Brief comparison of LSA and SAS concepts.
\r\n\t
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Dr. Wei Wu has received awards from many national societies for the originality and quality of his projects. He has authored 70 peer-reviewed papers in international journals.",coeditorOneBiosketch:"A pioneering researcher in obstetrics and holder of three registered patents. Dr. Qiuqin Tang's research interests include genetic and epigenetic risk factors of reproductive and developmental health. She has authored over 20 papers in international journals.",coeditorTwoBiosketch:null,coeditorThreeBiosketch:null,coeditorFourBiosketch:null,coeditorFiveBiosketch:null,editors:[{id:"178661",title:"Dr.",name:"Wei",middleName:null,surname:"Wu",slug:"wei-wu",fullName:"Wei Wu",profilePictureURL:"https://mts.intechopen.com/storage/users/178661/images/system/178661.jpeg",biography:"Dr. Wei Wu is an associate professor and associate department\nchair in the Department of Toxicology, Nanjing Medical University, China, where he received his Ph.D. in Toxicology in 2012.\nHe was a guest researcher at the National Institute of Environmental Health Sciences (NIEHS) between 2017 and 2018. Dr.\nWu is a member of different national and international societies\nin the fields of human reproduction and toxicology and has\nreceived awards from many national societies for the originality and quality of his\nprojects. Dr. Wu has authored seventy-three peer-reviewed papers in international\njournals. He has edited four books and collaborated on ten others as well as seventeen patents and in the organization of three international conferences. He is a\nreviewer for ninety-eight journals.",institutionString:"Nanjing Medical University",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"4",totalChapterViews:"0",totalEditedBooks:"4",institution:{name:"Nanjing Medical University",institutionURL:null,country:{name:"China"}}}],coeditorOne:{id:"184798",title:"Ms.",name:"Qiuqin",middleName:null,surname:"Tang",slug:"qiuqin-tang",fullName:"Qiuqin Tang",profilePictureURL:"https://mts.intechopen.com/storage/users/184798/images/13334_n.jpg",biography:"Qiuqin Tang is an attending doctor of The Women’s Hospital of Nanjing Medical University (Nanjing Maternity and Child Health Care Hospital). Her research interests include genetic and epigenetic risk factors of reproductive and developmental health. 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He is also the headmaster of the Family Planning Centre and Gynecological Cytology\nLaboratory at the same university. Dr. Tsikouras is a fellow of the\nInternational Academy of Clinical and Applied Thrombosis/Hemostasis. His scientific activities focus on paediatric and adolescence medicine, gynecological oncology, high-risk pregnancies. He is a reviewer for several international journals and has numerous scientific publications to his credit, including papers and book chapters. 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He\nis currently a professor in the Gynecology and Obstetrics Faculty\nof Medicine, University of Kiel, Germany, and honorary doctor\nat the Democritus University of Thrace, Alexandroupoli University Hospital He previously served as chief of the Department\nof Gynecology and Obstetrics at University Hospital RWTH Aachen,\nGermany. Dr. Rath is a reviewer for numerous journals and chief editor of Geburtshilfe und Frauenheilkunde (GebFra). 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Venkateswarlu",coverURL:"https://cdn.intechopen.com/books/images_new/371.jpg",editedByType:"Edited by",editors:[{id:"58592",title:"Dr.",name:"Arun",surname:"Shanker",slug:"arun-shanker",fullName:"Arun Shanker"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}}]},chapter:{item:{type:"chapter",id:"62440",title:"Licensed Shared Access Evolution to Provide Exclusive and Dynamic Shared Spectrum Access for Novel 5G Use Cases",doi:"10.5772/intechopen.79553",slug:"licensed-shared-access-evolution-to-provide-exclusive-and-dynamic-shared-spectrum-access-for-novel-5",body:'Demand for radio spectrum is constantly increasing as wireless services; especially, video streaming and emerging Internet of Things (IoT) are being adopted at an accelerating pace. Mobile phones, laptops, and tablets are becoming more and more common, and the quality of available content and services is also increasing. This has resulted in rapid increases in the amount of traffic in mobile networks, and the increases are predicted to continue [1, 2, 3]. This presents extreme challenges for mobile communication systems, as there is a lack of new spectrum resources to be allocated for the growing number of connected devices, services, and users.
The wireless communication technologies themselves are approaching the fundamental theoretical limits of bandwidth efficiency, but simultaneously the frequency bands are exclusively licensed to different services which might not utilize all of their spectrum resources. Valuable spectrum resources can be left unexploited at different frequencies if the license owner does not use them at all times or at all locations. For example, several spectrum measurement campaigns covering frequencies up to 3 GHz state that the spectrum utilization rate is on the scale of 10–20% [4, 5, 6], and thus, most of the spectrum resources remain unused. It is necessary to utilize the existing frequency resources more efficiently to satisfy the growing demand for spectrum, but the current exclusive licensing methods do not allow this. Recent international studies have concluded that spectrum sharing will play a major role in maximizing the amount of available spectrum for wireless communication systems [7, 8].
The current exclusive spectrum licensing needs to be updated or replaced to enable spectrum sharing. In spectrum sharing, the users who currently hold an exclusive license to use a frequency band are called incumbents and are the primary users of the band. If the incumbents are using their spectrum resources inefficiently, their spectrum resources could potentially be shared with other users who could use the vacant spectrum resources at certain times or at certain locations where the license holder does not have any transmissions. Spectrum occupancy measurements have been proposed to find candidate frequency bands for spectrum sharing [4]. The vacant spectrum resources could be utilized through dynamic spectrum access methods, such as opportunistic spectrum access (OSA) [9] or Licensed Shared Access (LSA) [10]. In OSA, the shared spectrum user chooses the best available vacant transmission channel in an opportunistic and dynamic manner as an unlicensed secondary user of the spectrum, who does not need a license but does not have any guarantees on the amount and quality of available spectrum and has no protection from any harmful interference.
Cognitive radio spectrum sharing can be divided into three different types: underlay, overlay, and interweave. In underlay spectrum sharing, the cognitive users are allowed to operate if the interference they cause to the incumbents is below a given level. In overlay spectrum sharing, the cognitive user needs to know the incumbent signal. The cognitive user then adds its own data to the incumbent data and transmits the combined signal. In interweave spectrum sharing, the cognitive radios exploit spectral holes. The spectral holes are spectrum which is not used to be the incumbent in time, frequency, or spatial dimension. In each of the cognitive spectrum sharing types, accurate spectrum sensing data are of paramount importance both to guarantee the protection of the incumbents and to maximize the capacity available for the cognitive users. The currently standardized LSA belongs to interweave category, typically uses static vertical long-term spectrum leasing, and does not include spectrum sensing capabilities.
In LSA, vacant spectrum resources can be leased to shared spectrum users, known as LSA licensees, who are guaranteed an exclusive access to the leased spectrum resources and are protected from harmful interference. The incumbents are also protected from interference and might receive economic benefits from leasing their underutilized spectrum resources. The traffic load of the incumbent (licensed) users in LSA does not affect the performance of the LSA licensees, as the LSA licensees’ transmissions are restricted so that they do not cause harmful interference to the incumbents under any circumstances. The terminology and definitions for shared spectrum access methods are diverse, but OSA and LSA could be considered as the two main categories in frequency bands with existing incumbents. Regardless of the used shared spectrum access method, it is essential to guarantee that the incumbents currently present in the band are protected from any harmful interference that could be induced by the newly introduced shared spectrum users.
The future LSA evolution will enable spectrum sensing and thus more dynamic use of spectrum. The current control solutions for network coordination are insufficient for heterogeneous 5G networks, where the performance of dense deployments could be further enhanced by advanced spectrum sharing [11]. 5G-PPP project called COHERENT considers the novel methods for coordinated control and spectrum management for 5G heterogeneous networks in LSA evolution.
Section 2 describes the development and architecture of LSA system for 2.3–2.4 GHz band. Section 3 discusses the feasibility, current status, and evolution of LSA toward 5G and makes a comparison to Spectrum Access System (SAS) concept developed in the USA. Section 4 describes an LSA evolution PMSE use case trial. Section 5 discusses the use of LSA evolution in 5G networks, and Section 6 gives the concluding remarks.
