\\n\\n
Released this past November, the list is based on data collected from the Web of Science and highlights some of the world’s most influential scientific minds by naming the researchers whose publications over the previous decade have included a high number of Highly Cited Papers placing them among the top 1% most-cited.
\\n\\nWe wish to congratulate all of the researchers named and especially our authors on this amazing accomplishment! We are happy and proud to share in their success!
Note: Edited in March 2021
\\n"}]',published:!0,mainMedia:{caption:"Highly Cited",originalUrl:"/media/original/117"}},components:[{type:"htmlEditorComponent",content:'IntechOpen is proud to announce that 191 of our authors have made the Clarivate™ Highly Cited Researchers List for 2020, ranking them among the top 1% most-cited.
\n\nThroughout the years, the list has named a total of 261 IntechOpen authors as Highly Cited. Of those researchers, 69 have been featured on the list multiple times.
\n\n\n\nReleased this past November, the list is based on data collected from the Web of Science and highlights some of the world’s most influential scientific minds by naming the researchers whose publications over the previous decade have included a high number of Highly Cited Papers placing them among the top 1% most-cited.
\n\nWe wish to congratulate all of the researchers named and especially our authors on this amazing accomplishment! We are happy and proud to share in their success!
Note: Edited in March 2021
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It is estimated that 40% of women and 12% of men will experience a symptomatic UTI, with incidences peaking in their early 20s or after age 85, respectively (1). Approximately 25% of these women will experience recurrence within 6 to 12 months (1). Uropathogenic
Despite significant advances in the understanding of UPEC biology, mechanistic details regarding the host response to UTI and full comprehension of genetic loci that influence susceptibility require additional work. As new and intriguing details of how uropathogens initiate infections and persist within the urinary tract have emerged, so has important information regarding how the immune system functions within the urinary tract. The complex cross-linking for innate and adaptive immune response as well as humoral and cellular effectors is the key to the urinary tract immune system and to its defense against pathogenic microorganisms. As antibiotic therapy becomes increasingly ineffective, modulating the innate and adaptive immune system in the urinary tract using TLR4 ligands and other immunomodulators may become viable options to combat UTIs.
\n\t\tUroepithelial adherence is critical for establishment of UTI. The urinary tract, comprised of the urethra, bladder, ureters and the kidneys, represents a formidable mechanical barrier to infection. In addition to the relative impregnability of the epithelium lining the tract, potential pathogens have to contend with the powerful flushing action of urine and the aggregating actions of urinary mucins (2;3). UPEC strains possess an impressive repertoire of adhesins that enable them to aggregate and adhere to cellular surfaces (4). Consequently, the first line of host defense against UTI is concentrated on preventing UPEC adherence to the bladder mucosa. The luminal surface of the bladder is lined with highly sulfated and anionic glycosaminoglycans (GAGs) that contribute to bladder wall impermeability and afford an antimicrobial anti-adherence property. Intuitively, urine flow seems to be a convenient defense mechanism; however, FimH binds to mannose moieties using “catch-bonds,” interactions that are actually strengthened by the sheer stress induced during urine flow (5). Thus, more active mechanisms, like umbrella cell exfoliation (6) that occurs by an apoptosis-like mechanism and is promoted by FimH (7) remove adherent UPEC. Tamm-Horsfall protein (THP) is a high-molecular-weight protein present in human urine (8) that binds E. coli fimbriae (9) by virtue of its mannose moieties, inhibiting fimbrial interaction with uroplakin receptors (10). This phenotype translated in vivo as thp−/− mice were unable to control lower-UTI (11). THP also appears to act as an innate-adaptive immunoregulatory molecule that can activate dendritic cells (12).
\n\t\t\tOf the various immune surveillance molecules the Toll-like receptor (TLR) family is the best characterized (13-16). Unlike the receptor for the FimH adhesin of UPEC, which promotes bacterial invasion and subsequent invasion of BECs (17), the TLRs function by detecting different PAMPs and then mobilizing appropriate immune defences. The common TLRs encountered in the urinary tract include TLR2 (recognizes bacterial lipoteichoic acid or lipoprotein), TLR3 (recognizes double stranded RNA), TLR4 (recognizes lipopolysaccharides (LPS)), TLR5 (recognizes flagellin), TLR9 (recognizes unmethylated CpG DNA of bacteria and viruses), and TLR11 (recognizes profiling of parasites). TLR5 and TLR11 are other TLRs shown in
Toll-like receptor 4 (TLR4) is important for signalling of innate immunity in response to UTI
\n\t\t\t\tUpon successful adherence to the uroepithelium, Toll-like receptor (TLR) recognition of pathogen-associated molecular patterns generates signaling cascades to control infection and direct adaptive responses (18). Particular close attention has been given to the role of TLR4 in UTIs. LR4 mutation (TLR4-/-) mice failed to initiate an immune response against UTI, and they developed an asymptomatic carrier state resembling human asymptomatic bacteriuria (ABU) (19). Interestingly, recent studies have shown that TLR4 has antimicrobial roles that appear to be specific to the urinary tract (20) (21). These include promotion of IL-6 and IL-8 secretion by activation of the MyD88- or cAMP-dependent signaling pathway, inhibition of bladder epithelial cell (BEC) invasion by bacteria, and expulsion of UPEC harboring in BECs (21-24). Clinical research found that children with UTI have lower TLR4 expression than age-matched controls without UTI. In relation to UTI history, children with low TLR4 expression on their neutrophils display an asymptomatic bacteriuria (ABU) carrier state lacking both inflammation and bacterial clearance (25). Meanwhile, adult patients with chronic UTI were found to have lower TLR4 expression than healthy controls without UTI (26). All these imply that enhanced TLR4 expression possibly contributes to increased mucosal immune response.
\n\t\t\t\tIt has been known that C3H/HeJ mice, harboring a mutation in the Toll/interleukin-1 receptor (TIR) domain of TLR4, cannot resolve UTI as efficiently as LPS-responsive C3H/HeN counterparts (27). In accordance, tlr4−/− mice had significantly higher bacterial burdens in their bladders than similarly infected wild-type mice (28). This clearance defect is the result of insufficient downstream cytokine and chemokine production and neutrophil recruitment (29). Data from mouse chimeras disclosed that TLR4 on both stromal and hematopoietic cells is critical for normal inflammatory responses and clearance of UPEC in the bladder and kidney (30). Correspondingly, children with low TLR4 expression on their neutrophils display an asymptomatic bacteriuria (ABU) carrier state lacking both inflammation and bacterial clearance (25). A similar response is exhibited by C3N/HeJ mice following UPEC inoculation (31).
\n\t\t\t\tTLR4-mediated signaling is mainly LPS independent
\n\t\t\t\tTLR4-mediated signaling in the urinary tract does not appear to be the result of the archetypal interaction with LPS. Both the role of LPS in and the molecular trigger of TLR4 signaling by UPEC are topics of debate (32). Studies using the A498 human kidney cell line indicate that TLR4 signaling in response to UPEC requires P fimbriae and can be mediated independently of LPS (33). Mechanistic details regarding this phenomenon include P fimbriae binding to surface glycosphingolipids (GSLs) and subsequent release of the GSL membrane-anchoring domain, ceramide (34). Ceramide appears to act as a TLR4 agonist and the putative intermediate for TLR4 signaling initiated by P fimbriae (34). Lastly, the FimH tip adhesin of type 1 fimbriae was recently shown to directly interact with TLR4, an additional means for LPS-independent stimulation by UPEC fimbriae (35)
\n\t\t\t\tTLR4-mediated signaling is also LPS dependent
\n\t\t\t\tIn contrast to LPS-independent signaling by P fimbriae, there appears to be a cooperative stimulation of TLR4 by LPS and type 1 fimbriae (36). This cooperative stimulation directly correlates with the level of cluster of differentiation 14 (CD14) expression on bladder cells (24). CD14 is an accessory molecule required for optimal TLR4 signaling in response to LPS (24). Immunohistochemical (IHC) analysis of human bladder biopsies revealed that CD14 expression is localized to the submucosa (37), suggesting that uroepithelial cells exposed to the lumen have little to no CD14 expression and therefore may not respond efficiently to LPS alone. These results support a role for both independent and cooperative TLR4 stimulation by UPEC fimbriae.
