acts as a reviewer of scientific journals and European projects under different research areas such as: drug delivery systems, nanotechnology and pharmaceutical biotechnology. Dr. Sezer is the author of many scientific publications in peer-reviewed journals and poster communications. Focus of his research activity is drug delivery, physico-chemical characterization and biological evaluation of biopolymers micro and nanoparticles as modified drug delivery system, and colloidal drug carriers (liposomes, nanoparticles etc.).",institutionString:null,institution:{name:"Marmara University",country:{name:"Turkey"}}},{id:"61051",title:"Prof.",name:"Andrea",middleName:null,surname:"Natale",slug:"andrea-natale",fullName:"Andrea Natale",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:null},{id:"100762",title:"Prof.",name:"Andrea",middleName:null,surname:"Natale",slug:"andrea-natale",fullName:"Andrea Natale",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"St David's Medical Center",country:{name:"United States of America"}}},{id:"107416",title:"Dr.",name:"Andrea",middleName:null,surname:"Natale",slug:"andrea-natale",fullName:"Andrea Natale",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Texas Cardiac Arrhythmia",country:{name:"United States of America"}}},{id:"64434",title:"Dr.",name:"Angkoon",middleName:null,surname:"Phinyomark",slug:"angkoon-phinyomark",fullName:"Angkoon Phinyomark",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/64434/images/2619_n.jpg",biography:"My name is Angkoon Phinyomark. I received a B.Eng. degree in Computer Engineering with First Class Honors in 2008 from Prince of Songkla University, Songkhla, Thailand, where I received a Ph.D. degree in Electrical Engineering. My research interests are primarily in the area of biomedical signal processing and classification notably EMG (electromyography signal), EOG (electrooculography signal), and EEG (electroencephalography signal), image analysis notably breast cancer analysis and optical coherence tomography, and rehabilitation engineering. I became a student member of IEEE in 2008. During October 2011-March 2012, I had worked at School of Computer Science and Electronic Engineering, University of Essex, Colchester, Essex, United Kingdom. In addition, during a B.Eng. I had been a visiting research student at Faculty of Computer Science, University of Murcia, Murcia, Spain for three months.\n\nI have published over 40 papers during 5 years in refereed journals, books, and conference proceedings in the areas of electro-physiological signals processing and classification, notably EMG and EOG signals, fractal analysis, wavelet analysis, texture analysis, feature extraction and machine learning algorithms, and assistive and rehabilitative devices. I have several computer programming language certificates, i.e. Sun Certified Programmer for the Java 2 Platform 1.4 (SCJP), Microsoft Certified Professional Developer, Web Developer (MCPD), Microsoft Certified Technology Specialist, .NET Framework 2.0 Web (MCTS). I am a Reviewer for several refereed journals and international conferences, such as IEEE Transactions on Biomedical Engineering, IEEE Transactions on Industrial Electronics, Optic Letters, Measurement Science Review, and also a member of the International Advisory Committee for 2012 IEEE Business Engineering and Industrial Applications and 2012 IEEE Symposium on Business, Engineering and Industrial Applications.",institutionString:null,institution:{name:"Joseph Fourier University",country:{name:"France"}}},{id:"55578",title:"Dr.",name:"Antonio",middleName:null,surname:"Jurado-Navas",slug:"antonio-jurado-navas",fullName:"Antonio Jurado-Navas",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/55578/images/4574_n.png",biography:"Antonio Jurado-Navas received the M.S. degree (2002) and the Ph.D. degree (2009) in Telecommunication Engineering, both from the University of Málaga (Spain). He first worked as a consultant at Vodafone-Spain. From 2004 to 2011, he was a Research Assistant with the Communications Engineering Department at the University of Málaga. In 2011, he became an Assistant Professor in the same department. From 2012 to 2015, he was with Ericsson Spain, where he was working on geo-location\ntools for third generation mobile networks. Since 2015, he is a Marie-Curie fellow at the Denmark Technical University. His current research interests include the areas of mobile communication systems and channel modeling in addition to atmospheric optical communications, adaptive optics and statistics",institutionString:null,institution:{name:"University of Malaga",country:{name:"Spain"}}}],filtersByRegion:[{group:"region",caption:"North America",value:1,count:5766},{group:"region",caption:"Middle and South America",value:2,count:5228},{group:"region",caption:"Africa",value:3,count:1717},{group:"region",caption:"Asia",value:4,count:10370},{group:"region",caption:"Australia and Oceania",value:5,count:897},{group:"region",caption:"Europe",value:6,count:15791}],offset:12,limit:12,total:118192},chapterEmbeded:{data:{}},editorApplication:{success:null,errors:{}},ofsBooks:{filterParams:{},books:[{type:"book",id:"8969",title:"Deserts and Desertification",subtitle:null,isOpenForSubmission:!0,hash:"4df95c7f295de7f6003e635d9a309fe9",slug:null,bookSignature:"Dr. Yajuan