\r\n\tAn update on clinical manifestations, their assessment, monitoring, and imagiology, including peripheral arthritis, enthesopathy, and extra-articular findings, and, the differential diagnosis with other diseases which evolves with axial and peripheral calcifications will be provided.
\r\n
\r\n\t \r\n\tAn important component of this book must be dedicated to the more recent treatments namely with biologic therapies but focusing also on new small molecule inhibitors and experimental therapies.
",isbn:"978-1-80356-243-8",printIsbn:"978-1-80356-242-1",pdfIsbn:"978-1-80356-244-5",doi:null,price:0,priceEur:0,priceUsd:0,slug:null,numberOfPages:0,isOpenForSubmission:!0,isSalesforceBook:!1,hash:"e07e8cf78550507643fbcf71a6a9d48b",bookSignature:"Dr. Jacome Bruges Armas",publishedDate:null,coverURL:"https://cdn.intechopen.com/books/images_new/11273.jpg",keywords:"Diagnostic Criteria, Occurrence, Peripheral Involvement, Extra-Articular Manifestations, Axial Imaging, MRI, Disease Activity, Physical Function, Potential Pathways, MHC, Drug Treatment, New Small Molecules",numberOfDownloads:null,numberOfWosCitations:0,numberOfCrossrefCitations:null,numberOfDimensionsCitations:null,numberOfTotalCitations:null,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"February 9th 2022",dateEndSecondStepPublish:"May 6th 2022",dateEndThirdStepPublish:"July 5th 2022",dateEndFourthStepPublish:"September 23rd 2022",dateEndFifthStepPublish:"November 22nd 2022",remainingDaysToSecondStep:"17 days",secondStepPassed:!0,currentStepOfPublishingProcess:3,editedByType:null,kuFlag:!1,biosketch:"Senior Specialist in Internal Medicine and Specialist in Oncology. 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\n
1. Introduction
\n
Submucosal leiomyomas or fibroids are estimated to be the cause of 5–10% of cases of abnormal uterine bleeding, pain, subfertility and infertility [1].
\n
This chapter focuses on the diagnostic methods to determine the type of submucosal leiomyomas present, their impact on uterine bleeding and infertility, and the methods used to resect these leiomyomas.
\n
\n
\n
2. Classification of fibroids
\n
It is important to classify fibroids according to the degree of endometrial cavity distortion when considering therapeutic options such as a surgical approach. The degree of intramural extension has implications for operative difficulty and risk. The most widely used system classifies submucous leiomyomas into three subtypes according to the proportion of the lesion’s diameter that is within the myometrium as determined by saline infusion sonography (SIS) or hysteroscopy. Type 0 leiomyomas are completely intracavitary, type 1 leiomyomas are less than 50% intramural and type 2 leiomyomas more than 50% intramural [2, 3].
\n
This classification has been shown to be predictive of the likelihood of complete surgical resection, which is the most predictive indicator of surgical success. Uterine size and the number of leiomyomas also have been shown to be independent prognostic variables for recurrence [2, 4].
\n
A newer and more detailed classification system has been devised and advocated by the International Federation of Gynecology and Obstetrics (FIGO). This system allows for categorization of the relationship of the leiomyoma outer boundary with the uterine serosa, a relationship that is important when evaluating women suitable for resectoscopic surgery. Thus, a type 2 leiomyoma that reaches the serosa is considered to be a type 2–5 lesion and therefore not a candidate for resectoscopic surgery (see Figure 1).
\n
Figure 1.
FIGO classification of submucous leiomyomas. Reproduced with permission granted by Elsevier.
\n
\n
2.1. Diagnostic methods for classifications of fibroids
\n
The methods to confirm the presence of a submucous fibroid include ultrasonography (typically transvaginal ultrasonography, TVUS), saline infusion sonography (SIS), diagnostic hysteroscopy, hysterosalpingography and magnetic resonance imaging (MRI). The diagnosis of submucous fibroids is generally achieved with one or a combination of hysteroscopy and radiological techniques. The aims are to distinguish leiomyomas from adenomyosis, confirmation of submucous location, as well the number, size, location and extent of myometrial penetration of each identified submucous myoma. The relationship of the submucous myoma to the uterine serosa is of particular importance as transcervical resection is not appropriate when the leiomyoma is very close to or in contact with the serosal layer of the uterus, due to an increased risk of uterine perforation and visceral injury with significant associated morbidity.
\n
A surgeon can get the best appreciation for the location and relationship of submucosal fibroids to the uterine serosa by reviewing the radiological images themselves prior to the planned operation. This well help them decide the best approach to resecting the fibroids. The quality of the images obtained therefore plays a significant role. These imaging modalities will be discussed in detail below [5].
\n
\n
2.1.1. Transvaginal ultrasonography (TVUS)
\n
TVUS has a sensitivity of 0.8 and a specificity of 0.7 for diagnosing submucous fibroids, and is generally thought to have limited use for exclusion of submucous fibroids and polyps (negative likelihood ratio 0.29) [6]. However, a prospective study suggested that when TVUS has been used as a first-step investigation, diagnostic hysteroscopy can be avoided in 40% of cases. This would suggest that it is a viable non-invasive initial investigation [6]. Unfortunately, TVUS is very operator dependent, a factor that must be considered when evaluating its reliability.
\n\n
\n
\n
2.1.2. Saline infusion sonography (SIS)
\n
Hysterosonography or saline infusion sonography (SIS) is a non-invasive imaging technique performed at the time of transvaginal ultrasound. Saline is introduced into the uterine cavity at the time of ultrasound and distends the uterine cavity to give better visualization of the endometrium and any intrauterine tumours or polyps [7].
\n
The procedure is best performed when the endometrium is thin and the patient is not pregnant, therefore the first ten days of a menstrual cycle. The cervix is identified by speculum examination and a fine catheter inserted into the cervical os with a saline containing syringe at the end of the catheter. A transvaginal ultrasound is then performed at the same time as the injection of the saline. The procedure takes no more than 10–15 minutes. The benefit of saline infusion sonography is that the intramural component of a submucous fibroid is then better visualized by the ultrasound (see Figure 2) [5]. There is high-quality evidence from a Cochrane systematic review that demonstrates SIS and hysteroscopy to be equivalent for the diagnosis of submucous leiomyomas, with both superior to TVUS [8]. The main drawbacks of this technique are the risk of infection (1%) and the discomfort associated with injection of sterile saline into the uterus.
\n
Figure 2.
Ultrasound before and after instillation of saline as a contrast medium.
\n
\n
\n
2.1.3. Diagnostic hysteroscopy
\n
Hysteroscopy involves inserting a telescope (usually 2.7–4 mm) into the endometrial cavity. The procedure may be performed in an outpatient setting without anaesthetic, even in nulliparous women and is highly successful, although some women (approximately 25%) will require local anaesthesia and some women may prefer general anaesthesia. If the patient requires a local anaesthetic, it can be administered by a paracervical block using 5 mL of 1% lignocaine. This can be injected at the level where a tenaculum is applied to the cervix and also at the 3 o’ clock and 9 o’ clock positions deep enough to the level of the internal cervical os. Other options are topical local anaesthetic gel, spray or cream [9, 10].
\n
As for any procedure on the uterus it is essential to exclude the possibility of pregnancy and active infection. The administration of a non-steroidal anti-inflammatory prior to the procedure has been demonstrated to reduce the patient’s posthysteroscopy discomfort [11].
\n
Two methods of uterine distension are used—carbon dioxide and normal saline instillation. A randomized controlled trial (RCT) of carbon dioxide versus normal saline instillation during hysteroscopy found that normal saline provided comparable visualization to carbon dioxide with reduced procedure time and patient discomfort [12]. The distending pressure normally used is 80–100 mmHg.
\n
Diagnostic hysteroscopy can be used to assess and document uterine abnormalities which should then be recorded by digital images. These can be used to plan an operative procedure and also facilitate the patient’s understanding of their pathology (see Figure 3). The procedure should be performed quickly to avoid patient discomfort and manipulation of the cervix when rotating the hysteroscope should be avoided.
\n
Figure 3.
Hysteroscopic image of fibroid prior to resection.
\n
\n
\n
2.1.4. Magnetic resonance imaging (MRI)
\n
Magnetic resonance imaging (MRI) is a costly imaging technique which is not available in all units. However, the use of T2-weighted images allows accurate localisation of the demarcation between the endometrium and myometrium. MRI is the most accurate modality in assessing the adnexae and the uterus because it provides information on the size, location, number and perfusion of leiomyomas as well as the presence of other uterine pathology including adenomyosis or endometriosis [13].
\n
A double-blinded study demonstrated that although TVUS and MRI are roughly equivalent in diagnosing the presence of leiomyomas, the determination of other features such as location and proportion of the tumour in the endometrial cavity, is best accomplished with MRI. It was shown to be the most reliable method of evaluation when compared with vaginal ultrasound, hysterosonography and hysteroscopy, with 100% sensitivity and 91% specificity (gold standard was pathological examination) [14].
\n
MRI was superior to the TVUS and SIS in evaluating the relationship of submucous leiomyomas to the myometrium [15]. MRI is becoming more available for the assessment of submucosal fibroids; however, the costs involved and its availability limit its use.
\n
\n
\n
\n
\n
3. Indications for surgery
\n
If a submucosal fibroid is confirmed with selected diagnostic modalities, the decision to operate should be individualized based on the patient and their symptoms. It is believed that one in three women with fibroids experience abnormal uterine bleeding (AUB) and that the presence of a submucosal fibroid increases the chance of this. The two most common indications for surgery are described below [16, 17].
\n
\n
3.1. Menorrhagia
\n
There is little evidence implicating the role of FIGO staged submucous leiomyomas as the cause of haemorrhage requiring urgent intervention [18]. However, there is evidence to suggest that submucous leiomyomas can cause chronic abnormal uterine bleeding and heavy menstrual bleeding (HMB).
\n
A systematic review of 11 studies demonstrated the prevalence of submucous myomas in women with AUB was 23.4%. Submucous myomas were found in 23.4% of premenopausal women (six studies) and 4.5% of postmenopausal women with AUB (one study). Although these studies fell short of proving that submucous myomas cause AUB they suggest that there may be a relationship. The incidence of submucous fibroids in 323 consecutive asymptomatic women undergoing sterilization was reported at 1.8%, whereas in a series of women with abnormal uterine bleeding, submucous fibroids were reported more frequently (6–34%) [19].
\n
Broadbent and Magos [20], measured menstrual blood loss before and after hysteroscopic surgery of submucosal fibroids and showed that surgery improved both dysmenorrhea and heavy bleeding. They demonstrated that after surgery there was a significant reduction in the duration, blood loss and pain score associated with menstruation.
\n
There are various theories for the pathophysiology of how submucous fibroids contribute to abnormal uterine bleeding and menorrhagia. It is thought that the mechanisms involved in haemostasis and prostaglandin production in the endometrium can be disturbed by the presence of fibroids. Another hypothesis is that it can be due to increased endometrial surface area of the endometrium. Both submucous and intramural fibroids have the potential to cause this [21].
\n
\n
\n
3.2. Infertility
\n
Women undergoing IVF treatment in the presence of a submucosal fibroid have lower clinical pregnancy rates than those without fibroids (10% vs. 30%) as seen in a retrospective comparative study of over 400 assisted reproductive treatment cycles. This may suggest an association between submucosal fibroids and subfertility. One major drawback was that in this study there were only nine patients in the submucosal fibroid group. Similar results were recorded in a study by Farhi et al. [22, 23]. There have been no appropriately designed studies to demonstrate a direct causal relationship between the presence of fibroids and infertility.
\n
Many hypotheses have been generated to explain how fibroids might cause infertility. Perfusion studies have shown that blood flow to uterine fibroids is less than that to the adjacent myometrium. Blood flow to the uterine arteries is also different in a fibroid uterus than a non-fibroid uterus [24]. This and the fact that there may be endometrial inflammation and an altered local hormonal environment may affect embryo implantation. Myomas also seem to alter uterine contractility possibly interfering with sperm and ovum interaction or embryo migration [25]. This may especially be true in a uterus with multiple large fibroids with cavity distortion.
\n
Six systematic reviews or meta-analyses published between 2001 and 2010 assessed whether fibroids have an impact on fertility. On the whole, it appears that women with fibroids have decreased fertility. The presence of fibroids, regardless of location, significantly decreases both implantation and clinical pregnancy rates (RR 0.821; 95% CI 0.722–0.932, P = 0.002 and RR 0.849; 95% CI 0.734–0.982, P < 0.03, respectively). The impact of fibroid number and size on fertility has not been clearly elucidated. Reproductive success does, however, seem to be related to fibroid location [26, 27].
