Surgical options in the management of faecal incontinence.
\\n\\n
Released this past November, the list is based on data collected from the Web of Science and highlights some of the world’s most influential scientific minds by naming the researchers whose publications over the previous decade have included a high number of Highly Cited Papers placing them among the top 1% most-cited.
\\n\\nWe wish to congratulate all of the researchers named and especially our authors on this amazing accomplishment! We are happy and proud to share in their success!
\\n"}]',published:!0,mainMedia:null},components:[{type:"htmlEditorComponent",content:'IntechOpen is proud to announce that 179 of our authors have made the Clarivate™ Highly Cited Researchers List for 2020, ranking them among the top 1% most-cited.
\n\nThroughout the years, the list has named a total of 252 IntechOpen authors as Highly Cited. Of those researchers, 69 have been featured on the list multiple times.
\n\n\n\nReleased this past November, the list is based on data collected from the Web of Science and highlights some of the world’s most influential scientific minds by naming the researchers whose publications over the previous decade have included a high number of Highly Cited Papers placing them among the top 1% most-cited.
\n\nWe wish to congratulate all of the researchers named and especially our authors on this amazing accomplishment! We are happy and proud to share in their success!
\n'}],latestNews:[{slug:"stanford-university-identifies-top-2-scientists-over-1-000-are-intechopen-authors-and-editors-20210122",title:"Stanford University Identifies Top 2% Scientists, Over 1,000 are IntechOpen Authors and Editors"},{slug:"intechopen-authors-included-in-the-highly-cited-researchers-list-for-2020-20210121",title:"IntechOpen Authors Included in the Highly Cited Researchers List for 2020"},{slug:"intechopen-maintains-position-as-the-world-s-largest-oa-book-publisher-20201218",title:"IntechOpen Maintains Position as the World’s Largest OA Book Publisher"},{slug:"all-intechopen-books-available-on-perlego-20201215",title:"All IntechOpen Books Available on Perlego"},{slug:"oiv-awards-recognizes-intechopen-s-editors-20201127",title:"OIV Awards Recognizes IntechOpen's Editors"},{slug:"intechopen-joins-crossref-s-initiative-for-open-abstracts-i4oa-to-boost-the-discovery-of-research-20201005",title:"IntechOpen joins Crossref's Initiative for Open Abstracts (I4OA) to Boost the Discovery of Research"},{slug:"intechopen-hits-milestone-5-000-open-access-books-published-20200908",title:"IntechOpen hits milestone: 5,000 Open Access books published!"},{slug:"intechopen-books-hosted-on-the-mathworks-book-program-20200819",title:"IntechOpen Books Hosted on the MathWorks Book Program"}]},book:{item:{type:"book",id:"8754",leadTitle:null,fullTitle:"Scheduling Problems - New Applications and Trends",title:"Scheduling Problems",subtitle:"New Applications and Trends",reviewType:"peer-reviewed",abstract:"Scheduling is defined as the process of assigning operations to resources over time to optimize a criterion. 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She is also the present Global Harmonization Initiative (GHI) Ambassador to Sri Lanka.",institutionString:"Australian College of Business & Technology",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"10",totalChapterViews:"0",totalEditedBooks:"7",institution:null}],coeditorOne:null,coeditorTwo:null,coeditorThree:null,coeditorFour:null,coeditorFive:null,topics:[{id:"6",title:"Biochemistry, Genetics and Molecular Biology",slug:"biochemistry-genetics-and-molecular-biology"}],chapters:[{id:"74859",title:"An Antioxidant Defense System in Radiation-Resistant Bacterium Deinococcus geothermalis against Oxidative Stress",slug:"an-antioxidant-defense-system-in-radiation-resistant-bacterium-deinococcus-geothermalis-against-oxid",totalDownloads:23,totalCrossrefCites:0,authors:[null]},{id:"74893",title:"Endogenous Enzymatic Antioxidant Defense and Pathologies",slug:"endogenous-enzymatic-antioxidant-defense-and-pathologies",totalDownloads:19,totalCrossrefCites:0,authors:[null]},{id:"75042",title:"Micronutrient Antioxidants in the Chemoprevention of Breast Cancer and Effect on Breast Cancer Outcomes",slug:"micronutrient-antioxidants-in-the-chemoprevention-of-breast-cancer-and-effect-on-breast-cancer-outco",totalDownloads:32,totalCrossrefCites:0,authors:[null]},{id:"74753",title:"Evolutionary Strategies of Highly Functional Catalases for Adaptation to High H2O2 Environments",slug:"evolutionary-strategies-of-highly-functional-catalases-for-adaptation-to-high-h2o2-environments",totalDownloads:27,totalCrossrefCites:0,authors:[null]},{id:"74706",title:"The Role of Lycopene in Chronic Lung Diseases",slug:"the-role-of-lycopene-in-chronic-lung-diseases",totalDownloads:67,totalCrossrefCites:0,authors:[null]},{id:"74380",title:"Thiol Reduction and Cardiolipin Improve Complex I Activity and Free Radical Production in Liver Mitochondria of Streptozotocin-Induced Diabetic Rats",slug:"thiol-reduction-and-cardiolipin-improve-complex-i-activity-and-free-radical-production-in-liver-mito",totalDownloads:54,totalCrossrefCites:0,authors:[null]},{id:"74927",title:"Antioxidants in Female Reproductive Biology",slug:"antioxidants-in-female-reproductive-biology",totalDownloads:8,totalCrossrefCites:0,authors:[null]},{id:"74748",title:"Reappraisal of Dietary Phytochemicals for Coronavirus Infection: Focus on Hesperidin and Quercetin",slug:"reappraisal-of-dietary-phytochemicals-for-coronavirus-infection-focus-on-hesperidin-and-quercetin",totalDownloads:444,totalCrossrefCites:0,authors:[null]},{id:"75198",title:"Management of Diabetic Eye Disease using Carotenoids and Nutrients",slug:"management-of-diabetic-eye-disease-using-carotenoids-and-nutrients",totalDownloads:33,totalCrossrefCites:0,authors:[null]},{id:"74807",title:"Vitamin C and Sepsis",slug:"vitamin-c-and-sepsis",totalDownloads:40,totalCrossrefCites:0,authors:[null]},{id:"74793",title:"Phytochemical Antioxidants: Past, Present and Future",slug:"phytochemical-antioxidants-past-present-and-future",totalDownloads:40,totalCrossrefCites:0,authors:[null]},{id:"75026",title:"Role of Antioxidants Supplementation in the Treatment of Male Infertility",slug:"role-of-antioxidants-supplementation-in-the-treatment-of-male-infertility",totalDownloads:40,totalCrossrefCites:0,authors:[null]},{id:"75226",title:"Use of Selected Antioxidant-Rich Spices and Herbs in Foods",slug:"use-of-selected-antioxidant-rich-spices-and-herbs-in-foods",totalDownloads:19,totalCrossrefCites:0,authors:[null]},{id:"74790",title:"Antioxidant Activity: The Presence and Impact of Hydroxyl Groups in Small Molecules of Natural and Synthetic Origin",slug:"antioxidant-activity-the-presence-and-impact-of-hydroxyl-groups-in-small-molecules-of-natural-and-sy",totalDownloads:77,totalCrossrefCites:0,authors:[null]},{id:"74678",title:"Role of Secondary Metabolites to Attenuate Stress Damages in Plants",slug:"role-of-secondary-metabolites-to-attenuate-stress-damages-in-plants",totalDownloads:41,totalCrossrefCites:0,authors:[null]},{id:"74332",title:"The Two Sides of Dietary Antioxidants in Cancer Therapy",slug:"the-two-sides-of-dietary-antioxidants-in-cancer-therapy",totalDownloads:50,totalCrossrefCites:0,authors:[null]}],productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"},personalPublishingAssistant:{id:"280415",firstName:"Josip",lastName:"Knapic",middleName:null,title:"Mr.",imageUrl:"https://mts.intechopen.com/storage/users/280415/images/8050_n.jpg",email:"josip@intechopen.com",biography:"As an Author Service Manager my responsibilities include monitoring and facilitating all publishing activities for authors and editors. From chapter submission and review, to approval and revision, copy-editing and design, until final publication, I work closely with authors and editors to ensure a simple and easy publishing process. I maintain constant and effective communication with authors, editors and reviewers, which allows for a level of personal support that enables contributors to fully commit and concentrate on the chapters they are writing, editing, or reviewing. I assist authors in the preparation of their full chapter submissions and track important deadlines and ensure they are met. I help to coordinate internal processes such as linguistic review, and monitor the technical aspects of the process. As an ASM I am also involved in the acquisition of editors. Whether that be identifying an exceptional author and proposing an editorship collaboration, or contacting researchers who would like the opportunity to work with IntechOpen, I establish and help manage author and editor acquisition and contact."