Commercially available covered esophageal stents
\r\n\tIn the book the theory and practice of microwave heating are discussed. The intended scope covers the results of recent research related to the generation, transmission and reception of microwave energy, its application in the field of organic and inorganic chemistry, physics of plasma processes, industrial microwave drying and sintering, as well as in medicine for therapeutic effects on internal organs and tissues of the human body and microbiology. Both theoretical and experimental studies are anticipated.
\r\n\r\n\tThe book aims to be of interest not only for specialists in the field of theory and practice of microwave heating but also for readers of non-specialists in the field of microwave technology and those who want to study in general terms the problem of interaction of the electromagnetic field with objects of living and nonliving nature.
",isbn:"978-1-83968-227-8",printIsbn:"978-1-83968-226-1",pdfIsbn:"978-1-83968-228-5",doi:null,price:0,priceEur:0,priceUsd:0,slug:null,numberOfPages:0,isOpenForSubmission:!1,hash:"8f6a41e4f5ce0e9c48628516d7c92050",bookSignature:"Prof. Gennadiy Churyumov",publishedDate:null,coverURL:"https://cdn.intechopen.com/books/images_new/10089.jpg",keywords:"Electromagnetic Wave, Microwave Energy Application, Electromagnetic Energy Generation, Intelligent Microwave Heating, Microwave Organic Chemistry, Microwave Reactor, Microwave Discharge, Microwave Plasma, Microwave Drying System, Tissue Microwave Heating, Measurement Automation, Industrial Microwave Process",numberOfDownloads:224,numberOfWosCitations:0,numberOfCrossrefCitations:0,numberOfDimensionsCitations:0,numberOfTotalCitations:0,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"July 3rd 2020",dateEndSecondStepPublish:"July 24th 2020",dateEndThirdStepPublish:"September 22nd 2020",dateEndFourthStepPublish:"December 11th 2020",dateEndFifthStepPublish:"February 9th 2021",remainingDaysToSecondStep:"7 months",secondStepPassed:!0,currentStepOfPublishingProcess:5,editedByType:null,kuFlag:!1,biosketch:"Prof. Gennadiy I. Churyumov is a professor at two universities: Kharkiv National University of Radio Electronics, and Harbin Institute of Technology and a senior IEEE member.",coeditorOneBiosketch:null,coeditorTwoBiosketch:null,coeditorThreeBiosketch:null,coeditorFourBiosketch:null,coeditorFiveBiosketch:null,editors:[{id:"216155",title:"Prof.",name:"Gennadiy",middleName:null,surname:"Churyumov",slug:"gennadiy-churyumov",fullName:"Gennadiy Churyumov",profilePictureURL:"https://mts.intechopen.com/storage/users/216155/images/system/216155.jfif",biography:"Gennadiy I. Churyumov (M’96–SM’00) received the Dipl.-Ing. degree in Electronics Engineering and his Ph.D. degree from the Kharkiv Institute of Radio Electronics, Kharkiv, Ukraine, in 1974 and 1981, respectively, as well as the D.Sc. degree from the Institute of Radio Physics and Electronics, National Academy of Sciences of Ukraine, Kharkiv, Ukraine, in 1997. \n\nHe is a professor at two universities: Kharkiv National University of Radio Electronics, and Harbin Institute of Technology. \n\nHe is currently the Head of a Microwave & Optoelectronics Lab at the Department of Electronics Engineering at the Kharkiv National University of Radio Electronics. \n\nHis general research interests lie in the area of 2-D and 3-D computer modeling of electron-wave processes in vacuum tubes (magnetrons and TWTs), simulation techniques of electromagnetic problems and nonlinear phenomena, as well as high-power microwaves, including electromagnetic compatibility and survivability. \n\nHis current activity concentrates on the practical aspects of the application of microwave technologies.",institutionString:"Kharkiv National University of Radio Electronics (NURE)",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"2",totalChapterViews:"0",totalEditedBooks:"0",institution:null}],coeditorOne:null,coeditorTwo:null,coeditorThree:null,coeditorFour:null,coeditorFive:null,topics:[{id:"24",title:"Technology",slug:"technology"}],chapters:[{id:"74623",title:"Influence of the Microwaves on the Sol-Gel Syntheses and on the Properties of the Resulting Oxide Nanostructures",slug:"influence-of-the-microwaves-on-the-sol-gel-syntheses-and-on-the-properties-of-the-resulting-oxide-na",totalDownloads:94,totalCrossrefCites:0,authors:[null]},{id:"75284",title:"Microwave-Assisted Extraction of Bioactive Compounds (Review)",slug:"microwave-assisted-extraction-of-bioactive-compounds-review",totalDownloads:12,totalCrossrefCites:0,authors:[null]},{id:"75087",title:"Experimental Investigation on the Effect of Microwave Heating on Rock Cracking and Their Mechanical Properties",slug:"experimental-investigation-on-the-effect-of-microwave-heating-on-rock-cracking-and-their-mechanical-",totalDownloads:28,totalCrossrefCites:0,authors:[null]},{id:"74338",title:"Microwave Synthesized Functional Dyes",slug:"microwave-synthesized-functional-dyes",totalDownloads:21,totalCrossrefCites:0,authors:[null]},{id:"74744",title:"Doping of Semiconductors at Nanoscale with Microwave Heating (Overview)",slug:"doping-of-semiconductors-at-nanoscale-with-microwave-heating-overview",totalDownloads:45,totalCrossrefCites:0,authors:[null]},{id:"74664",title:"Microwave-Assisted Solid Extraction from Natural Matrices",slug:"microwave-assisted-solid-extraction-from-natural-matrices",totalDownloads:25,totalCrossrefCites:0,authors:[null]}],productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"},personalPublishingAssistant:{id:"252211",firstName:"Sara",lastName:"Debeuc",middleName:null,title:"Ms.",imageUrl:"https://mts.intechopen.com/storage/users/252211/images/7239_n.png",email:"sara.d@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, copyediting 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:"6826",title:"The Use of Technology in Sport",subtitle:"Emerging Challenges",isOpenForSubmission:!1,hash:"f17a3f9401ebfd1c9957c1b8f21c245b",slug:"the-use-of-technology-in-sport-emerging-challenges",bookSignature:"Daniel Almeida Marinho and Henrique Pereira Neiva",coverURL:"https://cdn.intechopen.com/books/images_new/6826.jpg",editedByType:"Edited by",editors:[{id:"177359",title:"Dr.",name:"Daniel Almeida",surname:"Marinho",slug:"daniel-almeida-marinho",fullName:"Daniel Almeida Marinho"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"8494",title:"Gyroscopes",subtitle:"Principles and 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by",editors:[{id:"4782",title:"Prof.",name:"Bishnu",surname:"Pal",slug:"bishnu-pal",fullName:"Bishnu Pal"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}}]},chapter:{item:{type:"chapter",id:"43563",title:"The Current Role of Endoscopic Stenting in Upper Gastrointestinal Surgery",doi:"10.5772/52631",slug:"the-current-role-of-endoscopic-stenting-in-upper-gastrointestinal-surgery",body:'\nStenting is well established in the non-operative management of many sites, including, vascular system, biliary tree and tracheobronchial tree. Within the upper gastrointestinal tract, stenting is most frequently employed in oesophagus, but currently the role of stenting in stomach and duodenal has widely gained acceptance.
\nThe first stent widely used in the esophagus was constructed from silicon rubber tube (Silastic, Dow Corning. Midland, MI). In 1959, Celestine described the use of plastic endoprosthesis introduced through laparotomy via an open gastrostomy to palliate the esophageal stricture but it was associated with high complication as high as 45%.[1] In 1970s, Atkinson introduced an endoscopically placed plastic endoprosthesis[2], which became popular over the years as it is associated with fewer complications despite smaller internal diameter. (Figure 1)\n
\nHowever, the invention of the self- expanding metal stent (SEMS) (Figure 2) marked the new era of modern esophageal stenting as it is associated with higher success rate, fewer complications and ease of insertion. The first description of the endoscopic placement of an expanding metallic spiral stent was made by Frimberger in 1983.[3] There are currently at least eight different types of metallic stent on the market, covered and uncovered, some of which have anti-reflux valves.