The development of LSA concept began in European regulation and standardization to create a method for the mobile network operators (MNOs) to deploy their networks into bands allocated for mobile broadband (MBB), which currently have incumbents operating in the band. The concept allows spectrum sharing between an MNO and the incumbents with licensing conditions and rules that benefit both stakeholders. Radio Spectrum Policy Group (RSPG) proposed LSA concept [12] as an extension to an earlier proposal by an industry consortium, called Authorized Shared Access (ASA) [13]. ASA is limited to the International Mobile Telecommunications (IMT) use, while LSA can also be applied to other types of spectrum sharing. The 2.3 GHz band was chosen as the first frequency band for which to develop the operating conditions for LSA.
International Telecommunication Union Radiocommunication Sector (ITU-R) has globally allocated the 2.3–2.4 GHz band for mobile broadband (MBB) systems at the World Radiocommunication Conference 2007 (WRC-07) [14]. However, the frequency band is currently used by different incumbents in European Conference of Postal and Telecommunications Administrations (CEPT) countries [15]. The main users are PMSE applications, such as wireless camera links [16]. They are typically used to transmit video and audio wirelessly from a camera to an outside broadcasting (OB) van, and the typical users thus are the broadcasting companies.
The spectrum occupancy of the 2.3 GHz band in a single location in Finland was studied using several weeks of spectrum measurement data from Turku spectrum observatory in [17, 18]. The results showed that spectrum occupancy was very low and sporadic, and the detected busy periods were only 3–9 seconds long. The wireless camera transmissions typically occupy a bandwidth of 20 MHz, meaning a 20% occupancy per transmission over the whole 100 MHz frequency band. The instantaneous channel occupancy values were between 0 and 30%, but when the occupancy was filtered with a 5-minute moving average filter, the occupancy was between 0 and 5%. The filtered values confirm that the periods when the spectrum is occupied are very short in time. In addition to the signals interpreted as wireless cameras, only a small number of higher power peaks, probably from narrowband amateur radio services, was detected. The wireless camera transmissions are very low power and difficult to detect, and the studies conducted with a professional level wireless camera in [18] demonstrate that the spectrum observatories are able to detect the wireless cameras only from distances smaller than 250 m. Thus, single-location spectrum occupancy measurements cannot be used to draw strong conclusions on the spectrum occupancy trends over large geographical areas.
One reason why allocating the 2.3 GHz band for MBB in Europe is important is that the frequency band is already in MBB use in other regions. Thus, the transmitter hardware already exists and can be easily implemented in mobile receivers for European market. An economic analysis [19] also indicates that the impact of making 2.3 GHz band available for MBB in Europe could be worth 6.5–22 billion euros. However, the national administrations are unwilling to move the current incumbents to other frequency bands. Such an operation would result in expenses to the incumbents who would need to update their equipment, and in addition, there is a lack of suitable unallocated frequency bands. As the utilization of the 2.3 GHz frequency band appears to be very low, an optimal solution would be to let the current incumbents stay in the frequency band and to allow the MBB operation by exploiting the vacant spectrum resources. Again, the protection of the current incumbents is essential. LSA is needed in the 2.3 GHz band to provide exclusive shared spectrum access to the MBB and to protect the current incumbents.
Working Group Frequency Management (WG FM) established Frequency Management 53 (FM53)—Reconfigurable Radio Systems (RRS) and LSA project team in September 2012. The aim of FM53 was to provide generic guidelines to CEPT administrations for the implementation of the LSA. The European Commission (EC) requested an opinion from RSPG on regulatory and economic aspects of LSA in November 2012 [20], and their final opinion from November 2013 [21] defined that LSA is “a regulatory approach aiming to facilitate the introduction of radiocommunication systems operated by a limited number of licensees under an individual licensing regime in a frequency band already assigned or expected to be assigned to one or more incumbent users. Under the LSA approach, the additional users are authorized to use the spectrum (or part of the spectrum) in accordance with sharing rules included in their rights of the use of spectrum, thereby allowing all the authorized users, including incumbents, to provide a certain QoS.”
Thus, LSA gives the MNOs a predictable QoS through individual licensing and exclusive shared access to the spectrum resources. The MNO accessing shared spectrum through temporary leasing is called LSA licensee. The functionalities of LSA are enabled mainly by two additional units on top of the existing mobile networks: the LSA Repository and the LSA Controller. The LSA Repository is a database containing information on incumbent spectrum utilization, while the task of the LSA Controller is to guarantee protection and interference-free operation for both types of users by using the data from the LSA Repository. The LSA Repository can be managed by the National Regulatory Authorities, the incumbents, or a trusted third party.
The LSA Repository contains information on the spectrum availability for LSA licensees and spectrum sharing rules. This information is communicated to the LSA Controller through a secure and reliable communication path. Based on the information from the LSA Repository, the LSA Controller controls the spectrum use of LSA licensee(s). There may be several LSA Repositories from which the LSA Controller gets the information on spectrum availability and also several LSA licensees’ networks.
Figure 1 illustrates the LSA architecture. Several incumbents provide information on their spectrum utilization to the LSA Repository, which communicates it to the LSA Controller. The LSA Controller provides this information to the MNO operations, administration, and maintenance (OAM), which instructs that the relevant base stations of the MBB network can use the spectrum resources which are not used by the incumbents in the band. These newly available spectrum resources are taken into use to provide additional capacity through carrier aggregation (CA). The underlying spectrum in other frequency bands (blue cells in the figure) is exclusively licensed for MBB transmissions, while the orange cells can provide additional capacity using the LSA spectrum resources in the 2.3 GHz band. On the right side of the figure, the incumbent operation prevents the use of LSA spectrum, and only the underlying MBB spectrum resources can be used. This is illustrated through the absence of orange LSA cells.
LSA architecture (Adapted from [
LSA Spectrum Resource Availability Information (LSRAI) contains the information on the LSA spectrum resource that may be used by the LSA licensee. LSRAI is generated in the LSA Repository and sent to the LSA Controller over the LSA1 interface using LSA1 protocol messages as defined in the ETSI technical specification [23]. The LSA Information Exchange Function to maintain the LSRAI synchronization between LSA Controllers and LSA Repositories and the LSA1 protocol are described in detail in [23].
As defined in [23], LSRAI has the following characteristics:
It contains one or more zones. A zone is an information object which describes a set of operational conditions or restrictions to be applied by the LSA licensee.
A zone has a zone type associated to it (e.g., restriction, protection, exclusion).
A zone contains space, frequency, radio, and time parameters:
Space parameters describing the geographical area to which the restriction applies.
Frequency parameters describing the frequency range to which the restriction applies.
Time parameters describing when the restriction applies.
Radio parameters describing the RF restrictions to be applied within the space/frequency/time combination defined by the above parameters
A zone has a zone ID and a zone configuration index associated to it.
This section considers the feasibility, current status, and evolution of LSA and briefly compares it to the US concept for licensed shared spectrum access; Spectrum Access System (SAS). The work on LSA has been very active in regulation and standardization: CEPT Reports [24, 25, 26], ECC harmonized conditions for the use of the 2.3 GHz band in [15, 27, 28, 29], and European Telecommunications Standards Institute (ETSI) standardization in [22, 23, 30, 31] provide all the measures needed for a National Regulatory Authorities in a CEPT country to create an implementation of LSA. A regulatory evaluation in [32] concluded that LSA implementations are feasible as they provide a simple spectrum sharing approach providing a high degree of certainty for both the incumbent and the LSA licensee with low impact to the systems and the concept has already been tested and approved. The use of LSA is a national matter, which does not require modifications to the ITU-R Radio Regulations (RR) but needs to comply with the current regulations.
A study on the feasibility of LSA from business perspective [33] concluded that LSA implementations could be profitable for MNOs in Finland if they have a reasonably good customer base and well-defined network launch and management. Most importantly, the MNO has to carefully investigate the techno-economics to see if there is a customer base large enough to justify the investments in new spectrum and network resources. A Finnish LSA trial environment is operated in Ylivieska [34, 35], but no commercial deployments of LSA in 2.3 GHz band are available yet. A service pilot with LSA radio licenses to commercial end users operating with incumbent wireless cameras in the 2.3 GHz band was announced in the Netherlands in May 2016 [36], and more pilots are expected in the near future. The LTE MNOs are expected to make fairly static multiyear spectrum sharing contracts with the incumbents to justify investments in building mobile network infrastructure for LSA operation [37]. LSA could also provide mechanisms to mitigate intra-MNO-system interference [37].