Zhu, Dr. Qinghong Luo and Dr. Yuguo Liu",coverURL:"https://cdn.intechopen.com/books/images_new/8969.jpg",editedByType:null,editors:[{id:"180427",title:"Dr.",name:"Yajuan",surname:"Zhu",slug:"yajuan-zhu",fullName:"Yajuan Zhu"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"8977",title:"Protein Kinase - New Opportunities, Challenges and Future Perspectives",subtitle:null,isOpenForSubmission:!0,hash:"6d200cc031706a565b554fdb1c478901",slug:null,bookSignature:"Dr. Rajesh Kumar Singh",coverURL:"https://cdn.intechopen.com/books/images_new/8977.jpg",editedByType:null,editors:[{id:"329385",title:"Dr.",name:"Rajesh",surname:"Singh",slug:"rajesh-singh",fullName:"Rajesh Singh"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"9659",title:"Fibroblasts - Advances in Cancer, Autoimmunity and Inflammation",subtitle:null,isOpenForSubmission:!0,hash:"926fa6446f6befbd363fc74971a56de2",slug:null,bookSignature:"Ph.D. Mojca Frank Bertoncelj and Ms. Katja Lakota",coverURL:"https://cdn.intechopen.com/books/images_new/9659.jpg",editedByType:null,editors:[{id:"328755",title:"Ph.D.",name:"Mojca",surname:"Frank Bertoncelj",slug:"mojca-frank-bertoncelj",fullName:"Mojca Frank Bertoncelj"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"9662",title:"Vegetation Index and Dynamics",subtitle:null,isOpenForSubmission:!0,hash:"0abf2a59ee63fc1ba4fb64d77c9b1be7",slug:null,bookSignature:"Dr. Eusebio Cano Carmona, Dr. Ricardo Quinto Canas, Dr. Ana Cano Ortiz and Dr. Carmelo Maria Musarella",coverURL:"https://cdn.intechopen.com/books/images_new/9662.jpg",editedByType:null,editors:[{id:"87846",title:"Dr.",name:"Eusebio",surname:"Cano Carmona",slug:"eusebio-cano-carmona",fullName:"Eusebio Cano Carmona"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"9667",title:"Neuroimmunology",subtitle:null,isOpenForSubmission:!0,hash:"9cf0e8203ce088c0b84add014fd8d382",slug:null,bookSignature:"Prof. Robert Weissert",coverURL:"https://cdn.intechopen.com/books/images_new/9667.jpg",editedByType:null,editors:[{id:"79343",title:"Prof.",name:"Robert",surname:"Weissert",slug:"robert-weissert",fullName:"Robert Weissert"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"9816",title:"Idiopathic Pulmonary Fibrosis",subtitle:null,isOpenForSubmission:!0,hash:"365bb9762ba33db2d07e677690af1772",slug:null,bookSignature:"Dr. Salim Surani and Dr. Venkat Rajasurya",coverURL:"https://cdn.intechopen.com/books/images_new/9816.jpg",editedByType:null,editors:[{id:"15654",title:"Dr.",name:"Salim",surname:"Surani",slug:"salim-surani",fullName:"Salim Surani"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"10176",title:"Microgrids and Local Energy Systems",subtitle:null,isOpenForSubmission:!0,hash:"c32b4a5351a88f263074b0d0ca813a9c",slug:null,bookSignature:"Prof. Nick Jenkins",coverURL:"https://cdn.intechopen.com/books/images_new/10176.jpg",editedByType:null,editors:[{id:"55219",title:"Prof.",name:"Nick",surname:"Jenkins",slug:"nick-jenkins",fullName:"Nick Jenkins"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"10218",title:"Flagellar Motility in Cells",subtitle:null,isOpenForSubmission:!0,hash:"5fcc15570365a82d9f2c4816f4e0ee2e",slug:null,bookSignature:"Prof. Yusuf Bozkurt",coverURL:"https://cdn.intechopen.com/books/images_new/10218.jpg",editedByType:null,editors:[{id:"90846",title:"Prof.",name:"Yusuf",surname:"Bozkurt",slug:"yusuf-bozkurt",fullName:"Yusuf Bozkurt"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"10231",title:"Proton Therapy",subtitle:null,isOpenForSubmission:!0,hash:"f4a9009287953c8d1d89f0fa9b7597b0",slug:null,bookSignature:"",coverURL:"https://cdn.intechopen.com/books/images_new/10231.jpg",editedByType:null,editors:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"10270",title:"Fog Computing",subtitle:null,isOpenForSubmission:!0,hash:"54853b3034f0348a6157b5591f8d95f3",slug:null,bookSignature:"Dr. Isiaka Ajewale Alimi, Dr. Nelson Muga, Dr. Qin Xin and Dr. Paulo P. Monteiro",coverURL:"https://cdn.intechopen.com/books/images_new/10270.jpg",editedByType:null,editors:[{id:"208236",title:"Dr.",name:"Isiaka",surname:"Alimi",slug:"isiaka-alimi",fullName:"Isiaka Alimi"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"10343",title:"Ocular Hypertension",subtitle:null,isOpenForSubmission:!0,hash:"0ff71cc7e0d9f394f41162c0c825588a",slug:null,bookSignature:"Prof. Michele Lanza",coverURL:"https://cdn.intechopen.com/books/images_new/10343.jpg",editedByType:null,editors:[{id:"240088",title:"Prof.",name:"Michele",surname:"Lanza",slug:"michele-lanza",fullName:"Michele Lanza"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"10370",title:"Advances in Fundamental and Applied Research on Spatial Audio",subtitle:null,isOpenForSubmission:!0,hash:"f16232a481c08a05cc191ac64cf2c69e",slug:null,bookSignature:"Dr. Brian FG Katz and Dr. Piotr Majdak",coverURL:"https://cdn.intechopen.com/books/images_new/10370.jpg",editedByType:null,editors:[{id:"278731",title:"Dr.",name:"Brian FG",surname:"Katz",slug:"brian-fg-katz",fullName:"Brian FG Katz"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}}],filtersByTopic:[{group:"topic",caption:"Agricultural and Biological Sciences",value:5,count:16},{group:"topic",caption:"Biochemistry, Genetics and Molecular