Comparison of the properties of mouse ES cells (mESCs), mouse epiblast stem cells (mEpiSCs), human ES cells (hESCs) and human iPS cells (hiPSCs).
\\n\\n
Dr. Pletser’s experience includes 30 years of working with the European Space Agency as a Senior Physicist/Engineer and coordinating their parabolic flight campaigns, and he is the Guinness World Record holder for the most number of aircraft flown (12) in parabolas, personally logging more than 7,300 parabolas.
\\n\\nSeeing the 5,000th book published makes us at the same time proud, happy, humble, and grateful. This is a great opportunity to stop and celebrate what we have done so far, but is also an opportunity to engage even more, grow, and succeed. It wouldn't be possible to get here without the synergy of team members’ hard work and authors and editors who devote time and their expertise into Open Access book publishing with us.
\\n\\nOver these years, we have gone from pioneering the scientific Open Access book publishing field to being the world’s largest Open Access book publisher. Nonetheless, our vision has remained the same: to meet the challenges of making relevant knowledge available to the worldwide community under the Open Access model.
\\n\\nWe are excited about the present, and we look forward to sharing many more successes in the future.
\\n\\nThank you all for being part of the journey. 5,000 times thank you!
\\n\\nNow with 5,000 titles available Open Access, which one will you read next?
\\n\\nRead, share and download for free: https://www.intechopen.com/books
\\n\\n\\n\\n
\\n"}]',published:!0,mainMedia:null},components:[{type:"htmlEditorComponent",content:'
Preparation of Space Experiments edited by international leading expert Dr. Vladimir Pletser, Director of Space Training Operations at Blue Abyss is the 5,000th Open Access book published by IntechOpen and our milestone publication!
\n\n"This book presents some of the current trends in space microgravity research. The eleven chapters introduce various facets of space research in physical sciences, human physiology and technology developed using the microgravity environment not only to improve our fundamental understanding in these domains but also to adapt this new knowledge for application on earth." says the editor. Listen what else Dr. Pletser has to say...
\n\n\n\nDr. Pletser’s experience includes 30 years of working with the European Space Agency as a Senior Physicist/Engineer and coordinating their parabolic flight campaigns, and he is the Guinness World Record holder for the most number of aircraft flown (12) in parabolas, personally logging more than 7,300 parabolas.
\n\nSeeing the 5,000th book published makes us at the same time proud, happy, humble, and grateful. This is a great opportunity to stop and celebrate what we have done so far, but is also an opportunity to engage even more, grow, and succeed. It wouldn't be possible to get here without the synergy of team members’ hard work and authors and editors who devote time and their expertise into Open Access book publishing with us.
\n\nOver these years, we have gone from pioneering the scientific Open Access book publishing field to being the world’s largest Open Access book publisher. Nonetheless, our vision has remained the same: to meet the challenges of making relevant knowledge available to the worldwide community under the Open Access model.
\n\nWe are excited about the present, and we look forward to sharing many more successes in the future.
\n\nThank you all for being part of the journey. 5,000 times thank you!
\n\nNow with 5,000 titles available Open Access, which one will you read next?
\n\nRead, share and download for free: https://www.intechopen.com/books
\n\n\n\n
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Embryonic stem (ES) cells isolated from the inner cell mass (ICM) of blastocysts possess the defining pluroptency: unlimited self-renewal and giving rise to all cells of the organism[1, 2]. Thus, ES cells hold great promise for regenerative medicine to treat many diseases including heart failure, diabetes, Alzheimer’s and Parkinson’s disease by replacing the damaged cells with ES cell-derived healthy ones. The recent advent of induced pluripotent stem (iPS) cells reprogrammed from somatic cells has the potential to revolutionize the field of regenerative medicine since patient-derived iPS cells, in principle, circumvent the ethical problems and immune rejection associated with human ES cells[3]. Nevertheless, the future clinical translation of ES cells and iPS cells is facing numerous hurdles. Understanding the molecular mechanisms that impart ES cells with pluripotency may help address some of these challenges. The past few years have seen tremendous progress in understanding of mechanisms which govern ES cell pluripotency. In this chapter, we will review critical signaling and transcription factor networks that have been identified to maintain ES cell pluripotency.
ES cells require extrinsic growth factors to maintain their pluripotency in culture. These extrinsic growth factors act on different signaling pathways to regulate intrinsic transcription factor networks to sustain ES cells in the undifferentiated state. The signaling pathways required to support pluripotency in mouse ES cell are distinct from those in human ES cells (Figure 1).
Exogenous growth factors signal through distinct signaling pathways to regulate transcription factors for ES cell pluripotency.
Mouse ES cells were originally cultured on feeder layers derived from mouse embryonic fibroblasts (MEF). Later it was found that Leukaemia Inhibitory Factor (LIF), a member of the Interleukin-6 cytokines produced by MEFs, was the key factor to maintain pluripotency of mouse ES cells by inhibiting their differentiation[4]. Upon LIF binding, the LIF receptor recruits gp130 to form a heterodimer which subsequently activates Janus kinase (JAK) through transphosphorylation[5]. Activated JAK then phosphorylate gp130, creating a docking site to bind the SH2 domain of Signal Transducers and Activators of Transcription 3 (STAT3)[6-9]. Once STAT3 binds to the gp130 docking site, JAK then phosphorylates the recruited STAT3. Phosphorylated STAT3 forms a homodimer, which subsequently translocate into the nucleus, where it binds to gene enhancers to regulate target gene expression[10-12].
Although the LIF/JAK/STAT3 pathway has been well documented to maintain pluripotency of mouse ES cells in the presence of serum, the mechanisms by which activated STAT3 functions in this regard is poorly understood. Recently, studies in identification of STAT3 target genes have improved our understanding of activated STAT3 in maintaining pluripotency. Chen et al identified 718 STAT3-bound genomic sites that were co-occupied by pluripotency transcription markers (Oct4, Sox2 and Nanog) by using chromatin immunoprecipitation sequencing (ChIP-seq)[12]. In addition, Kidder and colleagues found that STAT3 target genes enriched in ES cells were downregulated in differentiated cells by mapping STAT3 binding targets in mouse ES cells and differentiated embryoid bodies (EBs)[13]. Along with these results, it has been demonstrated that knocking down STAT3-target genes induces activation of endodermal and mesodermal genes, supporting the conclusion that STAT3 prevents mESC differentiation by suppressing lineage-specific genes[14].
Interestingly, the LIF receptor and gp130 are also expressed in human ES cells and human LIF can induce STAT3 phosphorylation and nuclear translocation in human ES cells. However, human LIF is unable to maintain the pluripotent state of human ESs, suggesting that mouse and human ES cells require distinct signaling mechanisms to govern their pluripotency[15].
TGF-β superfamily consists of more than 40 members, including TGF-β, Activin, Nodal, and bone morphogenetic proteins (BMPs). The TGF-β members transduce signals by binding to heteromeric complexes of serine/threonine kinase receptors, type I and type II receptors, which subsequently activate intracellular Smad proteins. Smads 2 and 3 are specifically activated by activin, nodal and TGF-β ligands, whereas Smads 1, 5 and 8 are activated by BMP ligands[16, 17] (Figure 1). The TGF-β-related signaling pathways play complex roles in regulating the pluripotency and cell fate of ES cells.
Bone Morphogenetic Protein (BMP) is a subset of the TGF-β superfamily[18]. When BMP ligands bind to type II BMP receptors (BMPRII), BMPRII then recruits and phosphorylates type I BMP receptors (BMPRI). Activated type I receptors subsequently phosphorylate BMP-responsive SMAD1/5/8 which then forms a complex with SMAD4 and translocates into nucleus to regulate target gene expression (Figure 1). In mouse ES cells, LIF can substitute MEF feeder layers in maintaining pluripotency in the presence of animal serum by activating the transcription factor STAT3. However, in serum-free cultures, LIF is insufficient to block neural differentiation and maintain pluripotency. Recently, Ying et al reported that BMP was able to replace serum to maintain pluripotency of mouse ES cells in the presence of LIF. BMP has been shown to phosphorylate SMAD1/5 and activate inhibitors of differentiation (
In contrast to a maintenance role in mouse ES cell pluripotency, BMP has been shown to promote human ES cells differentiation to trophoblasts, and inhibiting BMP signaling with the BMP antagonist, Noggin, sustains the undifferentiated state of human ES cells[20, 21]. In consistence, dorsomorphin and DMH1, small molecule BMP inhibitors previously identified in our lab, were shown to promote long-term self-renewal an pluripotency of human ES cells, presumably by inhibiting BMP induced extraembryonic lineage differentiation[22-25].