A concept called SAS is in development in the USA. It is very similar to LSA, as both of them include incumbent users and licensed shared users who have exclusive shared access to the spectrum. The Licensed Shared Access in SAS is known as Priority Access License (PAL). LSA excludes opportunistic access where no protection from incumbents is provided, but SAS adds an additional third tier for unlicensed opportunistic spectrum access with General Authorized Access (GAA), as shown in Figure 2. PAL users are protected from interference from GAA tier, but not from the incumbents.
Overview of the level of access rights in different tiers of SAS and LSA sharing models.
The SAS design ensures protection also for the incumbents who cannot provide a priori information to a central database. This is a major difference to LSA, where this information has to be communicated to a central database (LSA Repository) in order to protect the incumbents. The incumbents operating in the Citizens Broadband Radio Service (CBRS) band include military services whose information is too sensitive to be stored in a database. Instead, SAS includes Environmental Sensing Capability (ESC) component which uses spectrum sensing to provide the needed data for spectrum access decisions. As [38] states, spectrum sensing is not a trivial matter, especially with the strict requirements in SAS. ESC will not be used in the first phase of SAS deployment, which restricts the SAS operation in the zones with military incumbents near coastal areas until a suitable ESC technology is available. ESC technologies have already been developed and demonstrated in SAS trials [39]. Unlike LSA, SAS standardization is still in progress, but the industrial interest in CBRS Alliance [40] is strong and advances are expected in the near future. The first commercial SAS deployments are expected during 2018 [41] in 3.55–3.7 GHz CBRS [42] band in the USA. Table 1 gives a brief comparison of the key features of the LSA and SAS concepts. More detailed considerations and comparisons from both technical and business perspectives are given in [43, 44].
LSA | SAS | |
---|---|---|
Tiers | Two tiers with individual access | 3-tier system; two tiers with individual access and a third license-exempt tier |
Database | Centralized geo-location database based on static a priori information on the incumbents | Centralized geolocation database with information based on spectrum sensing technologies |
Spectral efficiency | Less efficient use of spectrum | More efficient use of spectrum |
Use of spectrum | Current version is a static framework for long-term spectrum leasing in 2.3 GHz band. Future LSA evolution will include spectrum sensing to provide more dynamic use of spectrum | GAA tier enables very flexible and dynamic short-term use of spectrum with a very low entry barrier, but the GAA spectrum access and quality are less certain than with the exclusive LSA licenses |
Software and hardware | Minimal additions to the existing 3GPP network ecosystem. | Requires new near real-time sensing capabilities and big data and spectrum analytics |
Complexity | Less complex | Very complex due to the spectrum sensing needed for the GAA tier |
Adaptability | Initially focused on Europe but easily adaptable to other regions | Initially specific to US federal use, additional adaptability is needed for other regions |
Brief comparison of LSA and SAS concepts.
LSA and SAS are currently defined for use only in the mentioned frequency bands with their specific incumbents, but the basic operational principles are straightforward to adopt to other sub-6 GHz frequency bands, where spectrum sharing is more relevant. Spectrum sharing is less relevant in higher frequency ranges, such as mmWaves, where wireless communication is not so much limited by interference, but the higher path losses. The ETSI LSA standardization was done partly in liaison with the 3rd Generation Partnership Project (3GPP) [45], which has studied how LSA could provide a global solution for a 3GPP MNO in [46]. LSA has also been recognized as one of the future technology trends for IMT in the ITU-R Working Party 5D on IMT systems [47].
5G and its new use cases require a more dynamic approach to access shared spectrum resources than ETSI LSA for 2.3–2.4 GHz band can provide. Spectrum sensing techniques are needed as the more dynamic access to spectrum cannot be achieved by using static a priori information. The dominant problems in spectrum sensing are the removal of shadowing and multipath fading. Methods to overcome these problems through cooperative mobile measurements to create interference maps are discussed in [48], but the current technologies related to spectrum sensing are still not able to guarantee protection from harmful interference [43].
A concept called LSA evolution is currently under development. The use of spectrum sensing is considered to provide more dynamic version of LSA, which is needed for the novel 5G use cases [49, 50]. The original LSA specification assumes that the spectrum is available for the operator always when the incumbent does not use the spectrum. The spectrum is available for the operator within the regulative area, like country borders, excluding the areas where the incumbent uses the spectrum. From spectrum perspective, high QoS is achieved when the incumbent does not use the spectrum.
The interest in private LTE and 5G networks has grown due to the increased number of IMT frequency bands, higher frequency ranges, variety in spectrum assignments for 3GPP technologies, and revolution of wireless industrial communication [51]. The feasibility study [52] addresses these issues and applies learning from the later developed SAS/CBRS system at the same time. The study considers, for example, how to provide temporary spectrum access for local high-quality wireless networks.
The new concepts for LSA evolution include short-term license periods, possibility to allocate spectrum locally, and supporting co-primary sharing, which can guarantee the quality of service from spectrum perspective [49, 53]. Most LTE use is static, when the spectrum assignments are considered. Even if the user equipments (UEs) are mobile, the spectrum use is more determined by the eNodeBs. They traditionally require masts, electricity, backhaul connectivity, and professional installers.
The temporary LTE or 5G spectrum access is most likely to be related to PMSE, Public Protection and Disaster Relief (PPDR), or Test and Development (T&D) licenses. The current mobile networks are wide area networks even if they are built for capacity. Most private LTE and 5G networks are local. PMSE, PPDR, and T&D networks are both temporary and local and thus can benefit most from LSA evolution.
This section presents a trial of LSA evolution system developed for 5G PMSE use case. The trial focuses on utilizing LSA for sharing spectrum in 2.3–2.4 GHz band between wireless cameras (PMSE) and mobile network operator (MNO) serving users. When the spectrum is required by the incumbents, such as wireless video cameras during a sports event, the transmissions of the mobile network in this area need to be controlled to allow the operation of the wireless cameras in the band. The mobile network base stations on this band can be shut down or their transmission powers and potentially operating frequencies controlled.
The developed LSA evolution system allows to set priorities for different users of the spectrum, and thus it is possible, for example, to give the highest priority to the old/proprietary PMSE systems which cannot communicate bidirectionally with the spectrum manager, which includes the functionalities of LSA Controller and LSA Repository. The LTE/5G-based equipment can be controlled (their transmission frequencies and power levels adjusted) so that no interference is caused toward the old/proprietary PMSE equipment or other LTE/5G-based equipment.
The trial assumes that the broadcasters and other PMSE stakeholders may have a mixture of proprietary and LTE/5G PMSE wireless technology in use in the future. This trial demonstrates how broadcasters can gradually move from proprietary 2.3 GHz wireless camera technology to 2.3 GHz LTE/5G PMSE. Both old and new equipment can be used simultaneously within the trial system. One major advantage of LTE/5G radio-based PMSE is that the spectrum manager can directly control the equipment (e.g., change its operating frequency to avoid interference). Another advantage of having an own PMSE LTE/5G system compared to using commercial LTE/5G networks for the PMSE traffic is that the PMSE stakeholder is able to fully control the use and thus the load of its own PMSE system.
The architecture of the trial setup shown in Figure 3 consists of PMSE equipment operating occasionally on 2.3 GHz band and MNO LTE network operating on 700 and 2.3 GHz bands. This represents a situation where MNO employs additional capacity on 2.3 GHz band using, for example, supplemental downlink (SDL) concept. Proprietary PMSE equipment represents an OFDM-based proprietary solution for wireless cameras operating on the band. PMSE LTE in Figure 3 is a rapidly deployable LTE/5G network for PMSE purposes. Commercial base stations and LTE terminals were used in the trial. The proprietary PMSE equipment was emulated in the trial with a DVB-T/DVB-T2 transmission and Samsung S8 phones streaming video served as LTE-based PMSE equipment.
Spectrum demonstration architecture.
Spectrum manager orchestrates the operation of the different systems on 2.3 GHz shared band. PMSE system information is collected with a web-based reservation system, where the users of the devices can make reservations for their intended use. The reservation system has been piloted in the Netherlands in 2017–2018 [34]. The control of the PMSE devices also takes place through the reservation system so that the user of the devices is informed about the required spectrum use changes and the user has to deploy the configuration changes in their devices.