\nThe use of endoscopic stent has an increasing role in upper gastrointestinal tract diseases as it offers immediate relief of obstruction and immediate coverage for anastomotic leak in a minimally invasive approach. Recently various self-expanding metal or plastic stents have been developed for palliation of malignant obstruction of the gastrointestinal tracts. The major impact of these newer stents relates to the ease of insertion due to smaller delivery system with fewer complications and self –expandable property. However, the physician‘s perception of ease of placement has major influence in choosing the type of stent to be used.[4]
\nA Plastic stent which is successfully place endoscopically through the esophageal cancer
A retrievable self-expanding metallic stent
This review mainly focuses on the current status of self-expanding stent placement in esophageal and gastric disease, as well as considering the suitable candidate, side-effect, potential complications in relation to our experience of endoscopic stenting in various upper gastrointestinal tract disease, particularly in the management of post-operative complication.
\nThe stents are broadly classified into metallic and plastic stent. Metallic stents are made from nitinol (nickel-titanium alloy) or stainless steel and all are self-expanding metallic stents (SEMS). Although the metal used in this stent are made to be inert, resistant to erosion and non-allergenic but when the stent coils embedded into the mucosa, they still could trigger mild inflammatory reaction with fibrosis formation that reduce the risk of migration but it makes its removal difficult. The nitinol stent has thermal shape memory feature that enables it to expand at body temperature and adapts to the shape of a particular lesion. The initial type of metallic stent was uncovered but because of issues of tumour in-growth through the stent and tissue reaction, thus the current available stent is fully or partially covered. Current design of covered stent incorporates features such as partly uncovered portion, proximal flaring, placing the covering material on inside, to reduce the migration rate. The materials used for covered stent are silicone or plastic. However, the risk of stent migration is higher in the covered stent especially in high risk area such as distal esophagus. The covered stent is useful in benign lesion as it is easier to remove once the stricture expands. Stents are available in a wide variety of lengths and diameters. The most commonly available used stents are usually the 10-12cm long, 18- 21 mm diameter, covered SEMS. Besides, the availability of proximal release stent allows the stenting of very high esophageal lesion much easier with precise positioning under endoscopic guidance without flouroscopy[5] (Figure 3)\n
\nTwo types of stent release mechanism
The self-expanding plastic stent (SEPS) is the latest development of stent design and it is indicated for esophageal stenosis such as refractory benign strictures and malignant esophageal stricture. Polyflex esophageal stent (Boston Scientific, USA) is the only stent on the market which is indicated for benign esophageal stricture and can be placed temporary up to 9 months according to manufacture guideline. However, the utility of this device is constrained by the requirement of a relatively large (12-14 mm) rigid introducer, manual assembly and the necessity of fluoroscopic guidance using a wire for appropriate positioning.
\nThe important type of stents that are available on the market are given in Table 1\n
\n\n Name \n | \n\n Manufacturer\n | \n\n Material \n | \nDiameter (mm) | \n Length (mm) | \n \n Delivery system size (mm)\n | \n\n Special features\n | \n
Polyflex | \nBoston Scientific, USA | \nPolyester, silicone covered | \n16-21 | \n90-150 | \n12.0-14.0 | \nNeed manual assembly prior to stent placement. Indicated for benign esophageal stricture | \n
Niti-S | \nTaewoong Medical, Korea | \nNitinol wire, silicone covered | \n16-20 | \n60-150 | \n5.8-6.5 | \nFully covered. Proximal/ distal release available. Retrievable if misplaced. Proximal lasso. Antireflux variant available | \n
UltraflexTM\n | \nBoston Scientific, USA | \nNitinol wire, polyurethane covered | \n18-23 | \n100-150 | \n6 | \nPartially covered at mid-portion. Ideal for upper 1/3 esophagus. Little expansile force. Not intended to be repositioned of removed once deployed. Large proximal flares | \n
Z-stent ® | \nWilson-Cook Medical,USA | \nStainless steel, polyurethane covered | \n18 | \n80-140 | \n10 | \nNon-shortening partially covered stent. Preloaded on a Z-speed introduction system | \n
BonastentTM\n | \nStandard Sci-Tech, Korea | \nNitinol wire, silicone covered | \n18 | \n60-150 | \n5 | \nFully covered. Repositionable if misplaced less than 50% of its length. Small delivery diameter (5 mm) Proximal and distal lasso,.Antireflux variant available | \n
Choo stent TM\n | \nM.I.Tech, Korea | \nNitinol wire, silicone covered | \n18 | \n60-170 | \n6 | \nRetrievable if misplaced. Proximal and distal lasso. Antireflux variant available | \n
Alimaxx-ESTM\n | \nMerit Medical system, USA | \nNitinol wire, polyurethane covered | \n12-14 | \n70-120 | \n7.4 | \nFully covered. Antimigration struts. Proximal suture knot for removal | \n
Commercially available covered esophageal stents
The aim for stenting is the palliation of malignant dysphagia in esophageal or gastric cancer in patients whom are not candidate for surgical resection due to extensive local or metastatic disease or poor functional status. Trecheo-esophageal fistula due to locally advanced cancer which leads to recurrent aspiration pneumonia is a good indication as studies has shown the used of covered stent may increase survival as compared to other therapies.[6]
\nThe used of covered stent in benign esophageal lesions such as leak or perforation especially in high risk patients too precarious for major operation, has gain increasing acceptance in upper GI surgery.[7] In this selected group of patient, the choice of stent is utmost important as the stent must be left long enough for the leak to heal but without complication of difficult removal later on. The new designed fully covered stent such as SEMS (Nitinol coved stent) and SEPS (Polyflex) are particular suitable in this situation. Most stents are left for 2 to 3 months for the perforation to heal.
\nThe use of stent in benign esophegeal stricture has also gain popularity in recent years.[8] Those refractory esophageal strictures with failure of serial dilatation probably are the best candidate in this indication.[9] Placement of fully covered retrievable stent after dilation as non-permanent dilator and remove it after 1 to 2 months after the fibrosis has stabilised.
\nThere are no real contraindications for stenting due to improvement of the stent design. Traditionally, it is not advisable to stent in high esophageal lesion due to risk of aspiration, pain or risk of tracheal compression. However, with the availability of new design and proximal release stent which allow accurate endoscopic placement make the treatment of this lesion a possibility.[10] In patient with advanced esophageal cancer with very short of expectancy (< 4 weeks) should probably not considered a candidate for stenting.
\nInformed consent should be obtained prior to stent placement especially the information regarding the expected benefit, risk and possible short and long term complications should be properly conveyed to patients
\nThe use of stenting has been shown to improve quality of life indices.[11, 12] The improvement of dysphagia has been the objective of the esophegeal stenting. The dysphagia score is used to assess the degree of dysphagia. (Table 2)[13] Most published series showed the overall immediate technical success rate in 100%, with improvement of dysphagia score approaching 90%.[12] The ability of oral intake to allow gastronomic pleasure is also another benefit, which not only improve the quality of life but possibly the nutrition status of the patient.