Although MEFs feeder layers were initially used to co-culture both mouse and human ES cells, signal factors secreted from MEFs to maintain pluripotency of the two types of ES cells are fundamentally different. Sato et al first discoveried that TGF-β and Nodal genes were highly expressed in undifferentiated human ES cells[26]. Beattie et al later reported that Activin A, a member of the TGF-β superfamily, was secreted by MEFs, and medium enriched with activin A can replace MEF feeder-layers or MEF-conditioned media to maintain human ES cells in an undifferentiated state[27]. In consistence, James et al demonstrated that the TGF-β/Activin/Nodal pathway was activated through the transcription factors Smad2/3 in undifferentiated human ES cells[28]. The notion that TGF-β/Activin/Nodal signaling supports human ES self-renewal and pluripotency is further supported by the fact that recombinant Activin or Nodal stimulation induces higher levels of pluripotent protein expression (Oct4 and Nanog), while inhibition of TGF-β/Activin/Nodal signaling with Lefty or Follistatin decreases expression of these pluripotent proteins in human ES cells[29, 30].
Recent studies have focused on understanding the molecular mechanisms of TGF-β/Activin/Nodal signaling in retaining human ES cells pluripotency. Xu and colleagues showed that TGF-β/Activin/Nodal signaling activated Smad2/3 which subsequently binds to the Nanog promoter in undifferentiated human ES cells to induce expression of Nanog, a pluripotent transcription factor[31]. Additionally, mutating the putative Smad-binding sites reduced the response of Nanog to modulation of TGF-β signaling[31]. Nanog was also shown to coordinate with Smad2 in a negative-feedback loop to inhibit human ES cell differentiation[32]. In contrast to its important role in maintaining human ES cell pluripotency, the TGF-β/Activin/Nodal signaling is not essential for pluripotency of mouse ES cells. Although this pathway was shown to be active in undifferentiated mouse ES cells as assessed by phosphorylation of smad 2/3, inhibition of smad 2/3 phosphorylation by SB431542 had no effect on the undifferentiated state of mouse ES cells[28]. However, the TGF-β/Activin/Nodal signaling may play a role in mouse ES proliferation. A recent study showed that Inhibition of TGF-β/Activin/Nodal signaling by Smad7 or SB-431542 dramatically decreased mouse ES cell proliferation without effect on their pluripotency[33].
GDF-3 is another TGF-beta superfamily member that plays opposite roles in mouse and human ES cells. GDF-3, which acts as a BMP antagonist by direct binding to BMP-4, is specifically expressed in the pluripotent state of both mouse and human ES cells[34]. Ectopic expression of GDF-3 leads to the maintenance of pluripotency in human ES cells, whereas a similar effect is observed in mouse ES cells when GDF-3 levels are decreased. In the absence of LIF, GDF-3-deficient mouse ES cells can still sustain pluripotent markers[34]. These results are consistent with previously discussed BMP signals which can promote pluripotency of mouse ES cells, but cause differentiation of human ES cells. Thus lower concentrations of BMP antagonists, such as GDF-3, may enhance pluripotency in mouse ES cells, whereas higher levels of GDF-3 may favor pluripotency of human ES cells by abrogating BMP signaling.
The importance of Fibroblast growth factor (FGF) signaling for human ES cells pluripotency is highlighted by the facts that human ES cells are traditionally cultured in the presence of Fibroblast growth factors (FGFs) either on fibroblast feeder layers or in fibroblast-conditioned medium[35, 36]. Studies have demonstrated that all four FGF receptors (FGFR1, FGFR3 and FGFR4) and several components (SOS1, PTPN11 and RAF1) of their downstream activation cascade are significantly upregulated in undifferentiated human ES cells, in comparison to differentiated human ES cells[37-39]. In consistence, withdrawal of FGFs or inhibition of FGF signaling by a FGFR inhibitor, SU5402, rapidly induces human ES cell differentiation[40-42].
Although the pluirpotency maintenance role of exogenous FGFs in human ES cell has been known for a long time, the molecular mechanisms by which they function remain unclear. FGFs signal by binding to FGF receptors (FGFRs), and activate multiple signaling cascades, including Mitogen-Activated Protein Kinases (MAPKs), the Janus kinase/signal transducer and activator of transcription (Jak/Stat), phosphatidylinositol 3-kinase (PI3K) and phosphoinositide phospholipase C (PLCg) pathway[43]. Several studies have highlighted the FGF contribution to the maintenance of human ES cells mainly through the FGF/MEK pathway (Figure 1), [44, 45]. Studies have showed that FGF2 induces feeder layer cells to secret TGFβ1 and insulin-like growth factor 2 (IGF2), which can subsequently promote the undifferentiated state of human ES cells[46, 47]. Bendall et al further reported that the function of exogenous FGFs in promoting ES self-renewal could be replaced by addition of IGF2 alone, suggesting an indirect role of FGFs for human ES cell growth. However, this model was challenged in subsequent publications from Wang et al who reported that exogenous IGF2 alone was insufficient to maintain undifferentiated growth of human ES cells, and they proposed that FGFs may play a direct role in blocking caspase-activated apoptosis through anoikis in human ES cells[48]. Recently, Eiselleova and colleagues postulated a new model whereby endogenous FGF-2 signaling maintained the undifferentiated state and survival of human ESCs, while exogenous FGF-2 mainly suppress cell death and apoptosis genes, thus indirectly contributing to the maintenance of human ES cell pluripotency[49].
FGF signaling in mouse ES cells has also been extensively investigated. Mouse ES cells genetically deficient in Fgf4 and extracellular-signal regulated kinase 2 (Erk2) differentiate inefficiently. These results can be reproduced using inhibitors of FGF receptor and ERK, suggesting blockage of the FGF/MEK signaling pathway promotes mouse ES cell pluripotency[50-52]. Indeed, serum-free mouse ES cell medium supplemented with FGF/MEK inhibitors and LIF permits the derivation of mouse ES cells in the absence of feeders from strains normally considered non-permissive[53]. In addition, a recently identified compound, Pluripotin/SC1, has been shown to maintain mouse ES pluripotency by inhibiting ERK1 and activating the phophoinositide-3 kinase (PI3K) pathway through blocking RasGAP[54-56] [57, 58]. Although inhibition of FGF/MEK pathway can attenuate ES cell differentiation, it is insufficient to support mouse ES cell self-renewal. Combination of the MEK inhibitor PD0325901 with the Glycogen synthase kinase-3 (GSK-3) inhibitor CHIR99021 (known as 2i) can efficiently sustain the pluripotency of mouse ES cells in the absence of exogenous cytokines[59, 60]. Several groups demonstrated that improvement of mouse ES cell pluripotency by inhibition of GSK-3 occurred via Wnt/β-catenin signaling, whereas many others argued that GSK3 was likely to exert β-catenin independent effects in ES cells[59, 61-67].
As demonstrated above, human and mouse ES cells are both derived from blastocyst-stage embryos, but they require different biological signals for maintaining pluripotency. In general, mouse ES cells maintain their pluripotency by activating LIF/STAT3 and BMP signaling, while human ES cells require TGF-β/Nodal and FGF/MEK pathways. Interestingly, several pathways, such as BMP and FGF/MEK, have completely oppositing effects on maintaining the pluriotency of mouse and human ES cells. Activation of BMP signaling and inhibition of the FGF/MEK pathway promote mouse ES self-renewal, whereas inhibition of BMP signaling and activation of FGF/MEK pathway sustain human ES cell pluripotency. These distinct signaling effects on pluripotency may reflect intrinsic differences between mouse and human ES cells. Recent studies have demonstrated that conventional human ES cells do not represent the “ground or naïve state” of stemness, but rather a more developmentally mature “primed state” resembling mouse epiblast stem cells (mEpiSCs) found in the post-implantation, pre-gastrulation stage of embryos [68-74]. Conventional human ES cells exhibit numerous similarities to the mouse EpiSCs over mouse ES cells (Table 1). For instance, conventional human ES cells and mouse EpiSCs display flattened cell colonies and epigenetic X-chromosome inactivation (XiXa), and require Activin and FGF for pluripotency maintanince. In contrast, mouse ES cells exhibit dome-shaped colony morphology and epigenetic activation of both X-chromosome (XaXa), and require LIF/STAT3 signaling to promote self-renewal. Subsequent studies have demonstrated that the medium containing “2i” (MEK inhibitor and GSK-3 inhibitor), when supplemented with other factors (such as forskolin), can efficiently convert conventional human ES cells into a ground or “naïve” state with display of hallmark features of mouse ES cells. This medium can also maintain human ES cell pluriptoency at the naïve state [69, 70, 72, 75-78].
\n\t\t\t\t | \n\t\t
Comparison of the properties of mouse ES cells (mESCs), mouse epiblast stem cells (mEpiSCs), human ES cells (hESCs) and human iPS cells (hiPSCs).
