Criteria of inclusion for TEM.
\\n\\n
IntechOpen was founded by scientists, for scientists, in order to make book publishing accessible around the globe. Over the last two decades, this has driven Open Access (OA) book publishing whilst levelling the playing field for global academics. Through our innovative publishing model and the support of the research community, we have now published over 5,700 Open Access books and are visited online by over three million academics every month. These researchers are increasingly working in broad technology-based subjects, driving multidisciplinary academic endeavours into human health, environment, and technology.
\\n\\nBy listening to our community, and in order to serve these rapidly growing areas which lie at the core of IntechOpen's expertise, we are launching a portfolio of Open Science journals:
\\n\\nAll three journals will publish under an Open Access model and embrace Open Science policies to help support the changing needs of academics in these fast-moving research areas. There will be direct links to preprint servers and data repositories, allowing full reproducibility and rapid dissemination of published papers to help accelerate the pace of research. Each journal has renowned Editors in Chief who will work alongside a global Editorial Board, delivering robust single-blind peer review. Supported by our internal editorial teams, this will ensure our authors will receive a quick, user-friendly, and personalised publishing experience.
\\n\\n"By launching our journals portfolio we are introducing new, dedicated homes for interdisciplinary technology-focused researchers to publish their work, whilst embracing Open Science and creating a unique global home for academics to disseminate their work. We are taking a leap toward Open Science continuing and expanding our fundamental commitment to openly sharing scientific research across the world, making it available for the benefit of all." Dr. Sara Uhac, IntechOpen CEO
\\n\\n"Our aim is to promote and create better science for a better world by increasing access to information and the latest scientific developments to all scientists, innovators, entrepreneurs and students and give them the opportunity to learn, observe and contribute to knowledge creation. Open Science promotes a swifter path from research to innovation to produce new products and services." Alex Lazinica, IntechOpen founder
\\n\\nIn conclusion, Natalia Reinic Babic, Head of Journal Publishing and Open Science at IntechOpen adds:
\\n\\n“On behalf of the journal team I’d like to thank all our Editors in Chief, Editorial Boards, internal supporting teams, and our scientific community for their continuous support in making this portfolio a reality - we couldn’t have done it without you! With your support in place, we are confident these journals will become as impactful and successful as our book publishing program and bring us closer to a more open (science) future.”
\\n\\nWe invite you to visit the journals homepage and learn more about the journal’s Editorial Boards, scope and vision as all three journals are now open for submissions.
\\n\\nFeel free to share this news on social media and help us mark this memorable moment!
\\n\\n\\n"}]',published:!0,mainMedia:{caption:"",originalUrl:"/media/original/237"}},components:[{type:"htmlEditorComponent",content:'
After years of being acknowledged as the world's leading publisher of Open Access books, today, we are proud to announce we’ve successfully launched a portfolio of Open Science journals covering rapidly expanding areas of interdisciplinary research.
\n\n\n\nIntechOpen was founded by scientists, for scientists, in order to make book publishing accessible around the globe. Over the last two decades, this has driven Open Access (OA) book publishing whilst levelling the playing field for global academics. Through our innovative publishing model and the support of the research community, we have now published over 5,700 Open Access books and are visited online by over three million academics every month. These researchers are increasingly working in broad technology-based subjects, driving multidisciplinary academic endeavours into human health, environment, and technology.
\n\nBy listening to our community, and in order to serve these rapidly growing areas which lie at the core of IntechOpen's expertise, we are launching a portfolio of Open Science journals:
\n\nAll three journals will publish under an Open Access model and embrace Open Science policies to help support the changing needs of academics in these fast-moving research areas. There will be direct links to preprint servers and data repositories, allowing full reproducibility and rapid dissemination of published papers to help accelerate the pace of research. Each journal has renowned Editors in Chief who will work alongside a global Editorial Board, delivering robust single-blind peer review. Supported by our internal editorial teams, this will ensure our authors will receive a quick, user-friendly, and personalised publishing experience.
\n\n"By launching our journals portfolio we are introducing new, dedicated homes for interdisciplinary technology-focused researchers to publish their work, whilst embracing Open Science and creating a unique global home for academics to disseminate their work. We are taking a leap toward Open Science continuing and expanding our fundamental commitment to openly sharing scientific research across the world, making it available for the benefit of all." Dr. Sara Uhac, IntechOpen CEO
\n\n"Our aim is to promote and create better science for a better world by increasing access to information and the latest scientific developments to all scientists, innovators, entrepreneurs and students and give them the opportunity to learn, observe and contribute to knowledge creation. Open Science promotes a swifter path from research to innovation to produce new products and services." Alex Lazinica, IntechOpen founder
\n\nIn conclusion, Natalia Reinic Babic, Head of Journal Publishing and Open Science at IntechOpen adds:
\n\n“On behalf of the journal team I’d like to thank all our Editors in Chief, Editorial Boards, internal supporting teams, and our scientific community for their continuous support in making this portfolio a reality - we couldn’t have done it without you! With your support in place, we are confident these journals will become as impactful and successful as our book publishing program and bring us closer to a more open (science) future.”
\n\nWe invite you to visit the journals homepage and learn more about the journal’s Editorial Boards, scope and vision as all three journals are now open for submissions.
\n\nFeel free to share this news on social media and help us mark this memorable moment!
\n\n\n'}],latestNews:[{slug:"webinar-introduction-to-open-science-wednesday-18-may-1-pm-cest-20220518",title:"Webinar: Introduction to Open Science | Wednesday 18 May, 1 PM CEST"},{slug:"step-in-the-right-direction-intechopen-launches-a-portfolio-of-open-science-journals-20220414",title:"Step in the Right Direction: IntechOpen Launches a Portfolio of Open Science Journals"},{slug:"let-s-meet-at-london-book-fair-5-7-april-2022-olympia-london-20220321",title:"Let’s meet at London Book Fair, 5-7 April 2022, Olympia London"},{slug:"50-books-published-as-part-of-intechopen-and-knowledge-unlatched-ku-collaboration-20220316",title:"50 Books published as part of IntechOpen and Knowledge Unlatched (KU) Collaboration"},{slug:"intechopen-joins-the-united-nations-sustainable-development-goals-publishers-compact-20221702",title:"IntechOpen joins the United Nations Sustainable Development Goals Publishers Compact"},{slug:"intechopen-signs-exclusive-representation-agreement-with-lsr-libros-servicios-y-representaciones-s-a-de-c-v-20211123",title:"IntechOpen Signs Exclusive Representation Agreement with LSR Libros Servicios y Representaciones S.A. de C.V"},{slug:"intechopen-expands-partnership-with-research4life-20211110",title:"IntechOpen Expands Partnership with Research4Life"},{slug:"introducing-intechopen-book-series-a-new-publishing-format-for-oa-books-20210915",title:"Introducing IntechOpen Book Series - A New Publishing Format for OA Books"}]},book:{item:{type:"book",id:"10926",leadTitle:null,fullTitle:"Traditional Plant-Based Forms of Treatment of Fungal Infections in Suriname - Phytochemical and Pharmacological Rationale",title:"Traditional Plant-Based Forms of Treatment of Fungal Infections in Suriname",subtitle:"Phytochemical and Pharmacological Rationale",reviewType:"peer-reviewed",abstract:"Plant-based traditional medicines are abundantly used in the Republic of Suriname (South America) for treating a wide variety of conditions including fungal infections. 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Transanal endoscopic microsurgery (TEM) is a minimally invasive technique introduced in 1983 by Professor G. Buess [1]. By merging endoscopy with microsurgery [2], Buess developed this natural orifice instrumentation and technique to overcome the technical difficulties that are inherent in the management of low rectal tumors, avoiding an invasive surgical procedure such as low anterior resection but with disease-free margins, unlike traditional local excision techniques. Before the development of TEM, the available methods for the management of rectal tumors included abdominal invasive surgery, in the form of anterior or posterior approach, and traditional transanal local excision techniques. In the anterior approach, the anatomic and technical difficulties restricted the surgeon; the posterior approaches were extremely radical with significant morbidity and mortality. These methods included the York Mason para-sacrococcygeal trans-sphinteric approach [3] for middle rectal tumors and the trans-coccygeal Kraske approach [4] for upper rectal lesions. Both the posterior techniques had high rates of complications: wound infection, fistulae, chronic pain, fecal incontinence, stenosis, high incidence of permanent stoma [5, 6]. Traditional transanal local excision techniques had several disadvantages such as poor exposure and lighting, with consequently increased risk of local recurrence. These techniques included the Parks transanal [7] approach and its variations according to Francillon [8] and Faivre [9]. In the Parks’ procedure [7] after positioning of Parks’ retractor, adrenaline submucosal injection was performed to raise the submucosa from the muscle plane, then two sutures were placed for traction, the mucosa was marked at about 1 cm from the tumor with diathermy, and it was excised following the muscle plane until complete tumor removal, with subsequent closure of the defect. According to the Francillon’s technique [8], several stitches were positioned on healthy mucosa at about 1 cm from the tumor, and their traction acted like a “parachute,” whereby the rectal wall harboring the tumor could be excised together with adjacent perirectal fat. Finally, in the Faivre technique [9], a flap of ano-rectal mucosa hosting the tumor was created and excised.
Buess, together with Richard Wolf Medical Instruments Division, developed a specific rectoscope and dedicated instrumentation to accomplish a revolutionary, highly technological, and new technique of rectal tumors excision by a transanal organ sparing minimally invasive approach but preserving oncological radicality, due to a magnified binocular 3D vision and excellent lighting [10].
The TEM system consists of a beveled rigid rectoscope of 4 cm in diameter and available in two sizes: 12 cm – short – or 20 cm – long – (Figure 1), depending on the preoperative location of the rectal lesion.
Rectoscope © Richard Wolf GmbH. All rights reserved.