}},relatedBooks:[{type:"book",id:"5505",title:"Superfood and Functional Food",subtitle:"An Overview of Their Processing and Utilization",isOpenForSubmission:!1,hash:"1c054794ab111a6e0a6bfebeb77baa8e",slug:"superfood-and-functional-food-an-overview-of-their-processing-and-utilization",bookSignature:"Viduranga Waisundara and Naofumi Shiomi",coverURL:"https://cdn.intechopen.com/books/images_new/5505.jpg",editedByType:"Edited by",editors:[{id:"194281",title:"Dr.",name:"Viduranga Yashasvi",surname:"Waisundara",slug:"viduranga-yashasvi-waisundara",fullName:"Viduranga Yashasvi Waisundara"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"6308",title:"Cassava",subtitle:null,isOpenForSubmission:!1,hash:"da8363274dca1c87f27e55966728f14a",slug:"cassava",bookSignature:"Viduranga Waisundara",coverURL:"https://cdn.intechopen.com/books/images_new/6308.jpg",editedByType:"Edited by",editors:[{id:"194281",title:"Dr.",name:"Viduranga Yashasvi",surname:"Waisundara",slug:"viduranga-yashasvi-waisundara",fullName:"Viduranga Yashasvi Waisundara"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"7006",title:"Biochemistry and Health Benefits of Fatty Acids",subtitle:null,isOpenForSubmission:!1,hash:"c93a00abd68b5eba67e5e719f67fd20b",slug:"biochemistry-and-health-benefits-of-fatty-acids",bookSignature:"Viduranga Waisundara",coverURL:"https://cdn.intechopen.com/books/images_new/7006.jpg",editedByType:"Edited by",editors:[{id:"194281",title:"Dr.",name:"Viduranga Yashasvi",surname:"Waisundara",slug:"viduranga-yashasvi-waisundara",fullName:"Viduranga Yashasvi Waisundara"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"6155",title:"Diabetes Food Plan",subtitle:null,isOpenForSubmission:!1,hash:"b826ff12304ae270954a41210f4e1582",slug:"diabetes-food-plan",bookSignature:"Viduranga Waisundara",coverURL:"https://cdn.intechopen.com/books/images_new/6155.jpg",editedByType:"Edited by",editors:[{id:"194281",title:"Dr.",name:"Viduranga Yashasvi",surname:"Waisundara",slug:"viduranga-yashasvi-waisundara",fullName:"Viduranga Yashasvi Waisundara"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"10111",title:"Apolipoproteins, Triglycerides and Cholesterol",subtitle:null,isOpenForSubmission:!1,hash:"29ed0d776c8e3b2af0e50b3c4cf5e415",slug:"apolipoproteins-triglycerides-and-cholesterol",bookSignature:"Viduranga Y. 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Corrosion introduces itself into many parts of our lives [1, 2]. The great majority of us have personal feeling for the importance of corrosion. Far too many have cringed at the emergence of rust holes in the body panels of relatively new automobiles [3]. The outdoor rusting of steel, household and garden appliances is a common fact of life. All have seen the strains on cooking utensils from hot foods or experienced the metallic taste in acid foods stored too long on open cans. That these effects are caused by corrosion is well known [4]. The glaring example related to corrosion is the appearance of cracks in certain portions of Taj Mahal, was due to steel dowels embedded inside had extensively corroded and rusted leading to fractures in the stoned [5]. However, corrosion is just as common in other material classes such as ceramics, plastics and rubber. Since, practically all environments are corrosive to some degree and are major contributing causes of material failure and also are a large economic cost to the society [6].
\nCorrosion can be viewed as a universal phenomenon, omnipresent and omnipotent. It is there everywhere, air, water, soil and in every environment, we encounter [7]. Known to people as rust, corrosion is an undesirable phenomenon which destroys the luster and beauty of the materials and lessens their life. Indian government spending around 3.5% Lakscrores of the nation’s GDP per annum for losses of corrosion [8]. Recent studies estimate that, not only in India, other countries also rise their funds for demand of corrosion inhibitors [9].
\nCorrosion costs manifest in the form of premature deterioration or failure necessitating maintenance, repairs and replacement of damaged parts.. Corrosion has a vast environmental and economic impact on all the surfaces of national infrastructure like highways, bridges, buildings, chemical processing units, waste water treatment and virtually on all metallic objects in our day to day life use [10]. Other than material loss, corrosion interferes not only with environment, also affects human safety and industrial operations severely. Awareness to corrosion and adaptation of timely and appropriate control measures hold the key in the abatement of corrosion failures [11].
\nThe spontaneous oxidation of metal is termed as corrosion [12], that is, Corrosion is the deterioration or destruction of metals and alloys in the presence of an environment by chemical or electrochemical means. The medium in which the metal undergoes corrosion is termed as corrosive or aggressive medium. Corrosion products formed are chemical compounds containing the metal in the oxidized form with the exception of gold and platinum, all other metals corrode and transform themselves into substances similar to the mineral ores from which they are extracted [13].
\nThe corrosion affects severely on the safe, reliable and efficient operation of equipment and structures than the simple loss of a mass of metal [14]. Failures of all kind of machineries and the need for expensive replacements may occur even though the amount of metal destroyed is quite small. Some of the major harmful effects of corrosion can be listed below:
\nNuclear plant shutdown due to failure, for example, nuclear reactor during decontamination process.
Replacement of corroded equipment resulting in heavy expenditure.
High cost preventive maintenance such as painting.
Loss of efficiency.
Loss of product from a corroded container.
Safety requirement measures from a fire hazard or explosion or release of toxic product.
Health problems, for example, drinking water contamination with lead is likely due to corrosion.
In general, metals are having unique properties like opaque, lustrous, conductivity, malleable and ductile in nature and are readily forms metallic bonds with other metals and ionic bonds with non-metals [15, 16]. The metals that have overlapping conduction bands and valence bands in their electronic structure.
\nMetals are obtained from their ore by the expenditure of large amounts of energy. Metals store heat as potential energy during the smelting and refining process and release this energy during the corrosion process after reacting with the environment. These metals can therefore be regarded as being in a metastable state and will tend to lose their energy by reverting to compounds more or less similar to their original states, for example the starting material for iron and steel making and the corrosion product rust has the same chemical composition (Fe2O3).
\nThe energy stored during melting and released during corrosion supplies the driving potential for the corrosion process to take place. Since most metallic compounds, and especially corrosion products, have little mechanical strength, a severely corroded piece of metal is quite useless for its original purpose [17]. Metals such as Mg, Al, Zn, and Fe which require larger amount of energy for refining are more susceptible to corrosion than metals which require lesser amount for refining such as gold, silver, platinum. A corrosion cycle is shown below (Figure 1).
\nCorrosion cycle process.
Corrosion has been classified into different methods. They are
Low temperature corrosion and high temperature corrosion (or)
Electrochemical corrosion and chemical corrosion (or)
Wet and Dry corrosion.
Wet corrosion occurs when the metal is in contact with an electrolytic conducting liquid or when two dissimilar metals or alloys are either immersed or dipped partially in the electrolytic conducting solutions. This is always associated with low temperature conditions. The corrosion process involves two reactions.
\nAt anode:
M (metal) → Mn+ + ne− (oxidation)
Mn + (metal ion) → Dissolves in solution
Mn + (metal ion) → Forms compound such as oxide
At Cathode:
2H+ + 2e− → H2↑ (in acid solution)
2H2O + 2e− → H2↑ + 2OH− (in alkaline solution)
O2 + 2H2O + 4e− → 4OH− (in neutral solution)
Dry corrosion takes place mainly through the direct chemical action of atmospheric gases and vapors present in the environment 30. This is most often associated with high temperature.
\nCorrosion can manifest itself in many forms such as uniform corrosion or general corrosion, galvanic corrosion, crevice corrosion, pitting corrosion, intergranular corrosion, selective leaching, erosion corrosion, stress corrosion, corrosion fatigue and fretting corrosion [18]. In order to improve the understanding between corrosion and design engineers it is classified into two broad categories. They are expressed in flow chart (Figure 2).
\nForms of corrosion.