\n
All systematic reviews and meta-analyses agree that subserosal fibroids do not have an impact on fertility. Submucosal fibroids (fibroids with endometrial impingement), however, have been shown uniformly to have a negative impact on rates of implantation, clinical pregnancy rate, miscarriage and live birth/ongoing pregnancy, although available studies are few and small [24, 27].
\n
In conclusion, submucosal fibroids are associated with reduced fertility and an increased miscarriage rate. Hysteroscopic myomectomy for submucosal fibroids is likely to improve fertility outcomes; however, the quality of available studies is poor and further research is required. The relative effect of multiple or different sized fibroids on fertility outcomes are also uncertain [28].
\n
\n
\n
\n
4. Surgical management of submucosal fibroids
\n
Surgical resection remains the mainstay for women with symptomatic submucosal fibroids. Medical therapy with gonadotrophin-releasing hormone analogues (GnRHa) appears useful in the short term but side effects limit their long-term use [5]. Medical management of fibroids delays efforts to conceive and is not recommended for the management of infertility associated with fibroids. However, short-term GnRH analog use in infertile women with fibroids can be useful for preoperative correction of anaemia or short-term reduction in fibroid volume [28].
\n
Newer, novel therapies including aromatase inhibitors, mifepristone, selective estrogen receptor modulators and selective progesterone receptor modulators have shown promise in symptom improvement and fibroid regression without the hypoestrogenic symptoms associated with GnRH analogues however they are currently only used in the setting of approved clinical trials on the management of fibroids in women with infertility.
\n
The same applies to other alternatives to surgery such as uterine artery embolization (UAE), magnetic resonance-guided focused ultrasound surgery (MRgFUS), myolysis and radio-frequency ablation (RFA) all of which are still being investigated in terms of their long-term impact on fertility [24, 28].
Transcervical resectoscopic myomectomy (TCRM) was performed in 1976 with a modified urologic resectoscope [29]. Traditionally, this has been the most common method of hysteroscopic resection of fibroids, but various new modalities such as vapourisation, morcellation and dissection are now being used in the surgical management of fibroids [3].
\n
Hysteroscopic myomectomy is the least invasive surgical approach for fibroid removal. It is most effective for patients with submucosal fibroids completely within the uterine cavity (type 0) or with at least 50% of the fibroid volume within the uterine cavity (type 1). Fibroids with less than 50% of the fibroid volume in the cavity (type 2) are much more difficult to resect completely and are more often associated with the need for repeated procedures.
\n
Submucous fibroids less than or equal to 5 cm diameter can be removed hysteroscopically however anything larger in diameter should be removed abdominally whether by laparoscopy or laparotomy (midline or pfannensteil) depending on surgeon’s skill and preference. Type 2 fibroids tend to require a multi-staged procedure when compared to type 0 and 1 [4, 24].
\n
\n
4.1.1. Patient selection
\n
Achievement of a high likelihood of surgical success requires good patient selection and relevant factors such as the number of submucous myomas, their location, size and type, and their relationship to the uterine serosa should be considered. When evaluating the suitability of patients for TCRM, it is important to consider the myoma type, the potential for incomplete excision and the patient’s tolerance for more than one procedure if required. The indication for fibroid resection is also very important.
\n
With resection of fibroids for abnormal bleeding, it is found that type 2 myomas could be eventually resected but required a larger number of repeat procedures than the more superficial types 0 and 1 myomas, which almost invariably are completed with a single operation [30, 31].
\n
A recently published randomized controlled trial compared treatment of submucous myomas in 215 women with primary infertility. Fertility rates increased after TCRM for type 0 and type 1 myomas, but no significant difference was noted between the groups for type 2 myomas. However, a number of questions related to the effects of resection of myomas on fertility remain unanswered and highlight the need for careful patient selection in this population [32].
\n
The same applies with regard to multiple pregnancy loss. Data from Pritts et al. suggest that in selected patients submucous myomectomy may reduce the rate of spontaneous abortion; however, more data are required to confirm this [27].
\n
\n
\n
4.1.2. Pre-operative preparation
\n
\n
4.1.2.1. Suppressive medical therapy before TCRM
\n
Commencing the patient on a gonadotrophin hormone-releasing (GnRH) analogue or selective progesterone receptor modulator (mifepristone or ulipristal acetate) [33] prior to the surgery allows the surgeon to operate when the endometrium is thin which can reduce operative time by allowing better visualization during the procedure. Theoretically, this also reduces intraoperative bleeding and fluid absorption. However, its main proven benefit is that it can reduce menstrual blood loss and correction of anaemia prior to surgery. This also aids with restoration of haemoglobin and iron stores for the woman. Whereas high-quality data exist demonstrating the efficacy of GnRH agonists in facilitating the treatment of anaemia before the procedure the data regarding the impact on other outcomes is more mixed, although the use of selective progesterone receptor blockers may show promise [34–36].
\n
\n
\n
4.1.2.2. Cervical preparation before TCRM
\n
Various methods are available for preoperative ripening of the cervix prior to hysteroscopic resection. The benefit of cervical ripening is to reduce the risk of cervical tears and uterine perforation that is associated with forceful dilatation. These risks are increased in postmenopausal women, for those without previous vaginal delivery and for women with previous surgery for cervical surgery or neoplasia. Options for ripening include laminaria tents, preoperative prostaglandins such as misoprostol and intraoperative intracervical injection of dilute vasopressin [3].
\n
Probably the best available evidence is for use of prostaglandins. High-quality evidence from randomized controlled trials suggests that misoprostol, a synthetic prostaglandin E1 analogue (200–400 mcg) taken orally or vaginally, 12–24 hours before surgery, facilitates cervical dilation and minimizes traumatic complications in premenopausal women [37]. The cervix is then usually dilated to accept a size 10 Hegar dilator.
\n
\n
\n
4.1.2.3. Prophylactic antibiotics and intra-operative preparation
\n
The risk of infection from hysteroscopic procedures is low, in the order of 0.5–1% with a risk of endometritis following resectoscopic myomectomy of 0.51% [38]. Most operators would however routinely administer prophylactic antibiotics to limit postoperative febrile morbidity, although there is no prospective data to support this practice.
\n
\n
\n
4.1.2.4. Anaesthesia
\n
Resection of a submucosal fibroid is usually performed after the administration of general anaesthetic, although it may be performed with spinal anaesthesia or with local anaesthetic; paracervical block and intrauterine injection of local anaesthetic in association with intravenous sedation [39].
\n
Increasingly over the last decade, more operative hysteroscopic procedures have been performed in an office-based setting. Mcilwaine et al. showed in a study of 42 patients that the Myosure lite device (uses electromechanical energy) can be successfully used to resect small fibroids in the outpatient setting with a high level of patient satisfaction with the use of local anaesthetic in a paracervical block [40].
\n
\n
\n
\n
\n
4.2. Surgical technique
\n
Patients are generally placed in lithotomy position: Trendelenburg positioning should be avoided. After an examination under anaesthesia, a bivalve speculum is placed in the vagina and the cervix identified. After placing a single tooth tenaculum on the anterior lip of the cervix (if the patient is conscious local anaesthetic spray can be applied prior to this), the cervix is dilated with Hegar dilators to size 10 sufficient to accommodate the 9 mm outer sheath of a standard resectoscope. The longer dilators with a gradually tapered tip are safer and minimize the risk of perforation [41].
\n
The correct and safe use of instruments available will enable the surgeon to most effectively carry out hysteroscopic fibroid resection. In the past, smaller fibroids have been removed with conventional instruments such as grasping polyp forceps or scissors; however, there is now a growing trend towards performing the procedure with devices under direct vision [3]. They have the added benefit of early recognition of the complication of uterine perforation and reducing its associated morbidity.
\n
\n
4.2.1. Hysteroscopic systems
\n
For optimum safety and effectiveness, the surgeon should have a detailed understanding of the design and assembly, and where necessary, troubleshooting strategies for the system in use.
\n
The most commonly employed system for removal of submucous myomas is the urologic resectoscope, slightly modified for gynaecological use. With this instrument, the fibroid can be resected under direct vision. The resectoscope consists of a 26 French gauge outer sheath diameter and 0° or 30° fore-oblique telescope with a 4 mm outer diameter. All modern resectoscopes are of a continuous flow design, allowing constant turnover of distending media that facilitates visualization of the fibroid by rinsing out blood and debris. There is a large calibre inflow (cystoscopy tubing) and outflow tubing that are connected to a fluid management system. The inflow is pressurized with a peristaltic pump with a maximum pressure setting of 150 mmHg and a maximum flow setting of 450 mL/minute, similar to standard resectoscopy [42]. Pressures selected are based on the mean arterial pressure of the patient as a first-line barrier to fluid intravasation, typically 80 mmHg.
\n
Standard technique to remove polyps and submucous myomas is resectoscopy with monopolar high-frequency electrical current. By means of a 5mm wire loop electrode, mounted on a working element with handpiece and integrated in an endoscope, tissue can be cut. Monopolar current necessitates the use of nonconducting, nonphysiologic, electrolyte-free irrigation and distention liquids such as sorbitol 5% or glycine 1.5% [3, 41, 42].
\n
The outflow tubing should be connected to both the under the buttocks collection bag as well the outflow adaptor of the hysteroscope itself. This maintains a negative pressure in the outflow tract and allows for continuous suction of debris-laden fluid from the endometrial cavity and an accurate count of fluid lost. The negative pressure may be increased if the view is too cloudy or decreased if there is inadequate uterine distension prior to increasing the distension pressure [5, 41].
\n
More commonly bipolar resectoscopes are being used as they require the use of isotonic conductive media, such as normal saline or lactate Ringers solution. This is because in a bipolar loop the active and return electrodes are in close proximity to one another a lower impedance media can be used. The risk of volume overload and electrolyte disturbance is significantly reduced with isotonic solutions.
\n
Small-diameter bipolar electrodes or laser fibers can be passed through the instrument channel of most standard hysteroscope sheaths 5 mm or greater in diameter. In some instances, dissection of smaller submucous myomas can be accomplished with such energy sources.
\n
The hysteroscopic morcellator is gaining more popularity in recent years. It was developed based on an orthopaedic shaver. It is a hollow device with a sideways opening that allows the blade to morcellate the leimyoma. It also has the ability to suction morcellated fragments of the fibroid simultaneously. This can also be used with saline distension media and does not require electrical current [42] (see Figure 4).
\n
Figure 4.
Surgeon holding Myosure(Hologic) hysteroscopic device (right). Inflow and outflow tubing for fluid management system (Aquilex Hologic) (left).
\n
\n
\n
4.2.2. Myomectomy procedure
\n
There are three basic methods for removing leiomyomas under hysteroscopic direction; morcellation, cutting with an electrosurgical loop and vaporization. The most commonly employed approaches use the resectoscope, a radiofrequency electrosurgical generator, and either a loop or a bulk-vapourising electrode.
\n
When performing radiofrequency-based hysteroscopic myomectomy on women who wish to preserve fertility, care should be taken to minimize thermal damage to the tissue adjacent to the incision and that the loop does not touch adjacent healthy endometrium.
\n
The traditional resectoscopic removal involves a slicing action of the fibroid. It can be performed with monopolar or bipolar cutting or coagulating current at a setting of 100 W. The electrosurgical loop is advanced beyond the fibroid and a repeated action of passing the cutting loop over the tissue in a backward direction, away from the fundus of the uterus is performed. In a pedunculated fibroid, the stalk can be transected and then removed by polyp forceps. Performing the procedure in a systematic way, starting at the top of the fibroid and working ones’ way down to its base is the ideal approach. It is important to avoid damage to normal endometrial tissue with the loop as much as possible. Repetitively removing the resectoscope from the uterus to remove tissue fragments is time consuming, causes cervical trauma and can lead to a loss of uterine distention with compensatory increased use of distention media. To avoid this resected tissue, fragments can be pushed towards the uterine fundus and removed at the end of the operation. The closer the association of the fibroid with the serosa of the uterus, the more challenging the resection is due to the significant intramural component. Methods to facilitate extrusion of the intramural component include using the natural contractility of the uterus [43], intraoperative prostaglandins to stimulate uterine smooth muscle contraction [38], intravenous ergometrine [44] and repeated release of the uterine distending pressure, to allow for natural uterine extrusion.
\n\n
For deep type 1 and type 2 fibroids that approach the uterine serosa (millimetres), it may be safer to perform a laparoscopy at the same time as the resection. This does not always prevent perforation but ensures early recognition of this complication and associated damage to other viscera. There is also the thought that the gas used to distend the abdominal cavity at laparoscopy can create a safety buffer in the unfortunate event of a perforation [45]. Type 0 and most type 1 fibroids are much more easily removed.
\n
When a submucosal fibroid has a significant intramural component (type 2), a multi-staged procedure will result in a more complete resection and is generally also thought to be safer as it avoids the complication of perforation which can occur during resection of the base of the fibroid.
