Degree of importance of the properties that a probiotic candidate must have.
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Dr. Tiefenbacher has published on a diverse array of topics that examine perception and behaviors with regards to the application of pesticides, releases of toxic chemicals, environments of the U.S.-Mexico borderlands, wildlife hazards, and the geography of wine. More recently his work pertains to spatial adaptation to climate change, spatial responses in wine growing regions to climate change, the geographies of viticulture and wine, artificial intelligence and machine learning to predict patterns of natural processes and hazards, historical ethnic enclaves in American cities and regions, and environmental adaptations of 19th century European immigrants to North America's landscapes.",institutionString:"Texas State University",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"1",totalChapterViews:"0",totalEditedBooks:"6",institution:{name:"Texas State University",institutionURL:null,country:{name:"United States of America"}}}],coeditorOne:null,coeditorTwo:null,coeditorThree:null,coeditorFour:null,coeditorFive:null,topics:[{id:"12",title:"Environmental Sciences",slug:"environmental-sciences"}],chapters:null,productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"},personalPublishingAssistant:{id:"194667",firstName:"Marijana",lastName:"Francetic",middleName:null,title:"Ms.",imageUrl:"https://mts.intechopen.com/storage/users/194667/images/4752_n.jpg",email:"marijana@intechopen.com",biography:"As an Author Service Manager my responsibilities include monitoring and facilitating all publishing activities for authors and editors. 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The incorporation of antibiotics to the culture species, besides eliminating the pathogenic microbiota, also eliminates bacteria that are beneficial for the same organism. Consequently, the accumulation of these chemicals in the organisms is not safe for human being who is the final consumer. The tendency today is to consume 100% natural foods, in search of a healthier and longer life. Likewise, the care of the environment over time has been regulated in different areas, privileging initiatives that have an environmental vision as a way to promote the care of the planet. In this area, the application of probiotics in fish culture mainly of commercial interest has been investigated for several decades. In this chapter, a bibliographical review of the recent probiotic studies in fish culture and the main results obtained from work on the use of probiotics in Seriola lalandi culture are made.
The word probiotic was first introduced by [1] to describe “substances secreted by one microorganism that stimulate the growth of another.” The name probiotic comes from the Greek “pro bios,” which means “for life” [2]. Arora & Baldi [3] indicate that to date, there is no legal definition for the term probiotic. However, these authors define it as viable microorganisms with beneficial effect on the host. Akhter et al. indicate that probiotics are microorganisms that are administered orally in a sufficient amount to alter the microbiota (by implantation or colonization) of the specific host and lead to benefits for the host’s health [4]. On the other hand, Banerjee et al. define probiotics as living microorganisms that confer beneficial effects to the host (improves immunity, helps digestion, protects against pathogens, improves water quality, and promotes growth and reproduction), and can be used as an alternative to antibiotics [5] (Figure 1). Probiotics include Gram-positive, Gram-negative bacteria, and many other organisms such as yeasts, bacteriophage, and single-celled algae [6]. In the field of aquaculture, the concept of probiotic should be defined taking into account other influencing factors that differentiate it from terrestrial probiotics. For example, Verschuere et al. extend this definition as “a living microbial complement that has a beneficial effect in the host by modifying the microbial community associated with the host or environment, ensuring a better utilization of the feed or improving the nutritional value, improving the host\'s response against a disease, or by improving the quality of its environment” [7].
The benefits generated by the dominance of probiotics in confined systems are related to: control in water quality; disease control; promotion of growth; improvement in digestion (enzymes); improvement in immune system; and source of nutrients, among others.
Das et al. suggest that probiotics are a new tool in disease control and improved water quality in the aquaculture industry. Currently, probiotics have become fashionable in the worldwide market as a dietary supplement [8]. The interest in its consumption is related to be within the category of functional/natural foods. Rapid consumer awareness is due to the currently proven therapeutic benefits of probiotics. The benefits associated with probiotics are related to nutrient contribution, to promote survival, to improve the host immune system [4], and to promote growth and/or antibacterial properties against pathogenic bacteria [9]. In addition, probiotics isolated from the same systems where they will be applied, generate greater interest by not presenting a threat to the surrounding ecosystem.
The aquaculture industry is one of the fastest growing food producing sectors in the world, as well as of significant economic importance, expectations of development estimate that much of the food of marine origin and of sweet water in the future will be provided by aquaculture. However, closed crops have threatened industry because of the proliferation of pathogens that until recently were controlled with the addition of antibiotics. The development of bacteria resistant to antibiotics means an enormous risk of transmission from the environment to the human (Pandiyan et al 2013). The development of bacteria resistant to antibiotics means an enormous risk of transmission from the environment to the human [10]. In addition, the use of antibiotics does not discriminate and equally eliminates the beneficial microbiota in the gastrointestinal system of the organisms of interest, as well as, it accumulates in organisms affecting to man as a final consumer [8]. Because of these problems, a global trend has been created that has led to the search for healthy alternatives with the environment to control the pathogens that cause diseases of commercial interest.
The definition of probiotics has evolved over the years, integrating new terms that are related to the new investigations regarding its application in situ. However, the magnitude of the benefit of probiotics will depend on: the concentration of the probiotic; the use of one or a mixture of probiotics of different species; the species and sanitary quality of the host; the stage of development of the host receiving the probiotic supplement (larva, juvenile and/or adult); and the physical-chemical-biological conditions of the environment. Finally, there are many interactions involved that also define the success or failure of probiotic application in culture systems. For this reason, it is fundamental to standardize the protocols, independent for each host species to be treated, since, the success of a probiotic in a specific host, does not guarantee the same beneficial result in another species of host.
Water quality is one of the criteria associated with outbreaks of fish diseases in crops. Therefore, it is essential to maintain water quality parameters that allow the production of disease-free fish [11]. Improving water quality, avoiding the accumulation of organic, nitrogen, ammonia, and nitrite waste are constant concerns in aquaculture crops. High concentrations of these compounds can be extremely damaging and cause massive mortalities [8]. In nature, these toxic substances are transformed into safer forms by the oxidizing bacteria of ammonia (ammonia to nitrite) and oxidizing bacteria of nitrites (nitrite to nitrate) [12].