\n\n Dysphagia score\n | \n\n Degree of dysphagia\n | \n
0 | \nNo dysphagia | \n
1 | \nAble to swallow some solid food only | \n
2 | \nAble to swallow semi-solid only | \n
3 | \nAble to swallow liquids only | \n
4 | \nComplete dysphagia | \n
The dysphagia score
Minor procedure complications which lead to morbidity were seen up to 40% in various series.[14, 15] Intra-procedure complications such as aspiration, sedation risk, malposition of the stent, bleeding and perforation could occur. Early complications may include chest pain, bleeding or tracheal compression. Late complications such as stent migration, tumour overgrowth or ingrowth[16-18], delayed perforation, food bolus impaction, fistula formation may occur. However, fistula and perforation due to stent insertion are uncommon. Early chest pain occur in most patient, but prolonged pain only occur in fewer than 13% of patients.[18] Pain is most severe with high stricture and when large diameter of stent is used.[19] The migration rate for those uncovered stent is less than 3% in esophagus, but increases to 6% if placed across the cardia.[13, 17] The migration rate of covered stent is generally up to 30%, especially when positioned across cardia.[17, 18, 20] The migrated stent should be retrieved endoscopically as it may cause small bowel obstruction or perforation.[21]
\nBefore placement of the stent, a barium swallow should be obtained to delineate the site and length of the esophageal stricture. The stent could be deployed under endoscopic visualization, fluoroscopic guidance with the aid of guide wire and sometime require pre-dilatation of the lesion. It is especially helpful to have a nurse who experienced in complex endoscopic procedure to facilitate the success of stent deployment. Esophageal dilation is usually done before stent insertion but it is not a pre-requisite for successful stent deployment. The precise requirement of dilatation generally depends on the type of stent to be used, dilatation to no more than 12mm is recommended, which will facilitate introduction of the delivery system and allow rapid expansion of the stent. However, most people advocate do not pre-dilate the stricture as the stricture itself with hold the stent to reduce the risk of migration.
\nDuring procedure, the patient lies in left lateral position, Xylocaine spray is applied to the pharynx, the patient is sedated with an intravenous agent such as midazolam and analgesia is provided such as fentanyl. If the endoscope is managed to transverse the lesion, the proximal and distal border of the lesion are marked using radio-opaque markers, endoclips or contrast such as lipoidal agent. The stent is introduced over the guide wire until the marking on the stent are placed within 2cm of more margins proximal and distal to the lesion. Final adjustment is made under fluoroscopic guidance to ensure that the stent adequately covers the Lesion’s marking. By slowly retracting the outer sheath of the delivery system while maintaining the position of the inner shaft, the stent is deployed under fluoroscopic guidance. It is important that the inner shaft of the delivery system is held stationary against the body while deployment and not allowed to move, as any movement may cause malposition of the stent. Endoscopic visualization of the stent placemen also could be performed, especially with the aid of transnasal endoscopy which allows direct visual control of the esophageal stent placement without fluoroscopy.[22] After full deployment of stent and the expansion of the stent is verified fluoroscopically, the olive tip and the delivery system should be removed with care to prevent the dislodgment of the stent. For those stent that is placed too distally, a strong forcep could be used to hold the proximal lasso and the traction of it allow the stent narrows and be positioned more proximally. (Figure 4) Immediately after the procedure, non-ionic contrast medium is introduced through the catheter to look for any procedural related complications, especially esophageal perforation and to ascertain the stent patency. Endoscopy also can be done to ascertain the position of the stent but the endoscope should not be passed through the stent to prevent dislodgment of the stent. Chest x-ray should be carried out later to verify the position of the stent to look for sign of perforation.
\nPatient should stayed overnight for post-procedure monitoring. Some patients might complain of chest discomfort or chest pain which could be relieved with simple analgesia. Occasionally the pain is so severe which needs stent removal.
\nPatient with stent must modify their diet to prevent food impaction that lead to stent occlusion. Diet should be introduced as tolerated. Patient with stent placed without anti-reflux valve should be started on a high dose proton pump inhibitor indefinitely to prevent gastro-esophageal reflux. Stent occlusion due to food impaction could be dislodged endoscopically but those occlusion arises due to tumour overgrowth necessitate co-axial stenting on previous stent or laser ablation.
\n\n Technical points to consider\n
\nCovered stent should be used for tumour with high risk of fistula formation and to prevent in-growth of tumour through the metal mesh.
Stents with antireflux valve should be considered if position across the gastroesophageal junction due to disabling gastroesophageal reflux.[20, 23]
The proximal margin of the stent could be hold to mucosal tissue using endoclips to prevent stent migration.[24][25](Figure 5)\n
The partially migrated stent could be fixed with another covered stent, placed coaxially overlapping the upper portion of the migrated stent.
Those SEMS that is difficult to be removed due to tissue in-growth through the uncovered portion, a covered SEPS could be inserted overlapping the SEMS to press the tissue out of the stent mesh and causing pressure necrosis. Both of the stent could be removed few days later.[26, 27]
The proximal lasso could be retracted with strong grasper resulting narrowing of the stent body for easier removal.
Use of endoclips to hold the proximal margin of stent to prevent stent migration.
The role of stenting in upper GI disease can be broadly dived into:
\nEsophagus:
\nStents used in esophageal malignancy
Stents used in benign esophageal lesion such as stricture or perforation
Stents used in post-operative complication
Stomach:
\nStents used in gastric outlet obstruction
Stents used in bariatric surgery
Most patients with upper GI cancer especially esophageal cancers presented late with locally advanced or metastatic disease, which preclude them form surgical resection.[28] Patients may have no symptoms until the diameter of the esophageal lumen has been reduced by 50% resulting in late presentation and poor prognosis.[29] However, the problem of dysphagia, vomiting and malnutrition will severely impair the quality of life of these patients. A variety of endoscopic treatment modalities such as thermal ablation, brachytherapy, photodynamic therapy, chemical injection, argon beam therapy and endoluminal stenting have been utilized with these objectives in mind, with options determined by the location and size of the tumour, as well as the patient\'s expected prognosis.[29] The use self-expanding stent in this kind of patients as a form of palliation,[30] instead of surgical bypass, is particular helpful in relieving the obstruction while allow them to eat, manage their oropharyngeal secretions, reduce aspiration risk, and improve the nutrition status.
\nThe esophageal stenting in malignancy can broadly divided into two situation:
\nPalliation in advanced cancer
Temporary stenting for patient undergoing neoadjuvant therapy
\n Palliation in advanced cancer\n
\nSEMS placement is a safe and effective technique with good symptom palliation in advanced esophageal cancer.[17] Case series showed that the dysphagia score improved faster, 85% within 2 week as compare to radiotherapy which the onset of palliation was slower, with only 50% of patients palliated at 2 weeks.[31] Successful stent placements are achieved in up to 98% cases.[32] In palliation of malignant esophagorespiratory fistula or perforation, covered metallic stent have a clinical success rate of 95-100%.[33, 34] (Figure 6) Sometime, fistulas close to the upper esophageal sphincter may be closed with placement of parallel covered metallic stents in the esophagus and trachea.[35] The quality of life also reported to improve after palliative esophageal stenting. [12] Another major problem of esophageal stenting in advanced cancer is the tumour overgrowth which leads to recurrent dysphagia in patient who is survives long enough.[16, 36] This can be easily intervened with co-axial stent as overlapping stent. [36](Figure 7)\n
\nA locally advanced esophageal cancer with tracheoesophageal fistula presented with recurrent aspiration pneumonia and treated successfully with a covered esophageal stent for symptomatic relief.
Tumour over growth at the distal end of the covered stent which was treated with another co-axial covered stent across the previous old stent to relieve the obstruction.
Temporary stenting before neoadjuvant therapy
\nDue to malignancy induced cachexia and dysphagia, nutrition compromise is extremely common for those patients undergoing neoadjuvant chemotherapy or radiotherapy, which result in poorer outcome after surgery. The insertion of stent in this setting has been reported to have higher stent related complication such as migration or perforation and also difficulty of surgery later on. However, with the advent of fully covered SEMS with much reduced complication rate has led to renew interest in this indication.