\n
Electrosurgical vapourisation of fibroids involves using an electrode of cylindrical or spherical shape which uses current to vapourise the tissue. This does not produce any tissue fragments which can be a disadvantage if a specimen is required for histopathological assessment [46]. There is some lower quality evidence which suggests that reduced systemic absorption of distention media may occur with hysteroscopic myomectomy using this approach [47]. This could be because tissue fragments are not produced and the procedure can be performed faster without the need for removing tissue fragments. As with any current, the duration of contact, resistance of the tissue and the power (wattage) determine the degree of current delivered through the dispersive electrode. The surgeon is responsible for being aware of the power settings, as if they are too high there is a risk of skin burns to the patient through the skin plate (see Figure 5).
\n
Another technique with increasing popularity is hysteroscopic morcellation. Using a modified prototype based on an orthopaedic arthroscopic tissue shaver, Dr. Mark Hans Emanuel was able to create a first-generation device that used mechanical energy rather than electrical energy to resect uterine tissue.
\n
Figure 5.
Hysteroscopic resection of a type 0 Fibroid (top) and at the end of a completed resection (bottom).
\n
Hysteroscopic morcellation aims to remove uterine leiomyomas during a single insertion of a hysteroscope into the uterus. This contrasts with traditional hysteroscopic resection of leiomyomas, in which the instrument is reinserted into the uterus multiple times. Hysteroscopic morcellation is intended to reduce the risk of traumatic injury to the uterus and the risk of inadvertent fluid overload associated with traditional procedures (because the procedure may be completed more rapidly). An intended advantage of the procedure over thermal ablation techniques is avoiding the risk of thermal injury.
\n
A hysteroscope is inserted into the uterus through the cervix, and saline is pumped through a small channel in the hysteroscope to distend the uterus. A specially designed morcellator is introduced via the hysteroscope and used to cut and simultaneously aspirate the leiomyoma tissue. The aspirated tissue can be collected for histological analysis. For polyps and type 0 and type 1 submucous myomas, hysteroscopic morcellation has been demonstrated to be both faster and easier to learn than traditional resectoscopy. The earliest published trial with a hysteroscopic morcellation device by Emanuel and colleagues showed a significant reduction in operating room time when removing polyps and type 0 and type 1 submucous myomas. In that study, polyps were removed with a 72% reduction in operating room time with a morcellator as compared with a resectoscope type 0 and type 1 myomas were removed in 61% less time, respectively [42]. Hence, hysteroscopic morcellation is most useful for small or pedunculated leiomyomas [48].
\n
\n
\n
\n
\n
5. Complications
\n
Hysteroscopic resection of submucosal fibroids is very safe in experienced hands. However, potential surgical complications include fluid overload, intraoperative and postoperative bleeding, uterine perforation, gas embolism, and infection with associated uterine synechiae.
\n
\n
5.1. Excessive fluid absorption
\n
Excess absorption of non-crystalloid distension media can cause serious fluid and electrolyte imbalance, pulmonary and cerebral oedema, cardiac failure, and death [49]. Although complications associated with excess fluid absorption are relatively uncommonly encountered, premenopausal women undergoing resectoscopic surgery in the uterus may be at greater risk because of the inhibitory impact of female gonadal steroids (most likely estrogen) on the sodium/potassium ATP’ase pump [50]. Studies have demonstrated that 100 mL intravasation correlates with a sodium decrease of approximately 1 mmol/L. One study demonstrated that cerebral oedema could be identified during computed tomography scanning from an intravasation of only 500 mL. Therefore, a meticulous measure of the inflow and outflow of fluid used is extremely important [51].
\n
Fluid absorption is increased when intrauterine pressure exceeds mean arterial pressure. Consequently, the intrauterine pressure should be maintained at the lowest pressure that allows good visualization for performance of the hysteroscopic myomectomy.
\n
Nonconducting (electrolyte free) distention mediums such as glycine 1.5% or mannitol 5% are used with the monopolar electrosurgical system. With excess absorption of these fluids, there is a risk of hyponatraemia; however, the more serious complication is of cerebral oedema due to a hypo-osmolar effect on plasma concentration. This rare side effect can be fatal.
\n
Electrolyte containing isotonic distention media (normal saline) can be used when mechanical or bipolar resections are employed. Its use reduces the risk of hyponatraemia and changes in serum osmolality when compared with nonconducting media. It can still cause fluid overload with consequent pulmonary oedema and therefore meticulous fluid balance should still be maintained.
\n
\n
\n
5.2. Trauma
\n
Other major complications consist of haemorrhage and uterine perforation. Perforation of the uterus can occur with dilators, mechanical grasping tools or the resectoscopic system. If perforation occurs with mechanical instruments, and no bowel injury is suspected, the patient can be managed expectantly with close observation for a 24-hour period. Laparoscopy must be performed if bowel injury is suspected, where there appears to be a large perforation, or in the presence of heavy bleeding. If perforation occurs with an activated electrode, one has to assume that there has been a bowel injury until proven otherwise, and laparoscopy or laparotomy is recommended.
\n
Uterine perforation can be a complication with serious associated morbidity. Reassuringly, the risk of this is generally low. In a study of 2100 operative hysteroscopies performed by experienced surgeons, 782 involved fibroid resection and uterine perforation occurred in 1.2% of those procedures and 1.6% of all hysteroscopies [52]. The prospective Mistletoe study which analysed techniques of endometrial ablation demonstrated a slightly higher uterine perforation rate of up to 2.5% when using the electrosurgical resection loop [53]. Up to a third of uterine perforations are thought to occur during cervical dilatation before the resection is actually commenced. This could be avoided by use of cervical priming agents as discussed prior to allow easier dilatation. Unrecognized injury is a serious incident as it is possible that a bowel burn may have occurred, if perforation occurred when using an activated electrode, potentially leading to peritonitis and a high index of suspicion must always be exercised.
\n
The above group also looked at rates of haemorrhage. Haemorrhage was defined as abnormal bleeding at the end of the procedure. In the 782 fibroid resections, the risk of operative haemorrhage was 0.4% [46].
\n
\n
\n
5.3. Bleeding
\n
Heavy bleeding from the endometrial cavity is uncommon after hysteroscopic surgery in general. If there is continuous bleeding after resection, a Foley catheter can be inserted into the uterine cavity and distended with up to 40 mL of saline until the bleeding settles from a tamponade effect. The balloon can be removed if the bleeding has settled in a few hours.
\n
Other pharmacological agents that have been investigated to reduce blood loss at myomectomy include tranexamic acid, prostaglandin E2 analogues (misoprostol and dinoprostone) and ascorbic acid. Randomized controlled trails of these agents compared to placebo showed statistically significant reduction in blood loss; however, sample sizes in these studies were small and had low to moderate quality evidence [54].
\n
A more invasive option for controlling bleeding is uterine artery embolization with interventional radiologic techniques if bleeding persists despite above measures.
\n
\n
\n
5.4. Thermal burns
\n
One must be very careful to avoid unintentional activation of the monopolar or bipolar pedals. If this occurs while the active electrode is resting on the patient it can cause serious burns to the abdomen, perineum, vagina or vulva [3].
\n
More sinister burns occur when the uterus is perforated by an active electrode causing injury to surrounding structures, most commonly the bowel or blood vessels. This type of injury can be prevented by making sure not to activate the electrode while it is being advanced into the endometrial cavity. It should only be activated when being withdrawn. As discussed before, if a uterine perforation is suspected due to an active electrode, the surgeon must perform an exploratory laparoscopy or laparotomy depending on the extent of perforation.
\n
\n
\n
5.5. Adhesions
\n
Intrauterine adhesions can occur after hysteroscopic myomectomy to the point that they adversely impact fertility. The incidence of intrauterine adhesions after hysteroscopic myomectomy was shown in one study to be 7.5% [55]. Postoperative adjuvant therapy, including estrogen therapy for four to eight weeks or insertion of an intrauterine device, paediatric Foley catheter or other balloon for one week postoperatively, have all been used to prevent further adhesion development. However, there is scant evidence to support the use of these postoperative therapies [56, 57].
\n
If, on preoperative assessment, it can be anticipated that a large proportion of the cavity will be stripped of endometrium after resection, an abdominal approach (laparotomy, laparoscopy or “robotic”) to myomectomy should be considered to reduce the formation of adhesions. In a retrospective study, when second look hysteroscopy was performed after one to three months on 153 women who underwent TCRM, 2 of 132 (1.5%) with single myomectomy had intrauterine adhesions [58].
\n
\n
\n
\n
6. Effectiveness of hysteroscopic resection of submucosal fibroids
\n
\n
6.1. Management of subfertility
\n
There is a lack of prospective randomized controlled trials assessing the true impact of surgical management of submucosal fibroids on fertility. This would be challenging to perform for obvious reasons. Many studies do not document that a comprehensive assessment of various causes of infertility was performed on the patient prior to surgery to isolate only those patients where the fibroid was the causative factor of subfertility. Other confounding factors are that conception rates are not recorded before and after surgery.
\n
A recently published RCT compared TCRM with no treatment in 215 women with primary infertility with demonstrated submucous fibroids on ultrasound. The two randomized groups were women who underwent either TCRM or diagnostic hysteroscopy with biopsy only. At follow up, 63% of the treatment group conceived but only 28% of the biopsy group had (RR 2.1 CI 1.5–2.9). The investigators concluded that fertility rates increased after hysteroscopic myomectomy in women with type 0 and type 1 myomas (p < 0.05) but the same was not seen in women with type 2 myomas [59].
\n
Similarly, Bozdag et al. demonstrated an improvement in spontaneous conception rates after the surgical removal of submucosal fibroids, but pregnancy rates following the removal of intramural or subserosal fibroids were no more improved than in the expectant management group of women with intramural or subserosal fibroids in situ [60]. A recent meta-analysis also demonstrated similar findings, with an improvement in pregnancy rates in infertile patients undergoing surgical removal of submucosal fibroids, but not in those undergoing surgical removal of intramural fibroids [27].
\n
In summary, the evidence suggests that in women with otherwise unexplained infertility, submucosal fibroids should be removed in order to improve conception and pregnancy rates but removal of subserosal fibroids is not recommended, and this approach is endorsed by national bodies [61]. There is fair evidence to recommend against myomectomy in women with intramural fibroids (hysteroscopically confirmed intact endometrium) and otherwise unexplained infertility, regardless of the size of the fibroids.
\n
\n
\n
6.2. Management of menorrhagia
\n
Derman et al. in 1991 performed the first large-scale trial of the long-term success of hysteroscopic electrosurgical resection of fibroids [62]. Over a 9-year follow-up period, 84% of patients avoided a further procedure and 7% of patients needed a second hysteroscopic resection. Further studies by Emanuel et al. and Hart et al. showed that 91% of patients avoided further surgery at two years follow-up and 73% at eight years follow-up. It was also shown that risk factors for requiring surgery included a larger uterus and multiple fibroids [51].
\n
Five series involving over 1400 women have shown that hysteroscopic myomectomy is an effective management option for dysfunctional uterine bleeding. Failure rates ranged from 14.5% to 30% for up to 4 years’ follow-up [63]. This would suggest surgery should be considered as first-line treatment for the management of symptomatic fibroids, including submucous fibroids. Submucous myomas (types 0, 1 and 2) up to 5 cm in diameter can be removed hysteroscopically. Type 2 myomas are more likely to require a two-staged procedure than types 0 and 1 because of the risk of excessive fluid absorption and uterine perforation. The risk of uterine perforation is particularly high when there is less than 5 mm distance between the uterine serosa and the fibroid [2].
\n
After TCRM alone, long-term cohort studies have indicated that patient satisfaction is in the range of 70–80%, with 14–16% of women requiring additional surgery [64].
\n
When women with heavy menstrual bleeding who are not interested in future fertility and have selected type 2 and type 1 submucous myomas, generally 3 cm or less in diameter, endometrial ablation appears to confer a high degree of success in the short term [3]. In a single-armed, one-year study of the Novasure radiofrequency ablation system (Hologic Inc., Bedford, MA) in patients with type 1 or 2 myomas, 95% of the 65 patients were successfully treated [65]. At the present time, there is inadequate evidence to suggest that one device or technique, such as resectoscopic ablation, is clearly more efficacious than another.
\n
Therefore, if the main symptom is heavy menstrual bleeding only and fertility is not required, consideration should be given at the time of transcervical resection of myoma to also perform endometrial ablation. This has been demonstrated in a cohort study, which showed a higher success rate in controlling bleeding when ablation was added to myomectomy [66].
\n
\n
\n
\n
7. Repeat resection of fibroids
\n
As can be seen from the success of surgery, for most patients the chance of avoiding further surgery is about 80% with long-term follow-up [67], but the success is lower in patients with type 2 fibroids [2, 67].