ES cell pluripotency is conferred by a unique transcriptional network[79]. Early global transcriptional profiles and genetic studies have identified several critical transcription factors that are required for the pluripotency of ES cells, such as Oct4, Sox2, Nanog, Foxd3 and Id, etc [80-88]. Here we will mainly focus on Oct4, Sox2 and Nanog, three key transcription factors of the core pluripotency transcriptional network.
OCT4 (also known as Oct3), a POU domain-containing transcription factor, was one of the first transcription factors identified as essential for both early embryo development and pluripotency maintenance in ES cells[84, 89]. The expression of Oct4 is activated at the 8-cell stage and is later restricted to the inner cell mass (ICM) and germ cells in early mouse embryogenesis
Sox2 is an HMG-box transcription factor that is detected in pluripotent cell lineages and the nervous system[101-103]. Inactivate Sox2
Nanog is another homeobox-containing transcription factor that is specifically expressed in pluripotent ES cells. The essential role of Nanog in maintaining the pluripotency of ES cells is highlighted by the facts that Nanog-deficient ES cells are prone to differentiation, whereas forced expression of Nanog partially renders ES cells self-renewal potential in the absence of LIF[85, 86, 109]. How Nanog regulates stem cell pluripotency remains entirely unknown. Studies have indicated that Nanog may maintain ES cell pluripotency by 1) downregulating downstream genes essential for cell differentiation such as Gata4 and Gata6 and 2) activating the expression of genes necessary for self-renewal such as Rex1 and Id[19, 85, 86]. Although it is widely accepted that Nanog, like Oct4 and Sox2, play a central role in pluripotency maintenance, this dogma has been challenged by a subsequent report that Nanog protein levels are undetectable in a fraction of ES cells that express Oct4, and the pure populations of Nanog−/− ES cells can be propagated without losing expression of other pluripotency markers[110].
Little is known about the mechanism by which Nanog is regulated in ES cells. Recently, Suzuki et al showed that Nanog expression was upregulated by BrachyuryT and STAT3 in mouse ES cells[111]. In human ES cells and in mouse EpiSCs, Vallier et al reported that Activin/Nodal signaling stimulated expression of Nanog, which in turn prevents FGF-induced neuroectoderm differentiation [112]. In addition, several studies indicated that the Oct4/Sox2 complex was directly bound to the Nanog promoter to regulate target gene expression [106, 107, 113]. Genomic studies have revealed that Oct4, Sox2, and Nanog frequently bind the same regulatory regions in undifferentiated mouse and human ESCs, and that these binding sites are often in close proximity to one another[113-116]. These results indicate that Oct4, Sox2, and Nanog may physically interact with each other and coordinately regulate target genes in some cases. Additionally, Goke and colleagues reported that combinatorial binding sites of the Oct4/Sox2/Nanog were more conserved between mouse and human ES cells than individual binding sites were [113, 114, 117-119].
Understanding the molecular mechanism of pluripotency can greatly expand our knowledge of ES cell biology and facilitate future stem cell clinical applications. In the past few years, we have seen tremendous advances in understanding ES cell pluripotency. Although mouse ES cells and conventional human ES cells require distinct signaling pathways to maintain pluripotency, they display similar gene expression profiles, activities of transcription factors (such as Oct4, Nanog and Sox2) and transcription factor networks. Our understanding of pluripotency has been further expanded by the advent of iPS cells and the very recent discovery that conventional human ES cells are more equivalent to mouse EpiSCs, but rather “naïve state” of mouse ES cells. Nevertheless, our knowledge of the molecular mechanisms of ES cell pluripotency is still very limited. For instance, it remains unknown how growth factors establish and control transcriptional networks to regulate pluripoency and how ES cells respond so precisely to exogenous cues. Given the rapid advance in ES cell biology, we anticipate the molecular mechanisms underlying pluripotency of ES cells will soon be uncovered and pluripotent stem cells, such as ES cells and iPS cells, will be widely used for clinical applications in the near future.
This work is funded by the seed fund of the Western University of Health Sciences.
Anal fistulas, especially complex anal fistulas, still present a challenge for surgeons because of their high recurrence rate, possible postoperative risk of fecal incontinence and also the fact that nowadays we still do not have a standardized procedure of choice for treatment.
An anal fistula is defined as an abnormal communication between perianal skin and anal canal, filled with granulation and fibrotic tissue that supports chronic inflammation, disabling spontaneous healing. Most fistulas are of cryptoglandular etiology, but can also be associated with inflammatory bowel disease (Mb Crohn), malignancies, trauma, pelvic sepsis or diverticulitis. Incidence of the disease is about 10 cases per 100,000 individuals with a male to female ratio of 2:1 [1, 2].
In the past, various classifications for anal fistulas were proposed. One of the most widespread classifications was Parks’ classification which classified fistulas according to their correlation with anal sphincter complex and divided fistulas into intersphincteric, transsphincteric, suprasphincteric and extrasphincteric [3].
Surgeons noticed, using traditional surgical techniques such as fistulotomy, fistulectomy or cutting seton, frequent continence disturbance following operations, especially in cases when fistula tract passed through deeper parts of sphincter complex and internal fistula opening was positioned more proximally in the anal canal.
To simplify classification and to prevent possible postoperative continence disturbance, colorectal surgeons nowadays mostly use simple classification which divides fistulas into two groups: simple and complex, according to the relation of the proportion of the anal sphincter mechanism they pass through. The classification that distinguishes simple and complex anal fistulas helps the surgeon to avoid using traditional techniques to prevent possible continence disturbance, but does not help in the decision which operative technique is best to use in the treatment of complex fistulas. Classification by Garg is extrapolated from multiple clinical scenarios and presents a better correlation with an actual patient case (Figure 1).
Garg classification of anal fistulas (with permission of Dr. Pankaj Garg).
Simple anal fistulas have only one tract that crosses less than 30% of the anal sphincter complex and can be treated by fistulotomy or fistulectomy with very low postoperative continence disturbance incidence and high healing rate.
All other fistulas are classified as complex. These fistulas cross the anal sphincter at a point that encompasses more than 30% of the external anal sphincter. They can have multiple tracts. Complex fistulas also include those about inflamatory bowel disease (IBD), those which are anteriorly positioned in female patients or those which are recurrent. If those fistulas are treated with fistulotomy or some other traditional technique, it can result in some type of postoperative fecal incontinence. The average rate of continence disturbance, such as flatus or liquid stool leakage following fistulotomy, was observed in 20–25% cases and up to 12% cases after cutting seton treatment [4, 5]. This effect on continence has resulted in traditional surgical techniques being less favorable for complex anal fistulas treatment and the incentive to use minimally invasive sphincter sparing techniques is increasing.
In anal fistula treatment, it is important to apply an appropriate surgical approach to obtain the best postoperative results such as high primary healing rate, low postoperative pain, low risk for any type of fecal incontinence, low recurrence rate and to subsequently increase postoperative patient’s life quality.
To delve into the intricacies of anal fistulas, one must first understand hypotheses that currently exist. The most widespread hypothesis is the cryptoglandular one which states that infected or inflamed anal glands are the cause of anal abscess and fistula [6]. This could be due to the ascending inflammation originating in the anal canal or blockage of discharge. Over almost 150 years, much research was done to find out exact relationship between anal glands and anal fistula, and while some researchers found them to correlate, others weren’t even able to prove the existence of anal glands or found them to be very variable at best [7]. Nevertheless, this is the predominant theory that surgeons adhere to throughout the modern surgery era, and anal glands seem to be the likely culprit. Despite this, etiology remains uncertain or unknown, but the inflammatory process seems to play a crucial role.
From the anatomical standpoint, it was stated by Parks that anal fistula is the chronic manifestation of anal abscess that is an acute condition. Fistula forms as a consequence of the medio-lateral spread of infection that subsequently may perforate the anal sphincter complex and extend to the perianal skin, thus forming a fistula [3]. More recently, Garg has shown that intersphincteric space plays a major role in anal fistula pathology, stating that almost all complex fistulas have some degree of intersphincteric involvement and that fistula in closed intersphincteric space acts like an abscess and must be treated accordingly [8, 9].
Molecular analyses of an anal fistula are scarce. One study has shown abundant expression of pro-inflammatory cytokine IL-1b in 93 % of the cryptoglandular anal fistulas, along with increased levels of cytokines IL-8, IL-12p40 and TNF-α in anal fistulas [10]. IL-1, especially IL-1β are strong pro-inflammatory cytokines that can be stimulated by other cytokines, microbial products and even IL-1β by auto stimulation, which can play a role in the recurrence or persistence of anal fistula. Tozer et al. showed immunological differences between cryptoglandular and Crohn’s disease-associated fistula [11]. While those are undoubtedly valuable findings that advance our understanding of anal fistula pathology, they still don’t change anything in our management of this problem.