Biology",value:6,count:4},{group:"topic",caption:"Business, Management and Economics",value:7,count:1},{group:"topic",caption:"Chemistry",value:8,count:8},{group:"topic",caption:"Computer and Information Science",value:9,count:6},{group:"topic",caption:"Earth and Planetary Sciences",value:10,count:7},{group:"topic",caption:"Engineering",value:11,count:16},{group:"topic",caption:"Environmental Sciences",value:12,count:2},{group:"topic",caption:"Immunology and Microbiology",value:13,count:3},{group:"topic",caption:"Materials Science",value:14,count:5},{group:"topic",caption:"Mathematics",value:15,count:1},{group:"topic",caption:"Medicine",value:16,count:24},{group:"topic",caption:"Neuroscience",value:18,count:1},{group:"topic",caption:"Pharmacology, Toxicology and Pharmaceutical Science",value:19,count:3},{group:"topic",caption:"Physics",value:20,count:3},{group:"topic",caption:"Psychology",value:21,count:4},{group:"topic",caption:"Robotics",value:22,count:1},{group:"topic",caption:"Social Sciences",value:23,count:3},{group:"topic",caption:"Technology",value:24,count:1},{group:"topic",caption:"Veterinary Medicine and Science",value:25,count:1}],offset:12,limit:12,total:191},popularBooks:{featuredBooks:[{type:"book",id:"9385",title:"Renewable Energy",subtitle:"Technologies and Applications",isOpenForSubmission:!1,hash:"a6b446d19166f17f313008e6c056f3d8",slug:"renewable-energy-technologies-and-applications",bookSignature:"Tolga Taner, Archana Tiwari and Taha Selim Ustun",coverURL:"https://cdn.intechopen.com/books/images_new/9385.jpg",editors:[{id:"197240",title:"Associate Prof.",name:"Tolga",middleName:null,surname:"Taner",slug:"tolga-taner",fullName:"Tolga Taner"}],equalEditorOne:{id:"186791",title:"Dr.",name:"Archana",middleName:null,surname:"Tiwari",slug:"archana-tiwari",fullName:"Archana Tiwari",profilePictureURL:"https://mts.intechopen.com/storage/users/186791/images/system/186791.jpg",biography:"Dr. Archana Tiwari is Associate Professor at Amity University, India. Her research interests include renewable sources of energy from microalgae and further utilizing the residual biomass for the generation of value-added products, bioremediation through microalgae and microbial consortium, antioxidative enzymes and stress, and nutraceuticals from microalgae. She has been working on algal biotechnology for the last two decades. She has published her research in many international journals and has authored many books and chapters with renowned publishing houses. She has also delivered talks as an invited speaker at many national and international conferences. Dr. Tiwari is the recipient of several awards including Researcher of the Year and Distinguished Scientist.",institutionString:"Amity University",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"3",totalChapterViews:"0",totalEditedBooks:"1",institution:{name:"Amity University",institutionURL:null,country:{name:"India"}}},equalEditorTwo:{id:"197609",title:"Prof.",name:"Taha Selim",middleName:null,surname:"Ustun",slug:"taha-selim-ustun",fullName:"Taha Selim Ustun",profilePictureURL:"https://mts.intechopen.com/storage/users/197609/images/system/197609.jpeg",biography:"Dr. Taha Selim Ustun received a Ph.D. in Electrical Engineering from Victoria University, Melbourne, Australia. He is a researcher with the Fukushima Renewable Energy Institute, AIST (FREA), where he leads the Smart Grid Cybersecurity Laboratory. Prior to that, he was a faculty member with the School of Electrical and Computer Engineering, Carnegie Mellon University, Pittsburgh, PA, USA. His current research interests include power systems protection, communication in power networks, distributed generation, microgrids, electric vehicle integration, and cybersecurity in smart grids. He serves on the editorial boards of IEEE Access, IEEE Transactions on Industrial Informatics, Energies, Electronics, Electricity, World Electric Vehicle and Information journals. Dr. Ustun is a member of the IEEE 2004 and 2800, IEC Renewable Energy Management WG 8, and IEC TC 57 WG17. He has been invited to run specialist courses in Africa, India, and China. He has delivered talks for the Qatar Foundation, the World Energy Council, the Waterloo Global Science Initiative, and the European Union Energy Initiative (EUEI). His research has attracted funding from prestigious programs in Japan, Australia, the European Union, and North America.",institutionString:"Fukushima Renewable Energy Institute, AIST (FREA)",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"1",totalChapterViews:"0",totalEditedBooks:"0",institution:{name:"National Institute of Advanced Industrial Science and Technology",institutionURL:null,country:{name:"Japan"}}},equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}},{type:"book",id:"10065",title:"Wavelet Theory",subtitle:null,isOpenForSubmission:!1,hash:"d8868e332169597ba2182d9b004d60de",slug:"wavelet-theory",bookSignature:"Somayeh Mohammady",coverURL:"https://cdn.intechopen.com/books/images_new/10065.jpg",editors:[{id:"109280",title:"Dr.",name:"Somayeh",middleName:null,surname:"Mohammady",slug:"somayeh-mohammady",fullName:"Somayeh Mohammady"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}},{type:"book",id:"9644",title:"Glaciers and the Polar