\n
The recurrence rate of fibroids is 15% and 10% of women who have a myomectomy will eventually need a hysterectomy within 10 years. Factors more likely to be associated with recurrence of fibroids are the woman’s age, number of fibroids, larger uterine size and childbirth after myomectomy [68].
\n
The success rate of a repeat resection has been described by Istre and Langebrekke [17]. Twenty-eight per cent of their 118 patients who needed repeat surgery (ablation or myomectomy) eventually proceeded to a hysterectomy. The main indication was pain due to a haematometra. One of the major causes of primary surgery failure was found to be deep adenomyosis and associated pain. It was suggested that MRI could be used as a diagnostic tool in those presenting with failed initial surgery, to select patients with adenomyosis, who are less likely to benefit from repeat surgery unless it is a hysterectomy. Of course, this option would not be of use to patients wishing to preserve fertility [69].
\n
\n
Acknowledgments
\n
We would like to thank the authors of the publications cited who have enabled us to write an up-to-date account of hysteroscopic surgery of submucosal fibroids. We would like to recognize these two publications as providing some of the background to our chapter, ‘The hysteroscopic management of leiomyomata by Prof R Hart in Uterine Leiomyomas: Pathogenesis and Management’ and the ‘AAGL practice report: practice guidelines for the diagnosis and management of submucous leiomyomas in the Journal of Minimally Invasive Gynecology.’
\n
\n',keywords:"fibroid, submucosal fibroid, leiomyoma, female infertility, abnormal uterine bleeding, surgery, hysteroscopy, resectoscope, hysteroscopic surgery, menorrhagia, recurrent miscarriage",chapterPDFUrl:"https://cdn.intechopen.com/pdfs/51944.pdf",chapterXML:"https://mts.intechopen.com/source/xml/51944.xml",downloadPdfUrl:"/chapter/pdf-download/51944",previewPdfUrl:"/chapter/pdf-preview/51944",totalDownloads:17705,totalViews:1532,totalCrossrefCites:0,totalDimensionsCites:1,totalAltmetricsMentions:0,impactScore:1,impactScorePercentile:65,impactScoreQuartile:3,hasAltmetrics:0,dateSubmitted:"April 1st 2016",dateReviewed:"July 11th 2016",datePrePublished:null,datePublished:"January 18th 2017",dateFinished:"August 6th 2016",readingETA:"0",abstract:"This chapter presents a contemporary summary of the evidence of the clinical impact of submucosal fibroids and discusses the methods used to investigate and surgically manage this common gynaecological condition.",reviewType:"peer-reviewed",bibtexUrl:"/chapter/bibtex/51944",risUrl:"/chapter/ris/51944",book:{id:"5409",slug:"fertility-oriented-female-reproductive-surgery"},signatures:"Rashi Kalra and Roger J Hart",authors:[{id:"187858",title:"Prof.",name:"Roger",middleName:null,surname:"Hart",fullName:"Roger Hart",slug:"roger-hart",email:"roger.hart@uwa.edu.au",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",institution:{name:"University of Western Australia",institutionURL:null,country:{name:"Australia"}}},{id:"187861",title:"Dr.",name:"Rashi",middleName:null,surname:"Kalra",fullName:"Rashi Kalra",slug:"rashi-kalra",email:"Rashi.Kalra@health.wa.gov.au",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",institution:null}],sections:[{id:"sec_1",title:"1. Introduction",level:"1"},{id:"sec_2",title:"2. Classification of fibroids",level:"1"},{id:"sec_2_2",title:"2.1. Diagnostic methods for classifications of fibroids",level:"2"},{id:"sec_2_3",title:"2.1.1. Transvaginal ultrasonography (TVUS)",level:"3"},{id:"sec_3_3",title:"2.1.2. Saline infusion sonography (SIS)",level:"3"},{id:"sec_4_3",title:"2.1.3. Diagnostic hysteroscopy",level:"3"},{id:"sec_5_3",title:"2.1.4. Magnetic resonance imaging (MRI)",level:"3"},{id:"sec_8",title:"3. Indications for surgery",level:"1"},{id:"sec_8_2",title:"3.1. Menorrhagia",level:"2"},{id:"sec_9_2",title:"3.2. Infertility",level:"2"},{id:"sec_11",title:"4. Surgical management of submucosal fibroids",level:"1"},{id:"sec_11_2",title:"4.1. Transcervical resectoscopic myomectomy (TCRM)",level:"2"},{id:"sec_11_3",title:"4.1.1. Patient selection",level:"3"},{id:"sec_12_3",title:"4.1.2. Pre-operative preparation",level:"3"},{id:"sec_12_4",title:"4.1.2.1. Suppressive medical therapy before TCRM",level:"4"},{id:"sec_13_4",title:"4.1.2.2. Cervical preparation before TCRM",level:"4"},{id:"sec_14_4",title:"4.1.2.3. Prophylactic antibiotics and intra-operative preparation",level:"4"},{id:"sec_15_4",title:"4.1.2.4. Anaesthesia",level:"4"},{id:"sec_18_2",title:"4.2. Surgical technique",level:"2"},{id:"sec_18_3",title:"4.2.1. Hysteroscopic systems",level:"3"},{id:"sec_19_3",title:"4.2.2. Myomectomy procedure",level:"3"},{id:"sec_22",title:"5. Complications",level:"1"},{id:"sec_22_2",title:"5.1. Excessive fluid absorption",level:"2"},{id:"sec_23_2",title:"5.2. Trauma",level:"2"},{id:"sec_24_2",title:"5.3. Bleeding",level:"2"},{id:"sec_25_2",title:"5.4. Thermal burns",level:"2"},{id:"sec_26_2",title:"5.5. Adhesions",level:"2"},{id:"sec_28",title:"6. Effectiveness of hysteroscopic resection of submucosal fibroids",level:"1"},{id:"sec_28_2",title:"6.1. Management of subfertility",level:"2"},{id:"sec_29_2",title:"6.2. Management of menorrhagia",level:"2"},{id:"sec_31",title:"7. Repeat resection of fibroids",level:"1"},{id:"sec_32",title:"Acknowledgments",level:"1"}],chapterReferences:[{id:"B1",body:'EE Wallach, NF Vlahos. Uterine myomas: an overview of development, clinical features, and management. Obstet Gynecol. 2004;104:393–406.'},{id:"B2",body:'K Wamsteker, S DeBlok, A Galilnat, RP Lueken. Transcervical hysteroscopic resection of submucous fibroids for abnormal uterine bleeding: results regarding the degree of intramural extension. Obstet Gynecol. 1993;82:736–40.'},{id:"B3",body:'J Abbott, MG Munro, L Muzzi. AAGL practice report: practice guidelines for the diagnosis and management of submucous leiomyomas. J Minim Invasive Gynecol.. 2012;19(2):152–71.'},{id:"B4",body:'MH Emanuel, K Wamsteker, AA Hart, G Metz. Long-term results of hysteroscopic myomectomy for abnormal uterine bleeding. Obstet Gynecol. 1999;93:743–48.'},{id:"B5",body:'Hart, Roger. The Hysteroscopic Management of Fibroids. In: Brosens I, editor. Uterine Leiomyomas: Pathogenesis and Management: Taylor and Francis Medical Books, Oxfordshire, UK, 2005.'},{id:"B6",body:'P Vercellini, I Cortesi, S Oldani, et al. The role of transvaginal ultrasonography and outpatient diagnostic hysteroscopy in the evaluation of women with menorrhagia. Hum Reprod. 1997;12:1768–71.'},{id:"B7",body:'FA Van den Brule, O Wery, J Huveneers, UJ Gaspard. Comparison of contrast hysterosonography and transvaginal ultrasonography for uterus imaging. J Gynecol Obstet Biol Reprod. 1999;28:131–6.'},{id:"B8",body:'C Farquhar, A Ekeroma, S Furness, B Arroll. A systematic review of transvaginal ultrasonography, sonohysterography and hysteroscopy for the investigation of abnormal uterine bleeding in premenopausal women. Acta Obstet Gynecol Scand. 2003;82:493–504.'},{id:"B9",body:'M Ruach, R Hart, A Magos. Outpatient hysteroscopy. Contemp Rev Obstet Gynaecol. 1998;10:295–302.'},{id:"B10",body:'MJ Cooper, JA Broadbent, BG Molnar et al. A series of 1000 consecutive out-patient diagnostic hysteroscopies. J Obstet Gynaecol. 1995;21:503–7.'},{id:"B11",body:'F Nagele, G Lockwood, AL Magos. Randomised placebo controlled trial of mefenamic acid for premedication at outpatient hysteroscopy: a pilot study. Br J Obstet Gynaecol. 1997;104:842–4.'},{id:"B12",body:'F Nagele, N Bournas, H O\'Connor H, et al. Comparison of carbon dioxide and normal saline for uterine distension in outpatient hysteroscopy. Fertil Steril. 1996;65:305–9.'},{id:"B13",body:'CP Stamatopoulos, T Mikos, GF Grimbizis, AS Dimitriadis, I Efstratiou, P Stamatopoulos, et al. Value of magnetic resonance imaging in diagnosis of adenomyosis and myomas of the uterus. J Minim Invasive Gynecol. 2012;19:620–26.'},{id:"B14",body:'M Dueholm, E Lundorf, ES Hansen, S Ledertoug, F Olesen. Accuracy of magnetic resonance imaging and transvaginal ultrasonography in the diagnosis, mapping, and measurement of uterine myomas. 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An evidence-based guideline for the management of uterine fibroids. New Zealand Guidelines Group 2000.'},{id:"B20",body:'JA Broadbent, AL Magos. Menstrual blood loss after hysteroscopic myomectomy. Gynae Endosc. 1995;4:41–4.'},{id:"B21",body:'MA Lumsden, EM Wallace. Clinical presentation of uterine fibroids. Baillieres Clin Obstet Gynaecol. 1998;12:177–95.'},{id:"B22",body:'T Eldar-Geva, S Meagher, DL Healy, V MacLachlan, S Breheny, C Wood. Effect of intramural, subserosal, and submucosal uterine fibroids on the outcome of assisted reproductive technology treatment. Fertil Steril. 1998;70:687–91.'},{id:"B23",body:'J Farhi, J Ashkenazi, D Feldberg, D Dicker, R Orvieto, Z Ben Rafael. Effect of uterine leiomyomata on the results of in-vitro fertilization treatment. Hum Reprod. 1995;10:2576–8.'},{id:"B24",body:'B Carranza-Mamane, Jon Havelock, R Hemmings et al. The management of uterine fibroids in women with otherwise unexplained infertility. 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Long-term results of hysteroscopic myomectomy in 235 patients. Eur J Obstet Gynecol Reprod Biol. 2007;30(II–2):232–7.'},{id:"B65",body:'R Sabbah, G Desaulniers Use of the NovaSure Impedance Controlled Endometrial Ablation System in patients with intracavitary disease: 12-month follow-up results of a prospective, single-arm clinical study. J Minim Invasive Gynecol. 2006;13(II–2):467–71.'},{id:"B66",body:'Loffer, FD. Improving results of hysteroscopic submucousal myomectomy for menorrhagia by concomitant endometrial ablation. J Minim Invasive Gynecol. 2005;12:254–60.'},{id:"B67",body:'R Hart, BG Molnar, A Magos. Long term follow up of hysteroscopic myomectomy assessed by survival analysis. Br J Obstet Gynaecol. 1999;106:700–5.'},{id:"B68",body:'Garcia, CR. Management of the symptomatic fibroid in women older than 40 years of age: hysterectomy or myomectomy? Obstet Gynecol Clin North Am. 1993;20:337–48.'},{id:"B69",body:'R Hart, A Magos. Endometrial ablation. Curr Opin Obstet Gynecol. 1997;9:226–32.'}],footnotes:[],contributors:[{corresp:null,contributorFullName:"Rashi Kalra",address:null,affiliation:'
King Edward Memorial Hospital, Subiaco, Perth, Australia
Fertility Specialists of Western Australia, Bethesda Hospital, Claremont, WA, Australia
Fertility Specialists of Western Australia, Bethesda Hospital, Claremont, WA, Australia
School of Women\'s and Infants’ Health, King Edward Memorial Hospital, University of Western Australia, Perth, WA, Australia
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1. Introduction
Olive oil is one of a great interest in the vegetable oils world market. It is produced from the fruit of olive (Olea europaea L.). Virgin olive oil (VOO) is obtained exclusively by mechanical cold extraction [1]. It is not subjected to any chemical treatments apart from washing, decantation, centrifugation, and filtration. These processes may be carried out without refining, which makes the obtained oils highly appreciated by consumers thanks to their rich nutritional value, several health benefits, and unique organoleptic properties. Olive oil organoleptic and nutritional characteristics arise from noble compounds it contains. VOO composition consists of an unsaponifiable fraction (1 to 2%) along with essential unsaturated fatty acids contained in glyceridic fraction (98 to 99%) [2]. The composition of olive oil is well outlined in the literature. An updated analysis of the composition of olive oil reported in the literature is shown in Figure 1. In fact, on November 29th, 2021, the Scopus database was chosen to search for peer-reviewed literature regarding olive oil composition. The search string: (“olive oil*” AND “composition*”) was utilized to extract bibliometric information from the Scopus online database. A total of 2980 publications were recovered through the literature search within the range of years from 2010 to 2021, 1892 of them representing about 65% are published in the interval of years from 2015 to 2021 (Figure 1).