\n\t\t\t\tDownstream signalling pathways important for signalling of innate immunity in response to UTI
\n\t\t\t\tInfection of knockout mice has revealed critical roles for myeloid differentiation primary response protein 88 (MyD88), TIR domain-containing adaptor inducing beta interferon (TRIF), and TRIF-related adaptor molecule (TRAM) in signaling for UPEC clearance (38). It is also apparent that different fimbrial types influence the corresponding downstream signaling pathways (38). Regardless of the fimbria involved in stimulation, all pathways involving these adaptor molecules result in activation of NF-κB and proinflammatory gene expression. Song and colleagues identified an accompanying proinflammatory bladder cell signaling pathway that is also dependent on TLR4 but results in a spike in intracellular calcium levels (39). This calcium spike leads to adenylyl cyclase 3 (AC3)-mediated increase in cAMP, protein kinase A (PKA) activation, phosphorylation of the cAMP response element-binding protein transcription factor (CREB), and proinflammatory gene expression such as transcription of IL-6 and IL-8 (39). Using selective blockade of these signaling cascades, Song et al. determined that activation of epithelial IL-6 secretion by
\n\t\t\t\t\t
Other TLR pathways have been implicated in host defense during UTI. In a recent case-control study of adult women with a history of UTI in which TLR genes were examined, polymorphisms in TLR1, TLR4, and TLR5 were correlated with protection from, or susceptibility to, some UTI phenotypes (40). TLR2 is stimulated by peptidoglycan, as might be presented by gram-positive uropathogens, including
\n\t\t\t\t\t
Surface molecules other than TLRs are also involved in host-UPEC interactions. Upon UPEC exposure, the cytoplasmic tail of uroplakin IIIa undergoes phosphorylation, and intracellular calcium levels increase, presumably important events for uroepithelial cell apoptosis and exfoliation(42) Although uroplakin Ia is thought to be the main receptor for UPEC FimH in vivo (167, 256, 286), type 1 fimbriae may bind to a number of host molecules, including uroplakin complexes (42) extracellular matrix proteins (43) CD molecules (44), and integrins (45). The CD44 ligand, hyaluronic acid (HA), accumulates in the urinary tract during UTI; UPEC can bind HA, thereby facilitating interaction with CD44 and tissue invasion (46). In accordance with this, cd44−/− mice are more resistant to UPEC kidney colonization and successive dissemination (46). Also, there are still unidentified players in inflammation and clearance of UPEC. For example, LPS-responder C3H/OuJ mice were found to be equally susceptible to UTI as non-LPS-responder C3H/HeJ mice yet demonstrated elevated levels of inflammation (47), revealing a susceptibility locus to map.
\n\t\t\tThat E. coli strains causing UTI have several functionally redundant systems dedicated to iron uptake (48) suggests that the urinary tract, like other host niches, is an iron-limited environment (49). Siderophores are secreted iron-chelating molecules that allow bacteria to scavenge free and host protein-bound iron (50). Enterobactin, for instance, can bind free ferric ions with a higher affinity than transferrin (51) a host iron transport protein responsible for regulating the free iron concentration in serum(52). A transferrin family member, lactoferrin, evokes antimicrobial activity by sequestering iron over a range of pH. Lactoferrin is secreted by kidney cells and is found in neutrophil granules and thus could be involved in combating UTI (53). Both transferrin and lactoferrin have been shown to evoke direct antimicrobial activity by disrupting Gram-negative membranes (54).
\n\t\t\t\tIn addition to iron sequestration, there are host factors that directly counter the action of siderophores. Early studies indicated that serum albumin, alone or in concert with other serum proteins, can impede bacterial siderophore function (55). In addition, the mammalian protein lipocalin 2 (Lcn2) can bind and sequester enterobactin and similar catecholate siderophores (56). Lcn2 inhibits enterobactin-dependent propagation of E. coli in vitro, and lcn2−/− mice are unable to control systemic E. coli burdens as well as wild-type mice (56) Production of Lcn2 is induced by TLR4, implicating iron regulation as a part of the immune response to infection(56). Murine GeneChip and quantitative PCR (qPCR) analyses confirmed that Lcn2 mRNA is upregulated by the uroepithelium of infected mice (57). Interestingly, these results were obtained in C3H/HeJ mice, indicating that a TLR4-independent signaling pathway can activate transcription of the lcn2 gene in response to UTI. Not surprisingly, UPEC has evolved a mechanism to counter Lcn2 siderophore sequestration. Encoded within the iroA gene cluster are glycosyltransferases that modify enterobactin in such a way that it cannot be bound by Lcn2 (58). Thus, both the host and UPEC have systems in place to manage their own iron stores and to inhibit iron acquisition by the other—a molecular arms race for an essential nutrient.
\n\t\t\tThe role for bacterial central metabolism during infection has only been recently appreciated (59). Genes important for glucose import were upregulated by the uroepithelium of C3H/HeJ mice experiencing UTI, possibly for either nutrient sequestration or energy to combat infection(57). This fact, coupled with the knowledge that UPEC does not chemotax toward glucose in vitro (60) or utilize glucose as a primary carbon source in vivo (61) implies that UPEC may have evolved to use alternative carbon sources in the urinary tract. These results imply that nutrient acquisition is also a crucial aspect of bacterial pathogenesis and the host response that may influence the outcome of UTI.
\n\t\t\tLife cycle of UPEC in urinary tract epithelium
\n\t\t\t\tThere has been a growing body of literature revealing that UPEC appears to have three distinct intracellular lifestyle components within the urinary tract (62). The first is uptake by apical endocytosis of Rab27b+/CD63+ fusiform vesicles, which are subsequently recycled back to the cell surface and exocytosed (20). The other two pathways both begin with uptake into a membrane-bound compartment which can lead to either a quiescent nonreplicative existence (63) or escape from compartmental life to undergo a highly replicative phase in the cell cytoplasm. While internalization via the fusiform vesicle pathway may be a side effect of normal bladder epithelium function, cellular uptake by the other two pathways is perhaps intended by UPEC to establish a reservoir to persist in the urinary tract (63). Indeed, UPEC has been shown to exist in the urinary tract for weeks, even after antibiotic treatment (64). Infection of 10 genetically distinct mouse strains also revealed that some strains were more susceptible to persistence than others, indicating that host hereditary components may also contribute to the ability of UPEC to persevere in the urinary tract (65).
\n\t\t\tInfected mouse bladder explants monitored by time lapse fluorescence videomicroscopy generated a model for the intracellular UPEC life cycle instigated after uptake in a membrane-bound compartment (nonfusiform vesicle route)(66). While the mechanism of compartmental escape remains undefined, once contained in cytoplasmic “intracellular bacterial communities” (IBCs), UPEC can undergo several changes in morphology, categorized as early, middle, and late IBC stages (66). Late IBCs that escape exfoliation with umbrella cells contain filamentous UPEC that are not present in C3H/HeJ mice, indicating that this morphological change may be a bacterial stress response to TLR4-mediated immune activation (66). This murine background also experienced increased incidence and severity of IBCs compared to immunocompetent mice (66). Urothelial cells proximal to IBCs in C3H/HeJ mice upregulate transferrin receptor, Lcn2, complement system components (C3, factor B, and CD55), and lysozyme (57). Involucrin and suprabasin transcripts were also increased, indicating that, in addition to gene products that function to eradicate bacteria, proteins important for epithelial integrity may be an imperative host response during UTI (57).
\n\t\t\t\tNotably, TLR4 also plays a noninflammatory role in host defense against UPEC by modulating the activity of the observed secretory and vesicular internalization pathways. TLR4-mediated PKA activation suppresses the lipid raft endocytic pathway (21), a possible effort to prevent the establishment of persistence reservoirs. Also along these lines, UPEC exocytosis in fusiform vesicles was actually accelerated by TLR4-mediated recognition of LPS and dependent on the activities of cAMP, Rab27b, caveolin-1, and the scaffolding protein MyRIP (22).