The rectoscope is fixed to the operating table with a multidirectional bearing, the Martin’s Arm, and a constant pneumorectum is obtained by an insufflation unit providing carbon dioxide insufflation, suction, and irrigation (Figure 2).
Martin’s Arm and insufflation system © Richard Wolf GmbH. All rights reserved.
The removable faceplate of the rectoscope has a port system to accommodate long curved instruments, the suction and coagulation cannula, and for placing the stereoscope with gas sealing (Figure 3). Through the stereoscope the surgeon obtains a magnified, three-dimensional vision of the rectal lesion with high-intensity lighting. The stereoscope can also be connected to a laparoscopic video unit, for procedure recording and teaching purposes.
Port System and Stereoscope © Richard Wolf GmbH. All rights reserved.
Given the instrumentation design, the lesion must always be located in the inferior part of the operative visual field. Therefore, a precise preoperative assessment of the rectal tumor position is of upmost importance because the patient’s position on the operative table depends on the localization of the rectal lesion: for anteriorly located lesions, a prone jack-knife position (Figure 4) is required, whereas a lithotomy position is needed for posterior lesions (Figure 5). These positions may have to be coupled with a lateral tilt of the operative table on one side or the other in case of lesions that are located on the lateral rectal wall. The patient’s position and the instrumentation settings may sometimes have to be changed during the procedure; therefore, an excellent supporting working team is fundamental.
The prone jack-knife position for anterior lesions.
The lithotomy position for posterior lesions.
Once the correct patient position and lesion exposure are obtained, the surgeon gets a magnified view of the distended rectum and can take advantage of a wide set of angled instruments (monopolar grasping forceps, scissors, needle holder, hook, silver clip applier, suction/irrigation, and coagulation cannula) to excise the lesion with adequate margins. The surgeon may therefore perform a full-thickness resection of the rectal lesion including the perilesional mesorectal fat, if necessary, and to close the residual defect with a running suture.
With the increase in laparoscopic experience, some limitations of TEM, such as costs, need for specific technical training, dedicated equipment, and instrumentation, encouraged the development of the transanal minimally invasive surgery (TAMIS) platform in 2009 [11]. TAMIS needs only a single-incision laparoscopic surgery port (SILSTM Port, Covidien, Mansfield, MA) that is first lubricated and then introduced into the anal canal (Figure 6). Through the SILS port, a standard bidimensional laparoscope and instrumentation are inserted into the rectum, and pneumorectum is achieved with a conventional laparoscopic insufflator. Therefore, TAMIS provides similar, although not equivalent, visibility as TEM without the need for expensive and specialized equipment.
SILS™ port and modified laparoscopic instrument for TAMIS ©Medtronic.
Furthermore, TAMIS enables dissection from different angles in multiple quadrants, avoiding the changes in patient’s position that may sometimes be required during TEM: all resections in TAMIS can be done in the lithotomy position. Initially TAMIS was employed only for local excision of distal rectal lesions, but it is reported to be a feasible option also for higher lesions with satisfactory outcome [12]. So, nowadays TAMIS is considered to be a valuable alternative to TEM, with technical advantages and same prognosis for full-thickness local excision of rectal lesions [13, 14].
The essential steps for both TEM and TAMIS are similar. They include: operative field exposure, tumor excision, and defect closure.
The first step is the positioning of the rectoscope or of the SILS Port, then the lesion is identified, and the rectoscope or SILS port is fixed in place in the correct position. CO2 insufflation is then started to create pneumorectum until reaching an endoluminal pressure of 8–10 mmHg.
Once the lesion is identified, the line of excision is circumferentially marked by electrocautery with at least a 5–10 mm safety margin from the lesion, and dissection then starts at its caudal margin. Tumor resection can be performed by monopolar hook, ultrasonic instruments, or electrothermal bipolar energy devices. Dissection is carried around the lesion until the yellow adipose tissue of the mesorectum is identified and reached for a full-thickness resection. Full-thickness resection with adequate safety margins is performed routinely, with preservation of sphincter muscles (Figure 7). Full-thickness resection could be the cause of inadvertent entry into the peritoneal cavity. Should this occur, a laparoscope can be inserted into the abdominal cavity during TAMIS or in a TEM performed in lithotomy position, for better control of the peritoneal repair. If TEM is performed in the prone position, the patient will have to be turned in lithotomy position for diagnostic laparoscopy. After tumor removal, a suction-irrigation cannula is used for irrigation of the residual cavity and to check the hemostasis. Bleeding is controlled by monopolar or radiofrequency coagulation.
Step-by-step dissection technique for full-thickness excision and residual defect.
Following the tumor excision, the residual defect in the rectal wall can either be closed or be left opened. In the literature, no difference between these two techniques is reported in terms of intraoperative results and final outcome [15]. Our personal preference is to close the defect, as previously reported [16, 17]. The closure can be performed with one or more interrupted or continuous sutures, with Lapraty (Ethicon®) preformed knots and with dedicated silver clips. In case of large defects, the closure can be carried out first by placing a single interrupted or figure of eight suture in the middle of the defect to draw the margins closer. At this stage, the endoluminal pressure can be reduced to facilitate suturing the margins of the defect with either single stitches or, preferably, with a running suture. The suture line should be closed without excessive tension not to cause tissue ischemia. Once the suture is completed, it is necessary to make sure that the rectal lumen has not been inadvertently closed. A suction-irrigation device is helpful in the final correct visualization of the suture.
Traditional indications of TEM and TAMIS are benign lesions and selected T1 rectal tumors, defined by Buess as sessile rectal adenomas and pT1 stage low-risk adenocarcinomas [1, 2].
The standard procedure for the management of benign adenomas with size and morphology that do not allow a complete endoscopic removal is now considered a full-thickness excision by TEM. In these patients, TEM may avoid the morbidity of major surgery with a low recurrence rate [2, 18].
Nowadays, however, with appropriately selected indications, endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) can be suitable alternative to surgery for subinvasive rectal tumor. In case of R1 endoscopic removal at final pathology, a subsequent salvage endoluminal loco-regional resection by TEM can be obtained aimed at achieving R0 resection [19].
In case of rectal cancer, a number of factors should be considered to set the indications for tumor excision by TEM. These factors include physical examination findings, preoperative imaging, and histopathological characteristics [20, 21, 22].
Preoperative staging examinations include:
total colonscopy and rigid rectoscopy with biopsies of the lesion to evaluate distance and circumferential position of the lesion;
digital examination to evaluate mobility or fixity of the tumor;
endorectal ultrasound scan;
magnetic resonance imaging (MRI) with 3 mm sections of abdomen and pelvis;
Total body computed tomography (CT).
Several studies concluded that in carefully selected low-risk T1 patients, TEM had a similar local recurrence rate than total mesorectal excision [23]. Criteria to set the indications for tumor excision by TEM are summarized in Table 1.
Anatomic | Histologic | Staging |
---|---|---|
|
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TEM and TAMIS are also effective for patients’ management after R1 polypectomy, after either EMR or ESD [24], avoiding total mesorectal excision, which would be an overtreatment. The oncological outcomes of transanal minimally invasive procedures in these patients are equal to more invasive surgery, with R0 status in all cases, low morbidity, and 0% mortality rate at a minimum 12 months follow-up [19].
Neoadjuvant chemoradiotherapy (n-CRT) is recommended by the European Society of Medical Oncology (ESMO) in cases of: advanced disease (T3c/T3d and over), MRI-predicted circumferential radial margin (CRM) (<1 mm), and lymph node involvement at MRI [25]. These characteristics of the tumor define the risk of local recurrence and metastatic disease, so the goal of n-CRT is to downsize or downstage the tumor and to avoid disease progression. Short-course neoadjuvant radiation therapy involves 25 Gy administered in doses of 5 Gy daily in 1 week, followed by surgery 1 week after completing neoadjuvant therapy; in 1997, the Swedish Rectal Cancer Study Group found a significant reduction in local recurrence rates between irradiated and control group [26]. Neoadjuvant long-course chemoradiation therapy described by Marks et al. [27] includes an overall administration of 50, 40 Gy in 28 fractions over 5 weeks, with concurrent continuous intravenous infusion of 5-FU. The radiation is administered in the areas of the anus, rectum, mesorectum, regional and iliac lymph nodes. Surgery is performed between 45 and 55 days after completion of chemoradiotherapy.
The standard treatment for T2–T3 rectal cancer after neoadjuvant chemoradiotherapy (n-CRT) is low anterior resection (open or laparoscopic approach) with total mesorectal excision (TME) [28, 29]. However, some studies report that combination of n-CRT with TEM is feasible in T2 and T3 rectal cancers [30, 31]. In a prospective randomized controlled trial, at a 5-year follow-up in selected post n-CRT patients with T2 rectal cancers, the local recurrence rates, the disease-free survival, and distant metastases rates showed no statistical difference in patients receiving TEM or TME [32]. Furthermore, the combination of n-CRT with TEM showed also advantages in preserving patients’ anal function and in lower disruption of patients’ quality of life [33, 34, 35].
Nevertheless, despite extensive mesorectal fat dissection during endoluminal loco-regional resection (ELRR) by TEM, in these patients the N parameter may remain incompletely defined, which may be a cause of concern. In the literature, an original modified sentinel lymph node procedure called nucleotide-guided mesorectal excision (NGME) [36] is described, which can improve the lymph node harvest during endoluminal resection by TEM/TAMIS and consequently obtain a better staging accuracy. During NGME, injection of 99 m-technetium-marked nanocolloid is performed in the peritumoral submucosa before starting the procedure. After specimen removal, the residual cavity is probed with a gamma camera in order to survey any residual radioactive area. In case of positivity, these areas are excised by TEM/TAMIS.
TEM may also be used when the focus is on palliation, if a curative treatment is impossible, in > T3 tumors in patients with unresectable metastases.