Both PMSE LTE and MNO LTE systems have a direct machine-to-machine (M2M) interface between the radio equipment and the spectrum manager. The priority order considered in the trial is as follows, from highest to lowest: PMSE, PMSE LTE, and MNO LTE. When the priority user changes the configuration of the LTE network, a notification about the change is automatically received in the spectrum manager. The spectrum manager processes the changed spectrum situation and evaluates if the lower priority use may cause harmful interference to the higher priority use. If there is a risk of interference, the spectrum manager evaluates which changes would be required to accommodate the higher priority use and to maintain the best possible service level also for the lower priority use.
On the high level, interference mitigation is implemented so that if there are frequency channels available, the lower priority use is transferred to those channels. If there are no other channels available, the power level of the secondary user is reduced or the transmission is denied. In this demonstration, the higher priority user is able to select the frequency channel to be used. An option for this could be that the higher priority user has the right to the spectrum resource in the band, but the specific frequency channel is determined by the spectrum manager.
The main target of the performed trial is to demonstrate the LSA evolution functions developed to the spectrum manager to enable dynamic spectrum sharing between users with different levels of priority. The steps performed in the trial were:
MNO LTE1 (700 MHz) and MNO LTE2 (2.3 GHz) serving users (web surfing, video streaming).
PMSE LTE (2.3 GHz) turns on as a rapidly deployable network for PMSE, and spectrum is available for both MNO LTE2 and PMSE LTE.
PMSE user registers to the spectrum manager registration system, on the frequency currently in use for PMSE LTE.
MNO LTE2 limits its transmission power (if necessary) to follow interference limits, and the users remain connected to at least B28 (700 MHz) base station.
PMSE LTE changes channel to give space to PMSE.
Proprietary PMSE equipment turns on.
Corresponding snapshots of the 2.3 GHz spectrum band are illustrated in Figure 4. First, the lowest priority LTE service, such as SDL of MNO LTE2, operates in the band. Then, PMSE using rapidly deployable LTE air interface (PMSE LTE) requests for spectrum. At the same time, there is enough free spectrum for both to operate. Then, the proprietary PMSE equipment requests for spectrum, and the spectrum manager allocates suitable frequencies and power levels for all users. If necessary, MNO LTE2 adjusts the transmission power according to regulated interference limits to allow for the operation of higher priority users. Also, PMSE LTE that is controlled by the spectrum manager via M2M interface switches frequency (e.g., due to the limitations of proprietary PMSE equipment tuning range). Finally, all three networks operate on the shared spectrum without causing interference to each other.
2.3 GHz spectrum use corresponding to trial steps.
A mobile service of a mobile network operator consists of different mobile network technologies, like GSM, WCDMA, LTE, and 5G. Each of the technologies, especially LTE, has several frequency bands. The bands below 1 GHz are coverage bands, and the bands above 2 GHz are capacity bands. The capacity bands are available only in densely populated areas.
Mobile phones primarily make the decision which technology and which band(s) they use. The availability of the LSA secondary bands cannot be guaranteed at any time or location, but the situation does not differ much from the availability of the capacity bands, when considering the availability of the bands from the mobile device perspective. At an arbitrary location and time, only a part of the deployed technologies and frequency bands are available for a specific mobile device. The generic secondary LSA spectrum use fits best to 5G enhanced Mobile Broadband (eMBB).
The original LSA was developed to allow mobile as a secondary user on the bands, which have other types of priority users. The recent development in ETSI RRS considers LSA for local high-quality networks. The main issue to ensure a guarantee of quality is to have a sharing agreement, where the LSA user is the primary user and is protected from interference. When the LSA users have a primary status and when they are protected from interference, LSA can be used also for 5G Ultrareliable Low-Latency Communication (URLLC).
When the 5G massive Machine-Type Communication (mMTC) is deployed in coverage networks, LSA may not be the best solution, as the spectrum sharing in the coverage bands is not as beneficial as in the capacity bands. On the other hand, many of the sub-GHz wide-area IoT networks operate on license-exempt bands, which cannot guarantee quality of service either.
The LSA spectrum sharing does not change mobility or handovers in the mobile networks compared to non-LSA mobile networks. The main issue in this respect is the graceful shutdown. The sharing agreement may allow a reasonable delay, i.e., several minutes or more, between the moment information that the primary user requiring interference protection arrives and the moment when the interference protection has to be carried out in the LSA system. In that case, the operations, administration, and maintenance (OAM) of the mobile network can force the mobile to non-LSA bands before the LSA system deploys the interference protection in the LSA band. The graceful shutdown is not a part of the LSA system but rather a feature of the OAM.
This chapter has discussed why spectrum sharing is needed and introduced the LSA concept developed to provide a predictable QoS and exclusive access to shared spectrum resources. The first phase of LSA development and standardization created a somewhat static system and rules for the use of LSA in the 2.3–2.4 GHz frequency band. This version of LSA is best suited to facilitate access to sub-6 GHz frequency bands where the existing incumbents are not efficiently using their spectral resources.
However, the novel use cases in 5G require a more dynamic access to the spectrum and novel solutions for coordinated control and spectrum management. Spectrum sensing techniques are needed to provide the more dynamic access to spectrum, as the current version of LSA and its static spectrum allocations are insufficient for this. The spectrum sensing techniques however still need to evolve to be able to guarantee protection from harmful interference.
The development of LSA evolution is underway, and the other new concepts needed for LSA evolution include short-term license periods, possibility to allocate spectrum locally, and support for co-primary sharing, which can guarantee the QoS from spectrum perspective. The chapter also described a demonstration of LSA evolution system with spectrum user prioritization, which was created for 5G PMSE use case.
This work is supported by Business Finland under the project Critical Operations over Regular Networks (CORNET). The views expressed in this contribution are those of the authors and do not necessarily represent the projects.
Pancreatic necrosis is the presence of nonviable pancreatic parenchyma or peripancreatic fat which may be localized or diffuse. It is classified radiologically according to the Atlanta Criteria as an acute necrotic collection (ANC), which is defined as a non-encapsulated area of necrosis, or as walled-off necrosis (WON), which is encapsulated [1]. Although pancreatic necrosis may result from trauma, malignancy, or chronic pancreatitis, the most common cause is acute pancreatitis; 20% of patients with acute pancreatitis develop necrosis. For patients who develop necrosis, the mortality rate is 15–30% [2]. Surgery has historically been the primary treatment for pancreatic necrosis. However, the superior outcomes associated with new, less invasive techniques have narrowed the scope for surgical intervention. Despite these shifts in practice, surgical care remains an important tool for the treatment of pancreatic necrosis.
Although the diagnosis of pancreatitis is generally clinical, the primary diagnostic tool for pancreatic necrosis is the computed tomography (CT) scan. With this modality, normal pancreatic parenchyma is low attenuation, 40–50 Hounsfield units (HU), but increases with contrast to 100–150 HU. In comparison, areas of necrosis remain hypoattenuating, <30 HU [3]. MRI and endoscopic ultrasound are also used, but CT scan is considered to be the gold standard for diagnosis and characterization [4].
Regardless of the presence of necrosis, fluid resuscitation, and early nutritional support are paramount to the treatment of patients with acute pancreatitis. For patients who are able to tolerate enteral nutrition, there is a significant reduction in the rates of infected pancreatic necrosis, multiorgan failure, surgical intervention, and mortality when compared to patients who are given total parenteral nutrition (TPN) [5, 6]. Thus, prior to initiation of TPN, patients should be evaluated for tolerance of oral, nasogastric, and nasojejunal feeding. Route notwithstanding, nutrition should be addressed in the first 24–48 hours of admission for acute pancreatitis [7].
Sterile pancreatic necrosis does not have a specific clinical presentation, but is more common in patients with symptoms lasting more than 48 hours and with concomitant organ failure [8]. The morbidity and mortality associated with pancreatic necrosis is exacerbated by development of infection, which may result of seeding associated with bacteremia, colonic bacterial translocation, or direct contamination from a procedure (e.g. endoscopic retrograde cholangiopancreatography (ERCP) or surgery) [9]. The risk of infection correlates with the degree of necrosis. If more than 30% of the pancreatic parenchyma is necrotic, there is a 22% risk of infection. If 30–50% is necrotic, the risk of infection is 37%. If necrosis exceeds 50%, the risk of infection is 46% [10]. The signs and symptoms of infected pancreatic necrosis are similar to those of other types of infection, including: fever, leukocytosis, and worsening condition with optimal supportive care. Once the necrosis becomes infected, the incidence of organ failure increases, along with the risk of mortality [11].