Environment",subtitle:null,isOpenForSubmission:!1,hash:"e8cfdc161794e3753ced54e6ff30873b",slug:"glaciers-and-the-polar-environment",bookSignature:"Masaki Kanao, Danilo Godone and Niccolò Dematteis",coverURL:"https://cdn.intechopen.com/books/images_new/9644.jpg",editors:[{id:"51959",title:"Dr.",name:"Masaki",middleName:null,surname:"Kanao",slug:"masaki-kanao",fullName:"Masaki Kanao"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}},{type:"book",id:"8985",title:"Natural Resources Management and Biological Sciences",subtitle:null,isOpenForSubmission:!1,hash:"5c2e219a6c021a40b5a20c041dea88c4",slug:"natural-resources-management-and-biological-sciences",bookSignature:"Edward R. Rhodes and Humood Naser",coverURL:"https://cdn.intechopen.com/books/images_new/8985.jpg",editors:[{id:"280886",title:"Prof.",name:"Edward R",middleName:null,surname:"Rhodes",slug:"edward-r-rhodes",fullName:"Edward R Rhodes"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}},{type:"book",id:"9671",title:"Macrophages",subtitle:null,isOpenForSubmission:!1,hash:"03b00fdc5f24b71d1ecdfd75076bfde6",slug:"macrophages",bookSignature:"Hridayesh Prakash",coverURL:"https://cdn.intechopen.com/books/images_new/9671.jpg",editors:[{id:"287184",title:"Dr.",name:"Hridayesh",middleName:null,surname:"Prakash",slug:"hridayesh-prakash",fullName:"Hridayesh Prakash"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}},{type:"book",id:"9313",title:"Clay Science and Technology",subtitle:null,isOpenForSubmission:!1,hash:"6fa7e70396ff10620e032bb6cfa6fb72",slug:"clay-science-and-technology",bookSignature:"Gustavo Morari Do Nascimento",coverURL:"https://cdn.intechopen.com/books/images_new/9313.jpg",editors:[{id:"7153",title:"Prof.",name:"Gustavo",middleName:null,surname:"Morari Do Nascimento",slug:"gustavo-morari-do-nascimento",fullName:"Gustavo Morari Do Nascimento"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}},{type:"book",id:"9888",title:"Nuclear Power Plants",subtitle:"The Processes from the Cradle to the Grave",isOpenForSubmission:!1,hash:"c2c8773e586f62155ab8221ebb72a849",slug:"nuclear-power-plants-the-processes-from-the-cradle-to-the-grave",bookSignature:"Nasser Awwad",coverURL:"https://cdn.intechopen.com/books/images_new/9888.jpg",editors:[{id:"145209",title:"Prof.",name:"Nasser",middleName:"S",surname:"Awwad",slug:"nasser-awwad",fullName:"Nasser Awwad"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}},{type:"book",id:"9027",title:"Human Blood Group Systems and Haemoglobinopathies",subtitle:null,isOpenForSubmission:!1,hash:"d00d8e40b11cfb2547d1122866531c7e",slug:"human-blood-group-systems-and-haemoglobinopathies",bookSignature:"Osaro Erhabor and Anjana Munshi",coverURL:"https://cdn.intechopen.com/books/images_new/9027.jpg",editors:[{id:"35140",title:null,name:"Osaro",middleName:null,surname:"Erhabor",slug:"osaro-erhabor",fullName:"Osaro Erhabor"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}},{type:"book",id:"7841",title:"New Insights Into Metabolic Syndrome",subtitle:null,isOpenForSubmission:!1,hash:"ef5accfac9772b9e2c9eff884f085510",slug:"new-insights-into-metabolic-syndrome",bookSignature:"Akikazu Takada",coverURL:"https://cdn.intechopen.com/books/images_new/7841.jpg",editors:[{id:"248459",title:"Dr.",name:"Akikazu",middleName:null,surname:"Takada",slug:"akikazu-takada",fullName:"Akikazu Takada"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}},{type:"book",id:"8558",title:"Aerodynamics",subtitle:null,isOpenForSubmission:!1,hash:"db7263fc198dfb539073ba0260a7f1aa",slug:"aerodynamics",bookSignature:"Mofid Gorji-Bandpy and Aly-Mousaad Aly",coverURL:"https://cdn.intechopen.com/books/images_new/8558.jpg",editors:[{id:"35542",title:"Prof.",name:"Mofid",middleName:null,surname:"Gorji-Bandpy",slug:"mofid-gorji-bandpy",fullName:"Mofid Gorji-Bandpy"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}},{type:"book",id:"7847",title:"Medical Toxicology",subtitle:null,isOpenForSubmission:!1,hash:"db9b65bea093de17a0855a1b27046247",slug:"medical-toxicology",bookSignature:"Pınar Erkekoglu and Tomohisa Ogawa",coverURL:"https://cdn.intechopen.com/books/images_new/7847.jpg",editors:[{id:"109978",title:"Prof.",name:"Pınar",middleName:null,surname:"Erkekoglu",slug:"pinar-erkekoglu",fullName:"Pınar Erkekoglu"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}},{type:"book",id:"10432",title:"Casting Processes and Modelling of Metallic Materials",subtitle:null,isOpenForSubmission:!1,hash:"2c5c9df938666bf5d1797727db203a6d",slug:"casting-processes-and-modelling-of-metallic-materials",bookSignature:"Zakaria Abdallah and Nada Aldoumani",coverURL:"https://cdn.intechopen.com/books/images_new/10432.jpg",editors:[{id:"201670",title:"Dr.",name:"Zak",middleName:null,surname:"Abdallah",slug:"zak-abdallah",fullName:"Zak Abdallah"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}}],offset:12,limit:12,total:5238},hotBookTopics:{hotBooks:[],offset:0,limit:12,total:null},publish:{},publishingProposal:{success:null,errors:{}},books:{featuredBooks:[{type:"book",id:"10065",title:"Wavelet Theory",subtitle:null,isOpenForSubmission:!1,hash:"d8868e332169597ba2182d9b004d60de",slug:"wavelet-theory",bookSignature:"Somayeh Mohammady",coverURL:"https://cdn.intechopen.com/books/images_new/10065.jpg",editors:[{id:"109280",title:"Dr.",name:"Somayeh",middleName:null,surname:"Mohammady",slug:"somayeh-mohammady",fullName:"Somayeh