\nThe use of stenting in neoadjuvant setting results in improvement of dysphagia score and nutrition has been reported in several studies.[37-39] Although it is safe with effective palliation of symptom with minimal complication, the migration does occur up to 48% especially in esophageal stenting across the gastroesophageal stenting.[40] However, the migration of stent is usually indicating a positive response to neoadjuvant therapy and the stent could easily be retrieved prior to surgery.[38] The fully covered SEMS do not appear to compromise surgical resection. [40]There is no increased risk of peri-operative complication due to stent in all these series.
\nBenign esophageal stricture in the esophagus can be due to a variety of causes such as reflux esophagitis, corrosive ingestion, post-radiation exposure, etc. The initial treatment of choice is serial dilatations. However, up to 30-40% of these strictures will recur and require repeated dilatation or even surgery.[41, 42] It is particularly important to differentiate between esophageal strictures that are simple (focal, straight strictures with a diameter that allows endoscope to passage) and those that are more complex (long, >2 cm, tortuous strictures with a narrow diameter).[9] These complex strictures are considered refractory when they cannot be dilated to an adequate diameter. The concept of using esophageal stent as a non-permanent dilator provides an alternative treatment of esophageal stricture instead of surgery.[43] The use of non-removable metal stents in benign esophageal stricture has been complicated by hyperplastic tissue reaction, tissue ingrowth, stricture formation and erosion into the surrounding organ. Therefore, removable fully covered self-expanding metal stent is recommended although the problem of tissue reaction or stent migrations also occur with these devises.[44]. The suggested stent of choice to be used in benign esophageal stricture is Polyflex stent (Boston Scientific, USA) as it causes less tissue reaction. This is the only SEPS available in the market and is approved for refractory benign stricture and treatment of trachea-esophageal fistula. This is self-expanding plastic stent made of polyester mesh that is fully covered with a silicone membrane with proximal flare to prevent migration. A systemic review showed the Polyflex is moderate effective, achieving dilatation free remission in 52% cases and achieves lower success rate when dealing with upper esophageal stricture.[8] This could due to more complex anatomy in upper esophagus which prevents effective remodelling of the stricture by SEPS. A recent meta-analysis showed that the efficacy of self-expanding covered stent placement in benign refractory strictures is only 46.2 % and associated with migration rate of 26.4 %.[45] Our early experience with this stent has been quite positive for the management of recurrent and refractory benign stricture. (Figure 8 and 9)
\nA 35 years old lady developed a short segment benign esophageal stricture at mid esophagus after cardiac surgery for closure of VSD and heart valve replacement. Multiple oesophageal dilatation had failed to relieve the obstruction. A polyflex stent was inserted temporary as non-permanent dilator with good symptomatic relief.
A high pharyngoesophageal stricture after laryngopharyngectomy treated with a proximal release fully covered Nitinol stent (TaewoongNiti-S, Korea) under endoscopic control.
Anastomotic leak in upper GI surgery is a serious complication especially when the leak is within the thoracic cavity with septic consequences. The sites of leak most commonly encountered are gastroesophageal or gastrojejunostomy or esophagojejunostomy anastomosis. Early intervention from the subtle clinical clues is the key to successful management. Traditionally, the management has most often consisted of re-operation for repair and drainage, prolonged hospitalisation and sometime necessitate resection of diversion which requires subsequent restorative surgery.
\nThe use of endoluminal stenting for esophageal leak instead of surgical intervention has been reported with good outcome.[46, 47] In a large series, up to 77.6% of patients with post-operative leak responded to stenting with a median duration of SEMS treatment of 83 days and the stent should be removed after 6 weeks.[48]Polyflex of SEPS type has also been used with good success rate.[49]
\nThe role of endoluminal stenting in Peri-operative setting could be considered in situations such as:
\nThose patients with an anastomotic leak that are diagnosed late in the course and in whom operative closure is not feasible.
Those patients with an anastomotic leak with medical condition who are too precarious for surgical intervention.
Those patients with chronic fistula due to anastomotic failure.
However, It has been shown that those anastomotic leak located in cervical esophagus, gastroesophageal junction, esophageal injury longer than 6 cm or an anastomotic leak associated with a more distal conduit leak tend to be not treated effectively with stenting. Therefore, traditional operative repair suggested to be used as initial therapy.[50]
\nIn our practice, the authors found that the fully covered retrievable stent and with large diameter up to 21-23mm should be used for effective sealing of the defect. There is a problem of peri-stent leak especially from the jejunal limb in some cases. However, it is usually a contained leak which could be drained percutaneously under image guidance. (Figure 10) Sometime, another stent has to be inserted across the previous stent for effective sealing. The SEPS is preferred to be used as it causes less tissue reaction and ease to be removed later. The inserted stent should be removed within 2 months and sometime we left it permanently in patient with advanced cancer. Similarly, post-operative anastomotic stricture could also be managed effectively with stent. Leakage at the anastomosis and stapler anastomosis were found to be the risk factors for the development of strictures.[51, 52] Improvement in quality of life and relief of dysphagia could be achieved when dilatation of the stricture fails. In conclusion, endoluminal stenting is a minimally invasive therapy of anastomotic complication which is a safe and effective. It results in rapid leak occlusion and avoids morbidity of re-operative repair.
\nPost esophagectomy anastomotic leak. Two leak points at the anastomotic site located at both lateral corner of the staple line. A fully covered Polyflex stent, measured 21 mm diameter and 90 mm length inserted. The leak was successfully contained and a percutaneously drain was inserted into the chest cavity for external drainage.
Esophageal perforation is most commonly iatrogenic induced but occasionally it occurs spontaneously such as in Boerhaeve’s syndrome. It carries a dismal prognosis due to mediastinitis and severe sepsis. Esophageal stenting has been shown to be effective in managing the leak as a less morbid intervention if compared with surgery.[48, 53] Several case series showed an effective healing leak rate up to 90%.[48, 54] The key to success outcome is prompt recognition of leak with rapid esophageal stenting immediately after the perforation and adequate debridement and lavage of the thoracic cavity. (Figure 11)\n
\nThe usual causes of gastric outlet obstruction are due to tumour in gastric antrum, duodenal stricture, or obstruction secondary to direct invasion or extrinsic compression from pancreatic carcinoma. The aim in palliation in patients with malignant gastric outlet obstruction is to reestablish oral intake by restoring gastrointestinal continuity. Gastric outlet obstruction was traditionally treated with surgical gastroenterostomy and stenting is usually reserved for patients who are not fit for surgery.
\nProlong nasojejunal tube feeding or percutaneous jejunostomy to provide nutrition is not an ideal palliation treatment in those patients not fit for surgical bypass as the tube will cause significant discomfort in these terminal ill patients. Therefore, internal stenting of the lesion will offer the best method of palliation for these patients, apart from relieve of obstruction but also able them to resume oral intake. (Figure 12) Stents can be successfully deployed in the majority of patients.[55] Stent placement appears to lead to a shorter time to symptomatic improvement, shorter time to resumption of an oral diet, and shorter hospital stays as compared with surgical options.[56] However, surgical bypass results in better long-term outcomes as compared to internal stenting. A recent randomised controlled trial showed that despite slow initial symptom improvement, gastrojejunostomy is associated with better long-term results and is therefore the treatment of choice in patients with a life expectancy of 2 months or longer.[57] Currently, the metallic uncovered stents are commonly used to prevent the risk of migration.
\nAnother interesting use of stent in locally advanced gastric cancer such as linitis plastica type which may cause gastroesophageal and gastric outlet obstruction. The placement of an extra long, covered stent traversing the cardioesophageal junction up to duodenum will provide symptomatic relief (Figure 13). The stent not only provides some degree of peroral intake but is able to relieve of the gastric outlet obstruction probably due to peri-stent flow.
\nLower esophageal perforation occurred after endoscopic dilatation and the defect was immediately stented under fluoroscopic control.
Barium meal showed good of barium trough the through the pyloric obstruction after internal stenting.