Differentiating sterile from infected necrosis based on clinical presentation can be difficult. Patients with sterile necrosis can proceed to organ failure in similar fashion to patients with infected necrosis. Infection can be detected non-invasively on CT scan by looking for the presence of gas locules within the area of necrosis, suggesting microbial gas production. However, these findings are not always seen on CT, and fine-needle aspiration (FNA) may be necessary for definitive diagnosis. Multiple FNA aspirates may be required due to the 10% false negative rate of this test [12].
However, proof of infection on radiology or by tissue culture is not necessary to initiate treatment. If infection is strongly suspected due to clinical course, antibiotics are indicated regardless of radiologic or tissue diagnosis. If no antibiotic sensitivities are available from culture results, broad-spectrum antibiotics should be started. Due to the ability to penetrate the necrotic tissue, carbapenems are considered first-line treatment [13]. Prophylactic use of antibiotics has not been shown to impact the rate of developing infected necrosis, systemic complications, mortality, or need for surgical intervention and is not recommended [14, 15, 16].
Prior to any invasive management, a patient should be treated with optimal supportive care. This includes fluid resuscitation, nutritional support, and antibiotics, if infection is suspected. The need for invasive management of sterile pancreatic necrosis is rare, especially in acute phase. However intervention may be necessary during the late phase for protracted abdominal pain, obstruction, or, less often, for failure of clinical improvement. Infected necrosis requires invasive intervention more often, both in order to gain source control and in order to resolve other non-infectious symptoms [17].
Although percutaneous and endoscopic interventions have historically been considered temporizing measures, not definitive management, many patients with pancreatic necrosis are successfully treated with these techniques, without need for more invasive therapy. Percutaneous drainage can successfully treat acute necrotizing pancreatitis in more than 50% of patients without need for surgical necrosectomy. The success rate with endoscopic therapy can reach 80% when used in conjunction with DEN [18, 19]. Thus, development of less invasive methods for addressing pancreatic necrosis led to a decrease in the indications for surgical intervention. The choice of intervention, percutaneous or endoscopic, is dependent on the situation, timing, and accessibility of the area of necrosis (Figure 1).
Flowchart for Management of Pancreatic Necrosis after Failure of conservative management. After failure of conservative management – Supportive care, antibiotics, and nutrition – The appropriate intervention depends on the nature of the necrosis. If it is associated with a disconnected duct, a separate pathway, which ends with distal pancreatectomy, internal drainage, or endoscopic translumenal stent placement, is indicated. If there is no disconnected duct, the correct pathway is dictated by the stage of necrosis, as a nonencapsulated acute necrotic collection or as walled off necrosis. Endoscopic and percutaneous strategies are preferred in each situation, and traditional, laparoscopic or open necrosectomy serves as the final option for patients that fail other management, or in hospitals without resources or staff to perform other procedures.
Endoscopic management of pancreatic necrosis is performed transmurally, either across the duodenum, for pancreatic head necrosis, or the stomach, for neck or body necrosis. Although technically feasible earlier in the clinical course, endoscopic intervention should be delayed to 4 weeks after onset of symptoms in order for an appropriate capsule to form around the necrotic tissue [20]. In cases where intervention can be delayed until WON form, and the WON is accessible transmurally, this is considered first-line intervention [18].
With or without the aid of endoscopic ultrasound (EUS), a plastic or self-expanding metal stent (SEMS) is placed from the lumen of the duodenum or stomach into the area of WON. In addition to allowing the WON to drain into the lumen, these stents also allow access to the area for debridement, via irrigation or DEN [21] (Figure 2). In DEN, an endoscope with one or two working ports is advanced through the previously placed, transluminal stent. Upon entering the WON, a number of tools, including forceps and snares are used to remove debris that would otherwise not be susceptible to removal with irrigation [21]. On average, 3–6 endoscopic interventions are necessary prior to resolution of necrosis [22].
Surgical approaches to Necrosectomy. Access the lesser sac and retroperitoneum for the purposes of pancreatic necrosectomy can be achieve through a number of approaches. Direct endoscopic necrosectomy (DEN) is performed by accessing the stomach via the esophagus and then creating a posterior gastrotomy. The transgastric approach, performed laparoscopically or open, requires both an anterior and a posterior gastrotomy. The lesser sac can also be accessed by opening the gastrocolic ligament or transverse mesocolon, either by traversing a previously established, drainage tract or with a surgical approach.
DEN was first compared to surgical necrosectomy in the Pancreatitis, Endoscopic Transgastric vs. Primary Necrosectomy in Patients with Infected Necrosis (PENQUIN) Trial. In this trial, patients in the surgery group underwent a number of different operations, including 6 video-assisted retroperitoneal debridement (VARD) surgeries, 4 open necrosectomies, and 2 percutaneous drainage placements without need for more invasive therapy. The two patient who did not have a necrosectomy were excluded from final statistical analysis. All 10 patients in the endoscopic group had ultrasound guided stent placement, irrigation, and DEN. Following intervention, the rates of new-onset organ failure and pancreatic fistula were lower in the endoscopic group. The trial also compared the groups with regard to a composite clinical outcome, which included major post-operative complications and mortality, and found a lower rate in the endoscopic group [23, 24]. These findings were later replicated in the Minimally-invasive Surgery Versus Endoscopy Randomized (MISER) Trial. Additionally, MISER showed lower rates of pancreatic fistula formation and a higher quality of life at 3 months after surgery in the endoscopic group [25]. In the Transluminal Endoscopic Step-up Approach Versus Minimally-invasive Surgical Step-up Approach in Patients with Infected Necrotizing Pancreatitis (TENSION) Trial, a larger randomized trial, no difference in mortality was observed. However, the rates of pancreatic fistula and length of stay favored the endoscopic group [26].
Percutaneous drainage is preferable in patients that are deemed too unstable to tolerate endoscopic drainage or if the area of necrosis extends into a dependent space, such as the paracolic gutters or pelvis. It is also an acceptable alternative when endoscopic drainage is unavailable or not technically feasible, specifically in the setting of ANC, when there is no capsule that could support an endoscopic stent [27].
Percutaneous drainage is usually CT-guided, although ultrasound-guided drainage can also be performed. These drains may be transperitoneal, with the external portion of the drain fixed in the anterior abdominal wall. These drains may also be placed through the flank, directly into the retroperitoneum, without traversing the peritoneum. In addition to draining ANC and WON, percutaneous drains can also be used for irrigation [28].
Although percutaneous drainage is successful as monotherapy in some patients, patients with larger areas of necrosis, multifocal necrosis, incomplete liquefaction, and pre-procedural organ failure are less likely to be adequately treated. While some of these factors can be overcome with larger drainage catheters, for these reasons, percutaneous drainage remains a bridge to therapy, allowing patients to survive the acute period of disease, and undergo definitive management later, with improved outcomes [26, 29, 30].
Surgical management may be minimally-invasive or open, but has the same two primary goals: obtaining source control by removing as much necrotic tissue as possible and providing access for irrigation and drainage. As a general principle, minimally-invasive approaches are preferred to open necrosectomy as first-line treatment. The improved outcomes of minimally-invasive technique lead to development of the “step-up” approach to management, which begins with percutaneous or endoscopic intervention, followed by a progression to surgical intervention as indicated by unresolved disease. However, the final treatment decision is dictated by the patient, surgeon, and available resources. A second principle is that surgical intervention should be delayed as long as possible in order to improve outcomes. Operating during the early, acute phase of pancreatitis, especially in the presence of ANC, rather than WON, is associated with higher morbidity and mortality regardless of surgical approach. A third principle is that long-term nutritional access, through a gastrostomy or gastrojejunostomy tube, should be obtained prior to concluding the procedure if no other method for enteral feeding has been established. Fourth, a cholecystectomy may also be performed if gallstones were implicated in the etiology of pancreatitis, provided the patient is adequately stable to undergo an additional procedure (Figure 1).