Other types of rectal tumors can also be treated with TEM or TAMIS approaches, such as neuroendocrine tumors, leiomyoma, gastrointestinal stromal tumors [25, 23].
TEM can also be used for treatment of iatrogenic fistulae after general surgery and gynecological or urological procedures, such as after prostatectomy or for management of recto-vaginal and recto-urinary fistulae [37, 38, 39]. Benign rectal strictures can also be treated by TEM [40, 41].
Accidental peritoneal entry during full-thickness TEM excision was in the past considered a serious complication requiring an aggressive management by conversion to standard laparotomy anterior resection (LAR) and fecal diversion [18, 42, 43]. More recently, larger transanal minimally invasive resection series showed a rate of peritoneal entry ranging from 0 to 32% [44, 45]. Proposed risk factors for accidental peritoneal opening include full-thickness TEM excision of lesions located in the upper rectum and in the anterior and lateral rectal wall [46, 47, 48]. These papers also demonstrated that for a surgeon with appropriate skills in transanal surgery, peritoneal entry during TEM can be safely closed transanally with direct defect sutures without the need for abdominal exploration [45, 46] and was not followed by increased postoperative morbidity [45, 48, 49]. As previously demonstrated in large TEM series, [47, 48], the occurrence of peritoneal entry was not associated with increased risks of infectious or other postoperative complications, or longer hospital stay. Several series have also demonstrated that peritoneal entry during TEM resection of rectal cancer was not associated with worse oncologic outcomes [48, 49]. Peritoneal entry during TAMIS has not been as frequently reported as during TEM procedures. In a TAMIS systematic review of 390 patients published in 2014, only four cases of inadvertent peritoneal opening have been documented during dissection of low rectal lesions, and only one required laparoscopic assistance for closure of the defect [50]. TAMIS experience for resection of upper rectal lesion is still limited in the literature, and among recent TAMIS series, the rate of peritoneal entry ranged from 0 to 10% [51, 52, 53]. However, a total of seven cases of peritoneal entry during TAMIS for upper rectal tumors have been described, six of which required conversion to laparoscopy or laparotomy. A recently published systematic review of 12 series of TEM procedures, including 4395 patients report that the rate of perforation into the peritoneal cavity was 5.1%, and conversion to an abdominal approach was required in 0.8% of cases [54]. Risk factor analysis identified anterior [46, 47] and upper rectal [45] tumor locations as significant risk factors for peritoneal entry. Also female sex during excision of anteriorly located lesions has been advocated as a risk factor due to the lower reflection of the anterior peritoneum in the female pelvis. Some authors state that in experienced hands, the majority of peritoneal defects could be closed transanally with significant decrease in conversion rate [49]. It is important to note that the definition used for peritoneal entry across different series is really heterogeneous, including: “major leakage of CO2 into the abdominal cavity resulted in significant technical difficulties” [55], “visible entrance into the peritoneal cavity” [46], “direct visualization of the defect during surgery” [45], while many studies do not explicitly state how they defined peritoneal entry [47, 48].
Transanal endoscopic direct closure of peritoneal defects appears to be feasible in more than 90% of cases, but it requires a significantly longer operating time (207.5 vs. 131.5 min) [55] from the increased technical complexity due to the loss of pneumorectum, producing a limited endoluminal vision and a troublesome reach of the peritoneal defect by the surgical instruments [49]. Authors experienced in both TEM and TAMIS transanal tumor excision have also suggested to shift to the TEM platform in case of peritoneal entry during TAMIS dissection, particularly for anterior and upper rectal lesions, to better manage the transanal peritoneal suture. This is due to the advantage offered by the rigid and longer rectoscope that is included in the TEM platform, which maintains the rectal wall stented allowing to suture the defect without the need for conversion [55]. In conclusion, peritoneal entry during local excision of a rectal tumor is a recognized intraoperative complication that can be adequately managed by endoluminal direct closure of the defect, not affecting the short- and long-term oncological results. However, extensive surgeon experience in transanal minimally invasive resection is required, together with the ability to use different transanal platforms. In the decision-making process for patient selection, the risk factors for peritoneal entry should be evaluated, considering the upper and anterior location of the lesion as an increased risk factor for this complication.
Postoperative rectal bleeding after TEM or TAMIS is the most frequently reported complication with a variable incidence ranging between 1.7% and 10.8% [56, 57, 58]. Nevertheless, in the literature the definition of rectal bleeding as a complication is heterogeneous, because the presence of a wound inside the rectum, whether completely sutured, partially sutured, or left open, causes variable blood emission after contact with the stools and with increasing internal pressure inside the rectum during defecation. This is a common occurrence, and it may be considered normal within the process. Therefore, rectal bleeding should be considered a cause of concern when the amount of blood loss produces anemia requiring blood transfusions and those requiring surgical revision, considering that more than 50% of post TEM/TAMIS bleeding episodes are self-limited. Some authors observed that bleeding is more consistent if it is associated with suture line dehiscence in patients with defect closure, and it is more frequent in patients whose defect was left open [59, 60]. Other authors instead did not observe a correlation between defect closure and risk for postoperative bleeding [15, 44]. Postoperative bleeding seems to be significantly reduced following the use of ultrasonic dissection during local excision, as compared with diathermy (1.1% vs. 6.3%) [44, 61]. According to Lee et al., postoperative bleeding was less common in sutured defects [12]. A retrospective analysis of 220 patients with full-thickness excision and 210 patients with partial-thickness excision showed an incidence of 30-day complications analogous for open and closed defects after full-thickness (15% vs. 12%, p = 0.432) and partial-thickness excisions (7% vs. 5%, p = 0.552). Although full-thickness excision in patients with open defects had a higher rate of clinically relevant postoperative bleeding complications (9% vs. 3%, p = 0.045) [62].
Use of hemostatic agents at the end of the resection is commonly part of the clinical practice; however, no focused trials have been published reporting its effectiveness in prevention of postoperative bleeding. In patients with consistent bleeding, usually endoscopic hemostatic techniques (argon, clipping, adrenaline injection), or TEM/TAMIS revision with defect suturing (or resuturing) may be effective in managing this complication without the need for creation of a diverting stoma or resorting to an anterior resection procedure [54, 57, 59].
The suture line dehiscence rate after full-thickness TEM and TAMIS is not negligible, and in the literature, it ranges between 2% and 22.7% [16, 17, 44, 63, 64]. Its clinical presentation may range from paucisymptomatic cases to a variable symptoms’ collection including rectal pain, bleeding, fever, and development of a pelvic abscess. Endoscopy is the primary investigation to assess the presence of suture line dehiscence, whereas transanal ultrasound, MRI, and CT scan should be reserved to the patients suspected for having developed a pelvic abscess. Many factors have been considered responsible for suture line dehiscence: tumor size and location [44], type of resection (full thickness), depth of excision, degree of tension on the suture line [16], type of suture (multiple interrupted sutures or single running suture) [60], previous neoadjuvant therapy [63, 64], and rectal wall ischemia [17]. Lateral or anterior location of the tumor associated with a defect size of 2 cm or more seems related to an increased risk of postoperative bleeding and pelvic collection with sepsis [56]. Bignell et al. reported that for lesions sited within 2 cm from the anal verge, an increased rate of complications occurs [44]. The risk of postoperative complications after neoadjuvant chemoradiotherapy was also reported by several authors [63, 64]. The high rate of suture line dehiscence in irradiated patients who underwent TEM/TAMIS could be a consequence of the detrimental effects of radiotherapy on the tissue, (free radical formation, DNA damage, tissue fibrosis, vascular thrombosis), with a consequently higher risk of suture line dehiscence and infection [65]. Moreover, in TEM irradiated patients, both sutured wound edges were previously irradiated, presenting all listed detrimental causes of damage, therefore the risk of wound complication is increased [63]. Some authors [16] suggested the degree of tension on the suture line and perirectal collection formation as primary causes for suture line dehiscence. This is particularly relevant in relation to extended endoluminal resection partially including perirectal fat, in which not only defect closure is mandatory to avoid pelvic contamination but the lack of tissue around the rectal wall resection becomes a “locus minoris resistentiae” where fluids collect increasing the suture line tension. With the aim of avoiding perirectal fluid collection, these authors proposed to stuff the rectal ampulla with two iodoform gauzes and to place a transanal Foley catheter with its tip well above the suture line for postoperative gas evacuation to be kept in place for 48 h. The rationale is to prevent overdistention of the rectal ampulla and at the same time obtain a moderate pressure to obliterate the remaining perirectal cavity. A wider residual cavity is subject to collection of larger amounts of fluids, which may lead to infection. This infected collection may spontaneously drain through the suture line, which in turn may lead to wound separation. The described technical details have reduced the dehiscence rate in the authors’ series from 12 to 0% for wide endoluminal resection independently of tumor location and previous radiation treatment.
Pelvic abscess occurs due to intraoperative seeding of bacteria aided by dissection into the retroperitoneum and diffusion from carbon dioxide insufflation. Extension of infection from the anal region into the retroperitoneum has been reported in the literature. Bacterial seeding may cause presacral and perirectal abscess that can extend into the perineal space or to the retroperitoneum along the psoas muscle. Its clinical presentation includes pelvic and anal pain, fever, increased inflammatory markers up to sepsis. Diagnosis requires radiological confirmation by CT scan or MRI to evaluate the extension of the infectious process and the involvement of pelvic and retroperitoneal structures. The occurrence of suture line dehiscence in full-thickness excision is considered a risk factor for pelvic abscess development. Bignell et al. series of 262 patients who underwent TEM for lesions located within 2 cm from the dentate line was associated with a higher incidence of pelvic sepsis (p < 0.02). Surprisingly, no statistical correlation between defect closure and pelvic abscess was found [44]. Many patients with pelvic sepsis were managed with diverting colostomy aimed at reducing perineal contamination [44, 63, 66]. Interventional radiology (IR) development, together with the extension of indications for percutaneous drainage, has progressively replaced the need for surgical revision in a large part of retroperitoneal and pelvic collections. Generally, retroperitoneal abscess management strategies include conservative treatment with antibiotics in association with radiologically guided percutaneous drains, versus traditional surgical exploration with abscess drainage and eventually fecal diversion [44, 63, 64, 66, 67]. The need for protective stoma should be evaluated and considered particularly in relation to the abscess extension and patients’ septic state. Small retroperitoneal abscesses (less than 3 cm in diameter) in a hemodynamically stable patient may be effectively treated with an extended course of antibiotics alone. However, larger abscesses or unresolving smaller abscesses must be drained either by percutaneous drain placement or by surgical exploration and drainage. Microbiological examination is required to shift from empirical antibiotic therapy to a tailored one. Surgery offers several advantages over IR drainage, including the ability to fully explore the anatomy and extent of the infection as well as the ability to remove fistulous tracts [68]. However, surgery does carry more significant risks, delays, and morbidity. Resolution and recurrence are similar between the surgical and IR approaches [68].