It has been argued that probiotic bacteria can be used as ecological biocontrol or bioremediation agent for the sustainable development of aquaculture [13, 14, 15]. Among the benefits attributed to probiotics are: decreased algae growth, decreased organic load, increased nutrient concentration, increased beneficial bacterial population, inhibition of potential pathogens, and increased concentration of dissolved oxygen [15]. Studies have shown that bacteria of the genus Bacillus have been considered as probiotics in water treatment because they have the particularity of converting organic matter into CO2 [16]. Laloo et al. [17] verified that three isolates of the genus Bacillus decreased nitrite, nitrate, and ammonium concentrations in ornamental fish water. This same phenomenon was also observed by Kim et al. [18] with the species Bacillus subtilis, Bacillus cereus, and Bacillus licheniformis, whose effects attributed it to mechanisms such as bioaccumulation, bioassimilation, and nitrification. In addition, it has been proven that the addition of probiotic bacteria reduces the load of pollutants such as heavy metals (Pb, Cd, Hg, Ni, etc.) [19]. Also, the use of Bacillus spp. can reduce the incidence of Vibriosis in water [16]. Other probiotic candidates such as Nitrosomonas sp. and Nitrobacter sp. have been shown to be beneficial in decreasing the pathogenic load in culture ponds [20]. Likewise, the species Rhodopseudomonas palustris, Lactobacillus plantarum, Lactobacillus casei, and Saccharomyces cerevisiae have been attributed to probiotic potential in the maintenance of water quality [21].
The application of probiotics for fish culture requires rigorous measures that determine its effectiveness. One of them is related to the abiotic (physical-chemical) or biotic (biological) factors that will stimulate the proliferation and dominance of the probiotic only if the conditions of its surroundings are favorable for this one. The application of probiotic can be done directly to the culture water or mixed with the inoculum of “green water,” which is the entrance of microalgae in high concentrations, commonly used in fish culture for food consumption in the initial phase of the larval culture (2 days after hatching). Another pathway of probiotic entry in same fish culture is through live feed that fish receive as rotifers (up to approximately day 19 after hatching) (Figure 2), and then the addition of Artemia (until about day 25 of culture after of hatching). Another route of entry is through the skin of the fish where probiotics can colonize the surface layer of the skin and then enter through it. Consequently, probiotics after inoculum in culture systems can be found in water, sediment, and organisms of culture (Figure 3).
(A) Rotifers (Brachionus rotundiformis) in clear field 40×. (B) Rotifers (B. rotundiformis) fed with microalgae supplemented with probiotic bacteria stained with DAPI (4′, 6-diamino-2-phenylindole) and visualized by 40× epifluorescence microscopy.
Probiotics in a confined system can be found in water, sediment, and organisms. The success of dominance in the system will depend on its concentration and whether the physical-chemical-biological factors are favorable for its development. Potential routes of entry of probiotics to fish may be more than one among which stand out: culture water; skin; food through microalgae, rotifers and/or Artemia.
According to Dawood et al. [22], a probiotic microorganism can meet the needs to develop successful aquaculture because it increases the key factors of yield in growth and disease resistance. Microorganisms intended to be used as probiotics in aquaculture should perform functions that should be considered safe not only for aquatic hosts but also for their environments and humans [23]. According to FAO [24], the probiotic effect on food can have the desired impact only if it contains at least 106–107 live probiotic bacteria per gram or milliliter.
Marine microorganisms have been recognized as potential sources of relatively more stable enzymes than homologous enzymes in terrestrial microorganisms; among them, the salinity, pressure, temperature, and lighting conditions differ. Marine microbial enzymes may enhance host digestion or molecular signals involved in the quorum perception in pathogens for aquaculture disease control [25].
It is essential that the strain selected as probiotic does not pose a risk to the host because of the secretion of antibacterial toxins. The preselection measures are very important and should be taken to evaluate their safety before being categorized as probiotic. In this regard, there are countries that have developed standards for the application of food additives with microorganisms [26]. Some of these norms are related to favoring potential probiotic bacteria isolated from the organism of interest to treat, mainly of the digestive system, since they have a greater capacity of adhesion to gastrointestinal mucus and tissues, compared to the foreign bacteria that are usually transient [27] as well as resistant to low pH.
The mechanism of action of each probiotic in specific is difficult to elucidate, because there are a variety of factors that interact between the probiotic and the surrounding environment. However, Table 1 highlights essential properties to qualify as a probiotic candidate.
Degree of importance of the properties that a probiotic candidate must have.
There is currently a variety of research focused on the probiotic search for fish culture. Table 2 below provides information based on a review of the last 5 years of research on the use of probiotics in fish aquaculture.