VARD is a technique, used as the final phase of the step-up approach, where the retroperitoneum is accessed through a previously established, left flank, percutaneous drainage tract (Figure 2). The tract is then serially dilated, in order to accommodate progressively larger drainage catheters. At the time of surgery, in order to facilitate introduction of laparoscopic instruments, a small, 4–6 centimeter incision is made where the tract exits the skin. After confirming entry into the WON with a probe, tissue and fluid are removed with suction. The laparoscope is then inserted, with or without CO2 insufflation, for continued debridement under direct visualization, using blunt laparoscopic forceps. Following debridement, again under direct visualization, large drainage catheters or chest tubes, 28-French or greater, are placed. After surgery, these catheters are used for repeated lavage as well as for drainage [31].
The superiority of VARD, and the step-up approach, compared to surgery for the treatment of necrotizing pancreatitis was first published in the Minimally-invasive Step-up Approach Versus Maximal Necrosectomy in Patients with Acute Necrotizing Pancreatitis (PANTER) Trial. In this study, 35% of the patients assigned to the step-up arm were successfully treated with percutaneous drainage alone. When comparing the step-up and surgical groups, the step-up group was less likely to have new-onset organ failure, less likely to develop an incisional hernia, and had an overall lower rate of endocrine insufficiency. However, the mortality rate was not significantly different, 19% in the step-up group versus 16% in surgery group [31].
A similar procedure, percutaneous endoscopic necrosectomy (PEN), can be performed utilizing a previously established percutaneous drainage tract. Unlike VARD, PEN utilizes a flexible endoscope, as compared to a rigid laparoscope. Because the endoscope has working ports, in addition to irrigation and suction, an additional incision around the tract is not needed. Also unlike VARD, PEN can be performed at bedside, with conscious sedation [32].
PEN was shown to be effective in a large, prospective study of 171 patients with infected pancreatic necrosis. The primary outcome investigated was control of sepsis and resolution of the infected collection. In this study, 18 of 26 (69%) patients with infected ANC and 23 of 27 (85%) with infected WON who underwent PEN were successfully treated, while the remainder required surgical necrosectomy. Predictors of failure included >50% parenchymal necrosis and early organ failure. ANC was not predictive. The overall mortality rate for this study was 38% [32, 33]. Although this technique has not been directly compared to surgery, VARD, or transmural endoscopy, this study demonstrated the safety and utility of PEN in patients with infected pancreatic necrosis.
Regardless of the type of minimally-invasive drainage, VARD or PEN, it has been shown that the “step-up approach,” beginning with drainage and progressing to debridement, is superior to upfront surgical approaches in terms of mortality, rates of pancreaticocutaneous fistula formation, and long-term morbidity [25, 30, 34].
In addition to utilizing a percutaneous drainage tract for necrosectomy, access can also be gained through the stomach. By entering the abdomen and opening the anterior wall of the stomach and then opening the posterior aspect of the stomach, access to the lesser sac and underlying pancreas is achieved (Figure 2). An aperture between the WON and posterior wall of the stomach is then created, either with sutures or by stapling, providing a definitive drainage tract. This tract is then used for necrosectomy following the same principles as DEN.
This approach is most well suited for WON limited to the lesser sac. When there is extensive necrosis extending to the retroperitoneum or paracolic gutters, VARD or traditional necrosectomy are more appropriate, due to the limited exposure with this method. These limitations are counterbalanced by the minimal amount of mobilization required to enter the lesser sac by the transgastric method [35].
When performed laparoscopically, five ports are typically placed; in addition to an umbilical port, two ports are placed in the right upper quadrant, one port is placed in the left upper quadrant, and one port in the epigastrium. After entering the abdomen and creating the anterior gastrotomy, an ultrasound is used to identify the necrosis and plan the locations of the posterior gastrotomy. Ultrasound is adjunctive to preoperative imaging, which is also essential to surgical planning. Both anterior and posterior gastrotomies should be made after placement of stay sutures. Upon entering the lesser sac, necrosectomy should be performed with blunt instruments, such as a ring forceps, taking great care to remove only loose material and avoid avulsing adherent tissue or vessels that may be bridging the area of necrosis. Following necrosectomy, a cystogastrostomy is created with an endoscopic stapler, or suture. The anterior gastrotomy is then closed with sutures or with a stapler [36].
When performed open, an upper midline incision is made, and the procedure proceeds in the same fashion as in the laparoscopic procedure. One difference in the open procedure is that many surgeons elect to use digital dissection for the necrosectomy, as opposed to instruments [37].
Open and laparoscopic approaches to transgastric drainage have been shown to have similar outcomes. In a recent retrospective review of patients from three tertiary referral centers, rates of morbidity, including rates of reoperation and hemorrhage, and mortality were not significantly different. However, the patients who underwent laparoscopic drainage had a higher rate of readmission. It should be noted that the overall mortality in this study was 2% at an average follow-up of 21 months, significantly less than reported elsewhere in the literature. The overall morbidity rate of 38% is in alignment with commonly reported rates elsewhere in literature [38].
Although surgical transgastric necrosectomy is relatively well tolerated, outcomes favor endoscopic transgastric drainage. Meta-analysis comparing the two show lower rates of overall major complications, pancreatic fistula formation, post-procedural organ failure, and hernia with an endoscopic approach. However, the overall rate of clinical resolution, post-operative bleeding, endocrine dysfunction, exocrine insufficiency, and mortality were not significantly different [39]. Thus, surgical transgastric necrosectomy is a valid alternative to other approaches of necrosectomy in the absence of an experienced endoscopist or at a center without access to advanced endoscopic tools.
Although utilization of a drainage tract and the transgastric approach are important for management of pancreatic necrosis, traditional laparoscopic and open necrosectomy methods also continue to be utilized.
For laparoscopic necrosectomy, patients are typically placed in lithotomy position, with the operating surgeon standing between the legs. An umbilical port is placed first. Upon entering the abdomen, a diagnostic laparoscopy should be performed. Subsequently, two left lateral ports and an epigastric port are placed. In some cases, a hand-assist port is placed to augment dissection and removal of tissue. Following lysis of adhesions, a transgastrocolic, for pancreatic head or body necrosis, or transmesocolic, for pancreatic tail necrosis, approach to retrogastric necrosectomy can be taken (Figure 2). Upon entering the area of necrosis, blunt instruments are used to remove loose, necrotic tissue. This tissue is then placed into an endocatch bag for removal from the abdomen. Dissection is alternated with irrigation and suction to remove as much necrotic tissue as possible [40]. Once the necrosectomy is complete, large drainage catheters are placed in the cavity, which also allow for post-operative irrigation. At this time, consideration should also be given to cholecystectomy, if gallstones were implicated in the development of pancreatitis, and to nutritional access. Depending on the specific study, mortality for patients who require laparoscopic necrosectomy ranges from 10 to 18%. Rates of reoperation also vary widely, ranging from 11 to 38% [41, 42].
The most invasive procedure used for the treatment of pancreatic necrosis is the open debridement. This technique is reserved for patients that fail other less invasive techniques, or patients who require concurrent intervention for another intraabdominal process, such as bowel ischemia or abdominal compartment syndrome. Unless midline laparotomy is required for another indication, the abdomen can be opened with bilateral, subcostal incisions. The gastrocolic ligament is then opened, and the stomach is reflected superiorly, exposing the lesser sac (Figure 2). The transverse mesocolon is then opened, exposing the retroperitoneum. The hepatic and splenic flexures of the transverse colon are often taken down at this point. A Kocher maneuver may also be necessary if the area of necrosis involves the head of the pancreas. Once the pancreas is adequately exposed, blunt debridement can begin. This is usually accomplished with digital dissection or with lavage in order to minimize the risk of bleeding or bile duct injury. These risks must be balances with adequate removal of loose, nonviable tissue. Wide drainage of the area with a sumping tube (i.e. Abramson drain) can facilitate continue lavage and debridement. The quality of the initial necrosectomy predicts the need for subsequent operations.
After necrosectomy, the abdomen may be kept open, with packing in place, to allow for repeated removal of necrotic tissue. Alternatively, the closed packing technique can also be used. This technique consists of filling the cavity created by the necrosectomy with gauze-filled Penrose drains. The drains are removed one at a time, until the cavity closes [43]. A third option is continuous irrigation, where large catheters are placed into the lesser sac under direct visualization. Additional drainage catheters are left in the peritoneal cavity. The abdomen is then closed and the large catheters are used for continuous installation of hypertonic fluid [44].