An extra long 23cm, fully covered Nitinol stent (Taewoong Niti-S, Korea) deployed crossing the gastroesophageal junction and pylorus in a’ linitis plastic type’ gastric cancer to bypass the obstruction.
Bariatric surgery has become an effective solution to treat morbid obesity. Laparoscopic adjustable gastric banding and laparoscopic Roux-en-Y gastric bypass carry a mortality rate of 0.1% and 0.5%, respectively. [58] Therefore, surgery on this high risk group of patients can be dangerous especially leak occur and carry a high risk of mortality if not detected and treated expediently. The leak usually arises from stapler line failures due to surgical technique, ischaemia and patient comorbid conditions. In sleeve gastrectomy, the leak site is usually found in the upper sleeve near the gastroesopheal junction.[59] Recently, the placement of long endoluninal stent have been demonstrated to be safe and effective to exclude the leak site, allowing oral intake and speeding healing.[59, 60]
\nThe recent development of bariatric surgery is the placement of the EndoBarrier duodenal jejunal bypass liner which appears to be a promising, safe and effective method for facilitating weight loss.[61] The EndoBarrier is a plastic flexible tube which is endoscopically placed in the duodenal bulb, directly behind the pylorus. It extends from the duodenum to the proximal jejunum. Recent studies have demonstrated significant weight reduction in comparison to control-diet patients.[62] However, the lack of long term result and small samples size studies call for a need for longer randomised controlled trial before its widespread use.[63]
\nAll the stent are equally effective in achieving symptomatic palliation in malignant dysphagia. The type of stent chosen is usually based on subjective physician\'s preference. However, the stents vary in features such as the ease of insertion, removability, migration and occlusion rates. Covered and uncovered stents have different functional characteristics and stent type must be selected on an individual basis. A recent meta-analysis suggests that SEMS are superior to SEPS in terms of stent insertion-related mortality, morbidity, and quality of palliation.[4] The uncovered variety is disadvantaged by high rate of tumour in-growth.[4] The currently available SEPS, Polyflex is cumbersome to use due to its larger introduced system and higher rate of migration. However, the SEPS is equally effective in relieving dysphagia and useful in case of tissue ingrowth/overgrowth after SEMS placement.[64]
\nStenting in upper gastrointestinal disease is now fully established in the management advanced cancer and complication due to surgery such as stricture or anastomotic leak. It offers a minimally invasive approach to address obstructive symptom and improve quality of life of patients. In difficult cases, a multi-disciplinary team approach involving surgeon, gastroenterologist and radiologist is the corner stone of successful endoscopic palliative therapy.
\nContinuous innovation of new stent will lead to higher technical and clinical success rates of endoscopic stenting, while reducing complication rates. Therefore, stenting will become much simpler and more convenient to use for physician but also more comfortable for the patients. Future development in stenting includes biodegradable stents for benign disease to reduce stent related complication [65] and radioactive [66]or drug-eluting[67] stents for malignant disease which will decrease tumour growth and sustain the stent patency.
\nThe authors wish to thanks Professor Dato’ Dr K L Goh, Head of Gastroenterology and Hepatology, University of Malaya for letting us to use some of his personal photo collection in preparation of this manuscript.
\nSince the turn of the twentieth century, the air temperature has risen, expected to proceed to rise as a result of climatic variability. These rises in temperatures may trigger high-temperature stress (HTS): serious damage to plants [1, 2]. As a result, food and feed security have become a crucial challenge under current prevailing agro-climatic conditions [3, 4, 5]. Climate modeling has indicated that high temperature during the day and night is threatening global agriculture production system [6]. The result is that maize crop yield is reduced globally [7, 8]. Maize is one of the important crops being cultivated globally with a wide range of uses, and it is an important food crop in the world [9, 10, 11], it has been primarily aimed for increasing yield, quality, and stability under different environments [12, 13, 14, 15]. Maize is an important component of human food, animal feed, and biofuel industries [5]. It ranks top among cereal crops globally and becomes raw material of numerous food and feed industries. Among growth limiting factors, heat stress has a major effect on maize growth and nutrient composition at different developmental stages. Since several abiotic stresses occur simultaneously, such as drought stress and heat stress, the development of improved breeding procedures is essential for increasing the maize productivity and quality [16]. There is a crucial need for further research to develop maize genotypes tolerant to high temperature and drought stress.
Various physiological and biochemical processes govern plant growth and yield. Stomatal conductance, for example, regulates water loss as transpiration as well as an influx of CO2 for its fixation in the Calvin cycle. Several researchers had suggested that the stomatal conductance is an important indirect heat-tolerant selection criterion in crops [17]. Similarly, osmoprotectants and chaperone proteins got an important part in the adaptive reaction of maize to heat stress and combined stresses. Moreover, leaf senescence-related proteins enhance maize tolerance to combined heat and drought stress [18]. Introgression of these traits in locally acclimated maize hybrids through potential donor hybrids helps in developing maize hybrids tolerant to heat and drought stress. Moreover, identification of donor genotypes possessing favorable traits is important in heat stress breeding programs [19]. Therefore, the present review aimed to evaluate the updates on the effect of heat stress on different plant developmental stages, some physiological and biochemical traits, yield and yield traits of maize. Moreover, this review included updates on various strategies used to improve crop tolerance against heat stress including, conventional breeding strategies, management practices, shotgun approaches, and molecular biology-based strategies. Given the critical analysis of success and limitations for improving maize crop productivity under heat stress, future directions for research are also suggested.
Temperature above 350C for a prolonged period is considered unfavorable for crop growth and development and, particularly 400C during flowering and grain filling have severe negative impacts on grain yield [5]. Plants under heat stress exhibited significantly reduced stomatal conductance resulting in a reduced rate of photosynthesis. Excessive heat also causes a reduction in net photosynthesis, leaf area, reduced biomass accumulation and seed weight [20]. However, heat-tolerant maize varieties that produced the highest metabolites are not usually high yielding varieties. The heat-tolerant maize varieties are usually characterized by the reduced plant height, leaves plant−1, and leaf area index ultimately reduced the yield. Therefore, several factors should be put into consideration when selecting for heat tolerance in maize. At the cellular level, HTS triggers the appearance of certain genes and increases the accumulation of certain metabolites that may enhance the heat enduring ability of plants [21]. Generally, remarkable genotypic variations in the stomatal conductance were observed [22, 23]. Stomatal conductance, which is a key trait of the photosynthetic leaf, was significantly influenced by abiotic stresses [24]. Delay canopy senescence due to various light interceptions by green leaf area has been reported to be necessary for high productivity of hybrid maize under normal watering and drought stress [16]. The impinging of high-intensity light to plants can lead to permanent damage to membrane structure [20]. The cell membrane is considered the first physiologically sensitive structure to the high temperature and becomes functionally inactive at heat stress [25]. Membrane function and cell wall stretch have inverse relation [26, 27]. Continuous damage in the biological membrane may downregulate the mobility of water, ions, and soluble organic solid molecules within plant cell membranes; hence carbon of production, transport, and accumulation may be affected by these factors. Membrane stability could be used as an assessment of high-temperature tolerance of plants. It is the most appropriate and convenient test; leakages of electrolytes at a high temperature can be measured by this test [28].
Soil plant analyses development (SPAD) value and grain yield have a significant relationship after anthesis, but no positive association has been noticed during the middle and later grain-filling stages [29, 30]. During HTS, the chlorophyll biosynthesis gene gets downregulated [31]. Experimental observation has suggested that the differences among net photosynthetic ratio after exposure to high temperatures were related to the conversion of the chlorophyll “a” into chlorophyll b ratio; due to low chlorophyll “a” and rapid leaf senescence, the photosynthetic rate is negatively affected [32]. HTS induces several metabolic events at the cellular and subcellular levels. The heat stress influences the production of ROS and oxidative stress as well [33, 34, 35]. The antioxidative defense system includes both enzymatic and nonenzymatic antioxidants that are shown to participate in response to the development of oxidative stress influenced by heat stress [21].