Probiotic | Fish tested | Activity | Reference |
---|---|---|---|
Bacillus licheniformis (TSB27) Lactobacillus thuringiensis Bacillus Plantarum Bacillus subtilis (B46). | Sparus aurata L. | Enhances the immune | [46] |
Shewanella putrefaciens Pdp11 | Solea senegalensis | Modulates the digestive microbiota, an increase in growth | [51] |
Bacillus pumilus H2 | Fish | Anti-Vibrio activity | [47] |
Bacillus subtilis WB60 | Anguilla japonica | Increased in weight, efficiency in food and protein | [52] |
Lac. pentosus BD6, Lac. fermentum LW2, Bacillus subtilis E20, Saccharomyces cerevisiae P13 | Asian seabass | Improved either the growth performance or disease resistance of Asian seabass against A. hydrophila | [53] |
Pseudoalteromonas sp. | Seriola lalandi | Increased larval survival | [54] |
Pseudoalteromonas sp. | Seriola lalandi | Increased larval survival | [55] |
Lactobacillus plantarum | Oreochromis niloticus | Decreases mortality and improves growth | [56] |
Bacillus subtilis Lactobacillus rhamnosus | Labeo rohita | Increased the value of biochemical components | [57] |
Lactobacillus casei | Keureling fish (Tor tambra) | Growth performance and feed efficiency increased | [58] |
Bacillus sp. MVF1 | Labeo rohita | Decreased susceptibility to disease | [59] |
Bacillus subtilis Bacillus licheniformis | Juvenile rainbow trout | Resistance against A. salmonicida | [60] |
Kocuria SM1 Rhodococcus SM2 | Oncorhynchus mykiss | Produces extracellular enzymes that may have a role in the host digestive processes | [50] |
Vibrio lentus | Dicentrarchus labrax | Protective effect against Vibriosis caused by V. harveyi in sea bass larvae | [61] |
Lactobacillus plantarum | Tilapia | Enhanced the growth performance and modulated some hematological parameters. | [45] |
Bacillus megaterium PTB 1.4 | Catfish | Increased the activity of digestive enzymes and the growth of catfish | [44] |
Lactobacillus rhamnosus | Pagrus major | Growth-promoting agent and Increases growth | [22] |
Lactobacillus acidophilus Bacillus subtilis Lactobacillus bulgaricus Saccharomyces cerevisiae | C. gariepinus | Increases larval survival | [43] |
Bacillus megaterium, Bacillus polymyxa Lactobacillus delbrueckii | Oreochromis sp. | Increased the performance of zootechnical parameters | [42] |
Enterococcus casseliflavus | Oncorhynchus mykiss. | Capability of improving growth performance and enhancing disease resistance by inmunomodulation | [62] |
Pseudoalteromonas sp. | Fish | Inhibitory activity against fish pathogens | [63] |
Pseudoalteromonas sp. Cepa MLms gA3 | Fish | Inhibitory activity against the pathogen V. anguillarum | [48] |
Bacillus sp. Pediococcus sp. | Solea senegalensis | Improvement protection against pathogen outbreaks and | [64] |
Lactobacillus plantarum (LP20) | Seriola dumerili | Improves immune response and stress | [65] |
Lactobacillus mesenteroides SMM69 Weissella cibaria P71 | Scophthalmus maximus L. | Antimicrobial activity against the turbot pathogens T. maritimum and V. splendidus | [66] |
Bacillus subtilis Bacillus licheniformis Bacillus sp. Pediococcus sp. | Oreochromis sp. | Resistance to S. agalactiae | [67] |
Enterococcus faecalis | Oncorhynchus mykiss | Favoring growth, stimulation of the immune system and protection of diseases | [68] |
Bibliographic review of research published in the last 5 years (2013–2017) on the use of probiotics in aquaculture of marine fish.
From this literature review, we can highlight the novel investigations carried out in Oncorhynchus mykiss, Seriola dumerili, and Sparus aurata in which it is shown that the probiotics of the genera Bacillus, Lactobacillus, and Enterococcus have the capacity to influence the immune system. In this regard, the most widely used probiotics in aquaculture are Bacillus and Lactobacillus because they have better yield in feed conversion, growth rate, weight gain [22, 42, 43], increase in digestive activity [44], increase in the growth performance of the fish [45], immunostimulant [46] and antagonistic activity against Vibrios [47]. In addition, according to the literature, it is common to find probiotics of the genus Pseudoalteromonas sp. [48, 49]. However, this genus has not yet been explored at the biotechnological level. On the other hand, there are probiotic strains of the genus Kocuria and Rhodococcus, which have shown a great resistance to the antibiotics and are able to produce extracellular enzymes [50]. This bibliographic review allows us to verify that the study of probiotics for use in fish aquaculture is an issue of current interest. The use of specific probiotics will allow controlling organism diseases, water quality of culture, improve survival, and in this way develop a sustainable aquaculture production avoiding the use of antibiotics.
In this section, we will introduce the results of research carried out in our laboratory regarding the use of probiotics in S. lalandi larvae. This study emerged with the interest of promoting the cultivation of this species in northern Chile, an area not yet developed on an industrial scale.
The yellowtail S. lalandi is a marine species of high commercial demand. However, this species have persistent difficulties with respect to larval survival. Based on the bibliographic background of the benefit of probiotic bacteria in larval fish culture, we isolated and identified bacteria from the gonads microbiota of S. lalandi juvenile. The results showed that 42% belong to the genus Pseudoalteromonas of the total isolated bacteria (46 strains), nine of which had inhibitory activity against pathogenic bacteria. Of these, Pseudoalteromonas sp. (SLP1-MESO) presented inhibitory activity against Yersinia ruckeri (35 mm inhibition halo by Dopazo technique) (Figure 4) and was the only one that was negative for hemolysis, proteolysis, and lipolysis. These properties make it a good candidate to use as a probiotic in the larval phase of fish culture, which can be incorporated into the fish through the food [63].
From left to right, juvenile S. lalandi used for isolation of Pseudoalteromonas sp. (SLP1-MESO) image of inhibitory activity by the Dopazo technique observed from the probiotic and the pathogen interaction.
In order to evaluate the effect of the probiotic potential of Pseudoalteromonas sp., isolated from Seriola specimens, this bacterium was added as a probiotic supplement in the culture of S. lalandi larvae. For this, larvae of S. lalandi cultivated in ponds of 450 lt were fed with rotifers (B. rotundiformis and B. plicatilis) and Artemia sp., which were previously fed with microalgae Nannochloropsis gaditana supplemented with the probiotic Pseudoalteromonas sp. (SLP1-MESO). The results showed that rotifers and Artemia were good vectors of probiotics because S. lalandi larvae fed probiotic supplement that had higher survival (Figure 5) and length than control at the end of the experiment. These findings show that the probiotic Pseudoalteromonas sp. is a good candidate for use in larval cultures of S. lalandi [54].
Evaluation of the survival at day of S. lalandi larvae fed with probiotics. Supplemented with probiotic bacteria (treatment) and without probiotic bacteria (control). Bars represent ± standard error of the mean. (Figure obtained from Leyton et al. [54]).