Mohammady"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}},{type:"book",id:"9644",title:"Glaciers and the Polar Environment",subtitle:null,isOpenForSubmission:!1,hash:"e8cfdc161794e3753ced54e6ff30873b",slug:"glaciers-and-the-polar-environment",bookSignature:"Masaki Kanao, Danilo Godone and Niccolò Dematteis",coverURL:"https://cdn.intechopen.com/books/images_new/9644.jpg",editors:[{id:"51959",title:"Dr.",name:"Masaki",middleName:null,surname:"Kanao",slug:"masaki-kanao",fullName:"Masaki Kanao"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}},{type:"book",id:"9385",title:"Renewable Energy",subtitle:"Technologies and Applications",isOpenForSubmission:!1,hash:"a6b446d19166f17f313008e6c056f3d8",slug:"renewable-energy-technologies-and-applications",bookSignature:"Tolga Taner, Archana Tiwari and Taha Selim Ustun",coverURL:"https://cdn.intechopen.com/books/images_new/9385.jpg",editors:[{id:"197240",title:"Associate Prof.",name:"Tolga",middleName:null,surname:"Taner",slug:"tolga-taner",fullName:"Tolga Taner"}],equalEditorOne:{id:"186791",title:"Dr.",name:"Archana",middleName:null,surname:"Tiwari",slug:"archana-tiwari",fullName:"Archana Tiwari",profilePictureURL:"https://mts.intechopen.com/storage/users/186791/images/system/186791.jpg",biography:"Dr. Archana Tiwari is Associate Professor at Amity University, India. Her research interests include renewable sources of energy from microalgae and further utilizing the residual biomass for the generation of value-added products, bioremediation through microalgae and microbial consortium, antioxidative enzymes and stress, and nutraceuticals from microalgae. She has been working on algal biotechnology for the last two decades. She has published her research in many international journals and has authored many books and chapters with renowned publishing houses. She has also delivered talks as an invited speaker at many national and international conferences. Dr. Tiwari is the recipient of several awards including Researcher of the Year and Distinguished Scientist.",institutionString:"Amity University",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"3",totalChapterViews:"0",totalEditedBooks:"1",institution:{name:"Amity University",institutionURL:null,country:{name:"India"}}},equalEditorTwo:{id:"197609",title:"Prof.",name:"Taha Selim",middleName:null,surname:"Ustun",slug:"taha-selim-ustun",fullName:"Taha Selim Ustun",profilePictureURL:"https://mts.intechopen.com/storage/users/197609/images/system/197609.jpeg",biography:"Dr. Taha Selim Ustun received a Ph.D. in Electrical Engineering from Victoria University, Melbourne, Australia. He is a researcher with the Fukushima Renewable Energy Institute, AIST (FREA), where he leads the Smart Grid Cybersecurity Laboratory. Prior to that, he was a faculty member with the School of Electrical and Computer Engineering, Carnegie Mellon University, Pittsburgh, PA, USA. His current research interests include power systems protection, communication in power networks, distributed generation, microgrids, electric vehicle integration, and cybersecurity in smart grids. He serves on the editorial boards of IEEE Access, IEEE Transactions on Industrial Informatics, Energies, Electronics, Electricity, World Electric Vehicle and Information journals. Dr. Ustun is a member of the IEEE 2004 and 2800, IEC Renewable Energy Management WG 8, and IEC TC 57 WG17. He has been invited to run specialist courses in Africa, India, and China. He has delivered talks for the Qatar Foundation, the World Energy Council, the Waterloo Global Science Initiative, and the European Union Energy Initiative (EUEI). His research has attracted funding from prestigious programs in Japan, Australia, the European Union, and North America.",institutionString:"Fukushima Renewable Energy Institute, AIST (FREA)",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"1",totalChapterViews:"0",totalEditedBooks:"0",institution:{name:"National Institute of Advanced Industrial Science and Technology",institutionURL:null,country:{name:"Japan"}}},equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}},{type:"book",id:"8985",title:"Natural Resources Management and Biological Sciences",subtitle:null,isOpenForSubmission:!1,hash:"5c2e219a6c021a40b5a20c041dea88c4",slug:"natural-resources-management-and-biological-sciences",bookSignature:"Edward R. Rhodes and Humood Naser",coverURL:"https://cdn.intechopen.com/books/images_new/8985.jpg",editors:[{id:"280886",title:"Prof.",name:"Edward R",middleName:null,surname:"Rhodes",slug:"edward-r-rhodes",fullName:"Edward R Rhodes"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}},{type:"book",id:"9671",title:"Macrophages",subtitle:null,isOpenForSubmission:!1,hash:"03b00fdc5f24b71d1ecdfd75076bfde6",slug:"macrophages",bookSignature:"Hridayesh Prakash",coverURL:"https://cdn.intechopen.com/books/images_new/9671.jpg",editors:[{id:"287184",title:"Dr.",name:"Hridayesh",middleName:null,surname:"Prakash",slug:"hridayesh-prakash",fullName:"Hridayesh Prakash"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}},{type:"book",id:"9313",title:"Clay Science and Technology",subtitle:null,isOpenForSubmission:!1,hash:"6fa7e70396ff10620e032bb6cfa6fb72",slug:"clay-science-and-technology",bookSignature:"Gustavo