As in patients who undergo laparoscopic necrosectomy, the rates of morbidity and mortality following open necrosectomy are high. Rates of post-operative morbidity range from 34 to 95% and mortality ranges from 6 to 47%, depending on the pre-operative severity of illness. Rates of reoperation vary depending on the packing technique. When the abdomen is left open, reoperation is planned rather than required because of deterioration or other complications, such as hemorrhage. Depending on the study, when the abdomen is left open, patients may return to the operating room from 1 to 17 time. Comparatively, relaparotomy is required in 17% of patients treated with closed packing require and 17–27% of patients treated with continuous irrigation. Rates of pancreatic fistula also differ depending on packing technique with a 25–46% rate in open abdomens, 53% rate in closed packing, and 13–19% rate with continuous irrigation [45].
The outcomes for both of these techniques are improved when intervention can be delayed at least 3 weeks. Delayed necrosectomy is associated with lower rates of exocrine and endocrine insufficiency, adverse post-operative events, including bleeding, and mortality [17, 46]. Early surgical intervention only provides a survival benefit in the case of decompression of abdominal compartment syndrome [47, 48].
When compared directly, in a retrospective case series, the rates of pancreatic fistula, post-operative pulmonary infections, and surgical site infections were all significantly lower with laparoscopic necrosectomy. Additionally, patients who underwent laparoscopic necrosectomy also had a shorter length of stay, but a longer initial operation. There was no difference in need for reoperation, overall morbidity, or mortality. It should be noted that mortality was very low compared to other literature in this study, 5.9% in the open group and 4% in the laparoscopic group [49].
While parenchymal destruction in pancreatic necrosis confers significant morbidity and mortality, the seriousness of this condition can be further compounded by concurrent disruption of the pancreatic duct. Disconnected pancreatic duct syndrome (DPDS) occurs when the remnant of pancreas distal to the necrosis, and duct disruption, remains viable and continues to release digestive enzymes into the retroperitoneum. DPDS most commonly occurs in the setting of severe acute pancreatitis, and can be found in up to 46% of patients with pancreatic necrosis [50]. DPDS can also occur as the result of trauma and chronic pancreatitis. The clinical presentation of DPDS is heterogenous. Some patients are asymptomatic and the injury is incidentally diagnosed on radiology. While others may have early satiety due to the size of the resulting fluid collection or symptomatic ascites [51, 52].
DPDS is an often overlooked complication due to the low accuracy of imaging in differentiating between full-thickness pancreatic necrosis, affecting the pancreatic duct, and partial thickness or peripancreatic necrosis. Often multiple imaging modalities are required for accurate diagnosis, which in turn leads to delays in diagnosis, increased morbidity, and increased costs [53, 54, 55]. Diagnostic criteria for DPDS include: necrosis of ≥2 cm of pancreatic parenchyma, viable pancreatic tissue distal to the area of necrosis, and extravasation of contrast when injected into the main pancreatic duct during ERCP [56].
Once DPDS is diagnosed, choice of intervention is dependent on the patient’s clinical condition and the phase of disease. As in pancreatic necrosis without DPDS, intervention during the acute phase, when inflammation is high, is not only challenging, but also hazardous. Although the historical standard of care for these patients was surgery, if a patient deteriorates during the acute phase, initial therapy should be percutaneous or endoscopic. Percutaneous drainage, although useful as a temporizing measure, especially in unstable patients, is unlikely to succeed as monotherapy [57, 58]. Although success rates are dependent on the extent of necrosis, transpapillary and transmural endoscopic interventions have better short-term outcomes, with up to an 87% success rate of fistula resolution [50, 59, 60]. However, in order for endoscopic treatment to be successful, multiple interventions are often required, including hybrid approaches with percutaneous drains. Further, long-term data regarding patency and migration of indwelling stents is not available [60, 61]. Thus, percutaneous and endoscopic treatments remain temporizing measures, rather than definitive treatment, for DPDS, except for in patients who are poor surgical candidates [62].
Once a patient reaches the late stage of disease, or if a patient deteriorates despite optimal percutaneous and endoscopic intervention during the acute phase, surgery becomes the primary treatment for DPDS. Because of the technical difficulty of operating in the retroperitoneum after tissue planes have been obscured by inflammation, and because of the frequency of splenic vein thrombosis, and resulting sinistral portal hypertension, this operation is usually performed with a midline laparotomy and not laparoscopically [63].
Surgery for DPDS consists of resection of the distal, disconnected pancreas, and creation of internal drainage tracts. These techniques may be used independently or in combination. When the entirety of the disconnected pancreas is resected, splenectomy is also performed in almost all cases. However, when a pancreatojejunostomy, pancreaticogastrostomy, or fistuloenterostomy is made with the viable distal pancreas, the spleen may be preserved, in addition to preserving the pancreatic remnant. In this way, internal drainage not only provide a conduit for pancreatic secretions, but also decreases the risk of exocrine pancreatic insufficiency and diabetes. Importantly, patients who undergo internal drainage, compared to other surgical modalities, also have lower incidence of organ failure, development of pancreatic fistula, and need for long-term percutaneous drainage [50, 64].
Pancreatic necrosis is a significant and challenging disease process with mortality reaching beyond 30% in most studies. Intervention begins with supportive care and nutritional support. However, invasive therapy is often needed, especially when necrosis becomes infected.
First-line interventions for pancreatic necrosis may be percutaneous or transmural endoscopic drainage depending on if the necrosis is encapsulated, the accessibility of the necrosis, the patient’s clinical condition, and the capabilities of the hospital. These minimally-invasive interventions are often successful as monotherapy, without the need for further intervention. They are also preferable to open or laparoscopic necrosectomy when performed as part of a step-up approach.
Despite all of the improvement in minimally-invasive management of pancreatic necrosis, some percentage of patients continue to require surgical intervention. Both laparoscopic and open approaches have been shown to be effective via transgastric, transgastrocolic, and transmesocolic routes.
When pancreatic necrosis is further complicated by a disconnected pancreatic duct, although minimally-invasive management has been described and shown to be effective, surgical management remains standard of care.
Despite the advances in care driven by clinical trials and new technology, management of pancreatic necrosis remains difficult. Further study is needed to reduce the morbidity and mortality of this devastating disease.
All authors contributed equally to the authorship of this chapter.
The authors declare no conflicts of interest.
The authors would like to thank the leadership of the Department of Surgery at the Donald and Barbara School of Medicine at Hofstra/Northwell, including Drs. Vihas Patel and Gene Coppa, for sponsoring the writing of this chapter.
acute necrotic collection computed tomography direct endoscopic necrosectomy disconnected pancreatic duct syndrome endoscopic retrograde cholangiopancreatography endoscopic ultrasound fine needle aspiration Hounsfield units percutaneous endoscopic necrosectomy self-expanding metal stent total parenteral nutrition walled of necrosis video-assisted retroperitoneal debridement
The Internet has irrevocably changed the dynamics of scholarly communication and publishing. Consequently, we find it necessary to indicate, unambiguously, our definition of what we consider to be a published scientific work.
",metaTitle:"Prior Publication Policy",metaDescription:"Prior Publication Policy",metaKeywords:null,canonicalURL:"/page/prior-publication-policy",contentRaw:'[{"type":"htmlEditorComponent","content":"A significant number of working papers, early drafts, and similar work in progress are openly shared online between members of the scientific community. It has become common to announce one’s own research on a personal website or a blog to gather comments and suggestions from other researchers. Such works and online postings are, indeed, published in the sense that they are made publicly available. However, this does not mean that if submitted for publication by IntechOpen they are not original works. We differentiate between reviewed and non-reviewed works when determining whether a work is original and has been published in a scholarly sense or not.
\\n\\nThe significance of Peer Review cannot be overstated when it comes to defining, in our terms, what constitutes a published scientific work. Peer Review is widely considered to be the cornerstone of modern publishing processes and the key value-adding contribution to a scholarly manuscript that a publisher can make.
\\n\\nOther than the issue of originality, research misconduct is another major issue that all publishers have to address. IntechOpen’s Retraction & Correction Policy and various publication ethics guidelines identify both redundant publication and (self)plagiarism to fall within the definition of research misconduct, thus constituting grounds for rejection or the issue of a Retraction if the work has already been published.