To achieve best results, accomplish a higher primary healing rate, prevent recurrence and risk of postoperative continence disturbance, it is essential to identify the entire course of fistula tract including infected anal gland in intersphincteric space, main and possible secondary tracts. In that way, one can decide which surgical option is best for the patient.
After performing DRE, additional usage of the metal probe with insertion through fistula canal should be done to identify which type of fistula patient has so one can decide which surgical option should be performed. In case of pain, this can be performed under anesthesia (EUA: examination under anesthesia) [12]. In the case of a simple anal fistula, it is usually sufficient to examine as mentioned above, but in cases of a complex anal fistula in most cases, additional diagnostic methods should be done.
Some diagnostic methods that have previously been used to verify the course of fistula tracts, have since been abandoned. One of these techniques is X-ray fistulography. This technique is not performed anymore because it does not show the correlation of the fistula tract to the anal sphincter complex, so in that way, surgeon does not know which type of anal fistula the patient has [13].
Possible options to verify the correlation of the fistula tract with anal sphincter complex are: CT fistulography, endoanal ultrasound (EUS) and MRI fistulography.
CT fistulography can be more accurate in cases associated with acute inflammations and abscesses, but it somewhat deficient in cases of mature anal fistula.
Endoanal ultrasound (EUS) is a very good option to verify fistula tract correlation with sphincter complex and possible secondary branches but it is a highly operator-dependent technique [14, 15, 16].
For now, the golden standard for anal fistula diagnosis and classification is magnetic resonance imaging (MRI). MRI helps not only to accurately demonstrate disease extension but also to predict prognosis, make therapy decisions and can be used in some cases in follow-up periods especially in the patient suffering from Crohn´s disease or recurrent fistula (Figure 2) [16, 17, 18, 19, 20, 21].
MR fistulography clearly shows horseshoe fistula on axial view.
One other possibility in the verification of main fistula tract and possible secondary branches is using fistuloscope during the diagnostic phase of VAAFT procedure (video-assisted anal fistula treatment) but the technique can also be considered as operator-dependent [22]. VAAFT procedure will be discussed later in this chapter.
It is stated that the ideal treatment for anal fistula lies on two principles. The first is the eradication of sepsis and promotion of fistula tract healing, and the second is preserving the sphincter complex and continence mechanism [23]. With simple fistulas, this can be achieved by laying open the fistulous tract with high healing rates and with no significant continence disturbance [24]. While simple fistulas have simple treatment solutions, the concept of treatment for complex fistulas is somewhat different, and while the above-mentioned principle holds, certain aspects should be explained.
Colorectal surgeons’ postulate that internal fistula openings should always be identified and closed. This was shown in a meta-analysis by Mei et al. with class I evidence for significant association between anal fistula recurrence and failure to identify and close internal fistula opening. The same meta-analysis also showed the connection between horseshoe fistula extensions and recurrence [25]. Both of these problems could be solved by applying video-assisted approach in treatment. This covers the first principle.
To achieve the second principle in complex anal fistula, sphincter preserving techniques should be used to address the anal continence problem. Currently, no study compares lay open techniques and sphincter preserving techniques for complex anal fistula treatment but other studies have shown that, in this case, lay open techniques have an unacceptably high incidence of continence disturbance, up to 25% [4]. Meanwhile, sphincter preserving techniques for complex fistulas, with the possible exception of rectal advancement flap, have shown to have no or only minor continence disturbances in up to 1.7% patients [26].
A somewhat different approach, arising from analysis of modern sphincter preserving techniques, to the ideal treatment of anal fistulas was described by Garg. He hypothesized that in order to successfully heal anal fistula, we should bear in mind three principles:
Intersphincteric fistula tract acts like an abscess in closed intersphincteric space.
Second principle follows the first: intersphincteric fistula must be drained and continuous drainage should be ensured.
Healing occurs progressively until interrupted irreversibly by a collection [9].
This may be the reason why most sphincter preserving treatment methods still do not have healing results comparable to lay open techniques.
When talking about traditional techniques in anal fistula treatment we refer to fistulotomy, fistulectomy or techniques with seton placement in the anal fistula canal. Even since Hippocrates, there have been advices and different references on how one should treat anal fistula [27]. Traditional techniques were used in the treatment of anal fistula during history, before the development of sphincter preserving techniques.
Fistulotomy as the oldest, simplest and most widely performed procedure in anal fistula treatment has its benefits and drawbacks. This procedure, with its synonym “lay open technique,” is quite a simple procedure in which the surgeon, after insertion of the metal probe, cuts (or lays open) the whole of fistula tract from the internal fistula opening which is located in the anal canal to the external opening situated on the perianal skin. Following this, the surgeon performs curettement of granulation tissue from the fistula tract remnant making, in a sense, an acute wound that should heal by secondary intention. Some surgeons perform additional marsupialization of wound edges the following fistulotomy to reduce postoperative bleeding and to speed up wound healing (Figure 3) [28].
Fistulotomy with marsupialization (shown by red arrows).
In this way, crucial postulates in anal fistula treatment are satisfied, except the preservation of anal sphincter complex to a lesser degree. Even though this procedure has a success rate of more than 90%, it is also associated with some type of postoperative continence disturbance in cases when the fistula tract crosses through deeper parts of the anal sphincter complex and when the internal fistula opening is placed more proximally in the anal canal. The incontinence rate following these procedures vary given the heterogeneity of anal fistulas, but can be up to 28% [4, 29].
In recent times, according to Garg’s classification, this technique should be only reserved for treatment of type 1 and 2 anal fistulae without risk of continence disturbance, meaning low intersphincteric and low transsphincteric fistula (simple anal fistula) [30].
Fistulectomy is performed by excising the whole of fistula tract, removing in that way the whole fistula tract from external fistula opening to internal fistula opening, without preservation of anal sphincter complex. In a meta-analysis that included 565 patients comparing fistulectomy and fistulotomy for low anal fistulas, there has been no conclusive evidence as to which procedure is better in simple anal fistula treatment [31].
Failure of treatment with fistulotomy of fistulectomy and recurrence is associated with inappropriate selection of patients with high anal fistulas or those with multiple tracts.
The seton placement technique distinguishes between “cutting” and “loose” seton.
Cutting seton technique is nowadays almost abandoned but was used to convert high anal fistula to low one which was later treated by lay open technique. Seton was made of unabsorbable material, placed through the anal fistula canal and then tightened enabling in that way slow cutting of the sphincter mechanism leaving behind a scar. The idea behind the technique was that it would prevent anal sphincter muscle to split and, in that way, to prevent serious problems with continence disturbance. It was proven however, that this technique has a high incidence of continence disturbance with high morbidity and recurrence rates [5].
When talking about the role of loose seton the situation is somewhat different. Loose seton should be placed through the fistula tract without tightening, helping in that way to reduce sepsis and to mature the fistula tract. This would be the first stage in resolving of anal fistula problem. Many surgeons advocate loose seton placement as an important step of rectal advancement flap procedure or LIFT (ligation of intersphincteric fistula tract) prior to that operation, even though there has not been clear clinical evidence [32, 33]. Seton placement before fistulotomy with sphincter reconstruction has shown its benefits in fistula treatment, namely in converting high transsphincteric to low transsphincteric fistula and also in the acute abscess stage before this procedure to reduce the risk of breakdown of sphincter repair [34].
As mentioned earlier, the high risk of postoperative continence disturbance after treatment of complex anal fistulas with traditional techniques, have led to the need for the development of new techniques, which would be dubbed “sphincter preserving techniques.” The main characteristic of such techniques is that they prevent or greatly reduce any possibility of postoperative fecal incontinence. Various sphincter preserving techniques were introduced in clinical practice in the last 10–15 years. Among these are laser treatment procedure (FiLaC®: fistula laser closure), fibrin glue treatment, anal fistula plug, VAAFT procedure (video-assisted anal fistula treatment), LIFT procedure (ligation of intersphincteric fistula tract), anal fistula treatment with platelet cells (PRP: platelet rich plasma), RAF (rectal advancement flap) and others. [22, 33, 35, 36, 37, 38, 39, 40, 41, 42].
Some sphincter preserving techniques weren’t broadly accepted given high cost, high recurrence rates or inability to reproduce similar results in other centers. Of above-mentioned sphincter preserving techniques, several gained wider acceptance, such as LIFT, VAAFT, and RAF technique.
Ligation of intersphincteric fistula tract (LIFT) is a sphincter preserving technique first performed and published by Rojanasakul [39]. This technique satisfies all goals of anal fistula treatment such as the closure of internal fistula opening, removal of infected intersphincteric fistula tract (anal gland) and eradication of remaining fistula tract. It is reserved for the treatment of complex transsphincteric anal fistulas. After identification of fistula tract using metal, probe surgeon makes a curvilinear incision on the anocutaneous border entering intersphincteric space and performs preparation of intersphincteric part of anal fistula, followed by removal of the intersphincteric portion of the fistula. Closure of remaining defect of anal fistula on internal and external anal sphincter muscle then follows. Curettement of remaining fistula tract from external fistula opening to external anal sphincter muscle should be performed. Intersphincteric space is then reconstructed and the perianal wound sutured.