This general corrosion also called as a uniform attack is the most common form of corrosion. It is normally characterized by a chemical or electrochemical reaction which proceeds uniformly over the entire exposed surface or over a large area [19]. The metal becomes thinner and eventually fails.
\nIt occurs when a potential difference exists between two dissimilar metals immersed in a corrosive solution. This potential difference produces a flow of electrons between the metals. Several investigations have shown that, galvanic corrosion is directly proportional to the area of the cathodic to the anodic metal [20]. A schematic diagram for galvanic corrosion is shown below(Figure 3).
\nSchematic representation of galvanic corrosion.
This kind of corrosion is attacked generally within crevices associated with small volumes of stagnant solution trapped in holes, surfaces, joints and crevices under bolt and rivet heads (Figure 4) [21]. It is also known as deposit or gasket corrosion.
\nSchematic representation of crevice corrosion.
Pitting corrosion is a localized attack resulting in the formation of holes in the metals. These holes are relatively small and they are looks like a rough surface (Figure 5), they were sometimes isolated or so close together. Pitting is one of the most destructive and insidious forms of corrosion [22].
\nSchematic representation of pitting corrosion.
Most of the metals and alloys are susceptible to intergranular corrosion, when exposed to specific corrosion environment which is shown in the Figure 6. Grain boundaries are usually more reactive than grain matrix. Hence localized attack occurs at and adjacent to grain boundaries with relatively little corrosion of the matrix. This type of attack is usually rapid and penetrates deep into the metal resulting in loss of strength and causes catastrophic failures. It is caused by,
Impurities at the grain boundaries
Enrichment of one of the elements in the alloy
Depletion of one of the elements in the boundary area.
Schematic representation of intergranular corrosion.
Selective leaching is the removal of an element from an alloy by corrosion. Selective removal of zinc from brass is a prime example of this form of attack. A similar attack has been observed with other alloys in which iron, aluminum, cobalt and chromium are removed. This type corrosion is undesirable as it yields a porous metal with poor mechanical properties (Figure 7).
\nSchematic representation of selective leaching corrosion.
It is the increase of attack of a metal because of relative movement between a corrosive medium and the metal surface. This type of erosion corrosion is usually associated with systems where high velocities of corrosive fluids or gases are encountered. This corrosion can be observed in piping system such as bends, elbows, pumps and condensers, etc. A Schematic representation of erosion corrosion is shown in Figure 8. Factors affecting erosion corrosion are nature of surface film, corrosion environment and presence of air bubbles with its size, chemical composition, suspended solids, corrosion resistance and metallurgical properties of metals and alloys.
\nSchematic representation of erosion corrosion.
The cracking of metal or alloy by the combined action of a tensile stress and a corrodent (Figure 9) is known as stress corrosion cracking. The susceptibility to stress corrosion cracking is due to certain metallurgical factors such as,
Chemical composition
Preferential orientation of grains
Composition and distribution of precipitates
Dislocation structure and environmental factors and structure of metal.
Schematic representation of stress corrosion.
It is defined as, “the reduction of the fatigue strength due to the presence of corrosive environment”. Corrosion fatigue occurs due to the combined action of tensile and compressive stress alternatively. Fatigue occurs at lower stress in corrosive environment.
\nFretting is a wear phenomenon enhanced by corrosion. It involves wear of a metal or alloy when in contact with another solid material in dry or humid air. Fretting is the result of abrasive wear surface oxide films, which form a contacting surfaces under load in atmospheric air which is shown in Figure 10. The factors which affect fretting corrosion are:
Magnitude of relative motion
Temperature
Environment
Metallurgical factors
Schematic representation of fretting corrosion.
Due to slight motion such as vibration, surface oxide and underlying metal, gets spoiled. The metal particles as a result of wear get oxidized to hard oxides which act as an additional abrasive medium. Further, the motion grinds the oxides particles thus causing wear.
\nIt is a special type of erosion corrosion which is caused due to the formation of vapor bubbles in a corrosive environment near a metal surface and when the bubbles collapse, attack arises for example, hydraulic turbulence, ship propellers, etc. It is similar to pitting corrosion but the surface is rough and has many close spaced pits (Figure 11).
\nSchematic representation of cavitation corrosion.
The extent and rate of corrosion depend on nature of the metals and the environments.
\n\n
Position of metals in EMF series
Overvoltage
Relative area of anodic and cathodic parts of the metal
Purity of the metal
Physical nature of the metal
Nature of the surface film
Solubility of products
Volatile corrosion products.
\n
Temperature range
Humidity of air
Impurities in water
Presence of suspended particles in atmosphere
Influence of pH
Nature of dissolved gases, dissolved salts, pollutants, etc.
Conductance of the corroding medium
Formation of oxygen concentration cell
Flow velocity of process steam
Polarization of electrodes.
Certain factors tend to accelerate the action of a corrosion cell which includes the establishment of well-defined locations on the metal surface for the anodic and cathodic reactions. Metals having a more positive (noble) potential in the galvanic series will tend to extract electrons from a metal which is in a more negative (base) position in the series and hence accelerate its corrosion when in contact with it [23]. Aggressive ions such as chloride tend to prevent the formation of protective oxide films on the metal surface and thus increase corrosion.
\nThe rate of corrosion is expressed based on the loss per unit time. The rate at which the attack takes place is of prime importance and is usually expressed in one of the two ways:
Weight loss per unit area per unit time, usually mdd (milligrams per square decimeter per day).
Decrease in thickness per unit time, that is, rate of penetration or the thickness of metal lost. This may be expressed in American units, mpy (mils per year) or in metric units or mmpy (millimeters per year).
Corrosion is destructive and silent operating processes. It poses problems to big as well as small industries. Since corrosion is inevitable to eliminate but can be minimized by adopting certain anticorrosion method rather than preventing it [24]. The practical methods available for the protection of metal against corrosion are diverse. They may be broadly based on,
Modification of metal
Modification of design
Modification of corrosive environment
Modification of metal environment potential
Use of inhibitors
Modification of surface
These methods can be used individually or in combination.. One of the best known methods of corrosion protection is using corrosion inhibitors instead of using the various methods to avoid or prevent destruction or degradation of metal surface. Because using inhibitors is following stand up due to low cost and practice method [25, 26].
\nAn inhibitor is a chemical substance or combination of substances which when added in very low concentrations in a corrosive environment effectively prevents or reduces corrosion without significant reaction with the components of the environment. Concentrations of corrosion inhibitors can vary from 1 to 15,000 ppm (0.0001 to 1.5 wt %). Inhibitors play a vital role in closed environmental systems that have good circulation so that an adequate and controlled concentration of inhibitor is ensured [27]. Such conditions can be met, for instance in cooling water recirculation systems, oil production, oil refining, and acid pickling of steel components. One of the more recognizable applications for inhibitors is in antifreeze for automobile radiators. Inhibitors may be organic or inorganic compounds and they are usually dissolved in aqueous environments [28].
\nAn inhibitor is a substance which when added to an environment in small concentration minimizes the loss of metal, reduces the extent of hydrogen embrittlement, protects the metal against pitting, reduces over pickling and acid fumes resulting from excessive reaction between the acid and basic metals and reduces acid consumption. They reduce corrosion by either acting as a barrier by forming an adsorbed layer or retarding the cathodic, the anodic or both processes [10]. A schematic representation of inhibitor process is shown in Figure 12.
\nSchematic representation of inhibition process.
Any corrosion retardation process or the reduction in the oxidation rate of the metal by addition of a chemical compound to the system is caused by corrosion inhibitors. Inhibitors are often easy to apply and offer the advantage of in-situ application without causing any significant disruption to the process. The use of corrosion inhibitors is one of the best methods of combating corrosion [11].
\nIn order that they can be used effectively, three factors must be considered, namely:
Identification of the corrosion problems.
Generally, the components of a corrosion cell (anode, cathode, electrolyte and electronic conductor) may be affected by corrosion inhibitors in order to reduce corrosion. The inhibitor may cause:
Anodic inhibition (increasing the polarization of the anode)
Cathodic inhibition (increasing the polarization of the cathode)
Resistance inhibition (increasing the electrical resistance of the circuit while forming a thin or thick deposit on the surface of the metal)
Diffusion restriction (restricting the diffusion of depolarizers, e.g., DO).
However there are several factors to be considered when choosing an inhibitor.
Cost of the inhibitor.
Toxicity of the inhibitor can cause ill effects on human beings and other living species.
Availability of the inhibitor determines the selection of it.
Inhibitor should be environment friendly.