Scientists showed that rather extreme heat intensity could cause serious tissue damage as well as mortality may arise in a matter of minutes and could ultimately be due to a massive collapse of cell organization [36]. Damages can occur just after deep-term exposures at moderate to maximum heat stress. Informal and gradual damages caused by high temperatures include chlorophyll and mitochondrial destruction of enzymatic activity, protein catabolism impairment, protein deterioration, and cell turgidity looseness [37]. As can be seen in studies, with either the introduction of heat-shocked proteins, plants and animals react to high-temperature pressure [38, 39]. These are intended to avoid species from the harmful impacts of heat stress as well as other sources of pressure [40]. A simple reaction to high-temperature stress is a reduction in regular cellular metabolism. This drop is especially marked at 45°C. The fall in the natural production of protein also goes hand in hand with increased expression and transcription of a fresh set of molecules identified as heat-shock proteins (HSPs) [41]. Previous studies demonstrated that in Zea mays, high-temperature stress reduced the protein production and changes the chemical structure of these proteins [42]. Heat stress at the reproduction phase negatively affects the physiology of plants like flower initiation, source-sink relationship, and falling of pods, which ultimately decreases the number of seeds [43]. High-temperature stress is most crucial for the physiological traits of crop plants. High temperature reduced the number of ears, number of kernels, chlorophyll efficiency, firing of leaf, and blasting of the tassel [44]. Climatic stress like high-temperature stress severely reduces the growth and yield of several crops belongs to Leguminosae (Fabaceae). Heat stress severely reduced the physiological growth development and production of Vigna radiata. Heat stress reduced dry matter production and other yield attributes [45].
HTS hampers the plant growth; particularly germination and seedling emergence are more sensitive [46]. Stressful environment severely reduces the germination and early seedling growth in several crop plants [47, 48]. However, seeds of sensitive crops exposed to 24 and 48 h moderate heat stress exhibited a higher germination rate. Such an increase in seed germination rate due to short-term exposure to moderate heat stress was attributed to the altered expression of gibberellin and abscisic acid biosynthesis genes [49]. The seedling stage is generally considered as the most sensitive stage to stress in maize development [50]. However, the detrimental impact of water deficit stress on the initial phase of growth and seedling establishment of maize plants cannot be underestimated [51, 52, 53].
The appropriate sowing date is important for seed germination and seedling establishment to physiological maturity. The heat-tolerant maize varieties germinated earlier than the non-drought tolerant maize varieties under the critical level of watering. During germination, HTS is associated with an impaired emergency, and a reduced plant stand and plant density [54]. Biochemical components such as soluble sugar and proline increased with increased stress, while starch content and relative water content reduced with increased water deficit [55]. Fluctuations in mean daily temperature (either it is maximum or minimum) disturb seed germination ability [56]. High-temperature stress is the main cause of the reduction in plant yield due to poor germination. [57, 58] studied the impact of high temperature on various developmental phases, especially at seedling emergence in various crop genotypes. Critical periods of stress in maize include seedling establishment stages, rapid growth period, pollination and grain-filling stage. It is proven that in the maize plant with the implementation of stress, not only the leaf area is reduced, but also its growth rate is affected and the appearance of each leaf is delayed [59].
HTS at the grain-filling stage in spring maize is the main obstacle [60]. Temperature beyond 40°C, mainly during flowering and grain filling has a severe impact on plant grain productivity [5]. Grain filling is highly sensitive to drought and heat, due to the involvement of the array of diverse enzymes and transporters, located in the leaves and seeds [45]. During HTS, the stability of the thylakoid membrane structure is reduced, resulting in degrading chlorophyll, which reduces light energy absorption, transfer, and photosynthetic carbon assimilation, and ultimately photosynthesis is reduced. Inhibited photosynthesis decreases the supply of photosynthates to the grain, leading to a serious reduction of kernel weight and grain yield [60, 61, 62]. Delay in the development of reproductive organs might be the result of the reduced cell division and cell elongation processes due to reduced supply of photosynthates and carbohydrate metabolism during the active vegetative growth stages [63].
A projection based on the increased daily maximum temperatures concluded that to increase the maize yields by 12% for the period 2016–2035, improved technologies would be needed [64]. Maize plant can face moderate to high temperature, but temperature above 35°C for a long duration is considered unfavorable for crop growth and development, and temperature beyond 40°C, mainly during flowering and grain filling will have a severe impact on plant grain productivity [5]. Meanwhile, early season temperature increases have induced the maize reproductive period to start earlier, developing the risk of water and heat stress. Declines in time to maturation of maize shown of independence of effects to availability of water, the potential of yield which becoming increasingly limited by warming itself [65]. Irrigation regimes were the major determinant of grain yield during the grain-filling stage in maize while significant differences in the number of kernels per row were obtained among irrigation regimes [66]. A large difference in grain yield is caused due to HTS, which is shown in Figure 1. Tissue injuries inversely influence the photosynthetic rate during heat stress, which can cause leaf damaging and increase the rate of leaf senescence that largely results in decreasing photosynthetic efficiency [44]. Reduced chlorophyll content, including grain yields and oxidative damages, possibly had a direct correlation under heat stress [5, 67]. Previous research studies indicate that high temperature has a severe effect on the cob growth rate as well as biomass partitioning [68]. Many factors including duration of pollen viability, increased kernel abortion rate, lower the rate of cell division in storage tissue (endosperm), decrease in starch synthesis, downregulate the sink capacity of developing kernel, increased rate of sugar accumulation, kernel development, and less/higher enzyme activities could be responsible for the reduction in kernel per row under heat stress [44, 67]. Stress environment leads to a severe reduction in yield of crop plants probably by disrupting leaf gas exchange properties, which not only limit the size of the source and sink tissues, but the phloem loading, assimilate translocation, and dry matter partitioning are also impaired [46]. Unsuccessful fertilization reduces the seed size and increases flower abortion rate owing to high temperature and it has negative effects on plant reproductive phase [69, 70]. Temperature range 0–35oC, is considered suitable for leaf growth, the temperature range 35–40oC has an inverse relation with leaf growth. Temperature beyond 35-40oC is responsible for lower net photosynthetic rate, which further leads to protein aggregation, enzyme inactivation, inhibition of protein synthesis leading to the degradation of protein synthesis [69, 71]. Eventually, an increase in temperature beyond its critical value leads to generating a heat stress that harms the morphological growth, grain yield, and yield-related attributes of two maize cultivars “Xida 319” and “Xida 889” [72].
Differences in total leaf collars, cumulative leaf area, and grain yield of three corn hybrids grown under normal Ames, Iowa temperatures and normal +4°C temperatures.
Temperatures higher than 35°C negatively affect maize grain quality. Grain quality, which is governed by factors including the duration and rate of grain filling and the availability of assimilates, is negatively influenced under water deficit conditions. Similar negative effects of stress were reported on the grain weight of wheat [15, 73, 74, 75]. Variations in flour quality in a hard-grained crop could be related to changes in protein composition due to heat stress during the grain-filling stage [76]. As per the findings of Mousavi et al. [77], heat stress at the flowering stage greatly reduced the starch content due to the reduction in the photosynthetic activities leading to an increase in the grain protein ratio. Usually, maize quality properties are affected by genotypes, environmental factors, and their interactions (Figure 2). Therefore, growth and development of maize are dramatically affected by heat stress leading to reduced grain weight with low starch, crude oil, and protein contents [30]. Grain filling is the most environmentally sensitive phase in maize, which strongly affects grain development quantitatively and qualitatively [7, 15]. Oury and Godin [78] reported a negative correlation between protein contents and grain weight in maize under stress conditions. Association analysis revealed that cob length, thousand-grain weight, and protein contents had a significant relationship with grain yield of maize [79].
Quality of maize is influenced by genotype, environment, and their interaction.