According to the two available meta-analyses, this procedure gives an overall success rate of 76.4 and 78 % respectively, with a low complication rate 5.5–13.9%. The most common complication was wound dehiscence, and others were bleeding, infection, hematoma, anal discharge. Only a low grade of postoperative fecal incontinence in 1.4% of patents was recorded (Figure 4) [33, 43].
LIFT procedure: identification of fistula tract in the intersphincteric plane; red arrow showing fistula tract.
This technique is easily reproducible without the necessity of investment in potentially expensive equipment. In case of dehiscence of intersphincteric space loose seton can be inserted through the intersphincteric wound, thus making conversion of transsphincteric fistula in intersphincteric one, which can be afterward treated by fistulotomy without fear of continence disturbance.
Video-assisted anal fistula treatment (VAAFT) procedure is the only technique that enables visualization and operation of anal fistula from within fistula tract, using specially designed equipment. This sphincter preserving technique was developed by Meinero who described short and long-term results [22].
Using a special instrument (fistuloscope), the surgeon visualizes the fistula tract from inside, which helps to identify possible secondary branches of the fistula tract, abscess cavities and later destroys all chronic granulation tissue in the fistula tract making in that way an acute wound which should heal by secondary intention. The important part of this technique is also to identify the internal fistula opening inside the anal canal and to close it securely (Figures 5–9).
Intraoperative view of the fistula tract through fistuloscope.
Fulguration of the fistulous tract.
View of the debris after fulguration.
Postoperative view after VAAFT for complex horseshoe fistula.
Healed wounds in the same patient.
Many surgeons worldwide accepted this technique in their everyday practice for the treatment of complex anal fistulas [22, 38, 44, 45, 46].
The main indication for this technique is the treatment of complex anal fistulas, especially cases with multiple secondary branches which are deep in the ischioanal fossa and are not easily reached. Also, VAAFT has its benefits in treatment of patients who have anal fistula associated with Crohn’s disease, helping to ameliorate symptoms associated with chronic anal fistula such as pain and soiling, thus significantly increasing patient’s quality of life [44, 47]. VAAFT technique is comparable with other sphincter preserving techniques to healing and patient satisfaction. Diminished postoperative pain, earlier recovery after surgery and smaller postoperative perianal wounds allows for earlier return to normal activities [48].
In case of failure, this technique can be repeated because there is no risk for any continence disturbance following this procedure. The proposed mechanism whereby repeated procedures have an incremental effect is the conversion of complex fistula with multiple tracts into a more manageable, low or simple fistula, which can be called conversion of the fistula. [38]
VAAFT technique has been proven to be a safe procedure, associated with good functional outcomes and a very low incidence of complications [22, 44, 45], which was shown in a published meta-analysis [46]. It showed a recurrence rate ranging from 7.5 to 33.3% with a weighted mean recurrence rate of 17.7%. Recurrence rates varied significantly depending on the method of internal fistula opening closure (mattress suture, stapler, rectal advancement flap). No affection of anal continence was documented.
This technique is one of the oldest techniques which were and still are reserved for the treatment of complex anal fistulas especially in cases with large internal fistula opening. When discussing this technique, we can’t talk about the “pure” sphincter preserving technique because flap should be performed by dissection of anorectal mucosa and adjacent internal anal sphincter muscle, so in that way, internal anal sphincter muscle does not stay intact.
When doing this procedure surgeon should identify and excise the internal fistula opening in the anal canal. Then the U-shaped or rhomboid flap with a wider base side should be performed by dissecting anorectal mucosa and adjacent internal anal sphincter muscle. Curettement and irrigation of the whole fistula tract should be performed, followed by suture of a defect in sphincter complex left by earlier fistula tract. The site is then a covered by previously prepared flap and sutured. Even though much research has been made about optimal flap thickness, researchers found that there was a statistically higher rate of primary healing in cases with thicker flaps, but also have noticed a higher rate of mild postoperative continence disturbance which was more severe than the thicker flap was (Figure 10) [41, 49, 50].
Formed rectal advancement flap.
There have been many publications and several systematic reviews and meta-analyses on this technique where the effectiveness was shown to be 60–80%, but the same cases also reported some degree of postoperative fecal disturbance [42, 50, 51].
Factors that could affect healing after flap procedure are obesity and smoking, so patients should be advised to quit smoking and to try to reduce their weight prior to flap operation [52, 53, 54]. To increase the effectiveness of this technique one should perform bigger rhomboid or U-shape flaps using the minimally invasive approach, avoiding tissue trauma made by surgical cautery, avoiding excessive grasping as well as the too big strain of suture line.
As mentioned earlier in this chapter, there is no universal approach for anal fistula treatment. Some other possible solutions may be hybrid sphincter preserving techniques, fistulotomy with primary sphincter reconstruction, TROPIS (trans anal opening of the intersphincteric space) and use of autologous platelet rich plasma in anal fistula treatment.
Hybrid sphincter preserving techniques are combinations of two or more sphincter preserving techniques in a single procedure to increase healing rates and achieving better results.
Several reports exist with different combinations of techniques with authors trying to achieve higher healing rates, but the majority of reports are on a single institution basis or case reports with a small number of patients.
A combination of VAAFT and LIFT techniques was performed with intention of secure closure of internal fistula opening from intersphincteric space and additional exploration and eradication of remaining fistula tract from external fistula opening with identification of possible secondary branches using fistuloscope [55, 56]. VAAFT was also used in different combinations with other sphincter preserving techniques such as FiLaC® procedure and with RAF procedure in cases with large internal fistula opening [38, 44, 57].
The combination of LIFT technique with the insertion of a bioprosthetic graft in intersphincteric space was also described in a study that included 31 patients, where the success rate was 94% in a one-year follow-up period [58]. Another study combined LIFT and human acellular dermal matrix as a bioprosthetic plug with a reported success rate of 95% on a 21-patient sample [59]. Rectal advancement flap with the injection of porcine dermal collagen implant through the external opening was combined in a study which included 24 patients with a success rate of 82.5% in a 14-month follow-up period [60].
It was to be expected that surgeons started to combine two or more sphincter preserving techniques to achieve better results, but until evidence is found that one technique, or combination of techniques, has significantly better results over the others, they should be tailored individually depending on patient’s case.
This approach in the treatment of anal fistulas has the same operative philosophy as fistulotomy or fistulectomy, but is reserved for higher fistulas. In this procedure surgeon after eradication of the fistula tract and possible secondary fistula branches to prevent recurrences, makes additional anal sphincter reconstruction to try to eliminate the possibility of postoperative fecal incontinence. Ratto et al. reported a 93.2% overall success rate with a low morbidity rate using this approach. Overall postoperative fecal incontinence was 12.4% mainly post-defecation soiling, without significant changes in anorectal manometry parameters [61]. Voon et al. reported their experience in using this technique and had good outcomes with a very low rate of continence disturbance in follow-up period [34]. Even though this technique has been implemented in guidelines for anal fistula treatment by several surgical societies, it wasn’t accepted worldwide as the standardized procedure [62]. In case of abscess formation as the initial presentation, it is crucial to place seton drainage to give enough time for maturing of the fistula and to prevent continence disturbance following fistulotomy.
This technique was described and published by Garg, who used this approach in the treatment of high complex anal fistulas with a high primary healing rate and very low incidence of morbidities [8]. It is well known that high intersphincteric parts of anal fistula and abscesses are difficult to reach through intersphincteric approach or probing from external fistula opening, as well as that they are usually branching.
TROPIS approach also satisfies golden principles in the treatment of anal fistula such as identification and resolving internal fistula opening problem, as well as intersphincteric fistula tract with the accompanying anal gland, and also eradication of remaining fistulous tract by curettement.
The procedure is done by laying open intersphincteric space through internal anal with preservation of external sphincter. The external tracts in the ischioanal fossa should be curetted and the intersphincteric space is left open for secondary healing. In the initial prospective cohort which included 61 patients, the success rate was 84.6% with no significant changes with continence. The study included patients with high transsphincteric (anterior and posterior) and high intersphincteric type of fistula [8].
TROPIS procedure is an excellent approach for posterior high transsphincteric type and high intersphincteric type of anal fistula, especially if transsphincteric fistula is located at the puborectalis level. However, combination with drainage (preoperative seton placement and postoperative drain placement in remaining tract from external fistula opening), curettement or excision of external tracts is necessary to reduce recurrences.