In order to verify the probiotic effectiveness of Pseudoalteromonas sp., on a larger scale, it was evaluated that the survival of S. lalandi larvae cultured in a mesocosmos system (50 m3 Pool) in submerged cages whose cubic structure support (800 lt volume) was composed of PVC pipes and the walls and bottom by mesh (450 μm of Swiss nylon) inoculated S. lalandi larvae and fed with B. rotundiformis and B. plicatilis and Artemia sp., supplemented with the probiotic bacterium Pseudoalteromonas sp. (SLP1-MESO) and the microalga N. gaditana. The survival of the larvae was evaluated until before the change of diet from live food to pellet. The results showed that the addition of the N. gaditana microalgae rich in fatty acids and the probiotic bacterium Pseudoalteromonas sp. (SLP1-MESO) inoculated in live food of rotifers and Artemia improved the survival of S. lalandi larvae (Figure 6), making it a good dietary alternative to optimize larval survival of this species, being able to be applied to other crops of interest commercial [69].
Survival (%) of S. lalandi larvae grown in cages in mesocosmos systems. Significant differences were observed between bacteria supplemented with probiotic (treatment) and bacteria without probiotic (control) (t-test = 4.896, p < 0.05). Control: N. gaditana + B. rotundiformis + B. plicatilis + Artemia sp. + larvae. Treatment: N. gaditana + B. rotundiformis + B. plicatilis + Artemia sp. + Pseudoalteromonas sp. SLP1 + larvae. Bars represent ± standard error of the mean. (Figure obtained from Plaza et al. [69]).
The use of fixed biofilms meshes (Nylon Sefar Switzerland, 450 μm) was evaluated as a vector to incorporate specific microalga-probiotic food and as a biological control for the benefit of S. lalandi larvae. Biofilms were composed of a mixture of diatoms dominated by Navicula phyllepta and bacteria of the family Rhodobacteraceae that were previously isolated from biofilms formed in culture cages of S. lalandi larvae. In addition, these specific biofilms were tested with the addition of the probiotic Pseudoalteromonas sp. (SLP1-MESO). The meshes with biofilms were immersed in ponds of 200 lt; during 10 days, the consumption and larval survival were evaluated. The results showed that the larvae consumed 70% of the biomass at 72 h in treatment and control without any negative effects on larvae or significant differences. However, a positive survival effect was observed in the biofilms treatments with probiotics obtaining 31% of survival compared to 13% of the control (Figure 7). These results demonstrated that this pathway of probiotic entry could be a good alternative for improving the survival of S. lalandi larvae [56].
Survival of larvae at the end of the experiment in 200 lt tank. LP: larvae tank treated with probiotics and biofilm. Control: larvae tank with probiotics without biofilm. Data represent the mean and standard deviation of larvae for two replicate tanks for each condition and a triplicate mesh per tank in 400 lt tank and three replicate tanks for each condition and a triplicate mesh per tank in 200 lt tank. (Figure obtained from Mata et al. [55]).
Finally, the analysis of the results obtained in these four research works would indicate that the bacterium Pseudoalteromonas sp. (SLP1-MESO) isolated from gonads of healthy juveniles of S. lalandi, is a good candidate to be used as a probiotic in the initial larval stages of this species, that is, before the transition from live food to pellet. Our results supported the background of this chapter on the benefits of probiotic bacteria to improve the survival of fish larvae. The different investigations on probiotics in aquaculture have been validating their use to improve the survival of organisms in culture. Probiotic production will be necesary por the future of aquaculture industry.
The marine microbial world does not stop surprising us, for its varied potential beneficial to animal health. Based on the literature cited in this chapter, it is evident that the probiotic search for fish application is wide. However, research must be strengthening with new biotechnological processes that allow the mass production and application of probiotics on an industrial scale at an attractive cost. In order to advance in this area and transfer the results of the research from laboratory to the industry, we must overcome some non-minor gaps, such as the legal permit that involves working with living organisms for human consumption. Despite this, it is comforting the increase in worldwide support of respect to the use of probiotics, is becoming a trend in the search for natural solutions to care the environment and to take advantage of what nature offers us.
The authors of this chapter continue to concentrate their research on the application of probiotics in the larval phase of organisms of commercial importance such as fish, molluscs, and currently echinoderms. We have the complete conviction that our specific marine wealth, located in front of the most arid desert in the world, will provide us with the solution to optimize aquaculture in phase larval stages, which will allow to increase the sustainability of aquaculture activity in Chile and South America.
The authors are grateful to the projects D10I1050 and D10E1050 of Fondef—CONICYT for supporting our research.
Despite its well-protected position, the liver is the most frequently affected abdominal organ by blunt or penetrating trauma [1, 2]. Over the past decades, the improvements in the assessment and management of hepatic injury have evolved significantly, thus resulting in better outcomes for affected patients [3]. The majority of such injuries develop following high-energy traffic accidents or violent behaviors [4]. Industrial and farming accidents also consist of a significant percentage of liver trauma. Blunt injuries are the majority of cases in Europe, Australia, and Asia, whereas penetrating injuries (stab and gunshot wounds) are most frequently encountered in North America and South Africa [5, 6].
\nBlunt trauma, as a result of traffic accident or fall from a height, may lead to deceleration injury due to the inertia of the liver [4]. The affected sites usually involve the attachments to the diaphragm and abdominal wall. These types of injury typically involve the right lobe, especially the posterior segments, and the caudate lobe, while a vascular injury may also be present with the respective hepatic arteries, portal and hepatic veins being affected [4, 7, 8]. The site of connection between inferior vena cava and hepatic veins is vulnerable to blunt traumas and may lead to serious venous injuries and a significant blood loss. Penetrating injuries are more frequently associated with significant vascular injuries at the liver site inflicted [4]. In this chapter, we aimed to describe the classification and appropriate investigations of liver injuries and elaborate on the use of damage control surgery (DCS) in this setting.