\\n\\nIn order to facilitate the tracking of a manuscript’s publishing history and its development from its earliest draft to the manuscript submitted, we encourage Authors to disclose any instances of a manuscript’s prior publication, whether it be through a conference presentation, a newspaper article, a working paper publicly available in a repository or a blog post.
\\n\\nA note to the Academic Editor containing detailed information about a submitted manuscript’s previous public availability is the preferred means of reporting prior publication. This helps us determine if there are any earlier versions of a manuscript that should be disclosed to our readers or if any of those earlier versions should be cited and listed in a manuscript’s references.
\\n\\nSome basic information about the editorial treatment of different varieties of prior publication is laid out below:
\\n\\n1. CONFERENCE PAPERS & PRESENTATIONS
\\n\\nGiven that conference papers and presentations generally pass through some sort of peer or editorial review, we consider them to be published in the accepted scholarly sense, particularly if they are published as a part of conference proceedings.
\\n\\nAll submitted manuscripts originating from a previously published conference paper must contain at least 50% of new original content to be accepted for review and considered for publication.
\\n\\nAuthors are required to report any links their manuscript might have with their earlier conference papers and presentations in a note to the Academic Editor, as well as in the manuscript itself. Additionally, Authors should obtain any necessary permissions from the publisher of their conference paper if copyright transfer occurred during the publishing process. Failure to do so may prevent Us from publishing an otherwise worthy work.
\\n\\n2. NEWSPAPER & MAGAZINE ARTICLES
\\n\\nNewspaper and magazine articles usually do not pass through any extensive peer or editorial review and we do not consider them to be published in the scholarly sense. Articles appearing in newspapers and magazines rarely possess the depth and structure characteristic of scholarly articles.
\\n\\nSubmitted manuscripts stemming from a previous newspaper or magazine article will be accepted for review and considered for publication. However, Authors are strongly advised to report any such publication in an accompanying note to the External Editor.
\\n\\nAs with the conference papers and presentations, Authors should obtain any necessary permissions from the newspaper or magazine that published the work, and indicate that they have done so in a note to the External Editor.
\\n\\n3. GREY LITERATURE
\\n\\nWhite papers, working papers, technical reports and all other forms of papers which fall within the scope of the ‘Luxembourg definition’ of grey literature do not pass through any extensive peer or editorial review and we do not consider them to be published in the scholarly sense.
\\n\\nAlthough such papers are regularly made publicly available via personal websites and institutional repositories, their general purpose is to gather comments and feedback from Authors’ colleagues in order to further improve a manuscript intended for future publication.
\\n\\nWhen submitting their work, Authors are required to disclose the existence of any publicly available earlier drafts in a note to the Academic Editor. In cases where earlier drafts of the submitted version of the manuscript are publicly available, any overlap between the versions will generally not be considered an instance of self-plagiarism.
\\n\\n4. SOCIAL MEDIA, BLOG & MESSAGE BOARD POSTINGS
\\n\\nWe feel that social media, blogs and message boards are generally used with the same intention as grey literature, to formulate ideas for a manuscript and gather early feedback from like-minded researchers in order to improve a particular piece of work before submitting it for publication. Therefore, we do not consider such internet postings to be publication in the scholarly sense.
\\n\\nNevertheless, Authors are encouraged to disclose the existence of any internet postings in which they outline and describe their research or posted passages of their manuscripts in a note to the Academic Editor. Please note that we will not strictly enforce this request in the same way that we would instructions we consider to be part of our conditions of acceptance for publication. We understand that it may be difficult to keep track of all one’s internet postings in which the researcher´s current work might be mentioned.
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\\n"}]'},components:[{type:"htmlEditorComponent",content:'A significant number of working papers, early drafts, and similar work in progress are openly shared online between members of the scientific community. It has become common to announce one’s own research on a personal website or a blog to gather comments and suggestions from other researchers. Such works and online postings are, indeed, published in the sense that they are made publicly available. However, this does not mean that if submitted for publication by IntechOpen they are not original works. We differentiate between reviewed and non-reviewed works when determining whether a work is original and has been published in a scholarly sense or not.
\n\nThe significance of Peer Review cannot be overstated when it comes to defining, in our terms, what constitutes a published scientific work. Peer Review is widely considered to be the cornerstone of modern publishing processes and the key value-adding contribution to a scholarly manuscript that a publisher can make.
\n\nOther than the issue of originality, research misconduct is another major issue that all publishers have to address. IntechOpen’s Retraction & Correction Policy and various publication ethics guidelines identify both redundant publication and (self)plagiarism to fall within the definition of research misconduct, thus constituting grounds for rejection or the issue of a Retraction if the work has already been published.
\n\nIn order to facilitate the tracking of a manuscript’s publishing history and its development from its earliest draft to the manuscript submitted, we encourage Authors to disclose any instances of a manuscript’s prior publication, whether it be through a conference presentation, a newspaper article, a working paper publicly available in a repository or a blog post.
\n\nA note to the Academic Editor containing detailed information about a submitted manuscript’s previous public availability is the preferred means of reporting prior publication. This helps us determine if there are any earlier versions of a manuscript that should be disclosed to our readers or if any of those earlier versions should be cited and listed in a manuscript’s references.
\n\nSome basic information about the editorial treatment of different varieties of prior publication is laid out below:
\n\n1. CONFERENCE PAPERS & PRESENTATIONS
\n\nGiven that conference papers and presentations generally pass through some sort of peer or editorial review, we consider them to be published in the accepted scholarly sense, particularly if they are published as a part of conference proceedings.
\n\nAll submitted manuscripts originating from a previously published conference paper must contain at least 50% of new original content to be accepted for review and considered for publication.
\n\nAuthors are required to report any links their manuscript might have with their earlier conference papers and presentations in a note to the Academic Editor, as well as in the manuscript itself. Additionally, Authors should obtain any necessary permissions from the publisher of their conference paper if copyright transfer occurred during the publishing process. Failure to do so may prevent Us from publishing an otherwise worthy work.
\n\n2. NEWSPAPER & MAGAZINE ARTICLES
\n\nNewspaper and magazine articles usually do not pass through any extensive peer or editorial review and we do not consider them to be published in the scholarly sense. Articles appearing in newspapers and magazines rarely possess the depth and structure characteristic of scholarly articles.
\n\nSubmitted manuscripts stemming from a previous newspaper or magazine article will be accepted for review and considered for publication. However, Authors are strongly advised to report any such publication in an accompanying note to the External Editor.
\n\nAs with the conference papers and presentations, Authors should obtain any necessary permissions from the newspaper or magazine that published the work, and indicate that they have done so in a note to the External Editor.
\n\n3. GREY LITERATURE
\n\nWhite papers, working papers, technical reports and all other forms of papers which fall within the scope of the ‘Luxembourg definition’ of grey literature do not pass through any extensive peer or editorial review and we do not consider them to be published in the scholarly sense.
\n\nAlthough such papers are regularly made publicly available via personal websites and institutional repositories, their general purpose is to gather comments and feedback from Authors’ colleagues in order to further improve a manuscript intended for future publication.
\n\nWhen submitting their work, Authors are required to disclose the existence of any publicly available earlier drafts in a note to the Academic Editor. In cases where earlier drafts of the submitted version of the manuscript are publicly available, any overlap between the versions will generally not be considered an instance of self-plagiarism.
\n\n4. SOCIAL MEDIA, BLOG & MESSAGE BOARD POSTINGS
\n\nWe feel that social media, blogs and message boards are generally used with the same intention as grey literature, to formulate ideas for a manuscript and gather early feedback from like-minded researchers in order to improve a particular piece of work before submitting it for publication. Therefore, we do not consider such internet postings to be publication in the scholarly sense.
\n\nNevertheless, Authors are encouraged to disclose the existence of any internet postings in which they outline and describe their research or posted passages of their manuscripts in a note to the Academic Editor. Please note that we will not strictly enforce this request in the same way that we would instructions we consider to be part of our conditions of acceptance for publication. We understand that it may be difficult to keep track of all one’s internet postings in which the researcher´s current work might be mentioned.
\n\nIn cases where there is any overlap between the Author´s submitted manuscript and related internet postings, we will generally not consider it to be an instance of self-plagiarism. This also holds true for any co-Author as well.
\n\nFor more information on this policy please contact permissions@intechopen.com.
\n\nPolicy last updated: 2017-03-20
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