Autologous platelet rich plasma (APRP) is nowadays used in various fields of medicine such as orthopedics, plastic surgery, dental medicine, but also in the treatment of anal fistula in the last decade. APRP is platelet concentration derived from centrifuged full blood after removal of red blood cells. Such prepared plasma is a rich source of various growth factors implicated in regeneration and tissue healing [63, 64].
The procedure consists of curettement of fistula tract and closure of internal fistula opening with an additional injection of previously prepared platelet rich autologous blood sample [65]. The majority of publications combined mucosal advancement flap with APRP injection [65, 66, 67]. Several publications reported an average healing rate from 60 to 90% [40, 66, 67, 68]. The drawbacks of mentioned publications were that they had a relatively small number of patients enrolled and still no meta-analyses exist on the subject. No problem with any type of postoperative fecal incontinence was reported. This is still considered to be a somewhat experimental procedure and is not widely used. The platelet separation procedure requires special equipment that is often only available in larger institutions. Also cost per patient exceeds that of the other techniques, which is why this technique needs more solid evidence for a patient benefit before it can be considered to become one of the mainstream sphincters preserving treatments.
We can say that fistulas associated with Crohn’s disease present a special entity in the treatment of anal fistulas. This kind of fistula presents a huge challenge for surgeons despite numerous surgical possibilities and technical advancements in recent years. Symptoms associated with Crohn’s anal fistula include purulent drainage, severe pain, possible continence disturbance which all can lead to a significant reduction in quality of life. These kinds of fistulas are often recurrent and hard to treat. The incidence of anal fistulas in patients with Crohn’s disease is 5 to 40% and is more common in patients who have a higher severity of colorectal inflammation [69, 70, 71].
Even though numerous surgical techniques have been described for the treatment of this kind of anal fistulas, the choice of which technique is best often depends on the anatomy, presence of local inflammation, type of fistula, and surgeon’s experience (Figure 11) [72, 73, 74].
Perianal form of Crohn’s disease in female patient: multiple treatment methods combined (fistulotomy with marsupialization, seton placement, VAAFT).
Many management proposals have been published, but all had higher reports of postoperative complications such as continence disturbance, infection and high recurrence rate compared to the same type of fistulas not associated with Crohn’s disease. Currently, numerous novel surgical sphincters preserving techniques are being studied to less invasively induce fistula healing while maintaining fecal continence. When we discuss surgical treatment of complex anal fistulas in Crohn’s disease, the goal should be to ameliorate symptoms associated with this kind of fistulas and to improve patients’ quality of life. Although, various endoscopic and surgical techniques exist, there is no gold-standard treatment strategy for patients with perianal fistulas [44, 47, 75, 76].
Treatment of Crohn’s disease-associated anal fistula should always be multidisciplinary including surgeons, radiologists and gastroenterologists with the use of antibiotics, immunosuppressors and anti-inflammatory agents [77, 78, 79, 80, 81].
General principles in the treatment of this condition are underlined here, but the treatment of an anal form of Crohn’s disease is a complex topic, requiring a chapter on its own.
The problem of anal continence presents a big obstacle when trying to treat anal fistula. It is of paramount importance to avoid any continence disturbances which in itself presents a hurdle to implementing more successful but invasive procedures regarding the anal sphincter mechanism. The solution might lie in a relatively new paradigm that puts intersphincteric space as a likely culprit to fistula recurrence or nonhealing, and subsequent shift in surgical approach. These new approaches still require multicentric verifications to be implemented as a mainstream treatment option.
Overall, novel approaches in anal fistula treatment, while not entirely successful in all of the patients, offer a significant increase in patients’ quality of life, and allow for repeated surgical procedures if the initial operation fails at no expense on the anal sphincter.
While various researchers made different molecular research on anal fistula that increased our understanding of fundamental pathologic mechanisms, still no findings translate into clinical practice in the sense that they made any difference on already existing surgical approaches.
The most widespread classification of fistulas are somewhat inadequate and do not transfer well to clinical situations. Parks classification may describe the relation of the anal fistula to anal sphincter muscles but does not distinguish between simple and complex fistulas. St. James University Hospital classification also doesn’t seem relatable to the clinical situations in the era of sphincter preserving techniques. A possible solution to this may be Garg classification that still needs confirmatory commentaries from other colorectal surgeons and proctologists.
Anal fistulas in Crohn’s disease present a different challenge. With current surgical solutions, we cannot hope to cure the condition but rather to ameliorate symptoms. Medical therapy in combination with surgical solutions can significantly reduce the severity of the disease and even hope to eradicate it completely.
The anal fistula condition remains a daunting task for the surgeon and a strenuous malady for the patient. Even though recent years brought advancements in the form of sphincter preserving techniques, which greatly improved treatment options, still no golden standard for anal fistula treatment exists. This problem still seems unlikely to resolve given the heterogeneity of pathology unless a radically different approach or breakthrough isn’t achieved.
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In 2010, he received a Ph.D. in Egyptology from the University of Basel, Switzerland.\nFrom 2012 to 2017, Dr. Pereira was a post-doctoral fellow at CHAM/FCSH – Universidade Nova de Lisboa.\nIn 2018, he became an Onassis Fellow, hosted by the Department of Mediterranean Studies, University of the Aegean, Greece. \nIn 2019, he became an auxiliary researcher at CHAM/FCSH – Universidade Nova de Lisboa. He teaches Middle Egyptian grammar, Hieratic, and disciplines regarding Egyptology, and the history of Phoenician and Greek expansion in the Mediterranean basin. \nIn 2021, he was awarded a CAARI Scholar in Residence Fellowship.",institutionString:"Universidade NOVA de Lisboa",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"1",totalChapterViews:"0",totalEditedBooks:"0",institution:{name:"Universidade Nova de Lisboa",institutionURL:null,country:{name:"Portugal"}}},equalEditorTwo:null,equalEditorThree:null,productType:{id:"4",chapterContentType:"chapter",authoredCaption:"Authored by"}},{type:"book",id:"10342",title:"Ovarian Cancer",subtitle:"Updates in Tumour Biology and Therapeutics",isOpenForSubmission:!1,hash:"25a0adac7f6afa7bcd0b6daa3ef6b538",slug:"ovarian-cancer-updates-in-tumour-biology-and-therapeutics",bookSignature:"Gwo-Yaw Ho and Kate Webber",coverURL:"https://cdn.intechopen.com/books/images_new/10342.jpg",editedByType:"Edited by",editors:[{id:"297757",title:null,name:"Gwo-Yaw",middleName:null,surname:"Ho",slug:"gwo-yaw-ho",fullName:"Gwo-Yaw Ho"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"10485",title:"Fibroids",subtitle:null,isOpenForSubmission:!1,hash:"64ad14b1aba83e47fb100fa63e21533e",slug:"fibroids",bookSignature:"Hassan Abduljabbar",coverURL:"https://cdn.intechopen.com/books/images_new/10485.jpg",editedByType:"Edited by",editors:[{id:"68175",title:"Prof.",name:"Hassan",middleName:"S",surname:"Abduljabbar",slug:"hassan-abduljabbar",fullName:"Hassan Abduljabbar"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}}],booksByTopicTotal:67,seriesByTopicCollection:[],seriesByTopicTotal:0,mostCitedChapters:[{id:"30747",doi:"10.5772/27200",title:"Cervical Cancer in Sub Sahara Africa",slug:"cervical-cancer-in-sub-sahara-africa",totalDownloads:8076,totalCrossrefCites:24,totalDimensionsCites:36,abstract:null,book:{id:"951",slug:"topics-on-cervical-cancer-with-an-advocacy-for-prevention",title:"Topics on Cervical Cancer With an Advocacy for Prevention",fullTitle:"Topics on Cervical Cancer With an Advocacy for Prevention"},signatures:"Atara