In order to avoid or reduce the corrosion of metallic materials, inhibitors used in cooling system must satisfy the following criteria
It must give good corrosion protection at a very low concentration of inhibitor.
It must protect all exposed materials from the attack of corrosion.
It must remain efficient in extreme operating conditions (higher temperature and velocity).
In case of an under or over dosage of inhibitor, corrosion rate should not increase drastically.
The inhibitor or reaction products of the inhibitor should not form any deposits on the metal surface particularly at locations where heat transfer takes place.
It should suppress both uniform and localized corrosion.
It should have long range effectiveness.
It should not cause toxicity and pollution problems.
One of the extensively studied topics in the field of corrosion is inhibition. Inhibition is a process of preventive measure against corrosive attack on metallic materials. Chemical compounds may be used which, when added in small concentrations to an aggressive environment, are able to decrease corrosion of the exposed metal [12].
\nCorrosion inhibitors can be any forms (solids, liquids and gases). Based on the solubility or dispersibility in fluids corrosion inhibitors are selected which are to be inhibited. Corrosion inhibitors have been found to be effective and flexible means of corrosion mitigation. The use of chemical inhibitors to decrease the rate of corrosion processes is quite variable. Corrosion inhibitors are used in oil and gas exploration and production, petroleum refineries, chemical manufacturing, heavy manufacturing, water treatment and product additive industries [29]. In the oil extraction, processing and chemical industries, corrosion inhibitors have always been considered to be the first line of defense. A great number of scientific studies have been devoted to the subject of corrosion inhibitors [30, 31].
\nOrganic and inorganic compounds constitute a large class of corrosion inhibitors, which as a general rule; affect the entire surface of a corroding metal when present in sufficient concentration. Most of the organic/inorganic compounds containing elements of groups V B, VI B or functional groups of the type amine, carbonyl and alcoholic groups are more effective corrosion inhibitors. The inhibitor is adsorbed on the entire metal surface of the corroding metal and so prevents attack from the corrosion. Organic inhibitors are adsorbed on the metals surface [32]. The inhibitors may be considered as two fundamental types, they are, those which form a protective barrier film on anodes or cathodes by reaction between the metal and the environment. This type of inhibitors function in neutral or in some cases, alkaline solution in which the main cathodic reaction is an oxygen reduction reaction in which the corroding metal surface is covered by a film oxide or hydroxide.
\nAnother type is initially adsorbed directly onto the metal surface by interaction between surface charges and ionic and/or molecular dipole charges. This division of inhibitor types results principally from the pH of the solution where they operate. Inhibitors must be present in a minimum concentration for them to be fully effective. This is very common with anodic inhibitors.
\nThe efficiency of organic inhibitors can be improved in the presence of certain halogen ions. Halogen ions are also known to inhibit corrosion to some extent in acid solutions. The efficiency of the corrosion inhibition is in the order; I- > Br- > Cl-. Fluoride does not show inhibition characteristics. Synergism of halogen ions can be attributed to the fact that the metal adsorbs halogen ions whose charge shifts the surface in a negative direction, thereby increasing adsorption of the cationic organic inhibitor. Being able to discover possible compounds that can be used as corrosion inhibitors requires a lot of hard work, innovation and laboratory analysis/synthesis [33].
\nCertain halogen ions present in the organic inhibitors are known to inhibit corrosion to some extent in acid solutions. The efficiency of the corrosion inhibition is following in the order of I− > Br− > Cl−. Fluoride does not shows any inhibition characteristics. Synergism of halogen ions can be attributed to the fact that the metal adsorbs halogen ions whose charge shifts the surface in a negative direction, thereby increasing adsorption of the cationic organic inhibitor.
\nCorrosion inhibitors are briefly classified (Figure 13) as follows,
\nClassification of corrosion inhibitors.
An anodic inhibitor increases the anodic polarization and hence moves the corrosion potential to the cathodic direction and hence also called as passivating inhibitors. Anodic inhibitors such as chromates, phosphates, tungstates and other ions of transition elements with high oxygen content are those that stifle the corrosion reaction occurring at the anode by forming a sparingly soluble compound with a newly produced metal ion. They are adsorbed on the metal surface forming a protective film or barrier, thereby reducing the corrosion rate. Anodic inhibitors build a thin protective film along the anode and increasing their potential and thus slow down the corrosion reaction [34].
\nAlthough, this type of control is affected, yet it may be dangerous since severe local attack can occur, if certain areas are left unprotected by depletion of the inhibitors. A number of inorganic inhibitors such as orthophosphates, silicates, etc. fall under anodic type. Even though anodic inhibitors are widely used, a few of them have some undesirable property. If such inhibitors are used in very low concentrations, they cause stimulation of corrosion such as pitting and for this reason anodic inhibitors are denoted as dangerous.
\nThere are two types of passivating inhibitors.
The oxidizing anions such as chromates, nitrites and nitrates that can passivate steel in the absence of oxygen.
The non-oxidizing ions such as phosphates, tungstates and molybdates that require the presence of oxygen to passivate steel.
In general, passivation inhibitors can actually cause pitting and accelerate corrosion when concentrations fall below minimum limits. For this reason, it is essential to monitor the inhibitor concentration.
\nCathodic inhibitors reduce corrosion by slowing the reduction reaction rate of the electrochemical corrosion cell. This is done by blocking the cathodic sites by precipitation. Cathodic inhibitors are effective when they slow down the cathodic reaction. Elements As, Bi and Sb are referred to as cathodic poisons which reduce the hydrogen reduction reaction rate and lower the overall corrosion rate. Removal of oxygen from the corrosive environment will significantly decrease the corrosion rate. This can be done through
The use of oxygen scavengers such as sodium sulfite and hydrazine which react with the oxygen and remove it from the solution
Vacuum de-aeration or
Boiling to lower the dissolved oxygen concentrations.
Cathodic inhibitors shift the corrosion potential to the anodic direction. [35, 36] Here the cations migrate towards the cathode surfaces where they are precipitated chemically or electrochemically and thus block these surfaces. The inhibiting action of cathodic inhibitors takes place by three mechanisms,
Cathodic poisons: The cathodic reduction process is suppressed by impeding the hydrogen recombination and mode of protection discharge but increase the tendency of the metal to be susceptible to hydrogen induced cracking.
Cathodic precipitates: Compounds such as calcium, magnesium will precipitate as oxides to form a protective layer which acts as a barrier on the metal surface.
Oxygen scavenger: These compounds react with oxygen present in the system to form a product and reduce corrosion. For example, As3+ and Sb3+ on dissolution of Fe in acids.
These inhibitors retard both the anodic and cathodic processes involved in the corrosion process and are therefore called mixed inhibitors [37]. They are typically film forming compounds that cause the formation of precipitates on the surface blocking both anodic and cathodic sites indirectly. Anodic inhibitors are, for the most part, dangerous inhibitors, especially if their concentrations are too less. But cathodic inhibitors are generally safe. Mixed inhibitors are less dangerous than pure anodic inhibitors, and in number of cases they may not increase the corrosion intensity. The most common inhibitors of this category are the silicates and the phosphates. Such inhibitors will have the more advantage that they control both the cathodic and anodic corrosion reactions.
\nThe compounds such as As2O3, Sb2O3 have been reported as inhibitors in acid media. In this case, the protection is due to the reduction of electro positive ions and deposition on the metal surface and lowering of the over voltage of main cathodic depolarization reaction [38]. Recently it is shown that the addition of heavy metal ions such as Pb2+, Ti+, Mn2+ and Cd2+ is found to inhibit corrosion of iron in acids.
\nOrganic compound containing oxygen, nitrogen, sulfur with multiple bonds have been reported as good corrosion inhibitors. Many organic inhibitors such as amines, aldehydes, alkaloids, nitro and nitroso compounds have been studied and tried as corrosion inhibitors [39]. Organic inhibitors can be anodic, cathodic and mixed type based on its reaction at the metal surface and potential. These are effective depending upon its size, carbon chain length, aromaticity, conjugation and nature of bonding atoms [40].
\nMetals, which form amphoteric oxides, are prone to corrosion in alkaline solutions. Many organic compounds are often used as inhibitors for metals in basic solutions [41]. Compounds such as thiourea, substituted phenols, naphthol, β-diketone, etc., have been used as effective inhibitors in basic solutions due to the formation of metal complexes.
\nInhibitors which are effective in acidic solutions do not function effectively in neutral solutions, since the mechanism is different in the two solutions [42, 43, 44]. In neutral solutions, the interaction of inhibitors with oxide covered metal surface and prevention of oxygen reduction reaction at the cathodic sites takes place. Such inhibitors protect the surface layers from aggressiveness. Some surface active chelating inhibitors have been found to be efficient inhibitors in near-neutral solutions [45].