\nThe liver is a wedge-shaped abdominal organ and is located in the right hypochondrium and epigastrium and may extend into the left hypochondrium [9, 10]. It is covered by fibrous Glisson’s capsule and is attached to the surrounding structures and the abdominal wall by several ligaments (falciform, coronary, triangular, hepatoduodenal and hepatogastric ligaments). It is divided into two lobes (right and left) by the falciform ligament, while two “accessory” lobes, the caudate and quadrate lobe, arise from the right lobe. The liver has unique double blood supply from the proper hepatic artery (25%) and portal vein (75%). Venous drainage is achieved through hepatic veins (right, middle, left) to the inferior vena cava.
\nThe Couinaud classification is the most widely used classification for functional liver anatomy [11]. It divides the liver into eight functionally independent segments, which have their own individual vascular supply and biliary drainage (Figure 1) [12]. A branch of the portal vein, hepatic artery, and bile duct are centrally located in each segment, while the vascular outflow to hepatic veins is located peripherally. Due to their functional independence, each segment can be safely resected without damaging the remaining liver parenchyma [13]. Nevertheless, the Couinaud classification system does not take into account the influence of vascular variations and does not provide liver surface landmarks for segment separation [14].
\nLiver functional anatomy – Couinaud classification system.
The liver segments are divided by portal vein branches and hepatic veins and are numbered clockwise [12]. The portal vein bifurcates at hepatic hilum into the left and right branches, which separate the liver into upper and lower segments. The right and left lobes are divided by middle hepatic vein, which runs along the Cantlie’s line from the inferior vena cava to the gallbladder fossa [15] Furthermore, the right hepatic vein divides the right lobe into anterior and posterior segments and left hepatic vein divides the left lobe into medial and lateral parts.
\nThe Caudate lobe (segment 1) is located posteriorly and often drains directly to inferior vena cava, while it can be supplied by both the right and the left portal vein branches, while segments II (superiorly) and III (inferiorly) are located medial to the left hepatic vein [16]. Segment IV (quadrate lobe) is located between the left and middle hepatic veins and is further divided by Bismuth into IVa (superiorly) and IVb (inferiorly) [17]. The anterior segments of the right hemiliver, V (inferiorly) and VIII (superiorly) lie between the middle and right hepatic veins, while the posterior right hemiliver segments, VI (inferiorly) and VII (superiorly), are located lateral to the right hepatic vein.
\nThe American Association for the Surgery of Trauma (AAST) grading scale is widely utilized for the classification of liver injury severity (Table 1) [18, 19]. However, it does not take into consideration the hemodynamic status of patients and the associated injuries. Thus, the World Society of Emergency Surgery (WSES) proposed a novel classification for the proper management of hepatic injuries involving AAST grade (1994 revision), hemodynamic stability, and mechanism of injury (Table 2) [2, 20].
\nAAST grade | \nInjury description | \n
---|---|
I | \nSubcapsular hematoma <10% of surface | \n
Parenchymal laceration or capsular tear <1 cm depth | \n|
II | \nSubcapsular hematoma 10–50% of surface area; intraparenchymal hematoma, <10 cm diameter | \n
Parenchymal laceration 1–3 cm in depth or < 10 cm in length | \n|
III | \nSubcapsular hematoma >50% of surface area or expanding; ruptured subcapsular or parenchymal hematoma; intraparenchymal hematoma >10 cm in diameter | \n
Parenchymal laceration >3 cm in depth | \n|
Any liver vascular injury or active bleeding contained within liver parenchyma | \n|
IV | \nParenchymal disruption 25–75% of hepatic lobe | \n
Active bleeding extending beyond the liver parenchyma into the peritoneum | \n|
V | \nParenchymal disruption >75% of hepatic lobe | \n
Juxtahepatic venous injury including retroheaptic vena cava and major hepatic veins | \n
The American Association for the Surgery of Trauma (AAST) liver injury scale (2018 revision).
Grade is based on highest grade assessment made during imaging, intraoperatively or pathologic specimen.
Advance one grade for multiple injuries up to grade III.
\n | WSES grade | \nAAST grade\n*\n\n | \nMechanism of Injury | \nHemodynamic status | \nCT-scan | \nFirst-line treatment | \n
---|---|---|---|---|---|---|
MINOR | \nI | \nI-II | \nBlunt/penetrating | \nStable | \nYES + local exploration in stab wounds | \nNOM + clinical/laboratory/radiological evaluation | \n
MODERATE | \nII | \nIII | \nBlunt/penetrating | \nStable | \n||
SEVERE | \nIII | \nIV-V | \nBlunt/penetrating | \nStable | \n||
IV | \nI-VI | \nBlunt/penetrating | \nUnstable | \nNO | \nSurgery | \n
The World Society of Emergency Surgery (WSES) classification and management of liver trauma.
American Association for the Surgery of Trauma (AAST) liver injury scale (1994 revision).
NOM: non-operative management.
Minor (WSES grade I) and moderate (WSES grade II) liver injuries concern hemodynamically stable patients after either blunt or penetrating trauma with AAST grade I-II or III lesions, respectively. Severe hepatic injuries include hemodynamically stable, AAST grade IV-VI lesions following penetrating or blunt trauma (WSES grade III) (Figure 2) or any hemodynamically unstable lesion (WSES grade IV).
\nComputed tomography scan demonstrating a severe liver injury.
The importance of the WSES classification and management approach is highlighted by the fact that patients suffering from high-grade AAST lesions, which are hemodynamically stable, can be successfully treated non-operatively [21]. On the contrary, “minor” AAST injuries combined with hemodynamic instability must be treated operatively in order to control the intrabdominal bleeding [20].
\nA liver injury should always be suspected in all patients suffering from a blunt or penetrating thoracoabdominal trauma, especially at the right site. Initial management of these patients should be based on the Advanced Trauma Life Support (ATLS) guidelines with fluid resuscitation and close monitoring being the first priorities [22]. Depending on the underlying injury mechanism, other concurrent injuries should also be evaluated and treated accordingly. The management of multi-trauma patients should take into consideration all the affected organs, and a multidisciplinary team is essential for the optimal treatment approach of these patients.