Figure 1.
Publication trends of olive oil composition (based on data retrieved from Scopus database).
2. Olive oil extraction technologies
Olive oil is made from fresh olives, which are extracted by mechanical processes [3]. Olive oil extraction technologies are summarized in Figure 2. There are two main olive oil extraction processes: traditional oil mills, and a relatively new extraction process known also by continuous mills and characterized by two or three phases [4, 5] Figure 2. All the above processes aim at separating the liquid oil phase from the other constituents of the fruit [6]. Likewise, olives should be processed as rapidly as possible after harvesting to reduce oxidation and preserve their quality [7].
Figure 2.
Scheme of discontinuous and continuous extraction systems. OMWW = olive mill wastewater.
Concerning the traditional press method, olive fruits liberated from leaves are washed, crushed using mill stones, and malaxed into a paste containing solid matter (core debris, epidermis, cell walls, etc.) and fluids (oil and vegetation water contained in the cells of olives). This is then spread on spherical mats [6]. Pressure with a hydraulic piston press is exerted then to obtain, firstly, a solid fraction (known as pomace) and, secondly, the mixture of oil and water is filled into a container and, eventually, the oil and water are then separated by gravity and collected through decantation [5]. The pressing process is the oldest method of obtaining olive oil [8]. Owing to lower production efficiency and high labor costs, during the last decade, the discontinuous pressing systems have widely been substituted by continuous systems, along with the development of centrifuge technology [4, 9]. After the steps of washing, crushing, and mixing, the mechanical extraction of the oil occurs mainly by a continuous process based on centrifugation using a decanter. The decanter centrifuge is equipped with a rotary bowl as well as a screw conveyor, which allows the processing of great quantities of olives in a short time [7]. Continuous separation systems can be divided into two-phase and three-phase systems, based on the decanter type used and the level of the phase of separation [9]. In the three-phase process, an additional amount of hot water is added to wash the oil, and then the three-phase decanter (insoluble solids, oil phase, and an aqueous phase), are separated following their density [7, 10]. Firstly, the solid wastes (insoluble solids), are separated from the remaining two phases in the decanter, and the liquid phases (oil phase as well as aqueous phase), are then subjected to vertical centrifugation to separate the olive oil from the olive mill wastewater [7].
Owing to the significant issue of wastewater produced, this three-phase system is preferred over the two-phase system since it is more eco-friendly [11]. This latest uses only a semi-liquid slurry (vegetation water along with insoluble solids) phase and the oil phase, a semi-liquid slurry, which is also known as two-phase olive mill waste [7]. This process has a reduced environmental impact owing to the reduced requirement of water as well as the amount of waste produced [7].
3. Olive oil composition
3.1 Bioactive compounds
Olive oil glyceridic fraction consists of triacylglycerols, diacylglycerols, monoacylglycerols and free fatty acids (FFA). Among them, 80% of them are unsaturated fatty acids. It is particularly rich in essential monounsaturated fatty acids (55–83% of oleic acid) and polyunsaturated fatty acids (2.5–21% of linoleic acid) [12]. The remaining fatty acids, apart from C16: 1, display an average value ranging from 0.3 to 3.5% (Table 1 and Figure 3). Nevertheless, linolenic acid is a minority and its concentration is lower than 1% [12]. A low level of linolenic acid can be used to detect adulteration via some vegetable oils such as rapeseed and soybean oils [13]. Small quantities of saturated fatty acids also compose the triglycerides of olive oil: stearic acid (about 0.5–5%) and palmitic acid (about 7.5–20%). The remaining fatty acids (C17: 0, C17: 1, C20: 0, C20: 1, and C22: 0) are found to be of lower magnitudes. Since their concentrations are below 0.5% (Table 1). The unsaponified matter (about 1–2%) contains sterols, triterpene alcohols, tocopherol (mainly α-tocopherol), tocotrienol polyphenols, and squalene. The oil also contains a non-negligible proportion of volatile compounds. The total phytosterols content of VOO ranges between 100 and 200 mg/100 g. Also, 100 mg/100 g represents the inferior limit set by the international olive council [12]. Apparent beta-sitosterol, (beta-sitosterol + delta-5-avenasterol + delta-5-23-stigmastadienol + clerosterol + sitostanol + delta 5–24-stigmastadienol) are the main compounds in the sterol fraction with a value more than 93% while β-sitosterol has the greatest relative percentage [14, 15] (Figure 4). VOO content also includes up to 4.5 g/100 g of total phytosterols [12]. The erythrodiol (5α-olean-12-ene-3β, 28-diol, homo-olestranol) in free and esterified forms and are the major triterpene di-alcohols found in olive oil [14], and their percentage reached up to 4.5% of the total content of sterols [12]. Moreover, four isoforms of tocopherols (α, β, γ, and δ-tocopherol) (Figure 5) and four tocotrienols (α, β, γ and δ- Tocotrienol) are present in olive oil. α-tocopherol is the main tocopherol found in olive oil, constituting more than 90% of the total tocopherol fraction [14]. Cunha et al. [16] reported that the proportions of tocopherols and tocotrienols ranged from 100 to 270 mg/kg in Portuguese olive oils [16]. Gharby et al. [47] found that the values of tocopherols varied from 150 to 250 mg/kg in three varieties (‘Arbequina’, ‘Moroccan Picholine’, and ‘Picual’) of olive oil [17]. Moreover, another study, based on the comparison of the tocopherol contents of olive oils from 4 different varieties harvested at different ripening periods found that the α-tocopherol (major tocopherol) in oils obtained from olives composed of 130.54–180.43 mg/kg [18]. In general, tocopherol and tocotrienol levels in oil fluctuate with several factors such as harvest year, climatic conditions, storage time, extraction method, soil properties and spacing between olive trees [19]. Tocopherols possess a strong antioxidant power [20]. Together with tocopherols and tocotrienols, olive oil contains other antioxidant molecules such as polyphenolic compounds.
Many research works have demonstrated that the content of tocopherols in VOO is lower than that of argan oil [21, 22, 23].
The phenolic compounds are endowed to have a large scale of biological functions including stability to auto-oxidation, beneficial effects on human health [24]. About their well-known activities, olive oil polyphenols have been proven to possess an effective role in maintaining the organoleptic properties and the stability of olive oils [25].
Such bioactive compounds are extensively studied for their anti-inflammatory, antioxidant, neuroprotective, cardioprotective, antidiabetic, antimicrobial, and anticancer properties [26, 27, 28, 29].
Franco et al. reported that phenolic compounds have a considerable increase during olive fruit growth. However, they are reduced when the fruits reach the maturation stage [30]. Khalatbary documented that the total phenolic content (TPC) in olive oils varies from 190 to 500 mg/kg [31]. In addition, in extra virgin olive oil, TPC commonly varies from 250 to 925 mg/kg [32]. Other factors including climatic conditions, variety, storage time, extraction conditions, soil properties, and analysis of polyphenolic compounds can lead to important variations in TPC [33]. Likewise, several classes of polyphenols are found in olive oils. These are presented as a separate class, to better understand the antioxidant phenolic chemistry of olive oil [33]. Finicelli et al. classify olive oil polyphenols following their chemical structure as follows [34]:
Phenolic alcohols with a hydroxyl group are linked to an aromatic hydrocarbon group. The main constituents of this class are oleocanthal, hydroxytyrosol, and tyrosol (Figure 6) [26].
Secoiridoids are phenolic compounds present in high amounts in olive oil in comparison to other plant species. The bitterness of extra virgin olive oil is a result of the content of secoiridoids [35].
Lignans are chemically characterized by the aggregation of aromatic aldehydes. The pulp of the olives as well as the woody part of the seed contains lignans. These molecules are liberated into the oil during the process of extraction without biochemical changes [36].
Flavonoids are chemically structured with two benzene rings attached via three linear carbon chains. The first flavonoids identified in VOO were flavones; their free forms, apigenin, and luteolin. They are the more abundant compounds [36].
Hydroxyisocromans are the only two molecules characterized in commercial VOO. These compounds are produced via the HydroxyTyrosol reaction with benzaldehyde and vanillin [37].
Phenolic acids are divided into two main classes: hydroxycinnamic acid along hydroxybenzoic acid [26].
Figure 6.
Some phenolic alcohols present in olive oil.
The volatile fraction of VOOs has been reported to have about 280 different compounds [38]. The majority of volatile compounds are quickly developed during olive milling as a result of the disturbance of olive cells [39]. Although, Nardella et al. reported that most of the volatile compounds typical of olive oils are generated during malaxation due to the activation of particular pathways, in which the lipoxygenase (LOX) enzyme plays an essential role in producing a large quantity of C6 aldehydes, esters, and alcohols. These constitute almost all of the positive sensory marks in olive oils [40]. Such changes are initiated when olive tissues are affected, thereby enhancing the liberation of endogenous enzymes like hydroperoxide lyase and lipoxygenase [40].
Besides, several analytical techniques have been used to determine volatiles composition in olive oil. The main important are: GC (gas chromatography), HPLC (high-performance liquid chromatography), HPLC/MS (high-performance liquid chromatography/mass spectroscopy), IRMS (isotope ratio mass spectroscopy), ICP (inductively coupled plasma spectroscopy), NMR (nuclear magnetic resonance), SPME-GC/MS (solid-phase microextraction followed by gas chromatography/mass spectrometry, SNIF/NMR (specific natural isotopic fractionation nuclear magnetic resonance), SCIRA (stable carbon isotope ratio analysis), PTR/MS (proton transfer mass spectrometry) [41]. Fregapane et al. reported that the composition of volatiles may be affected significantly according to many factors such as cropping season, olive variety, harvest time, technological parameters, and agronomic conditions among other factors [42]. Ghanbari et al. reported that several chemical factors such as hydrophobicity, volatility, position, and functional groups type are reported to be directly linked to the odor degree of a given volatile component more than its content [38]. Theodosi et al. investigated correlations between the composition of volatiles of olive oil and altitude variation. The findings demonstrate that the total volatile compounds of ‘Koroneiki’ olive oil samples and altitude levels are negatively associated. The most important volatile compounds are alcohols, aldehydes, esters, and hydrocarbons [43].
3.2 Physicochemical parameters
Parameters routinely used to evaluate physicochemical properties of olive oil include density, iodine value, refractive index, saponification value along with unsaponifiable matter. For vegetable oils including olive oil, both density and refraction index depend on the temperature [44]. Table 1 shows the ranges of the main physicochemical parameters of olive oil. The refractive index at 20°C varies in the range 1.463–1.472. At this same temperature, its density relative to water is between 0.906 and 0.919 [12]. The iodine value is a measure of the total number of double bonds found in an oil sample [1]. Olive oil displays an iodine value between 75 and 94 mg/100 g [17] (Table 1). This value is lower than that of argan oil (91–110 g I2/100 g), and cactus seed oil (131.5 ± 0.5 g (I2)/100 g) but higher than that of coconut oil (6.3–10.6 g (I2)/100 g) [13]. High iodine value is associated with the greater number of double bonds and reduced oxidative stability [45]. The saponification value is a measure of the average chain lengths of fatty acids. An oil sample with shorter fatty acids has a high saponification value. Moreover, according to CODEX STAN 33, the saponification value of olive oil varies between 184 and 196 mg (KOH)/g.
4. Quality control of olive oil
Olive oil is subject to enormous analytical and sensory controls to assess its overall quality. These analyses evaluate the freshness of the oil regarding hydrolytic and oxidative alterations to ensure the conformity of products to their labels. For example, extra VOO by simple routine analyses (free fatty acids, peroxide value, specific extinction (E270 along with E232) and/or purity blending with other oils and contaminants. These criteria require detailed analyses (triglycerides contents, fatty acids, sterols, tocopherols, etc. …). Organoleptic characteristics (taste, odor, color, etc. …) also have to be taken into account.