\nSubstances which usually have a sufficiently high equilibrium potential (redox or electrode potential) and sufficiently low over potential decrease corrosion rate on attainment of passivity and are called chemical passivators [46].
\nExample, nitrites are used as inhibitors for antifreeze cooling waters. Chromates are mostly used as inhibitors for recirculating cooling waters. Zinc molybdate is used as an inhibiting pigment for paints.
\nThese represent the most widely used class of inhibitors. In general, they are organic compounds which get adsorbed on the metal surface and provide a blanketing effect over the entire surface, that is, both in cathodic and anodic cases. Generally they effect both cathodic and anodic reactions equally, but in many cases the effect may not be equal. These are commonly used in the acid pickling of hot rolled products in order to remove the black mill scale and are thus known as pickling inhibitors [47, 48, 49].
\nExamples: Compounds containing lone pairs of electrons such as nitrogen atoms in amines, quinolines, sulfur atoms in thio compounds and oxygen atoms in aldehydes.
\nIn contrast to the adsorption inhibitors which form the straight forward adsorbed film of the inhibiting species, many substances called film forming inhibitors, appear to stop corrosion by forming a blocking or a barrier film of a material other than the actual inhibiting species itself. Such materials tend to be specific either to the cathode or to the anode. Zinc and calcium salts are the most common examples of cathodic film forming inhibitors. Benzoate is the common example of anodic film forming inhibitors, which inhibit corrosion during voyages [50].
\nAtmospheric corrosion of metals in closed spaces as in parcels during storage and shipment can be prevented by the use of certain substances called vapor phase inhibitors also called as volatile inhibitors [51, 52, 53, 54, 55, 56]. These are substances of low but significant vapor pressure. The vapor comes in contact with the surface of the metal and the adsorption of the inhibitor takes place. The moisture then hydrolyses it and releases protective ions which have corrosion inhibiting properties. Figure 14 shows the schematic representation vapor phase inhibitors.
\nSchematic representation of vapor phase inhibitors.
Examples,
Dicyclohexylamine chromate and benzotriazole for protecting copper.
Phenyl thiourea and cyclohexylamine chromate for brass.
Dicyclohexylamine nitrite for ferrous and nonferrous part.
Volatile corrosion inhibitors (VCIs) are compounds which transferred in a closed environment to the site of corrosion by volatilization from a source (Figure 15). If the corrosion product is volatile, it volatilizes as soon as it is formed, thereby leaving the underlying metal surface exposed for further attack. This causes rapid and continuous corrosion leading to excessive corrosion. Example, Molybdenum oxide (MoO3), the oxidation corrosion product of molybdenum is volatile. In closed vapor process (shipping containers), volatile solids such as salts of dicyclohexylamine, cyclohexylamine and hexamethylene amine are used as volatile corrosion inhibitors [52].
\nSchematic representation of volatile inhibitors.
These are single inhibitor which is used in cooling water systems. More often, a combination of inhibitors (anodic and cathodic) is used to obtain better corrosion protection properties [56]. Examples include chromate-phosphates, polyphosphate-silicate, zinc-tannins, and zinc-phosphates.
\nThese are compounds that forms precipitates on the metal surface, thereby providing a protective film. The most common inhibitors of this category are the silicates and the phosphates. For example, Sodium silicate, is used in many domestic water softeners to prevent the occurrence of rust [57, 58].
\nThere is no clear and accepted definition of “environmentally friendly” or “green” corrosion inhibitors. In practice, corrosion inhibition studies have become oriented towards human health and safety considerations. For this purpose recently, the researchers have been focused on the use of eco-friendly compounds such as plant extracts, expired nontoxic medicines, etc. which contains many organic compounds [59, 60, 61]. Amino acids, alkaloids, pigments and tannins are used as green alternatives for the toxic and hazardous compounds. Due to biodegradability, eco-friendliness, low cost and easy availability and the extracts of some common plants and medicinal plant and its products have been studied as corrosion inhibitors for various metals and alloys under different environmental conditions.
\nThe mechanism of the inhibition process of the corrosion inhibitors under consideration is mainly due to the adsorption. The phenomenon of adsorption is influenced by the nature and surface charge of the metal and by chemical structure of inhibitors. The surface charge of the metal is due to the electrical field which emerges at the interface on immersion in the electrolyte [62, 63, 64].
\nInhibition usually results from one or more of the following mechanisms
Adsorption of corrosion inhibitors onto metals
The inhibitive performance is usually depends on the fraction of the surface covered, θ with adsorbed inhibitor. But, at low surface coverage (θ < 0.1), the effectiveness of adsorbed inhibitor species in retarding the corrosion reactions may be greater than at high surface coverage.
Presence of surface charge on the metal
Adsorption of inhibitor on the metal surface may be due to dipoles of the adsorbed species or electrostatic force of attraction between ionic charges and the electric charge on the metal at the metal/solution interface.
Effect of functional group and structure
Usually, when the metal contains vacant electron orbitals of low energy such as transition metals. Inhibitors can also bond to metal surfaces by electron transfer to the metal to form a coordinate type of bond. Electron transfer from the adsorbed species is favored by the presence of relatively loosely bound electrons. Example: Anions and neutral organic molecules containing lone pair of electrons or electron systems associated with multiple bonds especially triple bonds or aromatic rings. The electron density at the functional group is directly proportional to the inhibitive efficiency in a series of related compounds.
Inhibitor and water molecules interaction
Adsorbed water molecule are removed from the metal surface due to displacement reaction of adsorbed inhibitor molecules and increases the size of hydrocarbon part of inhibitor, which leads to decreasing solubility and increasing adsorption ability. This is consistent with the increasing inhibitive efficiency observed at constant concentrations with increasing molecular size in a series of related compounds.
Interaction between adsorbed inhibitor species
Lateral interactions between adsorbed inhibitor species may become significantly increases the surface coverage and the adsorbed species. These interactions either attractive or repulsive. If attractive interactions occur between molecules containing large hydrocarbon components (e.g., n-alkyl chains), may the chain length increases. Then the increasing Van der Waals attractive force between the adjacent molecules leads to stronger adsorption at high coverage.
Adsorbed inhibitors reaction
The adsorbed corrosion inhibitor may react usually by chemical or electrochemical reduction to form a product that may exhibit inhibitive action. A process of added small quantity of substance is called as primary inhibition and that due to the reaction product is secondary inhibition. In these cases, the inhibitive efficiency may increase or decrease with time, it depends on the extent of secondary inhibition is more effective than the primary inhibition. For example, sulfoxides can be reduced to sulfides which are more efficient inhibitors.
Diffusion barrier formation
The absorbed inhibitor molecules may form a surface layer that acts as a physical barrier to the diffusion of ions or molecules and to or from the metal surface, and hence retard the rate of corrosion reactions. A surface film of these types of inhibitors affects both anodic and cathodic reactions.
Blocking of reaction sites
The blocking decreases the number of metal atoms at which corrosion reactions can occur. During this, mechanisms of the reactions are not affected, and the Tafel slopes of the polarization curves remain unaffected [65].
Electrode reactions
Corrosion reactions involve the formation of adsorbed intermediate molecules with surface metal atoms. The adsorbed inhibitors will forbid the formation of these adsorbed intermediates, but the electrode processes may proceed by alternative paths through intermediates containing the inhibitor. In this process, the inhibitor act as catalyst and remain unchanged. Such reactions of inhibitor are characterized by an increase in the Tafel slope of the anodic dissolution of the metal. Inhibitors may also retard the rate of hydrogen evolution on the metals by affecting the mechanism of the reaction [66]. This effect has been observed on iron in the presence of inhibitors such as phenylthiourea, aniline derivatives, benzaldehyde derivatives and pyridinium salts [67].
Electrical double layer alteration
The adsorption of ions or species that can form ions on metal surfaces will change the electrical double layer at the metal/solution interface, and this will affect the rates of the electrochemical reactions [68]. The adsorption of cations such as quaternary ammonium ions and protonated amines makes the potential more positive in the plane of the closest approach to the metal ions from the solution. This positive potential shift hinders the discharge of the positively charged hydrogen ions. These effects have been observed with sulfosalicylate ions and the benzoate ions [69, 70].
\n
Corrosion is a natural process which reduces the binding energy in metals and degrades the useful properties of materials.