\nAs far as hepatic trauma is concerned, in hemodynamically unstable patients, despite adequate fluid resuscitation, an immediate operation for bleeding control is indicated, whereas in stable patients, an appropriate workup protocol using ultrasonography or computerized tomography scanning (CT) can be followed. Hemodynamic instability is characterized by the following: heart rate > 120 bpm, systolic blood pressure < 90 mmHg, low urine output, increased respiratory rate (>30 respirations/minute), signs of skin vasoconstriction and altered level of consciousness [22]. Non-operative management necessitates medical centers capable of an accurate injury severity diagnosis, intensive management of patients, and prompt access to diagnostic modalities, interventional radiology, operation theater, and blood–blood products [20, 23].
\nUltrasound plays a significant role in the proper investigation of abdominal injuries. Focused Assessment with Sonography for Trauma (FAST) can be performed immediately at the emergency department and can help assess the pericardium, hepatorenal space (Morison’s pouch), perisplenic space and Douglas pouch to identify the presence of free fluid [22]. More detailed ultrasonography by an experienced radiologist is necessary for a more accurate investigation of liver parenchyma. Ultrasonography has widely replaced diagnostic peritoneal lavage (DPL) and has a high specificity of 95–100% [24]. Nevertheless, ultrasound examination is highly operator-depended and should be performed by experienced clinicians.
\nComputerized tomography (CT) scan is a valuable tool for the evaluation of stable patients with an abdominal injury [25]. A contrast-enhanced, multi-slice CT scan is reported to have a sensitivity and specificity of over 95% for detecting liver injuries [26, 27]. Subscapular and intraparenchymal hematomas, lacerations, and vascular injuries can be recognized. Furthermore, an active hemorrhage can be visualized as an extravasation of contrast medium. A CT scan can also successfully elucidate other abdominal injuries involving the spleen, kidneys, and bowel [26]. Finally, a follow-up CT scan can be utilized for the detection of delayed liver injury complications, including delayed hemorrhage, bile leak, biloma, arteriovenous malformations, and liver abscesses [4, 28].
\nDamage control surgery refers to the immediate steps taken in order to reduce blood loss, the risk of sepsis, morbidity, and mortality instead of a thorough patient workup in the intensive care unit (ICU) [29]. DCS has significantly improved the outcomes of patients presenting at the hospital with severe organ injuries, including liver injuries, and hemodynamic instability due to maneuvers to control the bleeding [1]. Uncontrolled bleeding can lead to coagulopathy secondary to the dilution and depletion of the coagulation factors, hypothermia, and acidosis, the so-called “lethal triad” or “medical bleeding” [21]. The onset of this series of events may necessitate the need for DCS, including temporary (perihepatic) packing of the bleeding sites, where physiological recovery is prioritized over anatomical repair [30].
\nThe earliest report on perihepatic packing to prevent uncontrolled bleeding from injuries to the liver dates back to 1908 by James Pringle [31], while later in 1913, Halstead described the use of a rubber sheet between the injured liver and the gauze packs [32]. Despite the improvements in outcomes, perihepatic packing was sparsely described in the literature [33] until Stone et al. [34] reported a survival rate of 76% in patients managed with “truncated laparotomy” compared to 7% in patients managed with definitive surgical repair. Rotondo et al. [35] introduced the term “damage control laparotomy” and demonstrated that this approach could improve survival in hemorrhaging trauma patients (requiring transfusion of >10 units of packed red blood cells) with multiple visceral penetrating injuries and major vessel injuries. The authors described the three steps of their approach, and the same research group later modified it by introducing a fourth pre-operative phase (Table 3) [36]. Since then, DCS has been successfully implemented for the management of major liver injury with optimal outcomes. The use of angioembolization in more recent series has been proposed as the logical augmentation of damage control approaches to control bleeding, but particularly in the case of high-grade injuries, it may lead to major hepatic necrosis [37].
\nDamage control (DC) Phase | \nDescription | \n
---|---|
DC0 | \n\n
| \n
DCI | \n\n
| \n
DCII | \n\n
| \n
DCIII | \n\n
| \n
The four Phases of damage control for exsanguinating penetrating abdominal injury by Johnson et al.
As mentioned earlier, DCS can play a vital role in the setting of the “lethal triad” and thus metabolic acidosis (pH <7.2), hypothermia (<34°C), and coagulopathy (prolonged activated partial thromboplastin time and prothrombin time > two times normal) constitute absolute indications for DCS. Uncontrolled major intra-abdominal bleeding, association with extra-abdominal injury, >10 units of blood transfusion, and hemodynamic instability (low blood pressure and tachycardia) are relative indications for DCS [29].
\nDC0 constitutes the first phase of the DCS process and takes place in the pre-hospital setting and in the emergency room. The most crucial aspects of this phase are injury pattern recognition in order to determine which patients will most likely benefit from DCS according to the absolute and relative indications, and the “scoop and run” concept to truncate scene times. The administration of blood products and tranexamic acid in the pre-hospital setting has been increasingly used [38, 39]. Given the significant improvements in trauma resuscitation strategies aiming at rapid bleeding control, management of coagulopathy, and diversion away from the over-resuscitation with crystalloids, the use of DCS may be required to a lesser extent in the future [40–42]. There is a growing body of evidence that the use of a high plasma to packed red blood cell ratio can lead to a decrease in hemorrhage-related mortality [43]. French lyophilized plasma – manufactured by the French Military Blood Institute – is a universal therapeutic viro-inactivated plasma that can be reconstituted in <6 min at the point-of-care and is compatible with any blood type [44]. Data suggest that French lyophilized plasma can be used more rapidly correct for the trauma-induced coagulopathy compared to fresh frozen plasma, particularly in the military setting [45]. Its role against normal saline in the management of post-traumatic coagulopathy prevention and correction in the pre-hospital civilian setting is currently under investigation (PREHO-PLYO study) [46], and it is awaited to revolutionize the current state of practice for the management of severe trauma, including liver injury.