Concerning the issue of defect closure indications, several studies have directly compared the outcomes of leaving the defect open versus suture closure, reporting variable results. The first randomized controlled trial (RCT) on this subject, with short follow-up at 30 days [15], showed postoperative bleeding to be the only complication encountered, and both techniques were judged to be equally safe. This result was confirmed by a large multicenter comparative study in which the rectal defects were left open in 47% of patients, without increased complications [52]. However, a more recent study has postulated that open management of the rectal defect after TEM may be associated with a higher postoperative complications rate (19% vs. 8.4% p = 0.03) but also with lower readmission rates (4.7 vs. 12.4%, p = 0.01) [60]. Brown et al. also underlined the importance of performing defect closure as a surgical training modality to achieve rectal wall suturing skills, because involuntary opening of the peritoneum during transanal excision does require such technical skills to manage this complication without conversion.
Another topic of concern has been the association of TEM defect management and increased postoperative pain. This was reported by a 2011 study, stating that postoperative pain after defect suture closure was associated with a high readmission rate and a high incidence of wound dehiscence [69]. However, a more recent multicenter RCT has refuted these results, reporting no difference in postoperative pain between sutured or open defect management [70]. In conclusion, there is no evidence that closure of the defect will prevent complications, both approaches being equally safe. Nevertheless, the decision to close or not the defect, particularly after full-thickness excision, should be evaluated according to multiple parameters, including tumor position and size, extension and depth of resection, and surgeon’s technical skills.
Rectovaginal fistula after transanal excision is a rare iatrogenic complication, but a particularly challenging one to treat. In the literature it has been reported in a few series with an incidence rate of 0.5%–2.3% [62, 66]. It usually occurs after excision of anteriorly located lesions in women. The integrity of the rectovaginal septum should be monitored during surgery, and a vaginal examination is performed in case of doubt. Vaginal fistulas can result also from suture line dehiscence after defect closure of anterior lesion with development of a perirectal collection draining through the vaginal orifice, due to the poor vascularization and fragility of the rectovaginal septum, to the higher intraluminal rectal pressure and to the even higher pressure exerted on it during defecation. These fistulas are difficult to treat, requiring in many cases multiple reinterventions, starting with creation of a temporary stoma and subsequent repair of the fistula, which may be subject to failure. Typical clinical presentations include vaginal passage of air, stool, purulent drainage, or ill-smelling discharge, often associated with urinary infection. Diagnosis includes digital rectovaginal bimanual examination, vaginoscopy and proctoscopy, transanal blue methylene test, or transanal injection of iodine contrast agent followed by conventional X-ray or CT scan and MRI. Across the years, different techniques have been proposed for the surgical management of this complication: skin flaps, muscle flaps, musculocutaneous flaps, intestinal flaps, and the Martius flap, including subcutaneous tissue and bulbocavernosus muscle from one of the labia minora, and graciloplastica. The success rates ranged from 62–92% for patients not previously treated by radiotherapy and not affected by inflammatory bowel disease [71, 72, 73, 74, 75, 76, 77]. Among the unusual indications for TEM, there is also the possibility to close the fistula orifice after fecal diversion by a deferred transanal approach, as described by some authors in small series with good results [78, 79, 80].
Under physiologic conditions, rectal intralumenal air pressure ranges between 5 and 25 cm H2O, but during transanal procedures, the intralumenal pressure increases due to gas insufflation [81]. Common to all cases of pneumo-mediastinum and pneumo-retroperitoneum, the pathophysiological mechanism begins with gas migrating from the pelvis to the retroperitoneum and then to the cervical spaces, passing through the diaphragmatic hiatus, the posterior mediastinum, following the course of tracheal and esophageal walls, and then through any space delimited by skull, diaphragm, and both anterior and posterior cervical fasciae (the so-called Godinsky’s space) or the retropharyngeal space [81]. Air migration might be limited in overweight and obese subjects, as fat fills in all anatomical spaces. In patients who underwent general anesthesia, it is very important to exclude other causes of extralumenal gas, such as esophageal or tracheobronchial perforations that may occur intraoperatively during nasogastric tube positioning or endotracheal intubation. In most cases, treatment may be conservative with restricted diet, intravenous antibiotics administration, and close observation [12, 82, 83, 84, 85], although some authors prefer to treat this condition by fecal diversion [86, 87]. The presence of perirectal fluid and gas collection aerosol dissemination of bacteria and the subsequent risk of cardiac and respiratory infection or generalized sepsis must be considered in evaluating the opportunity of operative management. Frequent clinical symptoms reported in the literature are fever, pain, and subcutaneous emphysema, together with other less frequent symptoms such as dyspnea, dysphagia, or positive Kernig’s sign. Fever seems to be a recurrent finding especially during the first postoperative day, without specific correlation with a septic state in patients who do not present with fluid collection or abscess [12, 82, 83, 84, 85]. Fever could be related to transient aerosol dissemination of enteric bacteria trough the fascial spaces. Asymptomatic fever with no clinical evidence of infectious site has been described also in patients not presenting with pneumoretroperitoneum or subcutaneous emphysema, showing a self-limited trend with resolution within 2–3 days [50, 54, 66, 88].
Urinary complications are the second most frequent short-term complication after bleeding and have been reported in 5–10.8% of patients after transanal surgery [12, 54, 57, 66]. Urinary retention is a common complication after transanal procedures, especially in anterior resection, mainly occurring in male patients. Often it is classified as a Clavien-Dindo [89] grade II sequel, and it is easily managed by placement of a transurethral catheter [12, 54, 57, 66]. Reasons may be related to different factors: the anterior location of the excised lesion, preexisting prostatic hypertrophy, spinal anesthesia, and premature removal of the bladder catheter.
Rectal stenosis is relatively infrequent complication after transanal excision of rectal lesions, poorly reported in the literature with an incidence rate of 1.5–5.8% [44, 90, 91, 92, 93]. Rectal stenosis is associated with fecal urgency and incontinence, and it has a negative impact on the patients’ quality of life [64]. In a recently published series of 761 patients undergoing TEM, the overall stenosis rate was 3.2%; analyzing the correlation between tumor size and subsequent stenosis development, the authors did not find postoperative stenosis in tumors measuring less than 5 cm in diameter, but it appeared in 6.8% of very large tumors (5–9 cm) and in 13.9% of ultralarge tumors (>10 cm) [93]. Altaf et al. report an incidence of stenosis of 5.8% following transanal surgery, but it did not become obstructive in any patient [91], therefore not requiring endoscopic treatment. Bignell et al. reported a 1.5% rate of rectal stenosis underlining that none of the patients received neoadjuvant therapy before surgery, but 50% of them underwent four quadrants lesion’s excision [44].
The etiology of stenosis following anterior resection and total mesorectal excision is multifactorial, and it includes postoperative leaks and pelvic sepsis. It is also widely believed that ischemia plays an important role in stenosis formation. On the contrary, transanal excision is not associated with major alteration of blood supply; therefore, it appears that the only factor that may play a role is mucosal ischemia in association with the extension of the dissection. Several authors agree on the fact that circumferential excision or resection of lesions measuring more than 5 cm in diameter is the main risk factor for rectal stenosis, independently from the distance of the tumor from the anal verge or from neoadjuvant radiotherapy [44, 90, 91]. Once stenosis has occurred, there are several treatment options that have been already described in the setting of rectal stenosis following anterior resection. These options include surgical resection, transanal strictureplasty, balloon or surgical dilatation, and stenting [90, 92, 94]. In the literature, the majority of cases of rectal stenosis following transanal surgery can be easily treated by endoscopic balloon dilatation or with a day-case procedure under general anesthesia using Hegar’s dilators by single or multiple sessions [56, 90, 92, 94]. Surgical resection of the stenotic tract or fecal diversion should be reserved only to those patients who are refractory to endoscopic conservative treatment.