In the previous study, the starch content in waxy maize grain was decreased, whereas protein content was increased, resulting in the change of grain quality [80]. However, the activities of enzymes involved in the synthesis of starch and protein are still lacking [81]. The qualitative and quantitative characteristics of grain productivity are mainly influenced by the environmental fluctuation and these changes inversely influence the development and maturing of seed that affect the seed-filling process and deposition of reserves [80]. Generally, high impinging of light affects negatively in plant productivity by causing premature senescence, decreased seed-filling duration, and enhancing remobilization of photosynthates from source to sink [82]. These factors combined, mainly lowers plant biomass and productivity, and finally lowers the assimilate production and mobilization of the reserve to different developing crops [83]. Generally, it is predicted that gene controlling cell division gets downregulated due to water stress, which could be responsible for the decreased cell number in cotyledons along with endosperm. However, further research is required to find out the actual mechanisms controlling these events. Probably due to low enzyme efficiency or high km carbohydrate gene gets downregulated in developing seedling, resulting in limited availability of sucrose, finally producing reduced seed size [45]. The time of seed filling reduced in pea, soybean, and white lupin, resulting in smaller grains [84]. Heat stress during grain filling markedly decreased starch accumulation in wheat [85] and rice [86].
High-temperature stress decreases the protein concentration in the wheat seeds during seed formation stage [76]. Carbon and nitrogen transmission in the seed is improved with the maximum temperature but C transfer is reduced by the daily temperature fluctuations [87]. Temperature variability effects are more visible on the size of seed than seed N contents [87]. Size of seed and protein concentration in the seed are inversely proportional to each other [88]. High-temperature stress reduces seed production, which ultimately declines the seed protein contents [89]. Protein accumulation in the seeds depends upon high-temperature stress [89]. When high-temperature stress occurs at the seed-filling stage it declines the seed protein contents [89]. When wheat crops are exposed to the high-temperature, glutenin protein production is decreased while gliadins protein production remains stable [90]. Seed protein contents of various crops are decreased after imposing the high-temperature stress, but various amino acid concentrations become low [91]. Heat stress damaged the protective layer of seed and food storage tissues of seed, which is why the quality of seed was deteriorated (Figure 3).
Quality of maize is deteriorated due to heat stress.
Enhancement of the antioxidant defense system is an important strategy to scavenge ROS by antioxidant enzymes [92]. Similar to antioxidant defense, phytohormones such as auxin (indole acetic acid, IAA), cytokinins (CKs), abscisic acid (ABA), ethylene (ET), gibberellins (GAs), salicylic acid (SA), brassinosteroids (BRs), and jasmonates (JAs) have key roles in coordinating various signal transduction pathways during the abiotic-stress response [93]. Many studies have shown that altering cultural practices, such as planting rate [94], planting date [95, 96], the phenological variation of crop cultivars [60, 95] soil management [97], nutrient management [60], and irrigation [60] can positively or negatively modify maize yield response to climate change.
Advancing or delaying the sowing date may be a potent, farmer-friendly and biologically viable strategy to avoid HTS. Earlier findings reported that earlier sowing dates and longer season varieties have overcome the negative effects of climate warming on spring maize yield [95]. Similarly, other findings reported by [98] showed that by changing sowing date from late April to late May, the mean daily temperature decreased 1.7 and 4.3°C whereas the diurnal temperature increased 4.3 and 3.1°C during grain-filling middle stage (16-45 days after silking) and grain-filling late stage (45 days after silking to maturity), respectively.
High air temperatures during the crop growing season can reduce harvestable yields. However, crop varieties with improved heat tolerance traits as well as crop management strategies at the farm scale are thus needed for climate change mitigation. Therefore, to mitigate the negative impact of increased growing season temperatures on crop growth and yield, especially in low latitude regions, heat-tolerant crop varieties, as well as modified farm management practices are needed, especially in the areas when irrigation is needed for crop production and irrigation water depends on the underground aquifers [99]. They also observed that applied irrigation at nighttime through subsurface drip reduced the root-zone soil temperature, which helped plant for improving plant growth and yield of corn. Optimizing irrigation has the potential to improve the water use efficiency of maize leading to enhanced heat tolerance [60]. Soil drought stress and atmospheric high temperature in the vegetative growth period could delay the process of growth of spring maize and shorten the reproductive stage, but those get improved when the soil moisture content in the maize field is maintained 65% field capacity by drip irrigation [100].
Plant growth hormones and exogenous chemicals (e.g., ABA and CaCl2) play important roles in strengthening heat tolerance in maize under HTS [60]. Exogenous ABA induces maize to produce HSPs, strengthening PSII heat tolerance [101]. An exogenous CaCl2 increases the maize cell membrane antioxidant capacity to improve heat tolerance [102]. Phytohormones such as auxin (IAA), cytokinins (CKs), abscisic acid (ABA), ethylene (ET), gibberellins (GAs), salicylic acid (SA), brassinosteroids (BRs), and jasmonates (JAs) have key roles in coordinating various signal transduction pathways during the abiotic-stress response [93].
Auxin or indole-3-acetic acid (Aux/IAA) acts as a chemical messenger to communicate cell activities when crops face different environmental stresses, including salinity, drought, waterlogging, extreme temperatures (heat, chilling, and freezing), heavy metals, light (intense and weak), and radiation (UV-A/B) [92, 103, 104]. Cytokinin (CK) is one of them, which functions solely and or with other hormones to mediate different mechanisms within plants in response to environmental fluctuations. During heat stress, protein denaturation and metabolic imbalance are occurred due to the excessive production of ROS. While to survive against heat stress, plants stimulate heat-shock proteins as a protective measure to prevent protein denaturation [105]. For example, the upregulation of heat-shock proteins in tobacco and bentgrass was recorded due to the enhancement of the antioxidant activity as a result of higher CK in plant cells [106]. Besides this, external application of CK inhibits the damage in photosynthesis under heat stress in maize, rice, and passion fruit [107, 108]. Salicylic acid (SA) is a naturally occurring phenolic compound [109] which plays a crucial part in the regulation of growth and development of the plants, and also a defensive mechanism to survive against abiotic stresses [110]. Similar to SA, abscisic acid (ABA) plays a vital role in plants’ physiological adjustments such as against abiotic stresses [111, 112] along with increasing seedling growth, endogenous levels of ABA, and reduced oxidative damage to plants due to heat stress. Similarly, Hasanuzzaman et al. [21] observed that ABA is a signaling molecule and also enhance the number of other signaling molecules such as nitric oxide for thermos-tolerance. Similar to other phytohormones, gibberellic acid (GAs) also interacts with other phytohormones in numerous developmental and stimulus-response processes in plants. GAs have been reported to alleviate the adverse effects of abiotic stress in plants, including rice as reported by Yamaguchi [113]. Brassinosteroids (BRs) is a new group of phytohormones, present in almost every part of the plants [114]. Similar to other phytohormones, BRs have shown tremendous potential against the abiotic stress-induced oxidative stress [103] including high temperature [115].
Inadequate and imbalanced nutrients and impaired soil fertility are associated with mineral-nutrient deficiencies and toxicities [116, 117, 118]. Adequate nutrition is essential for the integrity of plant structure and key physiological processes. For example, nitrogen (N) and magnesium are a structural part of chlorophyll and these are needed for photosynthesis. Nitrogen plays a very crucial role in temperature stress tolerance. At higher temperatures, the intensity of light is also very high. So, high light intensity, as a function of high temperature, which affects the uptake of mineral nutrients, ultimately influences the plant growth negatively. Since N plays a major role in the utilization of absorbed light energy and photosynthetic carbon metabolism [119, 120]. Whereas phosphorus is needed for energy production and storage; it is a structural part of nucleic acids and potassium is needed for osmotic regulation and activation of enzymes [117, 118]. Maize physiological function decreases under abiotic stress but can be compensated by nutritional management, for example, adequate potassium fertilizer improves cell membrane stability, turgor pressure, water potential in maize under water-deficit conditions [60]. Thus, a strategy to improve heat tolerance in maize at the grain-filling stage is to regulate nutrition.