\nOnce the patients reach the emergency room, immediate assessment by the trauma team and damage control resuscitation is vital. The surgical and critical care teams should strive towards obtaining vascular access with two large-bore catheters, inserting nasogastric tube and urinary catheter (unless there is blood at the urethral meatus, high riding prostate or prevalent perineal hematoma), rapid induction of anesthesia, drainage of the chest (if needed), intravenous broad-spectrum antibiotics and tetanus prophylaxis (if indicated), rapid rewarming and prevention of further hypothermia, and expedited transport to the operating room for DCS [30].
\nDCI starts with the exploratory laparotomy, which aims to control bleeding and limit contamination, and ends with the temporary closure of the abdominal wall. After the patient is positioned in a “cruciform” lie, the patient is prepped from chin to mid-thighs and a vertical midline incision from the xiphoid process to the pubic symphysis is made [30]. If the suspicion for a severe fracture of the pelvis is high, the incision should be limited just below the umbilicus to facilitate continuous tamponade of the suspected pelvic hematoma. If the patient is unstable, the incision should not be delayed if arterial or venous lines are not in place; these can be inserted during the operation.
\nIf the observed intra-abdominal bleeding is not considered to be major, compression on its own or the use of topical hemostatic agents, bipolar devices or electrocautery, argon beam coagulation, omental patching or even simple suturing of the liver parenchyma may be adequate to control the hemorrhage [2, 20, 47–49]. In the case of massive intra-abdominal hemorrhage, more aggressive maneuvers should be adopted, including perihepatic packing and manual compression, or even hepatic vascular isolation (i.e., intrahepatic balloon tamponade) [50, 51]. Injuries to the portal vein should be primarily repaired, while ligation of the portal vein should be considered only as an alternative – provided that the proper hepatic artery is intact – due to the increased risk of hepatic necrosis or massive intestinal edema [47]. Data suggest preferring liver packing or resection over portal vein ligation if only lobar or segmental branches of the portal vein are injured [2, 47, 52]. However, portal vein ligation is safer than arterial ligation regarding biliary complications or hepatic necrosis, and may even prepare the liver for staged extended liver resection [53]. If the surgeon comes across a proper hepatic artery injury, they should shoot for a primary repair; otherwise, selective hepatic artery ligation should be preferred, and if the common or right hepatic artery is to be ligated, cholecystectomy should follow to prevent gallbladder necrosis [1, 52]. When arterial control or the Pringle maneuver is inadequate to control the hemorrhage, the surgeon should suspect that there might be an aberrant hepatic artery [47]. If the bleeding arises from the area behind the liver, the injury is most likely to be found on the hepatic or retro-hepatic caval vein [2, 47, 54]. Inserting vascular shunts (i.e., atrio-caval shunt) might also be useful to control hemorrhage [29, 47]. In case of persistent bleeding and hemodynamic instability, resuscitative endovascular balloon occlusion of the aorta in the zone I and of the vena cava at the level of the retro-hepatic vena cava can serve as a bridge to more definitive procedures [47]. Liver resection should be avoided at this phase, but if absolutely necessary, non-anatomic resections should be preferred [2, 47, 48, 52], while resection of a hemorrhaging spleen or kidney can be performed, if needed in order to stop the bleeding [29]. Angioembolization should be advocated for either stable patients after the initial surgical hemostatic attempt or adjunctively in case of suspected uncontrolled bleeding despite the surgical hemostatic attempt [2, 47, 55]; data also suggest that its routine implementation immediately after DCS can significantly improve survival in grade IV or V liver injury [56]. Regarding contamination control, intrahepatic abscesses can be managed with percutaneous drainage, and bilomas may either resolve spontaneously or should also be managed with percutaneous drainage potentially with adjunct therapeutic endoscopic retrograde cholangiopancreatography and stent placement [47]. Abdominal wall closure is the final step before transitioning to DCII (transfer to the ICU) and should be only temporary without fascial closure to avoid abdominal compartment syndrome [30].
\nDCII involves taking the patient to the ICU postoperatively, where the goal is to restore the biochemical and physiological derangements. Managing fluid administration to bring the patient back to hemodynamic stability is often achieved through invasive monitoring (i.e., transthoracic echocardiography, transesophageal Doppler, pulmonary artery catheterization, etc.) [30]. Securing adequate oxygenation and aggressive rewarming of the patient are also necessary. The management of coagulopathy is crucial for survival, and the use of rotational thromboelastometry and other tests to assess how the coagulation cascade works along with massive blood transfusion practices have led to an improvement in outcomes and a decrease in blood transfusion requirements [30, 57]. Prevention of potentially fatal complications commonly seen in the ICU, including infection, adult respiratory distress syndrome, and deep vein thrombosis, is also important for patient survival [29]. This is the perfect opportunity for treating physicians to perform a complete reassessment of the patient and a “tertiary survey”, including imaging studies that may help identify previously unknown injuries.
\nDCIII involves definite repair of the injuries once the patient is stabilized and has returned to his “physiologic normality” and commonly takes place within 24–72 hours after admission to the ICU. The patient is taken back to the operating room for re-exploration and packing removal (preferably after 48 hours) [21]. That is also the stage when an anatomic liver resection may be performed (Figure 3), along with the removal of devitalized tissue or vascular shunts, anastomosis of vessels or bowel, or even a feeding jejunostomy. The phase ends with the permanent closure of the abdominal wall. This should be performed with the approximation of the fascial edges if gentle adduction permits; if this is not possible due to retroperitoneal or bowel wall edema, then the abdominal wall should be again only temporarily closed with the fascia left open. In that scenario, the patient is taken back to the ICU and provided the patient is hemodynamically stable, administration of diuretics to decrease the bowel edema should be considered [30]. This situation should then be managed with washouts and re-inspection of the abdomen regularly, while primary closure should be completed within seven days, particularly in the absence of signs of infection. Other abdominal closure alternatives should be considered if this is not possible. This will lead to a large ventral hernia that will require repair at some future time point [30].
\nSurgical management of severe liver injury with active bleeding.