\n\t\t\t\tThe role of urothelial regeneration in response to UPEC infection
\n\t\t\t\tOne of the consequences of UPEC infection is exfoliation of the superficial facet cell layer that lines the surface of the bladder lumen (67). Microarray analyses probing regenerative signals revealed that, in addition to genes involved in cell biological processes, inflammatory cytokines, chemokines, signaling molecules, and transcription factors are also upregulated in response to inoculation (68). While regeneration itself appears to be a function of basal stem/progenitor cells in the transitional epithelium (68) studies of the gut epithelium unveiled macrophages as “cellular transceivers” that relay MyD88-dependent inputs from the epithelium to colonic epithelial progenitors via direct contact (69). Whether or not macrophages play a similar role in the urinary tract remains unknown.
\n\t\t\tAntimicrobial peptides (AMPs) are short positively charged peptides secreted by both epithelial and hematopoietic cells that disrupt bacterial membranes and can be chemotactic for certain immune cells (70). Human β-defensin-1 mRNA and protein were found in kidney tissue, implicating this AMP in host defense against UPEC (71). More convincingly, mice deficient in defb1, a murine homolog of human β-defensin, have a significantly higher incidence of bacteriuria (72). Murine β-defensin is also a dendritic cell (DC) ligand that instigates upregulation of costimulatory molecules and maturation (73). The human cathelicidin, LL-37, and its murine homolog, cathelin-related antimicrobial peptide (CRAMP), are secreted in response to UPEC exposure (44). Studies using CRAMP-deficient mice revealed that epithelial-derived CRAMP is important during the early stages of UTI while leukocyte-derived CRAMP likely functions later when bacteria penetrate the kidney epithelium (46).
\n\t\t\tThe role of IL-8-mediated neutrophil recruitment in phenotypic susceptibility to UTIs
\n\t\t\t\tHuman C-X-C ligand 8 (hCXCL8; interleukin-8 (IL-8)) is the main chemoattractant for neutrophils in humans, and murine CXCL1 (mCXCL1) and mCXCL2 (also known as KC and MIP-2, respectively) are the functional mouse homologs of IL-8 (26). Bladder and kidney cell lines secrete IL-8 in response to UPEC (26). Human and murine studies both demonstrate that neutrophil migration to the UPEC-infected urinary tract is dependent on IL-8 (26). Additionally, mCXCL2 secretion is dependent on TLR4, as secretion was deficient in infected C3H/HeJ mice (100). hCXCR1 and hCXCR2 are receptors for a number of chemokines, including IL-8 (26). Both are expressed in bladder and kidney biopsies, and transmigration studies indicated that hCXCR1 plays a dominant role in IL-8-dependent neutrophil migration (74). Consistent with this, children prone to pyelonephritis tend to have low hCXCR1 expression and heterozygous hCXCR1 polymorphisms (74). Using a large cohort of families that included children with a history of recurrent UTIs, Svanborg and colleagues found that low CXCR1 (IL-8 receptor) expression levels correlated with the incidence of acute pyelonephritis (75). Subsequently, CXCR1 mutations and polymorphisms were identified in several patients with recurrent pyelonephritis (76). Although CXCR1 mutations were not correlated with pyelonephritis in a separate cohort of Italian children, IL-8 gene polymorphisms were found in this latter group (77). hCXCR1 deficiency results in impaired bacterial clearance but, unlike TLR4 deficiency, with intact inflammatory signaling that ultimately results in tissue damage(31).
\n\t\t\t\tSimilarly, mice lacking mCXCR2 (the functional homolog for hCXCL1) experience subepithelial accumulation of neutrophils, increased bacterial titers, and renal scarring after UPEC inoculation (78) and increased susceptibility to experimental UTI and urinary tract–derived bacteremia (79;80). These data indicate that normal function of neutrophils, their chemotactic ligands, and their chemokine receptors are required for bacterial clearance without postinflammatory sequelae.
\n\t\t\t\tThe role of other cytokines in phenotypic susceptibility to UTIs
\n\t\t\t\tDespite ample information on IL-8 in vitro and in vivo, a complete picture of the cytokine and chemokine dynamics during UTI was lacking. In response, a longitudinal assessment using a Bio-Plex format was conducted(81). Chemokine (C-C motif) ligand 2 (CCL2 or MCP-1), CCL4 (or MIP-1b), CCL5 (or RANTES), CXCL1, IL-1β, IL-6, IL-12p40, IL-17, tumor necrosis factor alpha (TNF-α), and granulocyte-colony stimulating factor (G-CSF) were all upregulated in bladder homogenates from UPEC-infected C57BL/6 mice (81). These results agreed with patient and cell line data regarding upregulation of IL-6 in response to UPEC (82). In mice, TNF-α expression was elevated at 1 h post-inoculation for rapid mobilization of acute responses (81); this waned at later time points, likely to prevent the deleterious effects of uncontrolled TNF-α signaling (16). Expression of most cytokines and chemokines peaked around 24 h post-inoculation, returning to near baseline at 2 weeks (81). These dynamics correlate well with the peak and resolution of bacterial burdens in C57BL/6 mice(81). One notable exception was IL-17, which was highly upregulated from 6 h to 1 week post-inoculation, remaining above baseline through the 2-week experimental duration(81). Importantly, IL-17A (the Th17 signature cytokine) contributes to innate clearance of UPEC through a mechanism involving cytokine and chemokine secretion and macrophage and neutrophil influx (26). Similar to TLR adaptor molecule usage (38) the type of fimbriae expressed also seems to influence the repertoire of chemokines secreted. Specifically, kidney cells exposed to type 1-fimbriated UPEC secrete neutrophil-associated chemokines, while P fimbriae-stimulated cells secrete chemokines targeting antigen-presenting cell (APC)- and Th1-specific cytokines, exemplified by CCL2 and CCL5 expression (83). In addition, IFN-γ and IL-4 (signature cytokines of the Th1 and Th2 lineages, respectively) and IL-10 (a T-regulatory (Treg) effector cytokine) knockout mice were tested for susceptibility to both acute cystitis and pyelonephritis (84). While il4−/− and il10−/− mice appear to experience infection dynamics similar to the wild type, ifnγ−/− mice had increased incidence and severity of UTI (84) implying a role for IFN-γ and Th1-mediated inflammatory responses during UTI.
\n\t\t\tInfected mouse bladders examined histologically display thickening of epithelium accompanied by robust infiltration of inflammatory cells and edema in the lamina propria (85). Neutrophils are the most rapid and abundant responders to the infected urinary tract (85). Efficient migration of neutrophils requires intracellular adhesion molecule 1 (ICAM-1) expression by epithelial cells and β2 integrin (CD11b/CD18) expression by neutrophils (30). G-CSF is also required for the neutrophil response, and unexpectedly, mice with neutralized G-CSF are more resistant to UTI(81). Although monocyte/macrophage numbers were similar in anti-G-CSF-treated mice, cytokines important for macrophage activation were upregulated, potentially leading to accelerated clearance by enhanced phagocytic killing (81). Despite counterintuitive phenotypes with respect to cytokine knock-down, antibody-mediated knockdown of the neutrophil population confirmed their crucial role in bacterial clearance, especially within the kidney (86). Lastly, the electrostatic properties of the UPEC P fimbrial tip adhesin may interfere with neutrophil binding, a potential host response evasion tactic specific to the kidney (86).
\n\t\t\tCompared to the neutrophil response, relatively little is known about APCs in the context of UTI. In mice, resident CD11c+ cells that express low to intermediate levels of F4/80 and CD11b macrophage markers were found in the kidney (87) while CD11c+ cells expressing the major histocompatibility class II activation marker were found in the bladder (30). In spite of macrophage marker expression, CD11c+ kidney cells had physical and functional characteristics of DCs (87). At 24 h post inoculation, CD11c+ cells that migrate to the bladder did not express CD8α, Gr-1, or B220 and thus were not plasmacytoid or lymphoid but appeared to be TNF-α- and inducible NOS (iNOS)-producing (Tip)-DCs (88) that express intermediate levels of CD11b. Infection studies in mice lacking Tip-DCs suggested that they are not necessary for the host response to acute UTI (88). Since Tip-DCs are necessary for the generation of mucosal IgA (89), their role may lie in mediating the humoral response to UPEC. Similar to what was observed for DCs, there appears to be a resident population of macrophages in bladder tissue that increases by several orders of magnitude in response to UTI (81). Monocytes expressing high levels of Gr-1, which can give rise to macrophages or DCs, are also recruited to the bladder in response to UPEC infection. Release of these cells from the bone marrow was dependent on CCR2 (90), and, correspondingly, CCL2 is upregulated in the bladder response to UTI(81).