The end result of corrosion involves a metal atom being oxidized, whereby it loses one or more electrons.
The corrosion manifests itself as a break-up of bulk metal to metal powder. Corrosion.
Corrosion inhibitors are a great effective method of preventing corrosion.
The knowledge of the method of the action, facilitates the choice of the inhibitors, improves efficiency, avoids the process is impaired and side effects.
It is important in the choice of inhibitor whatever may be the method, ascertain the subsequent effects of this towards the environment.
The environmental friendly inhibitors have shown excellent results, outperforming conventional inhibitors.
Faecal incontinence (FI) may be defined as an impaired ability of the control of the release of flatus or faeces. It is a socially stigmatising condition that may have an adverse effect on one’s quality of life. From the financial point of view, the investigation and treatment of faecal incontinence may add to a significant cost to the health systems of most countries. In fact, the annual treatment cost of patients in the UK with urinary and faecal incontinence is of about £500 million.
Many factors may be involved in the pathophysiology of FI. A thorough clinical assessment of the patient is therefore mandatory. This starts with a full history, which may include a cognitive assessment if necessary. The characteristics of the faeces and the type and frequency of incontinence should be noted. Urge incontinence is suggestive of poor external anal sphincter (EAS) function, whilst passive and post-defaecatory incontinence indicates that internal anal sphincter (IAS) function is weak. Various questionnaires that enable the clinician to quantify the degree of incontinence and the impact on quality of life are available. These include symptom-specific questionnaires, such as the ones developed by Vaizey et al. [1] and Wexner et al. [2] and the faecal incontinence quality of life (FIQOL) scale developed by Rockwood et al. [3], and also generic questionnaires such as the Short Form 36 (SF 36) [4].
A full examination of the patient, including the abdomen and perineum and a neurological examination in some cases, is necessary. Beneficial investigations include a flexible sigmoidoscopy, anal manometry (resting and squeeze pressure), rectal compliance, pudendal nerve terminal motor latency (PNTML) and endoanal ultrasound (EAUS). Clinicians, however, need to be able to determine which test to perform, and when, as well as be able to correctly interpret the results.
The management of FI is complex and multidisciplinary, involving the general practitioner, continence nurse, physiotherapist, gastroenterologist, urologist and colorectal surgeon. Conservative measures, which include patient education and support, improvement in diet and bowel habit, judicious use of anti-diarrhoeal medication and pelvic floor exercises, are used in the first instance. This is, in fact, recommended in the UK by the National Institute for Clinical Excellence (NICE) guideline ‘CG49 Faecal Incontinence’ [5]. If these measures fail, surgical intervention may be necessary. A variety of surgical options are available, with the appropriate therapy being selected depending on the cause of the incontinence and the patient’s cognitive function and general physical condition (Table 1). One of the surgical options available is the use of anal bulking agents.
|
Surgical options in the management of faecal incontinence.
Anal bulking agents have emerged as a treatment for FI, following the success of bulking agents for urinary stress incontinence in females. In the urology setting, bulking agents have been employed to augment the bladder neck and increase urethral resistance [6]. Therefore, the aim of anal bulking agents is to prevent FI by closing the anal canal or increasing the pressure within the anal sphincter.
The ideal characteristics of a bulking agent have been described in the literature [7]. The injected or implanted substance should be biocompatible, non-migratory, non-allergenic and noncarcinogenic. The substance should also be easy to inject or implant and should produce an improvement in continence, both in the short term and in the long term.
Anal injectables and implantables have been used to manage faecal incontinence for over 20 years. It may be useful to chart their development over the years and to classify this development into three phases. The first phase consists of the initial experimental studies that took place in the 1990s. The second phase, from about the year 2000 onwards, encompasses an increase in the number of studies using a wide variety of agents and injection techniques. The third phase features the latest generation of anal bulking agents, the implantable polyacrylonitrile, available as Gatekeeper (GK) and Sphinkeeper (SK) devices.
Anal bulking agents were first described in 1993 by Shafik [8]. Shafik, an Egyptian surgeon, is considered to be a pioneer in this field. In his first study, he described the outcomes following the injection of 5 ml of PTFE (polytef/Teflon) paste in 11 patients, 7 of whom had incontinence following a lateral internal sphincterotomy for anal fissure. In another study, the same author used 60 ml of abdominal wall fat as a submucosal injection into the rectal neck at 3 and 9 o’clock in 14 patients with partial faecal incontinence [9]. Pescatori’s group from Rome, Italy, reported the use of anal injection of autologous buttock fat to restore continence in one patient who had poor results following a sphincteroplasty. This patient’s continence improved following repeated injections [10].
The indications for injection of the anal bulking agents in these studies were various. Most patients had passive FI, but some had urge incontinence, indicating EAS disruption. The results of these initial studies showed that continence was improved in the short term. However, the medium- and long-term results were poor, probably because of the resorption or migration of the injected material. Reinjection was necessary in order to maintain continence.
A number of safety issues were raised with these studies. Teflon could potentially cause granuloma formation and sarcomas. The injection of autologous fat as a bulking agent in urology has been implicated in fatal fat embolism and stroke.
The second phase in the development of anal bulking agents consisted of a wide variation in the types of materials used, surgical technique and clinical indications [11]. Some of the materials used to bulk the anal sphincter were being used in urology to augment the bladder neck. Nine different types of injectable bulking agents have been used in these studies (Table 2).
Type of bulking agent | Commercial name(s) | Injection site | Injection route | Published studies | No. of patients |
---|---|---|---|---|---|
Silicone biomaterial. Polydimethylsiloxane elastomer particles suspended in a biocompatible hydrogel made of poly-N-vinyl-pyrrolidone | PTQ; Bioplastique | Intersphincteric; within IAS | Transsphincteric | 21 | 619 |
Carbon-coated zirconium beads, comprised of pyrolytic carbon-coated beads suspended in a water-based carrier gel containing β-glucan | Durasphere | Submucosal | Transmucosal; transsphincteric | 7 | 187 |
Spherical particles of calcium hydroxylapatite, suspended in a gel | Coaptite | Submucosal | Transsphincteric | 1 | 10 |
Dextranomer microspheres and stabilised sodium hyaluronate in phosphate-buffered 0.9% sodium chloride solution | NASHA Dx, Zuidex, Solesta | Submucosal | Transmucosal | 5 | 192 |
Glutaraldehyde cross-linked collagen | Contigen | Submucosal | Transmucosal | 2 | 90 |
Synthetic non-particulate hydrogel consisting of water (97.5%) and cross-linked polyacrylamide (2.5%) | Bulkamid | Intersphincteric | Intersphincteric | 1 | 5 |
Cross-linked porcine dermal collagen matrix | Permacol | Submucosal; intersphincteric | Transmucosal; intersphincteric | 5 | 172 |
8% ethylene vinyl alcohol copolymer dissolved in dimethyl sulfoxide. A spongy solid mass forms from the solidification of the hydrophobic copolymer when the solvent diffuses away on contact with tissue fluid | Onyx34 | Intersphincteric | Intersphincteric | 1 | 21 |
Expandable silicone microballoons filled with a biocompatible hydrogel made of poly-N-vinyl-pyrrolidone | Submucosal | Transmucosal | 1 | 6 |
Injectable materials used in the second phase of studies.
The clinical indications for which these bulking agents were used varied from study to study. These were:
Failure of conservative management of faecal incontinence.
Structurally intact but weak internal anal sphincter. This would be due to either primary idiopathic degeneration of the IAS or degeneration secondary to tissue disorders such as scleroderma.
IAS damage (childbirth, haemorrhoidectomy, anal stretch, sphincterotomy) (Figure 1).
Defect in the external anal sphincter.
Endoanal ultrasound scan showing a defect in the IAS of a 57-year-old lady with passive faecal incontinence following haemorrhoidectomy. The defect is present between the arrows from the 3 to the 5 o’clock positions.
The main indication was IAS dysfunction or disruption. Unlike the EAS, the IAS is not amenable to surgical repair.
The bulking agents may be inserted under local, regional (anal or pudendal nerve block) or general anaesthesia. The type of anaesthesia used depends on the preference of the patient and the surgeon. The patient may be positioned in the prone (jackknife), lithotomy or left lateral positions, although the latter position may not give a satisfactory view of the anorectum to enable accurate injection. A phosphate enema is usually administered preoperatively. The procedure is usually covered by prophylactic antibiotics, such as intravenous (IV) co-amoxiclav 1.2 g, cefuroxime 750 mg and metronidazole 500 mg or gentamicin 1.5 mg/kg and metronidazole 500 mg at induction.