Immediate resuscitation and DCS play a critical role in the outcomes of trauma patients in general, and particularly in those with severe liver injuries where the exsanguination of large amounts of blood is common. The decrease in the time from the scene to hospital and taking, the implementation of massive transfusion protocols, and the improvements in the approaches to control bleeding and contamination intraoperatively by leaving major resections for a later phase have revolutionized the outcomes after liver trauma over the past decades. The advents of pre-hospital care are awaited to change the need for DCS in the future.
\nThe Internet has irrevocably changed the dynamics of scholarly communication and publishing. Consequently, we find it necessary to indicate, unambiguously, our definition of what we consider to be a published scientific work.
",metaTitle:"Prior Publication Policy",metaDescription:"Prior Publication Policy",metaKeywords:null,canonicalURL:"/page/prior-publication-policy",contentRaw:'[{"type":"htmlEditorComponent","content":"A significant number of working papers, early drafts, and similar work in progress are openly shared online between members of the scientific community. It has become common to announce one’s own research on a personal website or a blog to gather comments and suggestions from other researchers. Such works and online postings are, indeed, published in the sense that they are made publicly available. However, this does not mean that if submitted for publication by IntechOpen they are not original works. We differentiate between reviewed and non-reviewed works when determining whether a work is original and has been published in a scholarly sense or not.
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\\n"}]'},components:[{type:"htmlEditorComponent",content:'A significant number of working papers, early drafts, and similar work in progress are openly shared online between members of the scientific community. It has become common to announce one’s own research on a personal website or a blog to gather comments and suggestions from other researchers. Such works and online postings are, indeed, published in the sense that they are made publicly available. However, this does not mean that if submitted for publication by IntechOpen they are not original works. We differentiate between reviewed and non-reviewed works when determining whether a work is original and has been published in a scholarly sense or not.
\n\nThe significance of Peer Review cannot be overstated when it comes to defining, in our terms, what constitutes a published scientific work. Peer Review is widely considered to be the cornerstone of modern publishing processes and the key value-adding contribution to a scholarly manuscript that a publisher can make.
\n\nOther than the issue of originality, research misconduct is another major issue that all publishers have to address. IntechOpen’s Retraction & Correction Policy and various publication ethics guidelines identify both redundant publication and (self)plagiarism to fall within the definition of research misconduct, thus constituting grounds for rejection or the issue of a Retraction if the work has already been published.
\n\nIn order to facilitate the tracking of a manuscript’s publishing history and its development from its earliest draft to the manuscript submitted, we encourage Authors to disclose any instances of a manuscript’s prior publication, whether it be through a conference presentation, a newspaper article, a working paper publicly available in a repository or a blog post.
\n\nA note to the Academic Editor containing detailed information about a submitted manuscript’s previous public availability is the preferred means of reporting prior publication. This helps us determine if there are any earlier versions of a manuscript that should be disclosed to our readers or if any of those earlier versions should be cited and listed in a manuscript’s references.
\n\nSome basic information about the editorial treatment of different varieties of prior publication is laid out below:
\n\n1. CONFERENCE PAPERS & PRESENTATIONS
\n\nGiven that conference papers and presentations generally pass through some sort of peer or editorial review, we consider them to be published in the accepted scholarly sense, particularly if they are published as a part of conference proceedings.
\n\nAll submitted manuscripts originating from a previously published conference paper must contain at least 50% of new original content to be accepted for review and considered for publication.
\n\nAuthors are required to report any links their manuscript might have with their earlier conference papers and presentations in a note to the Academic Editor, as well as in the manuscript itself. Additionally, Authors should obtain any necessary permissions from the publisher of their conference paper if copyright transfer occurred during the publishing process. Failure to do so may prevent Us from publishing an otherwise worthy work.
\n\n2. NEWSPAPER & MAGAZINE ARTICLES
\n\nNewspaper and magazine articles usually do not pass through any extensive peer or editorial review and we do not consider them to be published in the scholarly sense. Articles appearing in newspapers and magazines rarely possess the depth and structure characteristic of scholarly articles.
\n\nSubmitted manuscripts stemming from a previous newspaper or magazine article will be accepted for review and considered for publication. However, Authors are strongly advised to report any such publication in an accompanying note to the External Editor.
\n\nAs with the conference papers and presentations, Authors should obtain any necessary permissions from the newspaper or magazine that published the work, and indicate that they have done so in a note to the External Editor.
\n\n3. GREY LITERATURE
\n\nWhite papers, working papers, technical reports and all other forms of papers which fall within the scope of the ‘Luxembourg definition’ of grey literature do not pass through any extensive peer or editorial review and we do not consider them to be published in the scholarly sense.
\n\nAlthough such papers are regularly made publicly available via personal websites and institutional repositories, their general purpose is to gather comments and feedback from Authors’ colleagues in order to further improve a manuscript intended for future publication.
\n\nWhen submitting their work, Authors are required to disclose the existence of any publicly available earlier drafts in a note to the Academic Editor. In cases where earlier drafts of the submitted version of the manuscript are publicly available, any overlap between the versions will generally not be considered an instance of self-plagiarism.
\n\n4. SOCIAL MEDIA, BLOG & MESSAGE BOARD POSTINGS
\n\nWe feel that social media, blogs and message boards are generally used with the same intention as grey literature, to formulate ideas for a manuscript and gather early feedback from like-minded researchers in order to improve a particular piece of work before submitting it for publication. Therefore, we do not consider such internet postings to be publication in the scholarly sense.
\n\nNevertheless, Authors are encouraged to disclose the existence of any internet postings in which they outline and describe their research or posted passages of their manuscripts in a note to the Academic Editor. Please note that we will not strictly enforce this request in the same way that we would instructions we consider to be part of our conditions of acceptance for publication. We understand that it may be difficult to keep track of all one’s internet postings in which the researcher´s current work might be mentioned.
\n\nIn cases where there is any overlap between the Author´s submitted manuscript and related internet postings, we will generally not consider it to be an instance of self-plagiarism. This also holds true for any co-Author as well.
\n\nFor more information on this policy please contact permissions@intechopen.com.
\n\nPolicy last updated: 2017-03-20
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