Despite the large diffusion of TEM and TAMIS for organ-sparing tumor resection in rectal cancer, several issues have been investigated to assess the safety of both techniques concerning the postoperative functional outcomes. This is due to the risk that rectal and anal stretching produced by the introduction of a wide proctoscope or platform during surgery, as well as partial organ resection reducing rectal compliance, might be the cause of postoperative functional disorders such as fecal incontinence, urgency, and soiling, with subsequent impairment of the patient’s quality of life (QoL). A recently published systematic review including 29 studies reporting the functional results following TEM or TAMIS surgery and including almost 1300 patients reveals that several studies reported some deterioration in manometric scores after both TEM and TAMIS and suggested worsening function, at least in some items of the used scores, including de novo incontinence development in some patients. However, globally the QoL does not seem to be significantly impaired after either procedure [95]. After tumor resection, continence was recovered or improved in several series following both TEM [33, 96, 97, 98, 99, 100] and TAMIS [101, 102]. On the contrary, worsening of fecal continence scores was reported by some studies assessing TEM functional outcomes [102, 103, 104, 105, 106]. Sphincter damage caused by anal dilation during surgery with the rigid TEM rectoscopes or platforms that are 4 cm in diameter [107, 108] has been advocated as a risk factor for postoperative incontinence, as well the surgical duration [108]. Moreover, partial rectal wall resection reduces rectal compliance, which might also result in later development of fecal symptoms as incontinence and urgency [33]. However, it should be underlined that some studies, including the authors’ previous series [33, 100], reported that postoperative incontinence after TEM was transient in many patients and improved at long term postoperative follow-up [97, 107, 109, 110, 111]. All these changes in anorectal physiology are mainly detected within the first 30 postoperative days and seem to significantly improve at 1 year after surgery; hence, they might not be clinically relevant to the patients in the long run [33, 104]. Mora Lopez et al. [104] found that only closer distance to the anal verge seemed to affect continence. Other reported risk factors for fecal incontinence included male gender, age at surgery, surgical time, extended resection, and full-thickness resection [103, 105, 110]. Khoury et al. [112] found that continence can be also affected by repeated TEM procedures, as the result of multiple anal sphincter complex traumas. There are very few available studies that included patients who underwent chemoradiotherapy before TEM [35, 64, 110, 113] and TAMIS [108], hence no conclusive data are available, although worsening functional outcomes have been reported in this group of patients as compared with those who underwent transanal surgery alone [35, 110, 113]. A possible explanation for worse results in irradiated patients can be postulated due to radiotherapy impairment of muscles and nerve fiber integrity and reduced rectal wall elasticity [114, 115]. This was reported by the authors [35] and Ghiselli et al. [110] after TEM surgery and by Clermonts et al. after TAMIS procedures [108]. In conclusion, TEM and TAMIS can be considered safe in terms of long-term functional outcomes, with only transient impairment of fecal continence and worsening QoL, showing almost complete anorectal physiology recovery within 1 year from surgery. Nevertheless, the duration of surgery together with tumor features (location, stage, and size) can be considered as a risk factor for deterioration of functional results together with combination of radiation treatment.
Transanal excision of rectal tumors is a valid, safe, and reproducible alternative to conventional anterior resection for the treatment of early rectal cancer, showing comparable oncological results with the advantages of an organ-sparing surgical strategy favorably impacting on overall patients’ QoL as compared with low anterior resection. Encouraging results have been obtained also in the treatment of locally advanced tumors in association with n-CRT, although randomized controlled trials with long-term follow-up and shared protocols are still needed to definitely asses the role of TEM and TAMIS in non-early rectal cancer. Globally, the morbidity rate of both techniques is lower than after anterior resection, and their main complications including postoperative bleeding, suture line dehiscence, and urinary complications can be safely managed in most cases without conventional surgical revision or fecal diversion. The functional outcomes are also satisfactory, with mainly transient disturbance of anorectal physiology and progressive functional recovery. In conclusion, transanal excision techniques must be rightfully included in the armamentarium of the technical skills of any colorectal surgeon for the multimodality treatment of rectal cancer.
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However, various aspects of the pharmacological roles of anthocyanins remain in the dark, having still several obstacles to the development of robust diets or prescribing lines on consumption of anthocyanins. The chemical structure of anthocyanins determines in large measure its capacity and efficacy as an antioxidant agent. In this study, the following aspects are reviewed: the antioxidant effect of anthocyanin pigments; the oxidative stress, the bioavailability after intake and biological aspects of anthocyanins, the method for measuring the antioxidant activity of anthocyanins, the relationship between structure and activity; and the influence of the anthocyanins in the antioxidant activity of wines. Finally an overview of some potential uses in food industry is attempted mainly focusing in the anthocyanin encapsulation topic. Attention has been paid to the more recent publications in the field.",book:{id:"5828",slug:"flavonoids-from-biosynthesis-to-human-health",title:"Flavonoids",fullTitle:"Flavonoids - From Biosynthesis to Human Health"},signatures:"Julia Martín, Eugenia Marta Kuskoski, María José Navas and Agustín\nG. Asuero",authors:[{id:"190870",title:"Dr.",name:"Agustín G.",middleName:null,surname:"Asuero",slug:"agustin-g.-asuero",fullName:"Agustín G. 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Therefore, they have been extensively investigated but the interest in them is still increasing. The topics that will be discussed in this chapter describe the regulation of flavonoid biosynthesis, the roles of flavonoids in flowers, fruits and roots and mechanisms involved in pollination and their specific functions in the plant.",book:{id:"5828",slug:"flavonoids-from-biosynthesis-to-human-health",title:"Flavonoids",fullTitle:"Flavonoids - From Biosynthesis to Human Health"},signatures:"Erica L. Santos, Beatriz Helena L.N. Sales Maia, Aurea P. Ferriani and\nSirlei Dias Teixeira",authors:[{id:"200495",title:"Dr.",name:"Erica",middleName:null,surname:"Santos",slug:"erica-santos",fullName:"Erica Santos"},{id:"200497",title:"Prof.",name:"Beatriz Helena",middleName:null,surname:"Sales Maia",slug:"beatriz-helena-sales-maia",fullName:"Beatriz Helena Sales Maia"},{id:"205184",title:"MSc.",name:"Aurea",middleName:null,surname:"Ferriani",slug:"aurea-ferriani",fullName:"Aurea Ferriani"},{id:"205185",title:"Prof.",name:"Sirlei",middleName:null,surname:"Teixeira",slug:"sirlei-teixeira",fullName:"Sirlei Teixeira"}]}],mostDownloadedChaptersLast30Days:[{id:"32936",title:"Phytochemicals: Extraction Methods, Basic Structures and Mode of Action as Potential Chemotherapeutic Agents",slug:"phytochemicals-extraction-methods-basic-structures-and-mode-of-action-as-potential-chemotherapeutic-",totalDownloads:95158,totalCrossrefCites:15,totalDimensionsCites:113,abstract:null,book:{id:"878",slug:"phytochemicals-a-global-perspective-of-their-role-in-nutrition-and-health",title:"Phytochemicals",fullTitle:"Phytochemicals - A Global Perspective of Their Role in Nutrition and Health"},signatures:"James Hamuel Doughari",authors:[{id:"65370",title:"Dr.",name:"James",middleName:null,surname:"Hamuel Doughari",slug:"james-hamuel-doughari",fullName:"James Hamuel Doughari"}]},{id:"55821",title:"New Insights Regarding the Potential Health Benefits of Isoflavones",slug:"new-insights-regarding-the-potential-health-benefits-of-isoflavones",totalDownloads:2742,totalCrossrefCites:6,totalDimensionsCites:9,abstract:"Isoflavones are a class of plant secondary metabolites, with an estrogen‐like structure presenting a plethora of biological activities. The chapter discusses important facts about this class of phytoestrogens, from biosynthesis to the latest research about their health benefits. The following major points discussed are: biosynthesis, regulation, isolation, metabolism and bioavailability, isoflavones in diet and intake, and new insights regarding the therapeutic effect including cancer chemoprevention. The chapter ends with a mini review of own research of the anti‐inflammatory and chemopreventive activity of isoflavonoid genistein alone and incorporated in modern pharmaceutical formulations. The chapter updates the interested researchers in the field with the latest progress regarding potential health benefits of isoflavones.",book:{id:"5828",slug:"flavonoids-from-biosynthesis-to-human-health",title:"Flavonoids",fullTitle:"Flavonoids - From Biosynthesis to Human Health"},signatures:"Corina Danciu, Suciu Oana, Diana Simona Antal, Florina Ardelean, Aimée Rodica\nChiş, Codruţa Şoica, Florina Andrica, Cristina Dehelean and Vlaicu Brigitha",authors:[{id:"141027",title:"Dr.",name:"Cristina",middleName:null,surname:"Dehelean",slug:"cristina-dehelean",fullName:"Cristina Dehelean"},{id:"186372",title:"Prof.",name:"Corina",middleName:null,surname:"Danciu",slug:"corina-danciu",fullName:"Corina Danciu"},{id:"186678",title:"Dr.",name:"Codruta",middleName:null,surname:"Soica",slug:"codruta-soica",fullName:"Codruta Soica"},{id:"186679",title:"Dr.",name:"Diana",middleName:null,surname:"Antal",slug:"diana-antal",fullName:"Diana Antal"},{id:"205282",title:"Dr.",name:"Florina",middleName:null,surname:"Ardelean",slug:"florina-ardelean",fullName:"Florina