\n\t\t\tSome of the factors utilized by neutrophils, macrophages, and DCs for pathogen uptake and destruction have been described during UTI. iNOS generates the antimicrobial compound nitric oxide (NO) from l-arginine and was originally reported to be secreted by macrophages (91). Although iNOS is rapidly upregulated in the inoculated bladder(92) two independent groups reported that inos−/− mice are equally as susceptible to UTI as wild-type mice, suggesting that neuronal NOS, endothelial NOS, or myeloperoxidase may act as compensatory factors (93) Alternatively or in addition, inos−/− animals may lack a colonization phenotype because there are several factors (Hfq and Nsr-regulated genes, polyamines, and flavohemoglobin) expressed by UPEC that enhance tolerance to reactive nitrogen species in vitro (94) suggesting that NO production may be an ineffective host defense against UPEC.
\n\t\t\tWith respect to the complement system, it appears that UPEC is able to bind C3 to enter host uroepithelial cells via the surface receptors Crry or CD46 (95). Correspondingly, c3−/− mice are more resistant to renal damage and infection (95). As C3 levels are significantly higher in the urine of UTI patients (96) UPEC may stimulate C3 production for pathogenic means or has evolved to exploit this host defense factor.
\n\t\t\tInfection studies using severe combined immunodeficient (SCID) mice that lack functional B and T cells and nude mice that lack thymically derived T cells provide preliminary evidence of a role for innate-like lymphocytes (ILLs) in acute UTI host defense (97). Epithelial γδ T cells, B-1 cells, and natural killer T (NKT) cells are ILLs: cellular subsets that have relatively invariant receptors and reside in specific locations of the body (26). After a 2-day primary infection, SCID mice had significantly higher bacterial counts in their bladder and kidneys, while nude mice were colonized similarly to wild-type animals (97). The lack of a colonization phenotype in nude mice suggests that either antibody responses independent of thymus-derived T-cell help or extrathymically produced T cells may play a role in innate clearance of UPEC. The latter suggestion has some experimental support.
\n\t\t\t\t\n\t\t\t\t\t
γδ T cells can be produced extrathymically and rapidly secrete cytokines in response to stimulation (98). Resident γδ T cells found in the bladder increase in response to UTI (26), and TCR δ−/− mice are more susceptible to UTI than isogenic controls (84). As γδ TCR+ cells express IL-17A during UPEC-mediated UTI (26) this rapid-response cell population may function in concert with other innate factors to mediate neutrophil influx for clearance of UPEC.
\n\t\t\t\t\n\t\t\t\t\t
B-1 cells spontaneously secrete large quantities of polyspecific IgM against bacterial and self-antigens, and in contrast to conventional (B-2) B cells, do not require T-cell help (99). While IgM secreted by B-1 cells might play a role in innate clearance of UPEC, current evidence suggests otherwise. JHD mice, lacking both B-1 and B-2 cells (100) infected and monitored over a 14-day time period exhibited no significant increase in incidence or severity of cystitis (84).
\n\t\t\t\t\n\t\t\t\t\t
On a final note regarding ILLs, administration of α-galactosylceramide (α-GalCer), a ligand for CD1d-restricted NKT cells, alleviates renal UPEC infection (101). Consistent with this, a resident population of NK1.1+ cells (potentially NK or NKT cells) in the bladder of C57BL/6 mice that increases in response to UTI has been reported (26). Studies using a systemic E. coli infection model suggested that, similar to γδ T cells, NKT cells may act as early amplifiers of the innate immune response to UTI by rapid cytokine secretion (102).
\n\t\t\tAlthough susceptibility to UTI thus far appears to be related primarily to function of the innate immune system, additional determinants are likely important in this polygenic phenotype. For example, the increased susceptibility of C3H/HeJ mice was recently suggested to be due to at least two other loci in addition to
The individual\'s response to UTI is variable and the susceptibility to the infection is inheritable. Lundstedt et al. found in a family study, 15% of the relatives of pyelonephritis-prone children had UTI history, whereas the value was 3% in the controls(75). A evaluation of a familal predisposition about women with recurrent UTI described that 65.5% of mothers, 60.7% of daughters, and 48.6% of sisters of the women had a similar history (104). Many studies discovered that genitic variations of TLR4 and CXCR1 are association with susceptibility to different type of UTIs. And TLR4(896)AG genotype and TLR4(896)G alleles could increase the risk for UTI in childhood (76;105), CXCR1 G (2608) C gene polymorphism and expression are strong linked to acute pyelonephritis in children (77). Reduced expression levels of CXCR1 and TLR4 in neutrophils are associated with pyelonephritis, recurrent cystitis, and asymptomatic bacteriuria in children and premenopausal women (25)(78;106). Although these studies suggest the association of gene polymorphisms and expression of TLR4 and CXCR1 to UTIs, whether the variants are associated with UTI in adults is still unknown.
\n\t\t\tOther mediators also shape the extent of the polymorphonuclear leukocyte (PMN) response to infection. Perpetuation of the PMN response might be controlled by cytokines such as IL-17, which has an emerging role in bridging innate to adaptive immunity(107) and is present at high levels in the bladder at later time points. Plasminogen activator inhibitor type 1 (PAI-1) influences cell migration through its effects on integrin binding; upon UPEC infection of mice lacking PAI-1, kidneys bore significantly higher bacterial burdens and fewer PMN infiltrates than wild-type counterparts did (108). UPEC infection was recently demonstrated to induce the secretion of granulocyte colony-stimulating factor (gCSF) in the bladder, and antibody-mediated depletion of this cytokine reduced PMN influx following UPEC infection (81).
\n\t\t\t\tFinally, the secretion of a number of soluble antibacterial compounds into the urinary tract is induced by UPEC infection. UPEC infection also elicits the production of nitric oxide in association with upregulation of the iNOS gene (92). However, UPEC may employ strategies to resist the antibacterial effect of nitric oxide, as mice deficient in iNOS generally have shown no increased susceptibility to UTI (93;109). Among short antibacterial peptides, the human cathelicidin LL-37 is detectable in the urine during human cystitis, and mice deficient in its ortholog (CRAMP) demonstrate increased susceptibility to UTI (110).
\n\t\t\tExisting data regarding adaptive immune responses to UPEC are relatively limited. In a seminal study, Thumbikat and colleagues engineered a strain of UPEC to express ovalbumin to examine mechanisms behind antigen-specific adaptive immune responses in experimental UTI (111). In response to reinfection, CD4+ and CD8+ cells infiltrated the bladder and expressed the CD69 activation marker in the spleen (111), extending the findings of early IHC studies probing T- and B-cell populations in infected bladders (109). Furthermore, splenocytes, enriched splenic T cells, or serum antibodies from previously infected donor mice each protected wild-type naïve recipient mice against UPEC challenge (111). This result suggests that protection derived from natural infection is antibody mediated, as UPEC-specific antibody-secreting plasma cells could be present in both splenocyte and enriched T-cell preparations. As expected, transfers from naïve donor mice did not facilitate enhanced protection to recipients (111). This result is in contrast to a previous murine adoptive transfer study where SCID recipients receiving splenocytes from either naïve or vaccinated wild-type donors exhibited equal levels of enhanced clearance, despite the presence of antigen-specific plasma cells in the vaccinated donor cells (97). This result suggests that simply reconstituting immunosuppressed mice with lymphoid cells provides the means (likely stimulatory cytokines for phagocytic cells) for enhanced clearance. Conversely, wild-type recipient mice used in the former study only exhibited enhanced clearance when given cells or serum from antigen-educated, vaccinated donors (111), indicating that enhanced protection in individuals with intact immune systems will be provided only by stimulation of an effective adaptive immune response.