The injection of the bulking agent varies depending on the type of substance used and the clinical indications. Three different routes of needle insertion were mentioned in the literature: transmucosal, transsphincteric or intersphincteric. The bulking agent was placed submucosally, within the intersphincteric space or within the IAS itself. For example, porcine dermal collagen (Permacol) may be injected via the transmucosal or transsphincteric route using a disposable 19G needle [12] (Figure 2). In patients with an intact IAS, 2.5 ml of Permacol is equally injected into the submucosal space at the 3, 7 and 11 o’clock positions above the dentate line. In cases of an IAS defect, 5 ml of Permacol may be injected at the site of the defect, with 2.5 ml of the substance injected diametrically opposite. With silicone biomaterial (PTQ or Bioplastique), four doses of 2.5 ml of silicone are used, using an 18G needle [13, 14]. Patients with an intact IAS have the silicone injected transsphincterically into the intersphincteric space at the 2, 4, 8 and 10 o’clock positions. In patients with an IAS defect, for example, after a lateral internal sphincterotomy, a total of three doses of 2.5 ml of silicone are injected into the defect. A fourth dose is injected into the intersphincteric space contralateral to the IAS defect, to provide symmetry. With carbon-coated beads (Durasphere), a total of 10 ml is injected in four divided doses in the submucosal plane using an 18G needle [14].
Porcine dermal collagen (Permacol) in a 2.5 ml syringe.
It is of utmost importance to ensure that the anal mucosa is not breached during injection, since that would allow intra-anal leakage of the substance. Intravascular injection must also be avoided.
Once the injection is completed, it is a good practice to leave the needle and syringe in place for a few seconds. As the needle is being withdrawn, pressure on the needle track by the index finger may prevent leakage of the bulking agent [12].
The bulking agent may be injected freehand, with an anal retractor such as Eisenhammer used to identify the IAS and intersphincteric groove. A finger placed within the anal canal may be useful to guide the needle to its correct position. However endoanal ultrasound has been recommended to guide the needle to an optimum position [13], especially if the agent is to be injected into the intersphincteric space or adjacent to a defect in the IAS.
The majority of studies in this second phase of development were mainly case series and observational studies. Most of these studies reported either an improvement in the faecal continence scores or less frequent episodes of incontinence over time. Anorectal manometry testing is featured in some studies, with some showing an improvement in resting or squeeze pressures. Others studies showed no such improvement. Clinical improvement was not always associated with an increase in these pressures. Quality of life was formally assessed in some of these studies. The majority reported an improvement across various domains such as physical and social function.
To date there have been 6 randomised trials using anal bulking agents, with more than 400 patients. Two trials compared a bulking agent with a sham or saline injection. Siproudhis et al. in 2007 [15] compared a silicone biomaterial (PTQ) with a normal saline injection (control) into the intersphincteric space. PTQ did not demonstrate any appreciable clinical benefit when compared to the control. The trial was however deemed to be too small to detect any differences in continence. Graf et al. in 2011 [16] compared the injection of dextranomer (NASHA Dx) against sham injection (no substance injected). Continence was better in the short term (6 months) in the active intervention group, although interestingly about 30% of patients in the control group had an improvement in their continence. This same group, the NASHA Dx study group, published the results of a prospective multicentre trial in 2014, showing that ‘submucosal injection of NASHA Dx provided a significant improvement of FI symptoms in a majority of patients and this effect was stable during the course of the follow-up and maintained for 3 years’.
A small study with 10 patients by Maeda et al. in 2008 [17] revealed significant improvement at 6 weeks postinjection using injection of Bulkamid and Permacol. Continence decreased slightly in the Permacol group at 6 months. However there was no reported difference between the two agents. The numbers were too small to detect a difference. Tjandra et al. in 2009 reported the results of a randomised study comparing PTQ with carbon-coated beads (Durasphere) [14]. PTQ injection was associated with better continence scores and quality of life and was safer than Durasphere.
Tjandra et al. in 2004 reported the short-term benefits from ultrasound-guided injection of silicone biomaterial (PTQ) compared with digital guidance [13].
The follow-up for the majority of patients in studies was less than a median of 3 years. A question on the term durability and effectiveness of these agents is therefore raised. The majority (97%) of patients were only followed up once or twice. No long-term evidence on outcomes was available, and further conclusions were not warranted from the available data. None of the studies reported patient evaluation of outcomes, and thus it is difficult to gauge whether the improvement in the continence scores matched the practical symptom and quality of life improvements that mattered to the patients.
The majority of patients did not report any complications. The complications described were mainly pain, anal bruising and leakage of injected material [11, 12]. Less common complications were anal ulceration and infection (local cellulitis and abscess formation). There were two reported cases of local giant cell foreign body reaction after injection of silicone (PTQ) [18]. Durasphere has been associated with skin rashes and arthritis. Skin patch testing is therefore recommended before using this agent [14].
A relatively new and innovative development in anal bulking technology is the Gatekeeper and Sphinkeeper (THD S.p.A., Correggio, Italy). The material used is polyacrylonitrile (Hyexpan). Polyacrylonitrile is an inert, non-allergenic, nondegradable material that is also non-immunogenic and noncarcinogenic. First developed by Medtronic in Minneapolis, USA, it was originally used as an implant in the oesophagogastric junction for the management of gastro-oesophageal reflux disease.
The main indications for the use of the GK and SK are passive faecal incontinence, secondary to IAS dysfunction or damage, where conservative measures or injection of other bulking agents such as PTQ or Permacol has failed. However, the use of GK and SK in patients with other causes of FI is being explored.
The following are contraindications to the use of the GK and SK. Similar contraindications have also been described by the product manufacturers of other anal bulking agents:
Perianal sepsis
Inflammatory bowel diseases with anorectal involvement (Crohn’s disease, ulcerative colitis)
Anal, rectal or colon cancer undergoing active treatment
Rectal bleeding of unknown or undiagnosed origin
Rectal prolapse
Uncontrolled blood coagulation disorders
Pelvic radiotherapy
Immunosuppression
Pregnancy or planned pregnancy in the next 12 months.
Whereas the anal bulking agents that were developed in phases 1 and 2 are injected into or around the anal canal by means of a hypodermic syringe, the Hyexpan prostheses are implanted into the intersphincteric space using a custom-made gun (Figure 3).
The gatekeeper gun, made of the dispenser that houses one prosthesis and the delivery system. The Sphinkeeper delivery system and dispenser are similar but slightly larger.
The difference between GK and SK lies in the size of the prostheses. The dehydrated GK prostheses consist of thin solid cylinders, 22 mm long and 2 mm in diameter. The success of this material depends on its hydrophilic properties. Within 48 hours after implantation in the human tissue, the Hyexpan cylinders absorb water to become thicker and shorter. The in vitro maximum diameter is 6.5 mm and the length is 17 mm (Figure 4). The volume of each individual implant increases from approximately 70 mm3 to 500 mm3, a 750% increase. The implant also becomes much softer in consistency. On the other hand, the SK prostheses in the dehydrated state are thin, solid cylinders, 29 mm long with a diameter of 3 mm, changing their size to a length of 23 mm and a diameter of 7 mm within 48 h of contact with fluids.
(a) Shape of Hyexpan gatekeeper cylinder at insertion. (b) Fully expanded Hyexpan gatekeeper cylinder following contact with water.
The technique of implantation of the GK and SK is identical. The operation is performed under regional or general anaesthesia. Intravenous antibiotics are given at induction. The author’s patients receive gentamicin 1.5 mg/kg and metronidazole 500 mg IV. The patient is placed in the lithotomy position. A strict sterile technique is used. The IAS and intersphincteric groove are identified by the placement of an anal retractor (e.g. Eisenhammer). The author’s preference is a THD surgy Mini-light proctoscope, a self-illuminating anal and rectal retractor that gives a very good view of the anorectum without causing trauma to the anal sphincter (Figure 5). A 2 mm incision is made in the perianal skin, 2 cm from the anal verge (Figure 6).
Palpating the IAS and the intersphincteric groove at the 6 o’clock position with a THD surgy mini-light proctoscope in position.
Making an incision, 2 cm away from the anal verge, at the 6 o’clock position.
Having attached the dispenser to the delivery system, the needle is inserted through the incision and tunnelled to the intersphincteric margin and introduced into the intersphincteric space. The needle is then positioned so that the tip would lie just beyond the dentate line. When the needle is identified in the correct position, by direct vision and palpation and/or by endoanal ultrasound, the prosthesis is released into the intersphincteric space (Figure 7).