Morari Do Nascimento",coverURL:"https://cdn.intechopen.com/books/images_new/9313.jpg",editors:[{id:"7153",title:"Prof.",name:"Gustavo",middleName:null,surname:"Morari Do Nascimento",slug:"gustavo-morari-do-nascimento",fullName:"Gustavo Morari Do Nascimento"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}},{type:"book",id:"9888",title:"Nuclear Power Plants",subtitle:"The Processes from the Cradle to the Grave",isOpenForSubmission:!1,hash:"c2c8773e586f62155ab8221ebb72a849",slug:"nuclear-power-plants-the-processes-from-the-cradle-to-the-grave",bookSignature:"Nasser Awwad",coverURL:"https://cdn.intechopen.com/books/images_new/9888.jpg",editors:[{id:"145209",title:"Prof.",name:"Nasser",middleName:"S",surname:"Awwad",slug:"nasser-awwad",fullName:"Nasser Awwad"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}},{type:"book",id:"9027",title:"Human Blood Group Systems and Haemoglobinopathies",subtitle:null,isOpenForSubmission:!1,hash:"d00d8e40b11cfb2547d1122866531c7e",slug:"human-blood-group-systems-and-haemoglobinopathies",bookSignature:"Osaro Erhabor and Anjana Munshi",coverURL:"https://cdn.intechopen.com/books/images_new/9027.jpg",editors:[{id:"35140",title:null,name:"Osaro",middleName:null,surname:"Erhabor",slug:"osaro-erhabor",fullName:"Osaro Erhabor"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}},{type:"book",id:"10432",title:"Casting Processes and Modelling of Metallic Materials",subtitle:null,isOpenForSubmission:!1,hash:"2c5c9df938666bf5d1797727db203a6d",slug:"casting-processes-and-modelling-of-metallic-materials",bookSignature:"Zakaria Abdallah and Nada Aldoumani",coverURL:"https://cdn.intechopen.com/books/images_new/10432.jpg",editors:[{id:"201670",title:"Dr.",name:"Zak",middleName:null,surname:"Abdallah",slug:"zak-abdallah",fullName:"Zak Abdallah"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}},{type:"book",id:"7841",title:"New Insights Into Metabolic Syndrome",subtitle:null,isOpenForSubmission:!1,hash:"ef5accfac9772b9e2c9eff884f085510",slug:"new-insights-into-metabolic-syndrome",bookSignature:"Akikazu Takada",coverURL:"https://cdn.intechopen.com/books/images_new/7841.jpg",editors:[{id:"248459",title:"Dr.",name:"Akikazu",middleName:null,surname:"Takada",slug:"akikazu-takada",fullName:"Akikazu Takada"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}}],latestBooks:[{type:"book",id:"9550",title:"Entrepreneurship",subtitle:"Contemporary Issues",isOpenForSubmission:!1,hash:"9b4ac1ee5b743abf6f88495452b1e5e7",slug:"entrepreneurship-contemporary-issues",bookSignature:"Mladen Turuk",coverURL:"https://cdn.intechopen.com/books/images_new/9550.jpg",editedByType:"Edited by",editors:[{id:"319755",title:"Prof.",name:"Mladen",middleName:null,surname:"Turuk",slug:"mladen-turuk",fullName:"Mladen Turuk"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"10065",title:"Wavelet Theory",subtitle:null,isOpenForSubmission:!1,hash:"d8868e332169597ba2182d9b004d60de",slug:"wavelet-theory",bookSignature:"Somayeh Mohammady",coverURL:"https://cdn.intechopen.com/books/images_new/10065.jpg",editedByType:"Edited by",editors:[{id:"109280",title:"Dr.",name:"Somayeh",middleName:null,surname:"Mohammady",slug:"somayeh-mohammady",fullName:"Somayeh Mohammady"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"9313",title:"Clay Science and Technology",subtitle:null,isOpenForSubmission:!1,hash:"6fa7e70396ff10620e032bb6cfa6fb72",slug:"clay-science-and-technology",bookSignature:"Gustavo Morari Do Nascimento",coverURL:"https://cdn.intechopen.com/books/images_new/9313.jpg",editedByType:"Edited by",editors:[{id:"7153",title:"Prof.",name:"Gustavo",middleName:null,surname:"Morari Do Nascimento",slug:"gustavo-morari-do-nascimento",fullName:"Gustavo Morari Do Nascimento"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"9888",title:"Nuclear Power Plants",subtitle:"The Processes from the Cradle to the Grave",isOpenForSubmission:!1,hash:"c2c8773e586f62155ab8221ebb72a849",slug:"nuclear-power-plants-the-processes-from-the-cradle-to-the-grave",bookSignature:"Nasser Awwad",coverURL:"https://cdn.intechopen.com/books/images_new/9888.jpg",editedByType:"Edited by",editors:[{id:"145209",title:"Prof.",name:"Nasser",middleName:"S",surname:"Awwad",slug:"nasser-awwad",fullName:"Nasser Awwad"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"8098",title:"Resources of Water",subtitle:null,isOpenForSubmission:!1,hash:"d251652996624d932ef7b8ed62cf7cfc",slug:"resources-of-water",bookSignature:"Prathna Thanjavur Chandrasekaran, Muhammad Salik Javaid, Aftab Sadiq",coverURL:"https://cdn.intechopen.com/books/images_new/8098.jpg",editedByType:"Edited by",editors:[{id:"167917",title:"Dr.",name:"Prathna",middleName:null,surname:"Thanjavur Chandrasekaran",slug:"prathna-thanjavur-chandrasekaran",fullName:"Prathna Thanjavur Chandrasekaran"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"9644",title:"Glaciers and the Polar Environment",subtitle:null,isOpenForSubmission:!1,hash:"e8cfdc161794e3753ced54e6ff30873b",slug:"glaciers-and-the-polar-environment",bookSignature:"Masaki Kanao, Danilo Godone and Niccolò Dematteis",coverURL:"https://cdn.intechopen.com/books/images_new/9644.jpg",editedByType:"Edited by",editors:[{id:"51959",title:"Dr.",name:"Masaki",middleName:null,surname:"Kanao",slug:"masaki-kanao",fullName:"Masaki