\n\t\t\tT-cell subsets are characterized by transcription factors and cytokines involved in their differentiation and the particular effector cytokines they secrete. To date, studies have not implicated a skew toward Th1- or Th2-mediated UTI immunity (111). DC phagocytosis of infected apoptotic cells is the key event required for DCs to secrete the cytokine milieu necessary for Th17 development (112), and both DCs and infected apoptotic cells are present in the bladder during UTI. Despite this connection, IL-17A is dispensable for the generation of a protective response in a murine reinfection model, suggesting that Th17 cells may not play a role in adaptive responses to UPEC infection (26). Similar to APCs and other lymphocytes, there are resident CD8+ cells in the bladder that increase in response to infection (26;111). It has been suggested that the observed CD8+ cells are either classical cytotoxic T cells or intraepithelial lymphocytes that exert cytotoxic effects on UPEC- or virus-infected cells or rapidly secrete cytokines to mobilize innate immune responses (26). Lastly, the role of Treg subsets in UTI host defense has not been formally examined.
\n\t\t\tDespite the lack of detail regarding T-cell responses to UTI, there is ample evidence for antibody-mediated clearance of UPEC. The genitourinary tract has been recognized as part of the secretory immune system (113). UPEC-specific antibodies are detected in the urine of infected patients and in the urine or serum of animals exposed to UPEC antigens (111). Urinary IgG and IgA from UTI patients are capable of inhibiting UPEC adherence (114). Patient studies have also suggested that antibody responses to pyelonephritis are, in general, stronger and last longer than humoral responses to cystitis (115). Analysis of murine urine and serum samples collected before and after vaccination with OMP iron receptors allowed identification of immunological correlates of vaccine-induced protection against UTI (116). Specifically, levels of either urinary IgA or serum IgG (relative to serum IgM; denoted the class switch index) inversely correlated with bladder colonization in vaccinated mice (116). Presumably, urinary IgA plays a direct role in UPEC clearance from the bladder mucosa, while IgG may be a marker for class switching by B cells or also play a direct role in mucosal bacterial clearance. As mentioned earlier, infected JHD mice had wild-type levels of colonization in response to primary infection, suggesting that B cells have no role in innate clearance of UPEC (84). However, this result is not unexpected since both antigen presentation and antibody-mediated protection provided by B cells would likely play a role in adaptive responses, indicating a need for reevaluation of these mice in UPEC reinfection and vaccination challenge models.
\n\t\t\tThere are several practiced and proposed therapeutics for UTI management. Prophylactic treatments include estrogen in postmenopausal women (117) or cranberry juice (118) although the efficacy of the former remains controversial. Immunomodation strategies are emerging therapies for UTIs especially in the setting of increasing antimicrobial resistance.
\n\t\t\tSince the lining of the urinary tract is highly enriched in TLR4 molecules, administering TLR4 specific ligands directly to the urinary tract could trigger TLR4 mediated innate immune responses thereby enhancing local reactivity and resistance to infection. Treatment of UPEC-infected mice with forskolin, a drug that increases intracellular cyclic AMP (cAMP) levels, expels UPEC from intracellular vesicles into the extracellular milieu, rendering the bacteria susceptible to immune responses and antibiotics (20). Similarly, exposing the bladder to protamine sulfate, a highly cationic protein, removes bound and intracellular UPEC by causing umbrella cells to exfoliate (63)), unfortunately with a significant level of discomfort, as reported by study volunteers (119). In addition to a number of nonspecific chemical treatments (120)), both small-molecule inhibitors (121) and specific antibody directed against FimH (122) demonstrated some utility in preventing bacterial adherence. While antibiotic therapy remains the standard treatment for UTI, overuse leads to deleterious alterations of the normal host microbiota (123) and selection for resistant strains (124), prompting the need for vaccine-mediated prevention of UTI.
\n\t\t\t\tAstragalus is a Chinese herbal medicine, and Astragalus polysaccharide (APS) is its main components. Previous studies have demonstrated that APS could induce enhancement of expression of TLR4 on bladder epithelial cells (125) and astragalus also increases the TLR4 expression on monocytes in UTI patients. These suggest that similar to LPS, APS can activate pre-inflammatory factor secretion during the early stages of infection similar to LPS, promote TLR4 expression, and involve mucosal innate immunity of the urinary tract. However it remains to be seen whether this herbal medicine can be a therapeutic option for UTI.
\n\t\t\t\tThese observations suggest that activators of the TLR4 signalling pathway in the urinary tract can be effective therapeutic agents against infections. Furthermore, it is not necessary to use TLR4 ligands for activation of the pathway. Inducers of downstream substrates of the pathway are also effective activators of the innate immune response. Even if TLR4 ligands are employed for therapeutic use, it is unlikely that LPS will be the ligand of choice since LPS has intrinsic toxicity. A TLR4 ligand with greatly improved safety profiles, such as monophosphoryl lipid (MPL), could be used in its place (126).
\n\t\t\tThe involvement of TLRs in the immune response to UTI and current knowledge of their ability to incite innate and direct adaptive responses make them attractive adjuvant candidates for UTI vaccines (127). These and other mucosal adjuvants and variations in vaccination routes and schedules must be tested in an effort to generate UPEC-specific local and systemic antibodies(128) and optimize production of immunological memory, not tolerance. A more detailed knowledge of adaptive immune responses to UPEC is a prerequisite for the development of next-generation candidate vaccines for the prevention of UTI. More recently, a variety of experimental approaches have been applied to search for immunodominant epitopes, revealing an array of new candidate targets, and thus a number of vaccine antigens have been explored (26).
\n\t\t\t\tLipopolysaccharide (LPS) and side chain (O) antigen as vaccine targets
\n\t\t\t\tEarly vaccine studies focused on the lipopolysaccharide (LPS) side chain (O) antigen (129). There are trends regarding the frequencies of particular O antigens among UTI isolates(130) and O-antigen-specific antibodies demonstrate an anti-adhesive effect (130). Nonetheless, significant structural heterogeneity may represent an insurmountable obstacle for development of an O-antigen-based vaccine. Furthermore, a study evaluating antibody responses in mice intranasally vaccinated with a killed E. coli lacking capsule and O antigen demonstrated that these surface features actually obstruct optimal humoral responses (131)
\n\t\t\t\t\n\t\t\t\t\t
Later studies involved vaccines directed against particular virulence factors. The pore-forming toxin alpha-hemolysin (HlyA) and P fimbriae are proposed minimal factors required for colonization of and dissemination from the kidney (132). P fimbriae are adherence organelles that play a role in kidney colonization in mice and humans (133). There are convincing data using both murine (132) and primate models (134) that vaccination against P fimbriae or HlyA prevents renal colonization and damage. Additionally, to overcome P fimbrial allelic variability, linear peptide sequences that generated cross-reactive antibodies were evaluated as protective antigens (135). Despite these successes, vaccines targeting P fimbriae may not be effective because of their limited role during bladder colonization. Type 1 fimbria is a bona fide virulence factor of UPEC and, in contrast to P fimbria, is critical for bladder colonization (136). Animals vaccinated with various components of type 1 fimbriae had increased levels of antigen-specific antibodies and decreased levels of colonization upon challenge (137). Unfortunately, expression of type 1 fimbria is subject to phase variation, allowing UPEC to evade humoral responses targeting this organelle(138). Additionally, since nonpathogenic isolates also express type 1 fimbriae (139), targeting this population may result in detrimental disruption of the host microbiota. Also of note, both P and type 1 fimbriae were not necessary for colonization of the human neurogenic bladder, indicating the need for alternative targets in certain high-risk patient groups (140). Although vaccines based on P or type 1 pilus components have generated substantial mucosal antibody responses, protection from subsequent infections has been incomplete, perhaps because of phase variation in the expression of these antigens during infection.
\n\t\t\t\t\n\t\t\t\t\t
Iron is essential for nearly all organisms (141) and UPEC strains encode a battery of genes involved in iron acquisition. Vaccination with UPEC outer membrane protein (OMP) fractions enriched for iron receptors protects against experimental sepsis (142). Additionally, mice vaccinated subcutaneously with denatured IroN, an OMP siderophore receptor and urovirulence factor (143), had both increased levels of antigen-specific serum IgG and reduced kidney colonization upon challenge (144). Undetectable levels of IgA in the bladder mucosa after this vaccination may explain why these animals were not protected from cystitis (144). Recently, a broad functional vaccinology initiative was conducted using an “omics” approach to identify vaccine candidates: UPEC proteins that are pathogen-specific, antigenic, surface-exposed, and in vivo expressed (26). Strikingly, the top targets identified by this approach were all OMPs functioning in iron uptake. Intranasal vaccination with three of six candidates afforded protection from cystitis and pyelonephritis, suggesting that combining antigenic motifs found in these proteins may be an effective multivalent vaccine for UTI (26).