The gatekeeper needle at the 9 o’clock position, with the endoanal ultrasound probe in place to determine correct placement.
The steps may be repeated to insert up to 10 prostheses, equidistant from each other. The GK has been originally described with the insertion of between 4 and 6 prostheses, whereas the SK has been described with the use of 10 prostheses. The choice of inserting 4 as opposed to 6 or 10 prostheses is arbitrary. The use of 10 prostheses enables the formation of a circumferential or quasi-circumferential intersphincteric ring, akin to an artificial anal sphincter. The prostheses self-fix in the desired position, thereby preventing displacement and migration in the majority of cases.
The wounds are closed with a single absorbable suture (Figure 8). At the end of procedure, EAUS imaging will show the location of all prostheses. The procedure takes about 30 to 40 minutes to complete and is done as a day case. Oral metronidazole 400 mg tds is prescribed for 5 days postoperatively. Oral laxatives such as lactulose are prescribed to minimise the risk of constipation. The patients are advised to avoid any anal trauma as well as anal intercourse for at least 72 h after implant insertion. The patients are followed up after 6 weeks and 3 months thereafter. The material remains identifiable both by palpation and by endoanal ultrasonography in the postoperative period (Figures 9 and 10).
Up to 10 equidistant circumferential perianal wounds, each closed with an absorbable suture (Monocryl 3/0).
Endoanal ultrasound scan (Aloka) at 6 weeks following the implantation of six gatekeeper prostheses in a 72-year-old male with idiopathic passive faecal incontinence.
Endoanal ultrasound scan (B&K) at 6 weeks following the implantation of 10 Sphinkeeper prostheses in a 68-year-old female with passive faecal incontinence and previous episiotomy.
The first reported experience with the Gatekeeper was by Ratto et al. in 2011 [19]. This was a study with 14 patients. Eight had idiopathic FI, four had an IAS defect, and two had combined IAS and EAS defects. The median follow-up was of 12 months (ranging from 5 to 48 months). The authors reported a clinically significant improvement in continence in 13 patients, a sustained significant improvement in the Wexner and Vaizey scores and in the SF36 and FIQOL scores. No complications have been reported.
The second study was a comparative retrospective study by Parello et al. in 2012 [20]. Seven patients who had the Gatekeeper implanted were compared to six patients who underwent sacral nerve stimulation. The median follow-up was of 18 months in the Gatekeeper group and 20 months in the SNS group. The authors reported a sustained improvement in the Wexner continence scores with both modalities of treatment.
Fabiani et al. [21] used Gatekeeper for a group of patients affected by minor faecal incontinence. Four out of seven patients complained of passive incontinence prior to the procedure. After an average follow-up of 6 months, 6 patients reported a Wexner incontinence score under the value of 4, meaning that they rarely experienced symptoms (0 = perfect incontinence and 20 = complete incontinence). Only one patient who suffered mixed incontinence failed to respond.
Biondo et al. [22] concluded that Gatekeeper is a safe and effective procedure in more than 50% of patients for at least a year after implantation. They found that no patients had postoperative or long-term complications. Forty-eight per cent of patients were classed as responders, and significant differences were found between baseline mean Vaizey scores at 6 months, 12 months and last follow-up. At long-term follow-up (2.7 years), those patients that responded were found to have maintained an improvement more than 50% of their baseline Vaizey score.
In a multicentre study involving 54 patients and a clinical follow-up for a year, Ratto et al. [23] noted that after Gatekeeper implantation, incontinence to gas, liquid and solid stool improved significantly, soiling was reduced and the ability to defer defaecation was enhanced. All faecal incontinence severity scores were significantly reduced, and patients’ quality of life improved. At 12 months, 30 patients (56 per cent) showed at least 75 per cent improvement in all faecal incontinence parameters, and 7 (13 per cent) became fully continent. Dislodgement of a few prostheses was reported, but this made no difference to postoperative continence.
The author has carried out more than 40 GK procedures in a single centre since 2012. The main indications were idiopathic FI and passive incontinence following surgery (anal stretch for anal fissure and haemorrhoidectomy). All patients had failed conservative management. There was a significant sustained improvement in the median Vaizey scores. The median (range) Vaizey scores improved from 16 (12–17) preoperatively to 5 (3–9), 4 (3–7), 4 (3–5), 4 (3–5), 5 (3–6) and 5 (3–6) at 6 weeks and at 3, 6, 12, 24 and 36 months, respectively (p < 0.01, Wilcoxon test). There was also an improvement in the Rockwood quality of life scores. The author reports no complications apart from minor pain that is managed by paracetamol.
Publications on the Sphinkeeper are limited. Ratto et al. [24] treated 10 patients with SK and followed them up for 3 months. The study demonstrated that the SK, with its larger prostheses than that of GK, is safe and effective. The Pelvic Floor Society of the Association of Coloproctology of Great Britain and Ireland is currently collecting prospective data on the SK from multiple centres in the UK.
The development of anal injectable and implantable technology over the past 20 years has taken great strides forwards. Starting with the pioneering efforts of Shafik with autologous fat, more materials have been tried and used, the most popular being collagen (Permacol) and silicone (PTQ or Bioplastique). These agents were associated with variable and inconsistent results. Injections were frequently repeated to maintain continence in the long term. The latest generation of anal bulking agents is the implantable Hyexpan (Gatekeeper and Sphinkeeper). This material fits the criteria for the ‘ideal’ bulking agent. It overcomes most limitations of other bulking agents, and its use has shown very promising results.
The choice to implant the GK and SK prostheses into the intersphincteric space of the anal canal plays a key role. This location potentially avoids extrusion or migration of prostheses (different to what could happen if implanted into the submucosa). Moreover, thanks to the rapid increase of their volume, the prostheses self-fix and are unlikely to move after deployment.
The mechanism of action of anal bulking agents is a subject of debate. Most of the resting anal pressure is the function of the IAS, with some contribution from the EAS and anal cushions. Studies of faecal incontinence in patients who have undergone a traditional Milligan-Morgan haemorrhoidectomy lend support to the concept that anal cushions play an important part in the maintenance of the normal mechanism of continence. It is thought that the mechanism of action of a bulking agent injected into the submucosal space is an increase in the size of the natural anal cushions. On the other hand, a bulking agent injected or implanted into the intersphincteric space would bulk up the size of the anal sphincter. The end result would be an improvement in the seal of the lumen of the anal canal at rest and potentially an increase in resting anal pressure and in the length of the anal high pressure zone. When the injection is placed adjacent to an identifiable IAS defect, a better degree of anal canal sealing may be obtained through improvement in the configuration and symmetry of the anal canal [7]. Ratto argues that GK and SK, being embedded within the intersphincteric space, thereby pushing the EAS outwards and the IAS inwards, ‘may improve sphincter contractility by increasing sarcomere length as well as increase the length of the anal canal and provide a powerful “bulking effect”’ [24].
It is acknowledged that more research is required in this field. Most studies are case series with very few randomised trials. The Gatekeeper and Sphinkeeper, the latest generation of anal bulking agents, show promising results. Whether these results are maintained in the longer term or not awaits to be seen. The key factor however remains that correct patient selection is extremely important to achieve good results.
Larger series with longer follow-up and randomised controlled trials are therefore necessary. Further development on existing and emerging technology is also warranted.
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",metaTitle:"Copyright Policy",metaDescription:"Copyright is the term used to describe the rights related to the publication and distribution of original works. Most importantly from a publisher's perspective, copyright governs how authors, publishers and the general public can use, publish and distribute publications.",metaKeywords:null,canonicalURL:"/page/copyright-policy",contentRaw:'[{"type":"htmlEditorComponent","content":"Copyright is the term used to describe the rights related to the publication and distribution of original Works. Most importantly from a publisher's perspective, copyright governs how Authors, publishers and the general public can use, publish, and distribute publications.
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\\n"}]'},components:[{type:"htmlEditorComponent",content:'Copyright is the term used to describe the rights related to the publication and distribution of original Works. Most importantly from a publisher's perspective, copyright governs how Authors, publishers and the general public can use, publish, and distribute publications.
\n\nIntechOpen only publishes manuscripts for which it has publishing rights. This is governed by a publication agreement between the Author and IntechOpen. This agreement is accepted by the Author when the manuscript is submitted and deals with both the rights of the publisher and Author, as well as any obligations concerning a particular manuscript. However, in accepting this agreement, Authors continue to retain significant rights to use and share their publications.
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