Kanao"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"10432",title:"Casting Processes and Modelling of Metallic Materials",subtitle:null,isOpenForSubmission:!1,hash:"2c5c9df938666bf5d1797727db203a6d",slug:"casting-processes-and-modelling-of-metallic-materials",bookSignature:"Zakaria Abdallah and Nada Aldoumani",coverURL:"https://cdn.intechopen.com/books/images_new/10432.jpg",editedByType:"Edited by",editors:[{id:"201670",title:"Dr.",name:"Zak",middleName:null,surname:"Abdallah",slug:"zak-abdallah",fullName:"Zak Abdallah"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"9671",title:"Macrophages",subtitle:null,isOpenForSubmission:!1,hash:"03b00fdc5f24b71d1ecdfd75076bfde6",slug:"macrophages",bookSignature:"Hridayesh Prakash",coverURL:"https://cdn.intechopen.com/books/images_new/9671.jpg",editedByType:"Edited by",editors:[{id:"287184",title:"Dr.",name:"Hridayesh",middleName:null,surname:"Prakash",slug:"hridayesh-prakash",fullName:"Hridayesh Prakash"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"8415",title:"Extremophilic Microbes and Metabolites",subtitle:"Diversity, Bioprospecting and Biotechnological Applications",isOpenForSubmission:!1,hash:"93e0321bc93b89ff73730157738f8f97",slug:"extremophilic-microbes-and-metabolites-diversity-bioprospecting-and-biotechnological-applications",bookSignature:"Afef Najjari, Ameur Cherif, Haïtham Sghaier and Hadda Imene Ouzari",coverURL:"https://cdn.intechopen.com/books/images_new/8415.jpg",editedByType:"Edited by",editors:[{id:"196823",title:"Dr.",name:"Afef",middleName:null,surname:"Najjari",slug:"afef-najjari",fullName:"Afef Najjari"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"9731",title:"Oxidoreductase",subtitle:null,isOpenForSubmission:!1,hash:"852e6f862c85fc3adecdbaf822e64e6e",slug:"oxidoreductase",bookSignature:"Mahmoud Ahmed Mansour",coverURL:"https://cdn.intechopen.com/books/images_new/9731.jpg",editedByType:"Edited by",editors:[{id:"224662",title:"Prof.",name:"Mahmoud Ahmed",middleName:null,surname:"Mansour",slug:"mahmoud-ahmed-mansour",fullName:"Mahmoud Ahmed Mansour"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}}]},subject:{topic:{id:"1317",title:"Public Health",slug:"social-sciences-education-public-health",parent:{title:"Education",slug:"social-sciences-education"},numberOfBooks:1,numberOfAuthorsAndEditors:2,numberOfWosCitations:0,numberOfCrossrefCitations:7,numberOfDimensionsCitations:7,videoUrl:null,fallbackUrl:null,description:null},booksByTopicFilter:{topicSlug:"social-sciences-education-public-health",sort:"-publishedDate",limit:12,offset:0},booksByTopicCollection:[{type:"book",id:"8645",title:"Contemporary Topics in Graduate Medical Education",subtitle:null,isOpenForSubmission:!1,hash:"76d224ba3c158c43fda8141a61ababd6",slug:"contemporary-topics-in-graduate-medical-education",bookSignature:"Stanislaw P. Stawicki, Michael S. Firstenberg, James P. Orlando and Thomas J. Papadimos",coverURL:"https://cdn.intechopen.com/books/images_new/8645.jpg",editedByType:"Edited by",editors:[{id:"181694",title:"Dr.",name:"Stanislaw P.",middleName:null,surname:"Stawicki",slug:"stanislaw-p.-stawicki",fullName:"Stanislaw P. Stawicki"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}}],booksByTopicTotal:1,mostCitedChapters:[{id:"64635",doi:"10.5772/intechopen.82343",title:"Wellness in Residency: A Paradigm Shift",slug:"wellness-in-residency-a-paradigm-shift",totalDownloads:396,totalCrossrefCites:2,totalDimensionsCites:2,book:{slug:"contemporary-topics-in-graduate-medical-education",title:"Contemporary Topics in Graduate Medical Education",fullTitle:"Contemporary Topics in Graduate Medical Education"},signatures:"Roderick M. Quiros and Elspeth Black",authors:null},{id:"64979",doi:"10.5772/intechopen.82618",title:"Teaching Balanced Patient Care Using Principles of Reductionism and Holism: The Example of Chronic Low Back Pain",slug:"teaching-balanced-patient-care-using-principles-of-reductionism-and-holism-the-example-of-chronic-lo",totalDownloads:564,totalCrossrefCites:2,totalDimensionsCites:2,book:{slug:"contemporary-topics-in-graduate-medical-education",title:"Contemporary Topics in Graduate Medical Education",fullTitle:"Contemporary Topics in Graduate Medical Education"},signatures:"Alan Remde, Stephen DeTurk and Thomas Wojda",authors:null},{id:"63925",doi:"10.5772/intechopen.81532",title:"Curriculum Development: Foundations and Modern Advances in Graduate Medical Education",slug:"curriculum-development-foundations-and-modern-advances-in-graduate-medical-education",totalDownloads:1639,totalCrossrefCites:1,totalDimensionsCites:1,book:{slug:"contemporary-topics-in-graduate-medical-education",title:"Contemporary Topics in Graduate Medical Education",fullTitle:"Contemporary Topics in Graduate Medical Education"},signatures:"Simiao Li-Sauerwine and Andrew King",authors:null}],mostDownloadedChaptersLast30Days:[{id:"63925",title:"Curriculum Development: Foundations and Modern Advances in Graduate Medical Education",slug:"curriculum-development-foundations-and-modern-advances-in-graduate-medical-education",totalDownloads:1642,totalCrossrefCites:1,totalDimensionsCites:1,book:{slug:"contemporary-topics-in-graduate-medical-education",title:"Contemporary Topics in Graduate