Ardelean"},{id:"205283",title:"Dr.",name:"Aimée Rodica",middleName:null,surname:"Chis",slug:"aimee-rodica-chis",fullName:"Aimée Rodica Chis"},{id:"205284",title:"Dr.",name:"Florina",middleName:null,surname:"Andrica",slug:"florina-andrica",fullName:"Florina Andrica"}]},{id:"54574",title:"Flavonoids: Classification, Biosynthesis and Chemical Ecology",slug:"flavonoids-classification-biosynthesis-and-chemical-ecology",totalDownloads:4380,totalCrossrefCites:15,totalDimensionsCites:32,abstract:"Flavonoids are natural products widely distributed in the plant kingdom and form one of the main classes of secondary metabolites. They display a large range of structures and ecological significance (e.g., such as the colored pigments in many flower petals), serve as chemotaxonomic marker compounds and have a variety of biological activities. Therefore, they have been extensively investigated but the interest in them is still increasing. The topics that will be discussed in this chapter describe the regulation of flavonoid biosynthesis, the roles of flavonoids in flowers, fruits and roots and mechanisms involved in pollination and their specific functions in the plant.",book:{id:"5828",slug:"flavonoids-from-biosynthesis-to-human-health",title:"Flavonoids",fullTitle:"Flavonoids - From Biosynthesis to Human Health"},signatures:"Erica L. Santos, Beatriz Helena L.N. Sales Maia, Aurea P. Ferriani and\nSirlei Dias Teixeira",authors:[{id:"200495",title:"Dr.",name:"Erica",middleName:null,surname:"Santos",slug:"erica-santos",fullName:"Erica Santos"},{id:"200497",title:"Prof.",name:"Beatriz Helena",middleName:null,surname:"Sales Maia",slug:"beatriz-helena-sales-maia",fullName:"Beatriz Helena Sales Maia"},{id:"205184",title:"MSc.",name:"Aurea",middleName:null,surname:"Ferriani",slug:"aurea-ferriani",fullName:"Aurea Ferriani"},{id:"205185",title:"Prof.",name:"Sirlei",middleName:null,surname:"Teixeira",slug:"sirlei-teixeira",fullName:"Sirlei Teixeira"}]},{id:"54713",title:"Isolation and Structure Identification of Flavonoids",slug:"isolation-and-structure-identification-of-flavonoids",totalDownloads:3846,totalCrossrefCites:10,totalDimensionsCites:19,abstract:"Flavonoids, which possess a basic C15 phenyl‐benzopyrone skeleton, refer to a series of compounds in which two benzene rings (ring A and B) are connected to each other through three carbon atoms. Based on their core structure, flavonoids can be grouped into different flavonoid classes, such as flavonols, flavones, flavanones, flavanonols, anthocyanidins, isoflavones and chalcones. Flavonoids are often hydroxylated in positions 3, 5, 7, 3′, 4′ and/or 5′. Frequently, one or more of these hydroxyl groups are methylated, acetylated, prenylated or sulfated. In plants, flavonoids are often present as O‐ or C‐glycosides. The O‐glycosides have sugar substituents bound to a hydroxyl group of the aglycone, usually located at position 3 or 7, whereas the C‐glycosides have sugar groups bound to a carbon of the aglycone, usually 6‐C or 8‐C. The most common carbohydrates are rhamnose, glucose, galactose and arabinose. This chapter mainly introduces the methods of isolation and structure identification of flavonoids.",book:{id:"5828",slug:"flavonoids-from-biosynthesis-to-human-health",title:"Flavonoids",fullTitle:"Flavonoids - From Biosynthesis to Human Health"},signatures:"Weisheng Feng, Zhiyou Hao and Meng Li",authors:[{id:"197976",title:"Prof.",name:"Weisheng",middleName:null,surname:"Feng",slug:"weisheng-feng",fullName:"Weisheng Feng"},{id:"204969",title:"Dr.",name:"Zhiyou",middleName:null,surname:"Hao",slug:"zhiyou-hao",fullName:"Zhiyou Hao"},{id:"204970",title:"Dr.",name:"Meng",middleName:null,surname:"Li",slug:"meng-li",fullName:"Meng Li"}]},{id:"56399",title:"Onions: A Source of Flavonoids",slug:"onions-a-source-of-flavonoids",totalDownloads:3240,totalCrossrefCites:6,totalDimensionsCites:18,abstract:"Flavonoids are a large and diverse group of polyphenolic compounds with antioxidant effects, and onion (Allium cepa L.) is one of the richest sources of dietary flavonoids. Flavonoid content is affected by endogenous factors—genotype and agro-environmental conditions. Considerable research has been directed toward understanding the nature of polyphenols in different products and the factors influencing their accumulation. This review examines the impacts of pre- and postharvest factors on onions’ flavonoid content, highlighting how this knowledge may be used to modulate their composition and the potential use of onion by-products.",book:{id:"5828",slug:"flavonoids-from-biosynthesis-to-human-health",title:"Flavonoids",fullTitle:"Flavonoids - From Biosynthesis to Human Health"},signatures:"Ana Sofia Rodrigues, Domingos P.F. Almeida, Jesus Simal-Gándara\nand Maria Rosa Pérez-Gregorio",authors:[{id:"197692",title:"Prof.",name:"Ana",middleName:null,surname:"Rodrigues",slug:"ana-rodrigues",fullName:"Ana Rodrigues"}]}],onlineFirstChaptersFilter:{topicId:"361",limit:6,offset:0},onlineFirstChaptersCollection:[],onlineFirstChaptersTotal:0},preDownload:{success:null,errors:{}},subscriptionForm:{success:null,errors:{}},aboutIntechopen:{},privacyPolicy:{},peerReviewing:{},howOpenAccessPublishingWithIntechopenWorks:{},sponsorshipBooks:{sponsorshipBooks:[],offset:8,limit:8,total:0},allSeries:{pteSeriesList:[{id:"14",title:"Artificial Intelligence",numberOfPublishedBooks:9,numberOfPublishedChapters:89,numberOfOpenTopics:6,numberOfUpcomingTopics:0,issn:"2633-1403",doi:"10.5772/intechopen.79920",isOpenForSubmission:!0},{id:"7",title:"Biomedical Engineering",numberOfPublishedBooks:12,numberOfPublishedChapters:104,numberOfOpenTopics:3,numberOfUpcomingTopics:0,issn:"2631-5343",doi:"10.5772/intechopen.71985",isOpenForSubmission:!0}],lsSeriesList:[{id:"11",title:"Biochemistry",numberOfPublishedBooks:31,numberOfPublishedChapters:314,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2632-0983",doi:"10.5772/intechopen.72877",isOpenForSubmission:!0},{id:"25",title:"Environmental Sciences",numberOfPublishedBooks:1,numberOfPublishedChapters:11,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2754-6713",doi:"10.5772/intechopen.100362",isOpenForSubmission:!0},{id:"10",title:"Physiology",numberOfPublishedBooks:11,numberOfPublishedChapters:141,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2631-8261",doi:"10.5772/intechopen.72796",isOpenForSubmission:!0}],hsSeriesList:[{id:"3",title:"Dentistry",numberOfPublishedBooks:8,numberOfPublishedChapters:129,numberOfOpenTopics:2,numberOfUpcomingTopics:0,issn:"2631-6218",doi:"10.5772/intechopen.71199",isOpenForSubmission:!0},{id:"6",title:"Infectious Diseases",numberOfPublishedBooks:13,numberOfPublishedChapters:113,numberOfOpenTopics:3,numberOfUpcomingTopics:1,issn:"2631-6188",doi:"10.5772/intechopen.71852",isOpenForSubmission:!0},{id:"13",title:"Veterinary Medicine and Science",numberOfPublishedBooks:11,numberOfPublishedChapters:105,numberOfOpenTopics:3,numberOfUpcomingTopics:0,issn:"2632-0517",doi:"10.5772/intechopen.73681",isOpenForSubmission:!0}],sshSeriesList:[{id:"22",title:"Business, Management and Economics",numberOfPublishedBooks:1,numberOfPublishedChapters:18,numberOfOpenTopics:2,numberOfUpcomingTopics:1,issn:"2753-894X",doi:"10.5772/intechopen.100359",isOpenForSubmission:!0},{id:"23",title:"Education and Human Development",numberOfPublishedBooks:0,numberOfPublishedChapters:5,numberOfOpenTopics:1,numberOfUpcomingTopics:1,issn:null,doi:"10.5772/intechopen.100360",isOpenForSubmission:!0},{id:"24",title:"Sustainable Development",numberOfPublishedBooks:0,numberOfPublishedChapters:14,numberOfOpenTopics:5,numberOfUpcomingTopics:0,issn:null,doi:"10.5772/intechopen.100361",isOpenForSubmission:!0}],testimonialsList:[{id:"6",text:"It is great to work with the IntechOpen to produce a worthwhile collection of research that also becomes a great educational resource and guide for future research endeavors.",author:{id:"259298",name:"Edward",surname:"Narayan",institutionString:null,profilePictureURL:"https://mts.intechopen.com/storage/users/259298/images/system/259298.jpeg",slug:"edward-narayan",institution:{id:"3",name:"University of Queensland",country:{id:null,name:"Australia"}}}},{id:"13",text:"The collaboration with and support of the technical staff of IntechOpen is fantastic. The whole process of submitting an article and editing of the submitted article goes extremely smooth and fast, the number of reads and downloads of chapters is high, and the contributions are also frequently cited.",author:{id:"55578",name:"Antonio",surname:"Jurado-Navas",institutionString:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRisIQAS/Profile_Picture_1626166543950",slug:"antonio-jurado-navas",institution:{id:"720",name:"University of Malaga",country:{id:null,name:"Spain"}}}}]},series:{item:{id:"14",title:"Artificial Intelligence",doi:"10.5772/intechopen.79920",issn:"2633-1403",scope:"Artificial Intelligence (AI) is a rapidly developing multidisciplinary research area that aims to solve increasingly complex problems. In today's highly integrated world, AI promises to become a robust and powerful means for obtaining solutions to previously unsolvable problems. This Series is intended for researchers and students alike interested in this fascinating field and its many applications.",coverUrl:"https://cdn.intechopen.com/series/covers/14.jpg",latestPublicationDate:"June 11th, 2022",hasOnlineFirst:!0,numberOfPublishedBooks:9,editor:{id:"218714",title:"Prof.",name:"Andries",middleName:null,surname:"Engelbrecht",slug:"andries-engelbrecht",fullName:"Andries Engelbrecht",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRNR8QAO/Profile_Picture_1622640468300",biography:"Andries Engelbrecht received the Masters and PhD degrees in Computer Science from the University of Stellenbosch, South Africa, in 1994 and 1999 respectively. He is currently appointed as the Voigt Chair in Data Science in the Department of Industrial Engineering, with a joint appointment as Professor in the Computer Science Division, Stellenbosch University. Prior to his appointment at Stellenbosch University, he has been at the University of Pretoria, Department of Computer Science (1998-2018), where he was appointed as South Africa Research Chair in Artifical Intelligence (2007-2018), the head of the Department of Computer Science (2008-2017), and Director of the Institute for Big Data and Data Science (2017-2018). In addition to a number of research articles, he has written two books, Computational Intelligence: An Introduction and Fundamentals of Computational Swarm Intelligence.",institutionString:null,institution:{name:"Stellenbosch University",institutionURL:null,country:{name:"South Africa"}}},editorTwo:null,editorThree:null},subseries:{paginationCount:6,paginationItems:[{id:"22",title:"Applied Intelligence",coverUrl:"https://cdn.intechopen.com/series_topics/covers/22.jpg",isOpenForSubmission:!0,annualVolume:11418,editor:{id:"27170",title:"Prof.",name:"Carlos",middleName:"M.",surname:"Travieso-Gonzalez",slug:"carlos-travieso-gonzalez",fullName:"Carlos Travieso-Gonzalez",profilePictureURL:"https://mts.intechopen.com/storage/users/27170/images/system/27170.jpeg",biography:"Carlos M. Travieso-González received his MSc degree in Telecommunication Engineering at Polytechnic University of Catalonia (UPC), Spain in 1997, and his Ph.D. degree in 2002 at the University of Las Palmas de Gran Canaria (ULPGC-Spain). He is a full professor of signal processing and pattern recognition and is head of the Signals and Communications Department at ULPGC, teaching from 2001 on subjects on signal processing and learning theory. His research lines are biometrics, biomedical signals and images, data mining, classification system, signal and image processing, machine learning, and environmental intelligence. He has researched in 52 international and Spanish research projects, some of them as head researcher. He is co-author of 4 books, co-editor of 27 proceedings books, guest editor for 8 JCR-ISI international journals, and up to 24 book chapters. He has over 450 papers published in international journals and conferences (81 of them indexed on JCR – ISI - Web of Science). He has published seven patents in the Spanish Patent and Trademark Office. He has been a supervisor on 8 Ph.D. theses (11 more are under supervision), and 130 master theses. He is the founder of The IEEE IWOBI conference series and the president of its Steering Committee, as well as the founder of both the InnoEducaTIC and APPIS conference series. He is an evaluator of project proposals for the European Union (H2020), Medical Research Council (MRC, UK), Spanish Government (ANECA, Spain), Research National Agency (ANR, France), DAAD (Germany), Argentinian Government, and the Colombian Institutions. He has been a reviewer in different indexed international journals (<70) and conferences (<250) since 2001. He has been a member of the IASTED Technical Committee on Image Processing from 2007 and a member of the IASTED Technical Committee on Artificial Intelligence and Expert Systems from 2011. \n\nHe has held the general chair position for the following: ACM-APPIS (2020, 2021), IEEE-IWOBI (2019, 2020 and 2020), A PPIS (2018, 2019), IEEE-IWOBI (2014, 2015, 2017, 2018), InnoEducaTIC (2014, 2017), IEEE-INES (2013), NoLISP (2011), JRBP (2012), and IEEE-ICCST (2005)\n\nHe is an associate editor of the Computational Intelligence and Neuroscience Journal (Hindawi – Q2 JCR-ISI). He was vice dean from 2004 to 2010 in the Higher Technical School of Telecommunication Engineers at ULPGC and the vice dean of Graduate and Postgraduate Studies from March 2013 to November 2017. He won the “Catedra Telefonica” Awards in Modality of Knowledge Transfer, 2017, 2018, and 2019 editions, and awards in Modality of COVID Research in 2020.\n\nPublic References:\nResearcher ID http://www.researcherid.com/rid/N-5967-2014\nORCID https://orcid.org/0000-0002-4621-2768 \nScopus Author ID https://www.scopus.com/authid/detail.uri?authorId=6602376272\nScholar Google https://scholar.google.es/citations?user=G1ks9nIAAAAJ&hl=en \nResearchGate https://www.researchgate.net/profile/Carlos_Travieso",institutionString:null,institution:{name:"University of Las Palmas de Gran Canaria",institutionURL:null,country:{name:"Spain"}}},editorTwo:null,editorThree:null},{id:"23",title:"Computational Neuroscience",coverUrl:"https://cdn.intechopen.com/series_topics/covers/23.jpg",isOpenForSubmission:!0,annualVolume:11419,editor:{id:"14004",title:"Dr.",name:"Magnus",middleName:null,surname:"Johnsson",slug:"magnus-johnsson",fullName:"Magnus Johnsson",profilePictureURL:"https://mts.intechopen.com/storage/users/14004/images/system/14004.png",biography:"Dr Magnus Johnsson is a cross-disciplinary scientist, lecturer, scientific editor and AI/machine learning consultant from Sweden. \n\nHe is currently at Malmö University in Sweden, but also held positions at Lund University in Sweden and at Moscow Engineering Physics Institute. \nHe holds editorial positions at several international scientific journals and has served as a scientific editor for books and special journal issues. \nHis research interests are wide and include, but are not limited to, autonomous systems, computer modeling, artificial neural networks, artificial intelligence, cognitive neuroscience, cognitive robotics, cognitive architectures, cognitive aids and the philosophy of mind. \n\nDr. Johnsson has experience from working in the industry and he has a keen interest in the application of neural networks and artificial intelligence to fields like industry, finance, and medicine. \n\nWeb page: www.magnusjohnsson.se",institutionString:null,institution:{name:"Malmö University",institutionURL:null,country:{name:"Sweden"}}},editorTwo:null,editorThree:null},{id:"24",title:"Computer Vision",coverUrl:"https://cdn.intechopen.com/series_topics/covers/24.jpg",isOpenForSubmission:!0,annualVolume:11420,editor:{id:"294154",title:"Prof.",name:"George",middleName:null,surname:"Papakostas",slug:"george-papakostas",fullName:"George Papakostas",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002hYaGbQAK/Profile_Picture_1624519712088",biography:"George A. Papakostas has received a diploma in Electrical and Computer Engineering in 1999 and the M.Sc. and Ph.D. degrees in Electrical and Computer Engineering in 2002 and 2007, respectively, from the Democritus University of Thrace (DUTH), Greece. Dr. Papakostas serves as a Tenured Full Professor at the Department of Computer Science, International Hellenic University, Greece. Dr. Papakostas has 10 years of experience in large-scale systems design as a senior software engineer and technical manager, and 20 years of research experience in the field of Artificial Intelligence. Currently, he is the Head of the “Visual Computing” division of HUman-MAchines INteraction Laboratory (HUMAIN-Lab) and the Director of the MPhil program “Advanced Technologies in Informatics and Computers” hosted by the Department of Computer Science, International Hellenic University. He has (co)authored more than 150 publications in indexed journals, international conferences and book chapters, 1 book (in Greek), 3 edited books, and 5 journal special issues. His publications have more than 2100 citations with h-index 27 (GoogleScholar). His research interests include computer/machine vision, machine learning, pattern recognition, computational intelligence. \nDr. Papakostas served as a reviewer in numerous journals, as a program\ncommittee member in international conferences and he is a member of the IAENG, MIR Labs, EUCogIII, INSTICC and the Technical Chamber of Greece (TEE).",institutionString:null,institution:{name:"International Hellenic University",institutionURL:null,country:{name:"Greece"}}},editorTwo:null,editorThree:null},{id:"25",title:"Evolutionary Computation",coverUrl:"https://cdn.intechopen.com/series_topics/covers/25.jpg",isOpenForSubmission:!0,annualVolume:11421,editor:{id:"136112",title:"Dr.",name:"Sebastian",middleName:null,surname:"Ventura Soto",slug:"sebastian-ventura-soto",fullName:"Sebastian Ventura Soto",profilePictureURL:"https://mts.intechopen.com/storage/users/136112/images/system/136112.png",biography:"Sebastian Ventura is a Spanish researcher, a full professor with the Department of Computer Science and Numerical Analysis, University of Córdoba. Dr Ventura also holds the positions of Affiliated Professor at Virginia Commonwealth University (Richmond, USA) and Distinguished Adjunct Professor at King Abdulaziz University (Jeddah, Saudi Arabia). Additionally, he is deputy director of the Andalusian Research Institute in Data Science and Computational Intelligence (DaSCI) and heads the Knowledge Discovery and Intelligent Systems Research Laboratory. He has published more than ten books and over 300 articles in journals and scientific conferences. Currently, his work has received over 18,000 citations according to Google Scholar, including more than 2200 citations in 2020. In the last five years, he has published more than 60 papers in international journals indexed in the JCR (around 70% of them belonging to first quartile journals) and he has edited some Springer books “Supervised Descriptive Pattern Mining” (2018), “Multiple Instance Learning - Foundations and Algorithms” (2016), and “Pattern Mining with Evolutionary Algorithms” (2016). He has also been involved in more than 20 research projects supported by the Spanish and Andalusian governments and the European Union. He currently belongs to the editorial board of PeerJ Computer Science, Information Fusion and Engineering Applications of Artificial Intelligence journals, being also associate editor of Applied Computational Intelligence and Soft Computing and IEEE Transactions on Cybernetics. Finally, he is editor-in-chief of Progress in Artificial Intelligence. He is a Senior Member of the IEEE Computer, the IEEE Computational Intelligence, and the IEEE Systems, Man, and Cybernetics Societies, and the Association of Computing Machinery (ACM). Finally, his main research interests include data science, computational intelligence, and their applications.",institutionString:null,institution:{name:"University of Córdoba",institutionURL:null,country:{name:"Spain"}}},editorTwo:null,editorThree:null},{id:"26",title:"Machine Learning and Data Mining",coverUrl:"https://cdn.intechopen.com/series_topics/covers/26.jpg",isOpenForSubmission:!0,annualVolume:11422,editor:{id:"24555",title:"Dr.",name:"Marco Antonio",middleName:null,surname:"Aceves Fernandez",slug:"marco-antonio-aceves-fernandez",fullName:"Marco Antonio Aceves Fernandez",profilePictureURL:"https://mts.intechopen.com/storage/users/24555/images/system/24555.jpg",biography:"Dr. Marco Antonio Aceves Fernandez obtained his