Ntekim",authors:[{id:"69178",title:"Dr.",name:"Atara",middleName:"I",surname:"Ntekim",slug:"atara-ntekim",fullName:"Atara Ntekim"}]},{id:"43348",doi:"10.5772/55562",title:"Molecular Mechanisms of Platinum Resistance in Ovarian Cancer",slug:"molecular-mechanisms-of-platinum-resistance-in-ovarian-cancer",totalDownloads:4257,totalCrossrefCites:20,totalDimensionsCites:30,abstract:null,book:{id:"3449",slug:"ovarian-cancer-a-clinical-and-translational-update",title:"Ovarian Cancer",fullTitle:"Ovarian Cancer - A Clinical and Translational Update"},signatures:"Gonzalo Tapia and Ivan Diaz-Padilla",authors:[{id:"157073",title:"Dr.",name:"Ivan",middleName:null,surname:"Diaz-Padilla",slug:"ivan-diaz-padilla",fullName:"Ivan Diaz-Padilla"},{id:"166871",title:"Dr.",name:"Gonzalo",middleName:null,surname:"Tapia Rico",slug:"gonzalo-tapia-rico",fullName:"Gonzalo Tapia Rico"}]},{id:"37219",doi:"10.5772/47914",title:"Determining Factors of Cesarean Delivery Trends in Developing Countries: Lessons from Point G National Hospital (Bamako - Mali)",slug:"determining-factors-of-cesarean-delivery-trends-in-developing-countries-lessons-from-point-g-nat",totalDownloads:3047,totalCrossrefCites:7,totalDimensionsCites:21,abstract:null,book:{id:"952",slug:"cesarean-delivery",title:"Cesarean Delivery",fullTitle:"Cesarean Delivery"},signatures:"I. Teguete, Y. Traore, A. Sissoko, M. Y. Djire, A. Thera, T. Dolo, N. Mounkoro, M. Traore and A. Dolo",authors:[{id:"87496",title:"Dr.",name:"Ibrahima",middleName:null,surname:"Teguete",slug:"ibrahima-teguete",fullName:"Ibrahima Teguete"}]},{id:"31273",doi:"10.5772/31669",title:"Aqueous Extract of Human Placenta",slug:"aqueous-extract-of-human-placenta-as-a-therapeutic-agent",totalDownloads:5593,totalCrossrefCites:5,totalDimensionsCites:20,abstract:null,book:{id:"702",slug:"recent-advances-in-research-on-the-human-placenta",title:"Recent Advances in Research on the Human Placenta",fullTitle:"Recent Advances in Research on the Human Placenta"},signatures:"Piyali Datta Chakraborty and Debasish Bhattacharyya",authors:[{id:"88185",title:"Prof.",name:"Debasish",middleName:null,surname:"Bhattacharyya",slug:"debasish-bhattacharyya",fullName:"Debasish Bhattacharyya"},{id:"127848",title:"Dr.",name:"Piyali Datta",middleName:null,surname:"Chakraborty",slug:"piyali-datta-chakraborty",fullName:"Piyali Datta Chakraborty"}]},{id:"27121",doi:"10.5772/27439",title:"Clinical Risk Factors for Preterm Birth",slug:"clinical-risk-factors-for-preterm-birth",totalDownloads:8765,totalCrossrefCites:9,totalDimensionsCites:19,abstract:null,book:{id:"776",slug:"preterm-birth-mother-and-child",title:"Preterm Birth",fullTitle:"Preterm Birth - Mother and Child"},signatures:"Ifeoma Offiah, Keelin O’Donoghue and Louise Kenny",authors:[{id:"68552",title:"Dr.",name:"Ifeoma",middleName:null,surname:"Offiah",slug:"ifeoma-offiah",fullName:"Ifeoma Offiah"},{id:"70166",title:"Prof.",name:"Louise",middleName:null,surname:"Kenny",slug:"louise-kenny",fullName:"Louise Kenny"},{id:"74717",title:"Dr.",name:"Keelin",middleName:null,surname:"O'Donoghue",slug:"keelin-o'donoghue",fullName:"Keelin O'Donoghue"}]}],mostDownloadedChaptersLast30Days:[{id:"58219",title:"Congenital Abdominal Anomalies",slug:"congenital-abdominal-anomalies",totalDownloads:1420,totalCrossrefCites:0,totalDimensionsCites:0,abstract:"Introduction: Abdominal anomalies that appear during intrauterine life are complex due to many organs that are affected. In cases, the ultrasound appearance is a cystic image with different content and the differential diagnosis is often difficult. Body—research methods: the organs affected by abdominal congenital anomalies involve the gastrointestinal tract (stomach, duodenum, small bowel or colon, and gall bladder), the kidney and urinary tract, the peritoneal cavity (ascites), suprarenal glands, and tumors of the reproductive system (especially the ovaries). In order to identify the affected structures, it is mandatory to know the normal aspect of the abdominal content at different gestational ages. The diagnosis may be very difficult, but its accuracy is important, considering the need of further counseling the couple. In minor conditions, without chromosomal anomalies or associations, the outcome is usually good, and there are even possibilities of in utero treatment. In severe conditions, with poor outcome, the couple can choose to terminate the pregnancy, after counseling is provided. Conclusion: abdominal congenital anomalies are common findings in ultrasound screenings for anomalies in all the trimesters of pregnancy and their recognition is important for subsequent management.",book:{id:"6307",slug:"congenital-anomalies-from-the-embryo-to-the-neonate",title:"Congenital Anomalies",fullTitle:"Congenital Anomalies - From the Embryo to the Neonate"},signatures:"Ples Liana and Anca Lesnic",authors:[{id:"212333",title:"Associate Prof.",name:"Liana",middleName:null,surname:"Ples",slug:"liana-ples",fullName:"Liana Ples"}]},{id:"64417",title:"Introductory Chapter: A Comprehensive Approach to the Process of Breastfeeding",slug:"introductory-chapter-a-comprehensive-approach-to-the-process-of-breastfeeding",totalDownloads:1306,totalCrossrefCites:0,totalDimensionsCites:0,abstract:null,book:{id:"6191",slug:"selected-topics-in-breastfeeding",title:"Selected Topics in Breastfeeding",fullTitle:"Selected Topics in Breastfeeding"},signatures:"René Mauricio Barría P",authors:[{id:"88861",title:"Dr.",name:"R. Mauricio",middleName:null,surname:"Barría",slug:"r.-mauricio-barria",fullName:"R. Mauricio Barría"}]},{id:"62854",title:"The Surgical Technique of Caesarean Section: What is Evidence Based?",slug:"the-surgical-technique-of-caesarean-section-what-is-evidence-based-",totalDownloads:2586,totalCrossrefCites:1,totalDimensionsCites:1,abstract:"Caesarean section is the most frequent obstetric operation which is associated with increased maternal morbidity and mortality. Although these risks are low, affected women may suffer from severe consequences and this may affect subsequent pregnancies and deliveries. A variety of surgical approaches have been described, however, on low evidence level. The objective of this chapter is therefore to systematically search the literature and analyse the available evidence including preoperative workup, prophylactic antibiotics, skin disinfection, preoperative bladder catheterization as well as details of the individual steps of the actual operation itself such as skin incision types, preparation of soft tissue and womb, removal of the placenta, cervical dilatation and stitching of the womb, peritoneum, rectus muscle, fascia, subcutaneous fat, and skin. We systematically searched for meta-analysis, systematic reviews, and big studies and evaluated the evidence for each individual step.",book:{id:"6707",slug:"caesarean-section",title:"Caesarean Section",fullTitle:"Caesarean Section"},signatures:"Jan-Simon Lanowski and Constantin S. von Kaisenberg",authors:[{id:"100660",title:"Prof.",name:"Constantin",middleName:"Sylvius",surname:"Von Kaisenberg",slug:"constantin-von-kaisenberg",fullName:"Constantin Von Kaisenberg"},{id:"240353",title:"Dr.",name:"Jan-Simon",middleName:null,surname:"Lanowski",slug:"jan-simon-lanowski",fullName:"Jan-Simon Lanowski"}]},{id:"18348",title:"Anaesthetic Considerations during Laparoscopic Surgery",slug:"anaesthetic-considerations-during-laparoscopic-surgery",totalDownloads:28978,totalCrossrefCites:1,totalDimensionsCites:5,abstract:null,book:{id:"916",slug:"advanced-gynecologic-endoscopy",title:"Advanced Gynecologic Endoscopy",fullTitle:"Advanced Gynecologic Endoscopy"},signatures:"Maria F. Martín-Cancho, Diego Celdrán, Juan R. Lima, Maria S. Carrasco-Jimenez, Francisco M. Sánchez-Margallo and Jesús Usón-Gargallo",authors:[{id:"14715",title:"Prof.",name:"Francisco M.",middleName:null,surname:"Sánchez-Margallo",slug:"francisco-m.-sanchez-margallo",fullName:"Francisco M. Sánchez-Margallo"},{id:"29449",title:"Dr.",name:"Maria Fernanda",middleName:null,surname:"Martín-Cancho",slug:"maria-fernanda-martin-cancho",fullName:"Maria Fernanda Martín-Cancho"},{id:"39772",title:"Dr.",name:"Juan R.",middleName:null,surname:"Lima",slug:"juan-r.-lima",fullName:"Juan R. Lima"},{id:"39773",title:"Mr.",name:"Diego",middleName:null,surname:"Celdran",slug:"diego-celdran",fullName:"Diego Celdran"},{id:"39774",title:"Prof.",name:"Jesus",middleName:null,surname:"Usón-Gargallo",slug:"jesus-uson-gargallo",fullName:"Jesus Usón-Gargallo"},{id:"62320",title:"Prof.",name:"Maria Sol",middleName:null,surname:"Carrasco-Jiménez",slug:"maria-sol-carrasco-jimenez",fullName:"Maria Sol Carrasco-Jiménez"}]},{id:"41721",title:"Artificial Insemination in Poultry",slug:"artificial-insemination-in-poultry",totalDownloads:9631,totalCrossrefCites:5,totalDimensionsCites:14,abstract:null,book:{id:"3206",slug:"success-in-artificial-insemination-quality-of-semen-and-diagnostics-employed",title:"Success in Artificial Insemination",fullTitle:"Success in Artificial Insemination - Quality of Semen and Diagnostics Employed"},signatures:"M.R. Bakst and J.S. Dymond",authors:[{id:"155683",title:"Dr.",name:"Murray R.",middleName:null,surname:"Bakst",slug:"murray-r.