As for other vegetable oils, the olive oil oxidation leads to natural phenomena alteration [46, 47]. This can be controlled since fruit harvest until oil storage. Because of oxidation, physicochemical parameters such as acidity, peroxide value and extinction specific at wavelength 270 (λ270 or λ270) have been selected as the backbone of olive oil quality determination by the International Olive Council [12]. Also, acidity of olive oil is classified into four grades: extra-virgin (Acidity < 0.8 g/100 g), fine-virgin (0.8 < Acidity < 2 g/100 g), ordinary virgin (2 < acidity < 3.3 g/100 g), and lampante olive oil (Acidity > 3.3) (Table 2) [12].
Category olive oil
Acidity (g/100 g)
Peroxide index mEq O2/Kg
Extinction specific at K232
Extinction specific at K270
1. Extra virgin olive oil
≤ 0.8
≤ 20
≤ 2.50
≤ 0.22
2. Fine Virgin olive oil
≤ 2.0
≤ 20
≤ 2.60
≤ 0.25
3. Ordinary Virgin olive oil
≤ 3.3
≤ 20
no limit
≤ 0.30
4. Lampante olive oil
> 3.3
no limit
no limit
no limit
Table 2.
Limits established for acidity, peroxide index and extinction specific (K232 and K270) for each olive oil category.
The variability of the extra VOO, acid value according to various parameters has been studied [47]. Oil oxidative state is examined from peroxide value and specific extinction coefficients (K232 or K270). These indicate the presence of primary and secondary oxidation products [1, 48]. The peroxide value of extra VOO oil must be below 20 mEq O2/kg and specific extinction K232 < 2.5. The other two main indices used to evaluate the secondary oxidation products are the following: p-anisidine value and specific extinction K270 [1, 49]. The International Olive Council (IOC) has set 0.22 and 0.25 as a limit value for both the extra VOO and VOO, respectively [12].
Furthermore, along with oxidation and acidity concerns, the quantification of major compounds such as fatty acids (Figure 3), and minor compounds, like sterols (Figure 4), polyphenols, tocopherols, minerals elements, and other bioactive molecules, are also of great importance for the purity and for detection of olive oil adulteration, which is a complex problem. Owing to its high cost and demand, fraudsters blend VOO with cheaper edible oils (most often with sunflower and soybean oils) and sometimes with low-quality olive oil. Today, the problem exceeds the borders of the main producer countries and it tackles the international level market. In addition to known risks of commercializing a mixture of vegetable oils. There is another type of adulteration resulting from the mixing of relatively low and high-quality olive oil, and the outcome is a product, which is sold as “high quality extra VOO”. The control of adulteration, and authentication is of a crucial importance for the olive oil quality control. Codex Alimentarius (fats and oils), International Olive Council, and European Union Commission are dealing with the monitoring along with the regulation of VOO [50]. These international organizations have described the official control methods and have specified olive oil quality limits. Generally, all analytical techniques (chromatography, spectrophotometry, voltametric, differential scanning calorimetry), as well as several analytical methods, have been used to detect the adulteration of olive oil. Gas chromatography (GC), which analyzes oil fatty acids profile, can be used to detect virgin oil purity by distinguishing it from other vegetable oils such as sunflower, soybean, walnut, rapeseed, and canola oils [51]. Moreover, HPLC-technique can be used, to calculate, the difference between the theoretical and experimental equivalent carbon number (ΔECN42th). Likewise, the determination of phytosterols composition (namely campesterol Δ7-stigmasterol) using gas chromatography can be used to detect olive oil adulteration with low levels of cotton, corn, sunflower, soybean, and rapeseed oils [51]. In addition, Vietina et al. reported that the polymerase chain reaction (PCR) technique was demonstrated to be an efficient technique to detect VOO adulteration with cheaper vegetable oils by comparing their DNA melting profiles [52]. MS has also been used to detect the fraudulent presence of vegetable oils. Also, a lot of different techniques involving MS have been significantly developed, such as LC–MS, GC–MS, and MALDI-TOF/MS, which are of highly accurate identification [51]. Indeed, many other studies have also outlined the application of fluorescence spectroscopy, UV–Vis spectroscopy, [50] Fourier transform infrared spectroscopy [53] mid-infrared (MID) or near-infrared spectroscopy (NIR) [54] and Raman spectroscopy [55] for authentication and detection of adulteration of vegetables oil present in VOO [50]. Otherwise, differential scanning calorimetry (DSC) has also been used to detect argan oil purity by discriminating it from sunflower, high oleic sunflower as well as refined hazelnut oil [50]. Apetrei and Apetrei have investigated the use of the voltametric method based on modified EO carbon paste-based sensors to determine the adulteration of VOO with soybean and sunflower oils [56].
On the other hand, identification of contaminants is one of the multiple checks that must be performed on oils. Vegetable oils have limited values for aromatic hydrocarbons polycyclics (PAHs), heavy metals, mycotoxins, phthalates, and pesticides. Although, the physicochemical characterization of olive oil is an essential step, it is not sufficient and organoleptic characteristics along with the above-mentioned supplementary analyses are required for a full picture of olive oil quality [1].
To satisfy consumers, organoleptic characteristics (color, taste, smell, etc.) must be taken into account. This is particularly important for olive oil. The organoleptic analysis is an essential step for successful food marketing. It is an integral part of evaluating olive oil. IOC has established a procedure to evaluate the organoleptic characteristics of VOO according to COI/T.20/Doc. [12] No 15/Rev. 102,018. It has classified such characteristics into positive and negative attributes as highlighted in Tables 2 and 3.
Negative attributes
Fusty/muddy sediment
The characteristic flavor of oil obtained from olives stocked in such a way that they have developed an enhanced stage of anaerobic fermentation,
Musty-humid-earthy
Flavor characteristic of oils from fruits in which a lot of fungi and yeasts have been developed or from olives picked up with mud or earth and not been previously cleaned.
Winey- vinegary
The flavor characteristic of some oils reminiscent of vinegar or wine.
Acid-sour
The flavor is primarily caused by the formation of ethyl acetate, ethanol, and acetic acid.
Rancid
Flavor of oils that have been submitted to an intense oxidation process
Frostbitten olives (wet wood)
Flavor characteristic of oils obtained from olives that have been damaged by frost on the tree.
Positive attributes
Fruity
Characteristic of the oil that varies according to the variety and is obtained from fresh olives, ripe or not.
Bitter
Primary taste characteristic of oil extracted from green olives or olives that are becoming colored.
Pungent
Characteristic of oils obtained at the beginning of the crop year, mostly from olives that are not ripe yet.
Median of defect (Md)
Fruity median (Mf)
1. Extra virgin oil
Md = 0
Mf > 0
2. Virgin olive oil
Md ≤ 3.5
Mf > 0
3. Lampante oil
Md > 3.5
__
Table 3.
Organoleptic attributes of olive oil.
5. Olive oil enrichment with natural additives
Oxidation of lipids including oils is a major concern to food industries [57, 58]. While, vegetable oils are endowed with a wide variety of endogenous antioxidants (pigments, vitamins, tocols, phenols, etc.), the use of exogenous antioxidants is widely practiced to enhance oxidative stability. In this regard, synthetic antioxidants such as butylated hydroxyanisole (BHA), butylated hydroxytoluene (BHT), tertiary butylhydroquinone (TBHQ), as well propyl gallate are commercially used to extend oils’ shelf life by delaying or even hindering lipids degradation. These molecules are considered as Generally Recognized as Safe (GRAS) preservatives with a concentration limit of 0.02% in oils and fats [59]. In contrast, some reports associated these molecules with health risks because of carcinogenesis, leading to a restriction of the use of the GRAS list and a reduction of their utilization in different countries [59]. For this reason, natural antioxidants are a good alternative to replace the synthetic ones in preserving vegetable oils including olive oil [59, 60, 61]. An overview of factors involved in the balance of antioxidants and pro-oxidants as well as synthetic and natural antioxidants are summarized in Figure 7.
Figure 7.
An overview of factors involved in olive oil oxidative stability as well as natural and synthetic antioxidants. BHA, butylated hydroxyanisole; BHT, butylated hydrolxytoluene; TBHQ, tertiary butylhydroquinone; MUFA, monounsaturated fatty acids, and PUFA, polyunsaturated fatty acids.
Natural extracts sourced from various plant parts (peel, fruit, leaf, flower, and root) from different aromatic and medicinal herbs, agri-food residues and by-products were investigated for their antioxidant power as well as their use for the enrichment of olive oil with an emphasis on improving oxidative stability. Such natural extracts were proved to have a wide range of bioactive compounds were identified. These are mainly carotenoids and phenols [62, 63]. Promising results were obtained regarding the improvement of oxidative stability and shelf life of olive oil. Regarding the antioxidant activity of synthetic and natural additives, several mechanisms are involved. They act as free radical scavengers, inactivators of peroxides as well as other reactive oxygen species (ROS), singlet oxygen quenchers, metal ion chelators, quenchers of secondary oxidation products, and inhibitors of pro-oxidative enzymes, among other compounds [64]. Following these authors, antioxidants can be classified, based on their mode of action, into primary antioxidants. These break the oxidation chain reaction through scavenging free radical intermediates, however secondary antioxidants delay or even prevent oxidation through suppression of oxidation initiator, accelerators or regeneration of primary antioxidants.
6. Conclusions
Olive oil is an important food in the Mediterranean diet. Its importance and nutritional value arise from chemical composition. Its richness in essential fatty acids is behind their health-promoting properties. A set of other minor compounds such as polyphenols and tocopherols act as antioxidants which are directly associated with oxidative stability and shelf life of olive oil on one hand as well as human health on the other hand. Along with these endogenous antioxidants, olive oil quality can be enhanced through natural antioxidants extracted from herbs and agri-food residues.
Acknowledgments
This work has no acknowledgments.
Conflict of interest
The authors declare no conflict of interest.