\n\t\t\t\t\n\t\t\t\t\t
Vaccines consisting of bacterial components or whole cells have also been assessed. Transurethral immunization of mice with a live-attenuated UPEC strain lacking the ability to persist in the urinary tract engendered heterologous protection (145) a potential platform for further development. SolcoUrovac, a vaginal suppository containing 10 heat-killed uropathogenic strains, has been tested in mice, in nonhuman primates, and in clinical trials (26). While safe, SolcoUrovac vaccination did not result in appreciable increases in local specific antibody, nor did it afford protection without periodic readministration (146).
\n\t\t\t\t\n\t\t\t\t\t
Since B and T cells, which mediate adaptive immunity are critically dependent on signals derived from the innate immune system, modulators that boost innate immune responses may be of value in boosting adaptive immune responses (147-150). Thus, immunomodulators used to boost innate immune responses in the urinary tract may be also employed to boost adaptive immune responses. One of the reasons for administering vaccine antigens against UTIs in the genitourinary tract, as in the case of the vaginal mucosal vaccine mentioned above, is to evoke secretory IgA (sIgA) antibodies in the mucosal surfaces of the urinary tract. Whereas subcutaneous, intramuscular, or intravenous immunization evokes strong systemic IgG responses to the vaccine antigens, they fail to evoke IgA antibodies in the mucosal surfaces of the urinary tract where infections are initiated and where antibodies are most needed (111).
\n\t\t\t\tHowever, administering vaccines directly to the urinary tract is neither easy nor practical. A much more accessible mucosal site for the delivery of vaccines is the nasal passages. Delivery of proteus antigens into the nasal passages of mice have been shown to evoke high levels of sIgA in the urine and this was accompanied by impressive protection against Proteus mirabilis induced UTI (151). Immunization at nasal sites has been shown to be highly effective in evoking antigen specific serum IgG as well as sIgA responses in various mucosal sites presumably due to activation of the nasal associated lymphoid tissue (NALT) found in the nasal passage. Since the NALT is a potent immunologically inductive and sampling site, it can respond vigorously to vaccine antigens and if TLR ligands or other adjuvants are present, this response may be even more magnified (152). Taken together, an alternate or complementary approach for the management of UTIs in the future could be targeted administration of modulators of the TLR signalling pathway to boost both innate and adaptive responses in the urinary tract.
\n\t\t\t\tCumulatively, all the indications suggest that the urinary tract is able to mount an appreciable and protective adaptive immune response and that this property can be harnessed for vaccination purposes. An important and as yet unanswered question is the duration of protection in the urinary tract following infection or vaccination. Since up to 25% of women with UTIs that have no underlying immune competency issues have recurrences (153) it is conceivable that the immunity generated in the urinary tract could be relatively short lived and therefore frequent vaccinations may be required.
\n\t\t\tThe over use of broad spectrum antibiotics has led to the emergence of antibiotic resistant bacteria many of which have been implicated in UTIs. As a consequence, management of these infections constitutes a serious and growing medical challenge. Modulating or co-opting the powerful innate and adaptive immune systems of the urinary tract could potentially have important therapeutic and prophylactic implications for the treatment of UTIs, particularly where conventional approaches are ineffective.
\n\t\t\tThere is considerable work to be done to better understand the mechanisms of protective immunity against UPEC in the bladder. Specifically, available knockout mouse strains could be used to systematically evaluate the role of various receptors, signaling molecules, cytokines and chemokines, and cell types in controlling UPEC-mediated UTI and eliciting potent adaptive and memory immune responses. Ideally, the field can acquire insights on UTI immunity at a level suitable to rationally develop a much-needed vaccine that elicits sterilizing immunity against UPEC in the human urinary tract.
\n\t\t\tUnlike antibiotic treatment, immunomodulation will not be broadly applicable. Instead, it will have to be tailored to each patient and must take into consideration, among other factors, the virulence and antibiotic resistance profile of the infecting bacteria as well as the age, immune competence and genetic make-up of the patient. For example, employing TLR4 ligands to boost immunity in patients with defective TLR4 genes will not be productive but the use of activators of downstream components of the pathway could be useful. Thus, for these proposed emerging strategies to be completely effective, comprehensive information regarding relevant traits of the pathogen and the host will become necessary.
\n\t\tThe advancements in current knowledge of the human anatomy and diseases continuously led to innovation and improvements in surgical fields, with gallbladder surgery not being any different. Most of the advances were made in the last two centuries, lending the surgical pioneers perpetual reminiscence among colleagues. The names like Jean-Francois Calot, William S. Halsted, Carl Langenbuch, and others paved the way for successful gallbladder drainage and removal [1]. The introduction of open cholecystectomy led to the formation of new standards of care for the therapy of gallstones [1]. Moreover, the first video-laparoscopic gallbladder removal performed by French surgeon Philip Mouret meant the rapid spread of this new technique with majority replacement of the open surgery and changes to the state-of-the-art gallstone therapy making it in the process one of the most frequent surgeries currently performed worldwide [1, 2].
To perform a successful gallbladder surgery, the surgeon has to know the anatomy of this region and also be aware of potential anatomical variations resulting in a potentially more difficult surgery.
Most of the time, the intrahepatic biliary ducts consecutively join forming anterior and posterior segment ducts, which drain into the right hepatic duct, and medial and lateral segment ducts draining into the left hepatic duct. The union of the right and left hepatic ducts in the porta hepatis leads to the formation of the common hepatic duct (CHD) with its distal end formed by cystic duct junction and variation in the length from 1.0 to 7.5 cm depending on the junction site with the diameter of 0.4 cm [3].
In most people, the cystic duct joins the common hepatic duct at an angle of 40° from the right side and runs parallel to the CHD for a shorter or longer distance on average for 17 mm [3]. In some cases, the cystic duct may cross the CHD posteriorly or anteriorly and join the CHD from the left side [3].
Common bile duct (CBD)/ductus choledochus is formed by the union of the CHD and the cystic duct with its distal end at the papilla of Vater in the duodenum [3]. If the cystic duct enters the duodenum separately, the common bile duct is absent [3]. Standardly the length of CBD is diverse between 5 cm and 15 cm with an average diameter of 6 mm.
Gallbladder is a pouch 7–10 cm long able to contain 30–50 ml of bile and located on the visceral liver surface in the proximity of the liver segments IV and V [3]. Liver and gallbladder are separated by the Glisson capsule’s connective tissue and anteriorly, the gallbladder is covered with the peritoneum completely enfolding the
Schematic image of the extrahepatic biliary tree with hepatic artery and portal vein.
The blood supply to the gallbladder is secured by the cystic artery, which commonly arises from the right hepatic artery (RHA) and runs towards the gallbladder just right to the common hepatic duct through the hepatocystic triangle [3]. Venous drainage is secured by a number of small veins passing through the gallbladder bed to the liver from the hepatic site, and from the peritoneal site, small veins drain into the liver through the ascending veins of the common bile duct [3]. The lymphatic drainage is secured by the collecting trunks draining into the cystic node localised in the angle between the cystic and common hepatic ducts and into the hiatal node localised on the anterior border of the epiploic foramen [3].
The hepatocystic triangle is formed on the right side by the proximal part of the gallbladder and the cystic duct, on the left side by the common hepatic duct with the superior part being formed by the liver margin (Figure 2) [3]. Originally, the superior border of the Calot’s triangle was the cystic artery; however, this area enlarged throughout the years [3]. Several structures run in the hepatocystic triangle, which have to be identified prior to any definitive surgical intervention. We have to visualise the right hepatic artery, cystic artery, common hepatic duct, and potential variations either in vascular or in biliary system [3].
Schematic image of the extrahepatic biliary tree with identified hepatocystic triangle.