Medical Education",fullTitle:"Contemporary Topics in Graduate Medical Education"},signatures:"Simiao Li-Sauerwine and Andrew King",authors:null},{id:"67021",title:"Introductory Chapter: A Quest to Transform Graduate Medical Education into a Seamless Journey toward Practice Readiness",slug:"introductory-chapter-a-quest-to-transform-graduate-medical-education-into-a-seamless-journey-toward-",totalDownloads:309,totalCrossrefCites:0,totalDimensionsCites:0,book:{slug:"contemporary-topics-in-graduate-medical-education",title:"Contemporary Topics in Graduate Medical Education",fullTitle:"Contemporary Topics in Graduate Medical Education"},signatures:"Stanislaw P. Stawicki, Michael S. Firstenberg, James P. Orlando and Thomas J. Papadimos",authors:[{id:"181694",title:"Dr.",name:"Stanislaw P.",middleName:null,surname:"Stawicki",slug:"stanislaw-p.-stawicki",fullName:"Stanislaw P. Stawicki"}]},{id:"64979",title:"Teaching Balanced Patient Care Using Principles of Reductionism and Holism: The Example of Chronic Low Back Pain",slug:"teaching-balanced-patient-care-using-principles-of-reductionism-and-holism-the-example-of-chronic-lo",totalDownloads:566,totalCrossrefCites:2,totalDimensionsCites:2,book:{slug:"contemporary-topics-in-graduate-medical-education",title:"Contemporary Topics in Graduate Medical Education",fullTitle:"Contemporary Topics in Graduate Medical Education"},signatures:"Alan Remde, Stephen DeTurk and Thomas Wojda",authors:null},{id:"65522",title:"The Importance of Post-Doctoral Program to GME in an Academic Medical Center",slug:"the-importance-of-post-doctoral-program-to-gme-in-an-academic-medical-center",totalDownloads:295,totalCrossrefCites:0,totalDimensionsCites:0,book:{slug:"contemporary-topics-in-graduate-medical-education",title:"Contemporary Topics in Graduate Medical Education",fullTitle:"Contemporary Topics in Graduate Medical Education"},signatures:"Tracy L. Butryn, Parampreet Kaur, Vikas Yellapu, Alyssa Green and James Dalkiewicz",authors:null},{id:"66801",title:"Physician Burnout",slug:"physician-burnout",totalDownloads:440,totalCrossrefCites:1,totalDimensionsCites:1,book:{slug:"contemporary-topics-in-graduate-medical-education",title:"Contemporary Topics in Graduate Medical Education",fullTitle:"Contemporary Topics in Graduate Medical Education"},signatures:"Bess Connors, Charlotte Horne, Valery Vilchez and Sofya Asfaw",authors:null},{id:"66759",title:"Resident Autonomy",slug:"resident-autonomy",totalDownloads:443,totalCrossrefCites:1,totalDimensionsCites:1,book:{slug:"contemporary-topics-in-graduate-medical-education",title:"Contemporary Topics in Graduate Medical Education",fullTitle:"Contemporary Topics in Graduate Medical Education"},signatures:"Amanda Cooper and Steven Allen",authors:null},{id:"64635",title:"Wellness in Residency: A Paradigm Shift",slug:"wellness-in-residency-a-paradigm-shift",totalDownloads:397,totalCrossrefCites:2,totalDimensionsCites:2,book:{slug:"contemporary-topics-in-graduate-medical-education",title:"Contemporary Topics in Graduate Medical Education",fullTitle:"Contemporary Topics in Graduate Medical Education"},signatures:"Roderick M. Quiros and Elspeth Black",authors:null},{id:"64409",title:"Implementing Wellness Curriculum in Residency",slug:"implementing-wellness-curriculum-in-residency",totalDownloads:556,totalCrossrefCites:0,totalDimensionsCites:0,book:{slug:"contemporary-topics-in-graduate-medical-education",title:"Contemporary Topics in Graduate Medical Education",fullTitle:"Contemporary Topics in Graduate Medical Education"},signatures:"Nguyet-Cam V. Lam and Elspeth Black",authors:null},{id:"66601",title:"Leadership in Graduate Medical Education",slug:"leadership-in-graduate-medical-education",totalDownloads:311,totalCrossrefCites:0,totalDimensionsCites:0,book:{slug:"contemporary-topics-in-graduate-medical-education",title:"Contemporary Topics in Graduate Medical Education",fullTitle:"Contemporary Topics in Graduate Medical Education"},signatures:"Jay M. Yanoff",authors:null}],onlineFirstChaptersFilter:{topicSlug:"social-sciences-education-public-health",limit:3,offset:0},onlineFirstChaptersCollection:[],onlineFirstChaptersTotal:0},preDownload:{success:null,errors:{}},aboutIntechopen:{},privacyPolicy:{},peerReviewing:{},howOpenAccessPublishingWithIntechopenWorks:{},sponsorshipBooks:{sponsorshipBooks:[{type:"book",id:"10176",title:"Microgrids and Local Energy Systems",subtitle:null,isOpenForSubmission:!0,hash:"c32b4a5351a88f263074b0d0ca813a9c",slug:null,bookSignature:"Prof. Nick Jenkins",coverURL:"https://cdn.intechopen.com/books/images_new/10176.jpg",editedByType:null,editors:[{id:"55219",title:"Prof.",name:"Nick",middleName:null,surname:"Jenkins",slug:"nick-jenkins",fullName:"Nick Jenkins"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}}],offset:8,limit:8,total:1},route:{name:"chapter.detail",path:"/books/advanced-endoscopy/laparoscopic-pancreatoduodenectomy",hash:"",query:{},params:{book:"advanced-endoscopy",chapter:"laparoscopic-pancreatoduodenectomy"},fullPath:"/books/advanced-endoscopy/laparoscopic-pancreatoduodenectomy",meta:{},from:{name:null,path:"/",hash:"",query:{},params:{},fullPath:"/",meta:{}}}},function(){var e;(e=document.currentScript||document.scripts[document.scripts.length-1]).parentNode.removeChild(e)}()