-bakst",fullName:"Murray R. Bakst"},{id:"167852",title:"Dr.",name:"Jessica",middleName:null,surname:"Dymond",slug:"jessica-dymond",fullName:"Jessica Dymond"}]}],onlineFirstChaptersFilter:{topicId:"189",limit:6,offset:0},onlineFirstChaptersCollection:[{id:"80860",title:"From Open to Minimally Invasive: The Sacrocolpopexy",slug:"from-open-to-minimally-invasive-the-sacrocolpopexy",totalDownloads:52,totalDimensionsCites:0,doi:"10.5772/intechopen.101308",abstract:"With an increased demand for pelvic organ prolapse surgeries as the population ages, mesh-related osteomyelitis will become more prevalent. This case series enriches the paucity of data on management options for delayed osteomyelitis related to pelvic organ prolapse mesh. A literature review revealed no case reports of delayed onset osteomyelitis presenting up to a decade after colpopexy mesh placement. We present three cases of delayed osteomyelitis, their presentation, diagnosis and management at a tertiary academic referral center. Patients presented between 1 and 10 years after mesh colpopexy. Three different mesh materials were utilized during the initial procedures: Restorelle Y, Gynamesh and Gore-Tex mesh. The first case demonstrates failed expectant management with eventual surgical intervention on a medically compromised patient. The two subsequent cases describe elective complete mesh resection after several prior failed mesh revision attempts. This short case series and literature review illustrates that mesh-related osteomyelitis after a remote sacrocolpopexy carries significant morbidity. Mesh removal by means of minimally invasive surgery in the hands of an experienced surgical team utilizing DaVinci Robotic System is a good option and may lead to best patient outcomes.",book:{id:"11040",title:"Hysterectomy - Past, Present and Future",coverURL:"https://cdn.intechopen.com/books/images_new/11040.jpg"},signatures:"Adriana Fulginiti, Frank Borao, Martin Michalewski and Robert A. Graebe"},{id:"80782",title:"Cases of Postpartum Hemorrhage and Hysterectomy in Thailand’s Northern and Northeastern Provincial Hospitals",slug:"cases-of-postpartum-hemorrhage-and-hysterectomy-in-thailand-s-northern-and-northeastern-provincial-h",totalDownloads:49,totalDimensionsCites:0,doi:"10.5772/intechopen.102948",abstract:"PPH is a major cause of maternal death. Hysterectomy is safe to treat uncontrollable PPH. However, it may not be the best option for women who want to have children. The risk score tool to detect PPH earlier is needed in low-resource cities such as Chiang Rai and Sakon Nakhon province. This study aims to perform a risk score tool to prevent PPH in the northern and northeastern hospitals in Thailand; using mixed methods, identify risk factors for PPH from 20 articles globally and in Thailand using Med Calc, and develop the tool for prediction of PPH; and tool testing and a one-year follow-up on PPH-related hysterectomy cases. Results showed that this risk score tool can detect PPH earlier, reducing the number of PPH and hysterectomy cases. This risk score tool needs to be implemented in the same situations as hospitals to save pregnant women’s lives.",book:{id:"11040",title:"Hysterectomy - Past, Present and Future",coverURL:"https://cdn.intechopen.com/books/images_new/11040.jpg"},signatures:"Thawalsak Ratanasiri, Natakorn I. Tuporn, Somnuk Apiwantanagul, Thitima Nutrawong, Thawalrat Ratanasiri and Amornrat Ratanasiri"},{id:"80633",title:"Hysterectomy: Past, Present and Future",slug:"hysterectomy-past-present-and-future",totalDownloads:47,totalDimensionsCites:0,doi:"10.5772/intechopen.103086",abstract:"Hysterectomy is a major operation and is as old as time. This chapter touches briefly on the history of this procedure, its present aspects and general advice for these women who may need a hysterectomy, and finally the direction of new developments about it.",book:{id:"11040",title:"Hysterectomy - Past, Present and Future",coverURL:"https://cdn.intechopen.com/books/images_new/11040.jpg"},signatures:"Zouhair Odeh Amarin"},{id:"80589",title:"Perspective Chapter: Total Vaginal Hysterectomy for Unprolapsed Uterus",slug:"perspective-chapter-total-vaginal-hysterectomy-for-unprolapsed-uterus",totalDownloads:73,totalDimensionsCites:0,doi:"10.5772/intechopen.101383",abstract:"Vaginal hysterectomy was the first method to extract the uterus. Vaginal hysterectomy goes back a long way into the history of medicine. Although the first hysterectomy was carried out by Themison of Athens in the year 20 B.C., the idea of extracting the uterus through the vagina was first mentioned in 120 B.C. by Soranus of Ephesos, a distinguished obstetrician. The first elective vaginal hysterectomy was performed by J. Conrad Langenbeck in 1813. The patient was a 50-year-old multipara, who suffered from chronic pelvic pain attributed to a prolapsed uterus with a hard, bleeding tumor. The operation was carried out in challenging conditions, without anesthesia, proper instruments, or surgical assistants. Until the early 1950s, vaginal hysterectomy was the method of choice for removing the uterus. With the widespread introduction of general anesthesia and antibiotic therapy, the site of vaginal hysterectomy was taken over by abdominal hysterectomy. With the introduction of minimally invasive surgery in gynecology, vaginal hysterectomy has regained its place. Harry Reich performed the first total laparoscopic hysterectomy in 1989, being one of the most renowned vaginal surgeons, and he still claims at the beginning of the 21st century that … when the first choice of approach for hysterectomy is possible, is the vaginal route. This chapter presents the relevant anatomy from the point of view of the vaginal surgeon and the standard technique used by the author in over 5,000 vaginal hysterectomies. All intraoperative drawings and photographs are original.",book:{id:"11040",title:"Hysterectomy - Past, Present and Future",coverURL:"https://cdn.intechopen.com/books/images_new/11040.jpg"},signatures:"Petre Bratila"},{id:"80400",title:"Laparoscopic Hysterectomy in Morbidly Obese Patients",slug:"laparoscopic-hysterectomy-in-morbidly-obese-patients",totalDownloads:43,totalDimensionsCites:0,doi:"10.5772/intechopen.101307",abstract:"The following chapter will focus on laparoscopic hysterectomy in morbidly obese patients. The discussion reviews the physiological changes associated with morbid obesity and the potential implications on pneumoperitoneum during laparoscopic surgery. Important considerations such as perioperative care and operating room setup are discussed. Additionally, obtaining abdominal access, reviewing the surgical approach, and post-operative considerations are all highlighted within this chapter.",book:{id:"11040",title:"Hysterectomy - Past, Present and Future",coverURL:"https://cdn.intechopen.com/books/images_new/11040.jpg"},signatures:"Merima Ruhotina, Annemieke Wilcox, Shabnam Kashani and Masoud Azodi"},{id:"80238",title:"Surgical Site Infection after Hysterectomy",slug:"surgical-site-infection-after-hysterectomy",totalDownloads:117,totalDimensionsCites:0,doi:"10.5772/intechopen.101492",abstract:"Surgical site infections (SSIs) are associated with increased morbidity, mortality, and healthcare costs. SSIs are defined as an infection that occurs after surgery in the part of the body where the surgery took place. Approximately 1–4% of hysterectomies are complicated by SSIs, with higher rates reported for abdominal hysterectomy. Over the past decade, there has been an increasing number of minimally invasive hysterectomies, in conjunction with a decrease in abdominal hysterectomies. The reasons behind this trend are multifactorial but are mainly rooted in the well-documented advantages of minimally invasive surgery. Multiple studies have demonstrated a marked decrease in morbidity and mortality with minimally invasive surgeries. Specifically, evidence supports lower rates of SSIs after laparoscopic hysterectomy when compared to abdominal hysterectomy. In fact, the American College of Obstetricians and Gynecologist recommends minimally invasive approaches to hysterectomy whenever feasible. This chapter will review the current literature on surgical site infection (SSI) after hysterectomy for benign indications.",book:{id:"11040",title:"Hysterectomy - Past, Present and Future",coverURL:"https://cdn.intechopen.com/books/images_new/11040.jpg"},signatures:"Catherine W. Chan and Michael L. 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