The right and left hepatic duct mostly joins at the level of the porta hepatis; however, in some individuals, this connection may be more distal eventually resulting in the absence of the common hepatic duct and potentially endangering the right hepatic duct during the surgical intervention (Figure 3A) [3]. Accessory hepatic duct can drain into the cystic duct or it may be mistaken for the cystic duct, and therefore, the surgeon has to be careful where to ligate the cystic duct during the surgery to preserve its function (Figure 3C and D) [3]. A similar problem arises with the duplication of the cystic duct, which may drain into the right hepatic duct, and therefore in the case of the omission of such anomaly leads to a biliary leak (Figure 3E) [3].
Schematic image of biliary tract variations: A: distal union of the right and left hepatic duct resulting in the absence of CHD; B: accessory hepatic duct joining left hepatic duct; C: accessory hepatic duct joining distal cystic duct; D: accessory hepatic duct joining proximal cystic duct; E: accessory cystic duct joining right hepatic duct.
The right hepatic artery (RHA) after originating from the proper hepatic artery crosses the common hepatic duct posteriorly in 85% of cases and in 15% either RHA or its branches passes anteriorly [3]. For a short distance, RHA runs parallel to the cystic artery before turning upward towards the liver and therefore can be mistaken for the cystic artery [3]. The general rule for minimising such a mistake is that no artery in the Calot’s triangle with a diameter of more than 0.3 cm will be a cystic artery [3]. The superior mesenteric artery may give rise to an aberrant right hepatic artery entering the hepatocystic triangle from below and potentially giving rise to the cystic artery in the triangle [3]. In addition to the origins of the cystic artery from the right hepatic artery, there are reports describing the origins from the left hepatic artery with the course anterior to the common hepatic duct, while origins from the common hepatic artery or gastroduodenal artery mean the entry of the cystic artery to the hepatocystic triangle from below [3].
Individuals with the gallstone disease have in the majority of cases asymptomatic course mostly continuing throughout their lives and often are diagnosed only incidentally [4].
Therefore, asymptomatic patients do not require surgical intervention and we wait for the symptom appearance [4]. However, cholecystectomy is recommended for asymptomatic patients with an increased risk of gallbladder cancer, like those with gallstones larger than 3 cm, porcelain gallbladder, or with the presence of gallbladder adenomas [4, 5]. In addition, the surgical therapy is recommended in patients suffering from sickle cell disease and spherocytosis, if abdominal surgery is performed due to other concerns, to prevent the formation of pigment gallstones [4].
For patients, who are surgical candidates with uncomplicated gallstone disease with imaging confirmation of gallstones and symptomatic course mostly with the biliary colic, there is a recommendation for an elective surgical therapy [4]. Patients who present themselves to the emergency ward with the acute aggravation of the biliary colic are treated conservatively with planned surgical intervention after resolution of symptoms due to a lesser risk of complication in elective surgery compared to emergency surgery [4].
Patients with gallstone disease affected by complications such as acute cholecystitis, cholangitis, biliary pancreatitis are recommended to undergo definitive surgical therapy.
In the treatment of acute calculous cholecystitis, it is important to correctly recognise indications for emergency surgery, which are complicated acute cholecystitis with gallbladder gangrene/necrosis, gallbladder perforation, and disease progression despite the medical therapy [6].
If the reasons for emergency surgery are not present, we have to stratify patients benefiting from early surgical intervention and those not profiting from surgery based on their physical status. According to Vollmer et al. [6], the use of the American Society of Anaesthesiologists (ASA) physical status classification is a good option because of its simplicity and ability to stratify patients into low-risk (ASA I-II) and high-risk (III, IV, V) groups with low-risk group patients generally being recommended early cholecystectomy. High-risk group patients are offered nonsurgical therapy, although in case of disease progression and ineffective initial therapy the surgical intervention may be reevaluated [6].
In the group of low-risk patients, the cholecystectomy should be performed as early as possible during the hospitalisation optimally in the first 72 h from the onset of symptoms as it is presumed that the local inflammation worsens with time [6]. Although current Tokyo guidelines as well as World Society of Emergency Surgery guidelines recommend early laparoscopic cholecystectomy also in patients after 72 h, as it is deemed safe because some patients present to hospital already after 72 h from the symptom onset [6]. Patients who have symptoms for longer than 10 days should be planned for delayed cholecystectomy after 6–8 weeks after resolution of the inflammation [6].
In the group of high-risk patients, the initial treatment starts with non-surgical approaches; however, when the disease progresses into gallbladder gangrene/necrosis or perforation or does not respond either to medical therapy or to drainage intervention, the emergency cholecystectomy may be the only option despite the dangers of the surgery [6]. High-risk patients, who handle the acute phase, may be reassessed for delayed surgical intervention and in case of improved physical status may undergo surgery [6]. If the patient’s physical status does not improve even after the resolution of the inflammation, these patients are eligible for nonsurgical treatment of gallstone disease [6].
The higher frequency of gallstones in pregnancy compared to non-pregnant patients is based on the physiological functions of hormones released in higher quantities during the pregnancy [7]. Patients with uncomplicated symptomatic gallstone disease with recurrent biliary colic are indicated to undergo cholecystectomy [7]. Although in near term patients suffering from biliary colic, the surgery may by postpone until postpartum [7]. In such cases, it is recommended to perform surgery at least 6 weeks after delivery, but before 3 months after delivery prevent recurrent attacks of biliary colic [7]. Patients with complicated gallstone disease require complex treatment plans. For the patients with acute cholecystitis, the surgery is a safe indication for the mother and foetus in every trimester [7]. However, increased preterm delivery has been associated with the cholecystectomy in the third trimester in several studies [7].
Since the discovery of laparoscopy, this technique has been the mainstay in the surgical approach to gallstone disease regarding uncomplicated gallstone disease as well as complicated acute cholecystitis in low-risk and high-risk groups of patients as well as among pregnant patients unless there is an absolute anaesthetic contraindication [4, 6, 7]. The technical aspects of the laparoscopy in acute cholecystitis may be more demanding on the surgeon’s skills; therefore, it is no shame to convert to open cholecystectomy when the surgeon is unable to visualise important anatomical structures with the emphasis on the patient’s safety.
The basis for successful and safe cholecystectomy is thorough preoperative preparation with the highest emphasis on the patient’s physical status and correct indication for surgical therapy. It is important to assess any patient’s comorbidities such as cardiac disease, diabetes mellitus as well as factors potentially complicating cholecystectomy such as previous abdominal surgery in the upper half of the abdomen, inflammation, obesity, and pregnancy.
Setting a valid indication for surgical therapy based on the patient’s clinical status, anamnesis, and paraclinical investigations.
Assessment of patient’s physical status with his comorbidities resulting in the estimation of ASA level and definition of the patient’s fitness for surgery.
Assessment of local findings—potential signs of acute cholecystitis, biliary obstruction with the choledocholithiasis, any signs of cholecystoenteric fistula, severe liver diseases such as cirrhosis with portal hypertension, or hepatobiliary malignancy.
Assessment of the surgeon’s technical skills with adaptation and modification of surgical therapy based on the patient’s specific factors.
Patient’s informed consent with a comprehensive explanation of planned surgery with an explanation of potential complications such as biliary or vascular injuries, the need for conversion from laparoscopic approach to laparotomy, the potential necessity for postoperative ERCP or MRCP.
Eventually, this results in correct indication for surgical or nonsurgical therapy, the timing of the surgery, the type of planned surgery with optimal preoperative preparation (thromboprophylaxis according to Caprini score, antibiotics in indicated cases), and well-informed patient about every step of his procedure with solutions for potential complications [8].
Cholecystectomy is a common surgical procedure indicated in various gallbladder pathologies. Nowadays, it is one of the most commonly performed abdominal surgeries worldwide [2]. Even though the concepts of safe surgery have been adopted, the iatrogenic injuries to biliary structures are still a worldwide problem. Based on the nationwide databases, the incidence of major biliary duct injuries (BDI) is 0.1% in the case of elective laparoscopic cholecystectomy in comparison with 0.3% in emergency laparoscopic cholecystectomy [9]. Total BDI incidence is 0.4% for elective laparoscopic cholecystectomy compared to 0.8% in emergency laparoscopic cholecystectomy and 0.3% in open cholecystectomy [9]. The ongoing existence of complications in gallbladder surgery even more emphasises the importance of the safe surgery concept.