\n',keywords:"natural additives, chemical composition, enrichment, extraction technologies, olive oil",chapterPDFUrl:"https://cdn.intechopen.com/pdfs/80686.pdf",chapterXML:"https://mts.intechopen.com/source/xml/80686.xml",downloadPdfUrl:"/chapter/pdf-download/80686",previewPdfUrl:"/chapter/pdf-preview/80686",totalDownloads:64,totalViews:0,totalCrossrefCites:0,dateSubmitted:"December 12th 2021",dateReviewed:"January 17th 2022",datePrePublished:"March 2nd 2022",datePublished:null,dateFinished:"March 2nd 2022",readingETA:"0",abstract:"Virgin Olive oil (VOO) is considered the primary source of added fat in the Mediterranean diet. Its consumption is linked to numerous health-promoting properties along with its high energetic value. These properties are the results of various chemical compounds (fatty acids, tocopherols, polyphenols, etc.). VOO provides monounsaturated fatty acids, which lower total cholesterol and low-density lipoprotein cholesterol levels. VOO is obtained by three mechanical extraction processes, which can be classified into two systems that can be followed to extract olive oil from olives: the so-called traditional or discontinuous method, and the modern or continuous one. After the extraction of olive oil, its oxidative stability and chemical composition are subjected to deterioration especially when stored under inappropriate conditions (light, O2, temperature, etc.). To deal with the problem, VOO enrichment using natural additives became an important practice to enhance VOO oxidative stability and its chemical composition. In this chapter, various aspects related to VOO extraction processes, chemical composition, stability oxidative and enrichment via natural additives will be reviewed and discussed in light of published literature.",reviewType:"peer-reviewed",bibtexUrl:"/chapter/bibtex/80686",risUrl:"/chapter/ris/80686",signatures:"El Hassan Sakar and Said Gharby",book:{id:"11334",type:"book",title:"Olive Cultivation",subtitle:null,fullTitle:"Olive Cultivation",slug:null,publishedDate:null,bookSignature:"Associate Prof. Taner Yonar",coverURL:"https://cdn.intechopen.com/books/images_new/11334.jpg",licenceType:"CC BY 3.0",editedByType:null,isbn:"978-1-80355-442-6",printIsbn:"978-1-80355-441-9",pdfIsbn:"978-1-80355-443-3",isAvailableForWebshopOrdering:!0,editors:[{id:"190012",title:"Associate Prof.",name:"Taner",middleName:null,surname:"Yonar",slug:"taner-yonar",fullName:"Taner Yonar"}],productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"}},authors:null,sections:[{id:"sec_1",title:"1. Introduction",level:"1"},{id:"sec_2",title:"2. Olive oil extraction technologies",level:"1"},{id:"sec_3",title:"3. Olive oil composition",level:"1"},{id:"sec_3_2",title:"3.1 Bioactive compounds",level:"2"},{id:"sec_4_2",title:"3.2 Physicochemical parameters",level:"2"},{id:"sec_6",title:"4. Quality control of olive oil",level:"1"},{id:"sec_7",title:"5. Olive oil enrichment with natural additives",level:"1"},{id:"sec_8",title:"6. Conclusions",level:"1"},{id:"sec_9",title:"Acknowledgments",level:"1"},{id:"sec_12",title:"Conflict of interest",level:"1"}],chapterReferences:[{id:"B1",body:'Gharby S, Hajib A, Ibourki M, et al. Induced changes in olive oil subjected to various chemical refining steps: A comparative study of quality indices, fatty acids, bioactive minor components, and oxidation stability kinetic parameters. Chemical Data Collections. 2021;33:100702. DOI: 10.1016/j.cdc.2021.100702'},{id:"B2",body:'Flori L, Donnini S, Calderone V, et al. 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DOI: 10.3390/antiox10050785'},{id:"B62",body:'Yang Y, Song X, Sui X, et al. Rosemary extract can be used as a synthetic antioxidant to improve vegetable oil oxidative stability. Industrial Crops and Products. 2016;80:141-147. DOI: 10.1016/j.indcrop.2015.11.044'},{id:"B63",body:'Blasi F, Cossignani L. An overview of natural extracts with antioxidant activity for the improvement of the oxidative stability and shelf life of edible oils. PRO. 2020;8:956. DOI: 10.3390/PR8080956'},{id:"B64",body:'Fereidoon S, Ying Z. Lipid oxidation and improving the oxidative stability. Chemical Society Reviews. 2010;39:4067-4079. DOI: 10.1039/b922183m'}],footnotes:[],contributors:[{corresp:"yes",contributorFullName:"El Hassan Sakar",address:"e.sakar@uae.ac.ma",affiliation:'
Laboratory of Applied Botany, FS, Abdelmalek Essaadi University, Morocco
Laboratory Biotechnology, Materials and Environment (LBME), Polydisciplinary Faculty of Taroudant, Ibn Zohr University, Morocco
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He has both an MS and Ph.D. in Biomedical Engineering. He was previously a research scientist at the University of California Los Angeles (UCLA) and visiting professor and researcher at the University of North Dakota. He is currently working in artificial intelligence and its applications in medical signal processing. In addition, he is using digital signal processing in medical imaging and speech processing. Dr. Asadpour has developed brain-computer interfacing algorithms and has published books, book chapters, and several journal and conference papers in this field and other areas of intelligent signal processing. He has also designed medical devices, including a laser Doppler monitoring system.",institutionString:"Kaiser Permanente Southern California",institution:null},{id:"169608",title:"Prof.",name:"Marian",middleName:null,surname:"Găiceanu",slug:"marian-gaiceanu",fullName:"Marian Găiceanu",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/169608/images/system/169608.png",biography:"Prof. Dr. Marian Gaiceanu graduated from the Naval and Electrical Engineering Faculty, Dunarea de Jos University of Galati, Romania, in 1997. He received a Ph.D. (Magna Cum Laude) in Electrical Engineering in 2002. Since 2017, Dr. Gaiceanu has been a Ph.D. supervisor for students in Electrical Engineering. He has been employed at Dunarea de Jos University of Galati since 1996, where he is currently a professor. Dr. Gaiceanu is a member of the National Council for Attesting Titles, Diplomas and Certificates, an expert of the Executive Agency for Higher Education, Research Funding, and a member of the Senate of the Dunarea de Jos University of Galati. He has been the head of the Integrated Energy Conversion Systems and Advanced Control of Complex Processes Research Center, Romania, since 2016. He has conducted several projects in power converter systems for electrical drives, power quality, PEM and SOFC fuel cell power converters for utilities, electric vehicles, and marine applications with the Department of Regulation and Control, SIEI S.pA. (2002–2004) and the Polytechnic University of Turin, Italy (2002–2004, 2006–2007). He is a member of the Institute of Electrical and Electronics Engineers (IEEE) and cofounder-member of the IEEE Power Electronics Romanian Chapter. He is a guest editor at Energies and an academic book editor for IntechOpen. He is also a member of the editorial boards of the Journal of Electrical Engineering, Electronics, Control and Computer Science and Sustainability. Dr. Gaiceanu has been General Chairman of the IEEE International Symposium on Electrical and Electronics Engineering in the last six editions.",institutionString:'"Dunarea de Jos" University of Galati',institution:{name:'"Dunarea de Jos" University of Galati',country:{name:"Romania"}}},{id:"4519",title:"Prof.",name:"Jaydip",middleName:null,surname:"Sen",slug:"jaydip-sen",fullName:"Jaydip Sen",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/4519/images/system/4519.jpeg",biography:"Jaydip Sen is associated with Praxis Business School, Kolkata, India, as a professor in the Department of Data Science. His research areas include security and privacy issues in computing and communication, intrusion detection systems, machine learning, deep learning, and artificial intelligence in the financial domain. He has more than 200 publications in reputed international journals, refereed conference proceedings, and 20 book chapters in books published by internationally renowned publishing houses, such as Springer, CRC press, IGI Global, etc. Currently, he is serving on the editorial board of the prestigious journal Frontiers in Communications and Networks and in the technical program committees of a number of high-ranked international conferences organized by the IEEE, USA, and the ACM, USA. He has been listed among the top 2% of scientists in the world for the last three consecutive years, 2019 to 2021 as per studies conducted by the Stanford University, USA.",institutionString:"Praxis Business School",institution:null},{id:"320071",title:"Dr.",name:"Sidra",middleName:null,surname:"Mehtab",slug:"sidra-mehtab",fullName:"Sidra Mehtab",position:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0033Y00002v6KHoQAM/Profile_Picture_1584512086360",biography:"Sidra Mehtab has completed her BS with honors in Physics from Calcutta University, India in 2018. She has done MS in Data Science and Analytics from Maulana Abul Kalam Azad University of Technology (MAKAUT), Kolkata, India in 2020. Her research areas include Econometrics, Time Series Analysis, Machine Learning, Deep Learning, Artificial Intelligence, and Computer and Network Security with a particular focus on Cyber Security Analytics. Ms. Mehtab has published seven papers in international conferences and one of her papers has been accepted for publication in a reputable international journal. She has won the best paper awards in two prestigious international conferences – BAICONF 2019, and ICADCML 2021, organized in the Indian Institute of Management, Bangalore, India in December 2019, and SOA University, Bhubaneswar, India in January 2021. Besides, Ms. Mehtab has also published two book chapters in two books. Seven of her book chapters will be published in a volume shortly in 2021 by Cambridge Scholars’ Press, UK. Currently, she is working as the joint editor of two edited volumes on Time Series Analysis and Forecasting to be published in the first half of 2021 by an international house. Currently, she is working as a Data Scientist with an MNC in Delhi, India.",institutionString:"NSHM College of Management and Technology",institution:null},{id:"226240",title:"Dr.",name:"Andri Irfan",middleName:null,surname:"Rifai",slug:"andri-irfan-rifai",fullName:"Andri Irfan Rifai",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/226240/images/7412_n.jpg",biography:"Andri IRFAN is a Senior Lecturer of Civil Engineering and Planning. He completed the PhD at the Universitas Indonesia & Universidade do Minho with Sandwich Program Scholarship from the Directorate General of Higher Education and LPDP scholarship. He has been teaching for more than 19 years and much active to applied his knowledge in the project construction in Indonesia. His research interest ranges from pavement management system to advanced data mining techniques for transportation engineering. He has published more than 50 papers in journals and 2 books.",institutionString:null,institution:{name:"Universitas Internasional Batam",country:{name:"Indonesia"}}},{id:"314576",title:"Dr.",name:"Ibai",middleName:null,surname:"Laña",slug:"ibai-lana",fullName:"Ibai Laña",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/314576/images/system/314576.jpg",biography:"Dr. Ibai Laña works at TECNALIA as a data analyst. He received his Ph.D. in Artificial Intelligence from the University of the Basque Country (UPV/EHU), Spain, in 2018. He is currently a senior researcher at TECNALIA. His research interests fall within the intersection of intelligent transportation systems, machine learning, traffic data analysis, and data science. He has dealt with urban traffic forecasting problems, applying machine learning models and evolutionary algorithms. He has experience in origin-destination matrix estimation or point of interest and trajectory detection. Working with large volumes of data has given him a good command of big data processing tools and NoSQL databases. He has also been a visiting scholar at the Knowledge Engineering and Discovery Research Institute, Auckland University of Technology.",institutionString:"TECNALIA Research & Innovation",institution:{name:"Tecnalia",country:{name:"Spain"}}},{id:"314575",title:"Dr.",name:"Jesus",middleName:null,surname:"L. Lobo",slug:"jesus-l.-lobo",fullName:"Jesus L. Lobo",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/314575/images/system/314575.png",biography:"Dr. Jesús López is currently based in Bilbao (Spain) working at TECNALIA as Artificial Intelligence Research Scientist. In most cases, a project idea or a new research line needs to be investigated to see if it is good enough to take into production or to focus on it. That is exactly what he does, diving into Machine Learning algorithms and technologies to help TECNALIA to decide whether something is great in theory or will actually impact on the product or processes of its projects. So, he is expert at framing experiments, developing hypotheses, and proving whether they’re true or not, in order to investigate fundamental problems with a longer time horizon. He is also able to design and develop PoCs and system prototypes in simulation. He has participated in several national and internacional R&D projects.\n\nAs another relevant part of his everyday research work, he usually publishes his findings in reputed scientific refereed journals and international conferences, occasionally acting as reviewer and Programme Commitee member. Concretely, since 2018 he has published 9 JCR (8 Q1) journal papers, 9 conference papers (e.g. ECML PKDD 2021), and he has co-edited a book. He is also active in popular science writing data science stories for reputed blogs (KDNuggets, TowardsDataScience, Naukas). Besides, he has recently embarked on mentoring programmes as mentor, and has also worked as data science trainer.",institutionString:"TECNALIA Research & Innovation",institution:{name:"Tecnalia",country:{name:"Spain"}}},{id:"103779",title:"Prof.",name:"Yalcin",middleName:null,surname:"Isler",slug:"yalcin-isler",fullName:"Yalcin Isler",position:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRyQ8QAK/Profile_Picture_1628834958734",biography:"Yalcin Isler (1971 - Burdur / Turkey) received the B.Sc. degree in the Department of Electrical and Electronics Engineering from Anadolu University, Eskisehir, Turkey, in 1993, the M.Sc. degree from the Department of Electronics and Communication Engineering, Suleyman Demirel University, Isparta, Turkey, in 1996, the Ph.D. degree from the Department of Electrical and Electronics Engineering, Dokuz Eylul University, Izmir, Turkey, in 2009, and the Competence of Associate Professorship from the Turkish Interuniversity Council in 2019.\n\nHe was Lecturer at Burdur Vocational School in Suleyman Demirel University (1993-2000, Burdur / Turkey), Software Engineer (2000-2002, Izmir / Turkey), Research Assistant in Bulent Ecevit University (2002-2003, Zonguldak / Turkey), Research Assistant in Dokuz Eylul University (2003-2010, Izmir / Turkey), Assistant Professor at the Department of Electrical and Electronics Engineering in Bulent Ecevit University (2010-2012, Zonguldak / Turkey), Assistant Professor at the Department of Biomedical Engineering in Izmir Katip Celebi University (2012-2019, Izmir / Turkey). He is an Associate Professor at the Department of Biomedical Engineering at Izmir Katip Celebi University, Izmir / Turkey, since 2019. In addition to academics, he has also founded Islerya Medical and Information Technologies Company, Izmir / Turkey, since 2017.