Selection criteria have been proposed in traditional breeding to facilitate the detection of heat-tolerant maize variety. As different varieties respond differently to HTS, breeding heat-tolerant varieties is an effective strategy to improve heat tolerance at the spring maize grain-filling stage [60]. Screening of various cultivars was done to screen the warmness of the plant canopy, stomata behavior of upper most leaf (flag leaf), and photosynthesizing efficiency that are closely related to each other for the production maximum grain production under high-temperature stress conditions [121, 122, 123].
Under HT conditions, plants exhibit various mechanisms for surviving, which include long-term evolutionary phenological and morphological adaptations and short-term avoidance or acclimation mechanisms such as changing the leaf orientation, transpirational cooling, or alteration of membrane lipid compositions [92]. Also, high-temperature stress can be avoided by crop management practices such as selecting proper sowing methods, choice of sowing date, cultivars, irrigation methods, etc. It was discussed that combined hotter and drier climate change scenarios cause a greater maize yield reduction than hotter only scenarios. The incorporating drought and heat tolerance into maize germplasm has the potential to offset predicted yield losses and sustain maize productivity under climate change [19].
Tao and Zhao [60] reported that superoxide dismutase (SOD) increased and malonic dialdehyde (MDA) decreased in maize ear leaf for enhancing the stability of cell membrane, which helps to improve photosynthesis for good grain-filling characteristics (long quickly increase period and high mean rate of grain filling). It also produced high kernel weight under HTS [124, 125] leading to reporting of new origins of genetic engineering which exhibited leakage of electrolytes and MSI are the two basic parameters to screen the temperature stress-tolerant cultivars of various crops [126]. Electrical ions were gathered from the affected plants and were washed out with pure water to measure the membrane stability index MSI [127]. Seed production ability and stability index of the membrane were closely related to each other [3]. Mitochondrial tetrazolium is a very useful indicator of HTS sensitivity. Leaves’ tissues were dipped in triphenyl tetrazolium chloride chemical mixture during HTS. The spectrographic technique was used to quantify the related rates of triphenyl tetrazolium chloride reduction to formazan and tissues viability [128]. Heat tolerance (HT) of the crop is generally defined as the ability of the plant to grow and produce an economic yield under HS. This is a highly specific trait, and closely related to the species, even different organs and tissues of the same plant, may vary significantly in this respect. Plants have evolved various mechanisms for thriving under higher prevailing temperatures. They include short-term avoidance/acclimation mechanism or long-term evolutionary adaptations [92]. Many alternative traits related to heat resistance in Zea mays have been identified, including leaf kinetics, net photosynthesis rate (Pn), leaf anatomy at seedling stage [129] anther emergence [130], pollen grain viability [131], etc. However, the utility of those traits in stress breeding is not well established to date. Furthermore, most of the research focused on the heat stress on temperate maize, whereas only limited information is available on tropical maize [42].
One of the ways to deal with the adverse effects of heat stress may involve exploring some molecules that have the potential to protect the plants from the harmful effects of HT. In recent decades, exogenous application of protectants such as osmoprotectants, phytohormones, signaling molecules, trace elements, etc., have shown a beneficial effect on plants grown under HTS and these protectants have growth-promoting and antioxidant capacity [21, 92]. Exogenous applications of several phytohormones were found to be effective in mitigating heat stress in plants. Accumulation of osmolytes such as proline (Pro), glycine betaine (GB), and trehalose (Tre) is a well-known adaptive mechanism in plants against abiotic stress conditions including HT [92]. Supplementation with Pro and GB considerably reduced the H2O2 production, improved the accumulation of soluble sugars, and protected the developing tissues from heat stress effects. At the field level, managing or manipulating cultural practices, such as the timing and methods for sowing, irrigation management, and selection of cultivars and species, can also considerably decrease the adverse effects of HT stress. In recent decades, exogenous applications of protectants such as osmoprotectants, phytohormones, signaling molecules, trace elements, etc., have shown beneficial effects on plants growing under HT, due to the growth-promoting and antioxidant activities of these compounds [21, 92].
The genetic analytical study depends upon the genetic markers. Information about genetic reproduction aids to identify potential gene markers [132]. To mitigate the harmful effects of high-temperature several gene markers like a random polymorphic amplifier, AFLP (amplifier fragmentation length polymorphism), as well as sequenced simple repeats SSR, were used to increase the crop production under heat-stress [133, 134]. During genetic breeding, the SNP marker was used because of its genetic sequence in legumes to identify resistant genotypes against heat stress [135]. QTL chromosome numbers and their origin were very useful to mitigate the effects of heat stress [132]. Different molecular markers are studied in population genomics across the environment in many individuals to find out novel variation patterns and help to find if the genes have functions in significant ecological traits. Genome-wide association study (GWAS) is a powerful tool for understanding the complete set of genetic variants in different crop cultivars to recognize allelic variant linked with any specific [136]. GWASs generally highlight linkage among SNPs single nucleotide polymorphism marker and traits and based on GWAS design, genotyping tools, statistical models for examination, and results in interpretation [137].
Heat stress disturbed the crop metabolic activities by changing tissue balance. Heat stress directly produced toxic substances in plant tissues call ROS due to which plant suffers from oxidative stress. Moreover, to reduce oxidative damage resulting from heat-induced oxidative stress, plants have developed different adaptive mechanisms, via the biosynthesis of enzymatic and non-enzymatic antioxidants and the sequestering of other materials in crop tissues. Enhancement of antioxidant defense system is an important strategy to scavenge ROS by antioxidant enzymes such as ascorbate peroxidase (APX), ascorbate reductase (AR), catalase (CAT), glutathione reductase (GR), glutathione peroxidase (GPX), and superoxide dismutase (SOD) and with non-enzymatic antioxidants such as ascorbate (AsA), glutathione (GSH), carotenoids, flavanones, and anthocyanins [92]. Furthermore, adaptation to temperature changes, at the molecular level, was accompanied by the degradation of the normal proteins and the synthesis of HSPs involved in the mechanism of defense in plants. Seed germination is the most critical growth stage of the whole plant life cycle because it is the first step to carry out whole-plant growth and development, but heat stress is the main reducing factor of seedling emergence in semiarid areas [138, 139].
Heat stress and unprecedented climate changes have become a major challenge for sustainable crop production globally. Plant growth, development, and productivity get compromised due to heat stress. Elucidating maize hybrid for temperature tolerance could be an indispensable step toward a balanced yield. Tolerance and avoidance of stress could be an easy way to boost crop production under a changing climate; for example photosynthetic rate can be improved by targeting candidate traits and candidate genes involved in photosynthesis at a molecular level. It could lead to high assimilates production, more transportation of sugar to grain; finally, it decreases grain-filling rate, improves kernel size, and could be very useful to improve plant productivity. Heat-insensitive maize hybrids can be developed by gene editing CRISPER-CAS9 system through targeting a gene that is responsible for heat sensitivity. The base of further research should be focused on spring maize crops. Field experiments regarding the sowing date are essential by analyzing the impact of meteorological factors on maize growth and grain yield. Application of osmoprotectants, nanotechnology, and the use of sustainable agriculture agents have become necessary for further research. Further, interdisciplinary studies that include agronomy, animal sciences, and climate modeling are warranted to assess the impact of the feeding of both the HTS-tolerant maize varieties and those grown under heat stress on animal health and production. This review could encourage such interdisciplinary approaches to develop maize hybrids with high nutritional values and are not prone to drastic yield reductions owing to fluctuations in agro-climatic factors (especially temperature) and the outcome may lead to sustainable maize production in the tropics under changing climate.
The authors declare no conflicts of interest.
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