B.Sc. (Eng.) in Telematics from the Universidad de Colima, Mexico. He obtained both his M.Sc. and Ph.D. from the University of Liverpool, England, in the field of Intelligent Systems. He is a full professor at the Universidad Autonoma de Queretaro, Mexico, and a member of the National System of Researchers (SNI) since 2009. Dr. Aceves Fernandez has published more than 80 research papers as well as a number of book chapters and congress papers. He has contributed in more than 20 funded research projects, both academic and industrial, in the area of artificial intelligence, ranging from environmental, biomedical, automotive, aviation, consumer, and robotics to other applications. He is also a honorary president at the National Association of Embedded Systems (AMESE), a senior member of the IEEE, and a board member of many institutions. His research interests include intelligent and embedded systems.",institutionString:"Universidad Autonoma de Queretaro",institution:{name:"Autonomous University of Queretaro",institutionURL:null,country:{name:"Mexico"}}},editorTwo:null,editorThree:null},{id:"27",title:"Multi-Agent Systems",coverUrl:"https://cdn.intechopen.com/series_topics/covers/27.jpg",isOpenForSubmission:!0,annualVolume:11423,editor:{id:"148497",title:"Dr.",name:"Mehmet",middleName:"Emin",surname:"Aydin",slug:"mehmet-aydin",fullName:"Mehmet Aydin",profilePictureURL:"https://mts.intechopen.com/storage/users/148497/images/system/148497.jpg",biography:"Dr. Mehmet Emin Aydin is a Senior Lecturer with the Department of Computer Science and Creative Technology, the University of the West of England, Bristol, UK. His research interests include swarm intelligence, parallel and distributed metaheuristics, machine learning, intelligent agents and multi-agent systems, resource planning, scheduling and optimization, combinatorial optimization. Dr. Aydin is currently a Fellow of Higher Education Academy, UK, a member of EPSRC College, a senior member of IEEE and a senior member of ACM. In addition to being a member of advisory committees of many international conferences, he is an Editorial Board Member of various peer-reviewed international journals. He has served as guest editor for a number of special issues of peer-reviewed international journals.",institutionString:null,institution:{name:"University of the West of England",institutionURL:null,country:{name:"United Kingdom"}}},editorTwo:null,editorThree:null}]},overviewPageOFChapters:{paginationCount:19,paginationItems:[{id:"82196",title:"Multi-Features Assisted Age Invariant Face Recognition and Retrieval Using CNN with Scale Invariant Heat Kernel Signature",doi:"10.5772/intechopen.104944",signatures:"Kamarajugadda Kishore Kumar and Movva Pavani",slug:"multi-features-assisted-age-invariant-face-recognition-and-retrieval-using-cnn-with-scale-invariant-",totalDownloads:6,totalCrossrefCites:0,totalDimensionsCites:0,authors:null,book:{title:"Pattern Recognition - New Insights",coverURL:"https://cdn.intechopen.com/books/images_new/11442.jpg",subseries:{id:"26",title:"Machine Learning and Data Mining"}}},{id:"82063",title:"Evaluating Similarities and Differences between Machine Learning and Traditional Statistical Modeling in Healthcare Analytics",doi:"10.5772/intechopen.105116",signatures:"Michele Bennett, Ewa J. Kleczyk, Karin Hayes and Rajesh Mehta",slug:"evaluating-similarities-and-differences-between-machine-learning-and-traditional-statistical-modelin",totalDownloads:6,totalCrossrefCites:0,totalDimensionsCites:0,authors:null,book:{title:"Machine Learning and Data Mining - Annual Volume 2022",coverURL:"https://cdn.intechopen.com/books/images_new/11422.jpg",subseries:{id:"26",title:"Machine Learning and Data Mining"}}},{id:"81791",title:"Self-Supervised Contrastive Representation Learning in Computer Vision",doi:"10.5772/intechopen.104785",signatures:"Yalin Bastanlar and Semih Orhan",slug:"self-supervised-contrastive-representation-learning-in-computer-vision",totalDownloads:23,totalCrossrefCites:0,totalDimensionsCites:0,authors:null,book:{title:"Pattern Recognition - New Insights",coverURL:"https://cdn.intechopen.com/books/images_new/11442.jpg",subseries:{id:"26",title:"Machine Learning and Data Mining"}}},{id:"79345",title:"Application of Jump Diffusion Models in Insurance Claim Estimation",doi:"10.5772/intechopen.99853",signatures:"Leonard Mushunje, Chiedza Elvina Mashiri, Edina Chandiwana and Maxwell Mashasha",slug:"application-of-jump-diffusion-models-in-insurance-claim-estimation-1",totalDownloads:8,totalCrossrefCites:0,totalDimensionsCites:0,authors:null,book:{title:"Data Clustering",coverURL:"https://cdn.intechopen.com/books/images_new/10820.jpg",subseries:{id:"26",title:"Machine Learning and Data Mining"}}}]},overviewPagePublishedBooks:{paginationCount:9,paginationItems:[{type:"book",id:"7723",title:"Artificial Intelligence",subtitle:"Applications in Medicine and Biology",coverURL:"https://cdn.intechopen.com/books/images_new/7723.jpg",slug:"artificial-intelligence-applications-in-medicine-and-biology",publishedDate:"July 31st 2019",editedByType:"Edited by",bookSignature:"Marco Antonio Aceves-Fernandez",hash:"a3852659e727f95c98c740ed98146011",volumeInSeries:1,fullTitle:"Artificial Intelligence - Applications in Medicine and Biology",editors:[{id:"24555",title:"Dr.",name:"Marco Antonio",middleName:null,surname:"Aceves Fernandez",slug:"marco-antonio-aceves-fernandez",fullName:"Marco Antonio Aceves Fernandez",profilePictureURL:"https://mts.intechopen.com/storage/users/24555/images/system/24555.jpg",biography:"Dr. Marco Antonio Aceves Fernandez obtained his B.Sc. (Eng.) in Telematics from the Universidad de Colima, Mexico. He obtained both his M.Sc. and Ph.D. from the University of Liverpool, England, in the field of Intelligent Systems. He is a full professor at the Universidad Autonoma de Queretaro, Mexico, and a member of the National System of Researchers (SNI) since 2009. Dr. Aceves Fernandez has published more than 80 research papers as well as a number of book chapters and congress papers. He has contributed in more than 20 funded research projects, both academic and industrial, in the area of artificial intelligence, ranging from environmental, biomedical, automotive, aviation, consumer, and robotics to other applications. He is also a honorary president at the National Association of Embedded Systems (AMESE), a senior member of the IEEE, and a board member of many institutions. His research interests include intelligent and embedded systems.",institutionString:"Universidad Autonoma de Queretaro",institution:{name:"Autonomous University of Queretaro",institutionURL:null,country:{name:"Mexico"}}}]},{type:"book",id:"7726",title:"Swarm Intelligence",subtitle:"Recent Advances, New Perspectives and Applications",coverURL:"https://cdn.intechopen.com/books/images_new/7726.jpg",slug:"swarm-intelligence-recent-advances-new-perspectives-and-applications",publishedDate:"December 4th 2019",editedByType:"Edited by",bookSignature:"Javier Del Ser, Esther Villar and Eneko Osaba",hash:"e7ea7e74ce7a7a8e5359629e07c68d31",volumeInSeries:2,fullTitle:"Swarm Intelligence - Recent Advances, New Perspectives and Applications",editors:[{id:"49813",title:"Dr.",name:"Javier",middleName:null,surname:"Del Ser",slug:"javier-del-ser",fullName:"Javier Del Ser",profilePictureURL:"https://mts.intechopen.com/storage/users/49813/images/system/49813.png",biography:"Prof. Dr. Javier Del Ser received his first PhD in Telecommunication Engineering (Cum Laude) from the University of Navarra, Spain, in 2006, and a second PhD in Computational Intelligence (Summa Cum Laude) from the University of Alcala, Spain, in 2013. He is currently a principal researcher in data analytics and optimisation at TECNALIA (Spain), a visiting fellow at the Basque Center for Applied Mathematics (BCAM) and a part-time lecturer at the University of the Basque Country (UPV/EHU). His research interests gravitate on the use of descriptive, prescriptive and predictive algorithms for data mining and optimization in a diverse range of application fields such as Energy, Transport, Telecommunications, Health and Industry, among others. In these fields he has published more than 240 articles, co-supervised 8 Ph.D. theses, edited 6 books, coauthored 7 patents and participated/led more than 40 research projects. 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He is currently a full professor in\nthe Department of Automation and Applied Informatics at the\nsame university. Dr. Voloşencu is the author of ten books, seven\nbook chapters, and more than 160 papers published in journals\nand conference proceedings. He has also edited twelve books and\nhas twenty-seven patents to his name. He is a manager of research grants, editor in\nchief and member of international journal editorial boards, a former plenary speaker, a member of scientific committees, and chair at international conferences. His\nresearch is in the fields of control systems, control of electric drives, fuzzy control\nsystems, neural network applications, fault detection and diagnosis, sensor network\napplications, monitoring of distributed parameter systems, and power ultrasound\napplications. 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Among them are those associated with pollution, resource extraction and overexploitation, loss of biodiversity, soil degradation, disorderly land occupation and planning, and many others. These anthropic effects could potentially be caused by any inadequate management of the environment. However, ecosystems have a resilience that makes them react to disturbances which mitigate the negative effects. It is critical to understand how ecosystems, natural and anthropized, including urban environments, respond to actions that have a negative influence and how they are managed. It is also important to establish when the limits marked by the resilience and the breaking point are achieved and when no return is possible. The main focus for the chapters is to cover the subjects such as understanding how the environment resilience works, the mechanisms involved, and how to manage them in order to improve our interactions with the environment and promote the use of adequate management practices such as those outlined in the United Nations’ Sustainable Development Goals.
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