\n\nHis main research interests cover biomedical signal processing, pattern recognition, medical device design, programming, and embedded systems. He has many scientific papers and participated in several projects in these study fields. He was an IEEE Student Member (2009-2011) and IEEE Member (2011-2014) and has been IEEE Senior Member since 2014.",institutionString:null,institution:{name:"Izmir Kâtip Çelebi University",country:{name:"Turkey"}}},{id:"339677",title:"Dr.",name:"Mrinmoy",middleName:null,surname:"Roy",slug:"mrinmoy-roy",fullName:"Mrinmoy Roy",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/339677/images/16768_n.jpg",biography:"An accomplished Sales & Marketing professional with 12 years of cross-functional experience in well-known organisations such as CIPLA, LUPIN, GLENMARK, ASTRAZENECA across different segment of Sales & Marketing, International Business, Institutional Business, Product Management, Strategic Marketing of HIV, Oncology, Derma, Respiratory, Anti-Diabetic, Nutraceutical & Stomatological Product Portfolio and Generic as well as Chronic Critical Care Portfolio. A First Class MBA in International Business & Strategic Marketing, B.Pharm, D.Pharm, Google Certified Digital Marketing Professional. Qualified PhD Candidate in Operations and Management with special focus on Artificial Intelligence and Machine Learning adoption, analysis and use in Healthcare, Hospital & Pharma Domain. Seasoned with diverse therapy area of Pharmaceutical Sales & Marketing ranging from generating revenue through generating prescriptions, launching new products, and making them big brands with continuous strategy execution at the Physician and Patients level. Moved from Sales to Marketing and Business Development for 3.5 years in South East Asian Market operating from Manila, Philippines. Came back to India and handled and developed Brands such as Gluconorm, Lupisulin, Supracal, Absolut Woman, Hemozink, Fabiflu (For COVID 19), and many more. In my previous assignment I used to develop and execute strategies on Sales & Marketing, Commercialization & Business Development for Institution and Corporate Hospital Business portfolio of Oncology Therapy Area for AstraZeneca Pharma India Ltd. Being a Research Scholar and Student of ‘Operations Research & Management: Artificial Intelligence’ I published several pioneer research papers and book chapters on the same in Internationally reputed journals and Books indexed in Scopus, Springer and Ei Compendex, Google Scholar etc. Currently, I am launching PGDM Pharmaceutical Management Program in IIHMR Bangalore and spearheading the course curriculum and structure of the same. I am interested in Collaboration for Healthcare Innovation, Pharma AI Innovation, Future trend in Marketing and Management with incubation on Healthcare, Healthcare IT startups, AI-ML Modelling and Healthcare Algorithm based training module development. I am also an affiliated member of the Institute of Management Consultant of India, looking forward to Healthcare, Healthcare IT and Innovation, Pharma and Hospital Management Consulting works.",institutionString:null,institution:{name:"Lovely Professional University",country:{name:"India"}}},{id:"1063",title:"Prof.",name:"Constantin",middleName:null,surname:"Volosencu",slug:"constantin-volosencu",fullName:"Constantin Volosencu",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/1063/images/system/1063.png",biography:"Prof. Dr. Constantin Voloşencu graduated as an engineer from\nPolitehnica University of Timișoara, Romania, where he also\nobtained a doctorate degree. He is currently a full professor in\nthe Department of Automation and Applied Informatics at the\nsame university. Dr. Voloşencu is the author of ten books, seven\nbook chapters, and more than 160 papers published in journals\nand conference proceedings. He has also edited twelve books and\nhas twenty-seven patents to his name. He is a manager of research grants, editor in\nchief and member of international journal editorial boards, a former plenary speaker, a member of scientific committees, and chair at international conferences. His\nresearch is in the fields of control systems, control of electric drives, fuzzy control\nsystems, neural network applications, fault detection and diagnosis, sensor network\napplications, monitoring of distributed parameter systems, and power ultrasound\napplications. He has developed automation equipment for machine tools, spooling\nmachines, high-power ultrasound processes, and more.",institutionString:"Polytechnic University of Timişoara",institution:{name:"Polytechnic University of Timişoara",country:{name:"Romania"}}},{id:"221364",title:"Dr.",name:"Eneko",middleName:null,surname:"Osaba",slug:"eneko-osaba",fullName:"Eneko Osaba",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/221364/images/system/221364.jpg",biography:"Dr. Eneko Osaba works at TECNALIA as a senior researcher. He obtained his Ph.D. in Artificial Intelligence in 2015. He has participated in more than twenty-five local and European research projects, and in the publication of more than 130 papers. He has performed several stays at universities in the United Kingdom, Italy, and Malta. Dr. Osaba has served as a program committee member in more than forty international conferences and participated in organizing activities in more than ten international conferences. He is a member of the editorial board of the International Journal of Artificial Intelligence, Data in Brief, and Journal of Advanced Transportation. He is also a guest editor for the Journal of Computational Science, Neurocomputing, Swarm, and Evolutionary Computation and IEEE ITS Magazine.",institutionString:"TECNALIA Research & Innovation",institution:{name:"Tecnalia",country:{name:"Spain"}}},{id:"275829",title:"Dr.",name:"Esther",middleName:null,surname:"Villar-Rodriguez",slug:"esther-villar-rodriguez",fullName:"Esther Villar-Rodriguez",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/275829/images/system/275829.jpg",biography:"Dr. Esther Villar obtained a Ph.D. in Information and Communication Technologies from the University of Alcalá, Spain, in 2015. She obtained a degree in Computer Science from the University of Deusto, Spain, in 2010, and an MSc in Computer Languages and Systems from the National University of Distance Education, Spain, in 2012. Her areas of interest and knowledge include natural language processing (NLP), detection of impersonation in social networks, semantic web, and machine learning. Dr. Esther Villar made several contributions at conferences and publishing in various journals in those fields. Currently, she is working within the OPTIMA (Optimization Modeling & Analytics) business of TECNALIA’s ICT Division as a data scientist in projects related to the prediction and optimization of management and industrial processes (resource planning, energy efficiency, etc).",institutionString:"TECNALIA Research & Innovation",institution:{name:"Tecnalia",country:{name:"Spain"}}},{id:"49813",title:"Dr.",name:"Javier",middleName:null,surname:"Del Ser",slug:"javier-del-ser",fullName:"Javier Del Ser",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/49813/images/system/49813.png",biography:"Prof. Dr. Javier Del Ser received his first PhD in Telecommunication Engineering (Cum Laude) from the University of Navarra, Spain, in 2006, and a second PhD in Computational Intelligence (Summa Cum Laude) from the University of Alcala, Spain, in 2013. He is currently a principal researcher in data analytics and optimisation at TECNALIA (Spain), a visiting fellow at the Basque Center for Applied Mathematics (BCAM) and a part-time lecturer at the University of the Basque Country (UPV/EHU). His research interests gravitate on the use of descriptive, prescriptive and predictive algorithms for data mining and optimization in a diverse range of application fields such as Energy, Transport, Telecommunications, Health and Industry, among others. In these fields he has published more than 240 articles, co-supervised 8 Ph.D. theses, edited 6 books, coauthored 7 patents and participated/led more than 40 research projects. He is a Senior Member of the IEEE, and a recipient of the Biscay Talent prize for his academic career.",institutionString:"Tecnalia Research & Innovation",institution:null},{id:"278948",title:"Dr.",name:"Carlos Pedro",middleName:null,surname:"Gonçalves",slug:"carlos-pedro-goncalves",fullName:"Carlos Pedro Gonçalves",position:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRcmyQAC/Profile_Picture_1564224512145",biography:'Carlos Pedro Gonçalves (PhD) is an Associate Professor at Lusophone University of Humanities and Technologies and a researcher on Complexity Sciences, Quantum Technologies, Artificial Intelligence, Strategic Studies, Studies in Intelligence and Security, FinTech and Financial Risk Modeling. He is also a progammer with programming experience in:\n\nA) Quantum Computing using Qiskit Python module and IBM Quantum Experience Platform, with software developed on the simulation of Quantum Artificial Neural Networks and Quantum Cybersecurity;\n\nB) Artificial Intelligence and Machine learning programming in Python;\n\nC) Artificial Intelligence, Multiagent Systems Modeling and System Dynamics Modeling in Netlogo, with models developed in the areas of Chaos Theory, Econophysics, Artificial Intelligence, Classical and Quantum Complex Systems Science, with the Econophysics models having been cited worldwide and incorporated in PhD programs by different Universities.\n\nReceived an Arctic Code Vault Contributor status by GitHub, due to having developed open source software preserved in the \\"Arctic Code Vault\\" for future generations (https://archiveprogram.github.com/arctic-vault/), with the Strategy Analyzer A.I. module for decision making support (based on his PhD thesis, used in his Classes on Decision Making and in Strategic Intelligence Consulting Activities) and QNeural Python Quantum Neural Network simulator also preserved in the \\"Arctic Code Vault\\", for access to these software modules see: https://github.com/cpgoncalves. He is also a peer reviewer with outsanding review status from Elsevier journals, including Physica A, Neurocomputing and Engineering Applications of Artificial Intelligence. Science CV available at: https://www.cienciavitae.pt//pt/8E1C-A8B3-78C5 and ORCID: https://orcid.org/0000-0002-0298-3974',institutionString:"University of Lisbon",institution:{name:"Universidade Lusófona",country:{name:"Portugal"}}},{id:"241400",title:"Prof.",name:"Mohammed",middleName:null,surname:"Bsiss",slug:"mohammed-bsiss",fullName:"Mohammed Bsiss",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/241400/images/8062_n.jpg",biography:null,institutionString:null,institution:null},{id:"276128",title:"Dr.",name:"Hira",middleName:null,surname:"Fatima",slug:"hira-fatima",fullName:"Hira Fatima",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/276128/images/14420_n.jpg",biography:"Dr. Hira Fatima\nAssistant Professor\nDepartment of Mathematics\nInstitute of Applied Science\nMangalayatan University, Aligarh\nMobile: no : 8532041179\nhirafatima2014@gmal.com\n\nDr. Hira Fatima has received his Ph.D. degree in pure Mathematics from Aligarh Muslim University, Aligarh India. Currently working as an Assistant Professor in the Department of Mathematics, Institute of Applied Science, Mangalayatan University, Aligarh. She taught so many courses of Mathematics of UG and PG level. Her research Area of Expertise is Functional Analysis & Sequence Spaces. She has been working on Ideal Convergence of double sequence. She has published 17 research papers in National and International Journals including Cogent Mathematics, Filomat, Journal of Intelligent and Fuzzy Systems, Advances in Difference Equations, Journal of Mathematical Analysis, Journal of Mathematical & Computer Science etc. She has also reviewed few research papers for the and international journals. She is a member of Indian Mathematical Society.",institutionString:null,institution:null},{id:"414880",title:"Dr.",name:"Maryam",middleName:null,surname:"Vatankhah",slug:"maryam-vatankhah",fullName:"Maryam Vatankhah",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Borough of Manhattan Community College",country:{name:"United States of America"}}},{id:"414879",title:"Prof.",name:"Mohammad-Reza",middleName:null,surname:"Akbarzadeh-Totonchi",slug:"mohammad-reza-akbarzadeh-totonchi",fullName:"Mohammad-Reza Akbarzadeh-Totonchi",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Ferdowsi University of Mashhad",country:{name:"Iran"}}},{id:"414878",title:"Prof.",name:"Reza",middleName:null,surname:"Fazel-Rezai",slug:"reza-fazel-rezai",fullName:"Reza Fazel-Rezai",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"American Public University System",country:{name:"United States of America"}}},{id:"302698",title:"Dr.",name:"Yao",middleName:null,surname:"Shan",slug:"yao-shan",fullName:"Yao Shan",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Dalian University of Technology",country:{name:"China"}}},{id:"125911",title:"Prof.",name:"Jia-Ching",middleName:null,surname:"Wang",slug:"jia-ching-wang",fullName:"Jia-Ching Wang",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"National Central University",country:{name:"Taiwan"}}},{id:"357085",title:"Mr.",name:"P. 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\r\n\tThe Business and Management series topic focuses on the most pressing issues confronting organizations today and in the future. Businesses are trying to figure out how to lead in a time of global uncertainty. In emerging markets, issues such as ill-defined or unstable policies, as well as corrupt practices, can be hugely problematic. Changes in governments can result in new policy, regulations, and interest rates, all of which can be detrimental to foreign businesses and investments. A growing trend towards economic nationalism also makes the current global political landscape potentially hostile towards international businesses.
\r\n
\r\n\tThe demographic shifts are creating interesting challenges. People are living longer, resulting to an aging demographic. We have a large population of older workers and retirees who are living longer lives, combined with a declining birthrate in most parts of the world. Businesses of all types are looking at how technology is affecting their operations. Several questions arise, such as: How is technology changing what we do? How is it transforming us internally, how is it influencing our clients and our business strategy? It is about leveraging technology to improve efficiency, connect with customers more effectively, and drive innovation. The majority of innovative companies are technology-driven businesses. Realizing digital transformation is today’s top issue and will remain so for the next five years. Improving organizational agility, expanding portfolios of products and services, creating, and maintaining a culture of innovation, and developing next -generation leaders were also identified as top challenges in terms of both current and future issues.
\r\n
\r\n\tThe most sustained profitable growth occurs when a company expands its core business into an adjacent space. This has significant implications for management because innovation in business ecosystems differs from traditional, vertically integrated firms. Every organization in the ecosystem must be aware of the bigger picture. Innovation in ecosystems necessitates collaborative action to invent and appraise, efficient, cross-organizational knowledge flows, modular architectures, and good stewardship of legacy systems. It is built on multiple, interconnected platforms. Environmental factors have already had a significant impact in the West and will continue to have an impact globally. Businesses must take into account the environmental impact of their daily operations. The advantage of this market is that it is expected to grow more rapidly than the overall economy. Another significant challenge is preparing the next generation of leaders to elevate this to the number one priority within the next five years. There can be no culture of innovation unless there is diverse leadership or development of the next generation of leaders; and these diverse, next-generation leaders are the ones who will truly understand the digital strategies that will drive digital transformation.
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