The open cholecystectomy (OC) is currently performed in cases of gallbladder cancer, Mirizzi’s syndrome, choledochal cyst, and in cases of sclerotising cholangitis. The incision with its localisation must be adequate for good exploration including the use of intraoperative ultrasonography or radical procedure for cancer.
It is important to emphasise that the conversion from laparoscopic approach to open cholecystectomy is not a surgeon’s failure. It seems that the risk is higher in men, patients >60 years old, obese patients, patients with cirrhosis, patients after abdominal surgery in the upper part of the abdomen, patients with severe comorbidities, in case of large gallstones, febrilities, gangrenous cholecystitis, the duration of symptoms >48 h in urgent setting [10]. For the patient’s safety, the conversion may be considered in case of the surgeon’s inability to perform safe complicated laparoscopic cholecystectomy [10]. However, there is no evidence that the conversion will reduce or avert the risk of biliary duct injury [11]. Conversion to open surgery is an option in any difficult case. The most important focus in a cholecystectomy is the safe removal of the gallbladder and the avoidance of bile duct injuries.
Nowadays, the state-of-the-art surgical therapy for gallstones is laparoscopic cholecystectomy. Laparoscopy is associated with lower postoperative pain, shorter hospital stay, and shorter recovery period [12]. From the first laparoscopic cholecystectomy in the beginning of the 1990s, this technique has changed the therapy for many gallbladder pathologies. Laparoscopic cholecystectomy is indicated for the therapy of acute and chronic cholecystitis, symptomatic gallstone disease, biliary dyskinesis, acalculous cholecystitis, benign gallbladder tumors. According to a recently published meta-analysis, laparoscopic cholecystectomy is also a safe alternative to open cholecystectomy for early gallbladder cancer (stage Tis—T3) with comparable overall survival and the rate of complications [13].
Initially, we start with the insufflation of the carbon dioxide into the abdominal cavity until we reach the pneumoperitoneum with the intra-abdominal pressure of 15 mmHg. In conventional laparoscopic cholecystectomy, we continue with the placement of the multiple ports depending on the surgeon’s experience and skills. Surgeon standardly chooses 3 or 4 ports localised supraumbilically (10 mm port), subxiphoidally (10 mm port), and 1–2 ports in the right subcostal region (5 mm port). The key step in the safe gallbladder removal is the achievement of the critical view of safety (more on the topic in part 6) through meticulous preparation and dissection if this can be achieved. Only in this case, the surgeon can continue with the certainty that he/she has identified the cystic artery and the cystic duct. Both structures are then ligated and interrupted. Later on, we continue with the separation of the gallbladder from the gallbladder bed with the use of electrocautery or the harmonic scalpel. To achieve complete haemostasis, some authors recommend lowering intra-abdominal pressure to 8 mmHg for 2 min to spot potential venous bleeding, which can be undetectable with the intra-abdominal pressure of 15 mmHg. The gallbladder is extracted in the retrieval bag. The drainage in the subhepatic region after uncomplicated cholecystectomy is not routinely recommended. In the end, the trocars should be extracted under direct visualisation, and to prevent incisional hernias, some authors recommend fascial sutures in case of ports larger than 5 mm.
Even though the benefits of the conventional multiple ports access laparoscopic cholecystectomy are undeniable, the efforts to further minimise the traumatisation of the abdominal wall continued with the effort to reduce the number of ports. It was shown that laparoscopic cholecystectomy with the use of only one incision is possible in the clinical setting [14]. The limitations of this technique are the difficulties with the triangulation while using linear laparoscopic tools, limited view, and the possibility of the tools’ collisions. SILC can be indicated in patients with uncomplicated disease, with BMI <35 kg/m2, in whom there is a low probability of conversion either to multiple ports access laparoscopy or open cholecystectomy [15]. However, the role of the SILC compared to conventional LC in day-to-day praxis is debatable based on non-existent clear benefits beyond lower postoperative pain and improved cosmetic effects with no option to clarify the impact on the quality of life [15]. On the other hand, among the disadvantages are the higher occurrence of adverse events with prolonged duration of the surgery and frequent demand for additional port [15].
The first thing that may compromise our ability to perform safe laparoscopic cholecystectomy may be the problem with the port placement. When we place a supraumbilical port in obese or tall patients in the umbilicus, it can create too low of a view [16]. Another issue with the limitations of fine motor movements may arise when placing the subxiphoidal port too low or not perpendicular to the abdominal wall while creating a form of “port tension” [16]. Tool collisions may happen when we place the surgeon’s left-hand port in line with the camera view or the lateral retraction port [16].
The dissection of the gallbladder should be done with the proper incision of the peritoneum, therefore releasing the gallbladder from the liver [16]. A common issue may be with insufficient retraction of the infundibulum inferiorly and laterally and endangering the common hepatic duct or common bile duct by the possibility of an alignment with the cystic duct in the same plane [16]. Important to remember is to use the clips, ligations, or electrosurgical energy on ductal structures only after the visualisation of the regional anatomy [16]. The critical view of safety cannot be achieved unless the bottom third of the cystic plate is fully exposed with adequate dissection of the hepatocystic triangle and clear identification of the cystic duct and the cystic artery [16]. When the CVS is not achievable, the attempt to perform total cholecystectomy is a risk for the patient and we must utilise a bail-out manoeuver [16].
With the introduction of a robot-assisted surgical system, minimally invasive surgery comes to a new era. In 1998, Himpens first reported the robot-assisted cholecystectomy [17]. Since then, the application of the robotic system has been significantly improved, not only for hepatobiliary and pancreatic surgery but also for urological surgery, gynecology, thoracic surgery, and cardiac surgery. The application of daVinci™ robot-assisted surgical platform overcomes the shortcomings of many laparoscopic techniques [17].
Robot-assisted surgical platform with the single incision has overcome many limitations of single-incision laparoscopic cholecystectomy with bridling the triangulation, quality of view, and movement options [18]. The indication for SIRC is very similar to that of conventional LC. The relative contraindication being the same for SIRC and SILC; however thanks to better triangulation and surgical skills with the robotic platform, SIRC is being more frequently used in patients with higher BMI, acute cholecystitis, and patients with previous abdominal surgeries in the upper abdomen [19].
Over the years, there have been many methods for reducing the risk of biliary structures injuries while performing cholecystectomy. Fisher’s method, in which the surgeon removes the gallbladder from the gallbladder bed and then identifies the cystic artery and cystic duct which are sequentially ligated, is deemed overcome due to 95% penetration of laparoscopy in the gallbladder surgery [12]. The introduction of the Strassberg method in 1995 meant firstly the preparation of cystic artery and cystic duct in a hepatocystic triangle with identification of cystic duct entering the gallbladder infundibulum [20]. This method is currently called the critical view of safety technique (Figure 4) [20].
Schematic image of critical view of safety.
Critical view of safety (CVS) technique is composed of three steps:
Identification and visualisation of hepatocystic triangle without the exposition of the common hepatic duct.
Visualisation of infundibular part of the gallbladder with the preparation and separation from gallbladder bed (anterior and posterior view).
Visualisation of only 2 structures entering the gallbladder before ligation—a cystic artery and cystic duct [21].
This concept is widely accepted and represents the basis of the safe cholecystectomy model to minimise the incidence of iatrogenic biliary ducts injuries [20]. Combination of this method and correct indication for surgery, good preoperative preparation and planning, and meticulous dissection constitute a modern approach towards safe cholecystectomy with reduced risk of biliary structure injury. Due to the scientific verification of reduction in BDIs, the critical view of safety is routinely recommended over other methods [22]. However, CVS cannot always be easily achieved with the most frequent incompleteness in the separation of the infundibular part of the gallbladder from the gallbladder bed. In other cases, the CVS cannot be utilised because of advanced inflammation or scar formation in the hepatocystic triangle due to ongoing or former inflammatory processes [23]. The literature recognised the BDIs to be more frequent in surgeries performed by young residents during the early part of their learning curve in the laparoscopic cholecystectomy. Therefore, it is important for the resident to complete a critical view of safety with the mentoring surgeon to confirm it before ligating any structures [23].
The concept of CVS cannot be achieved in every case of cholecystectomy; therefore in those situations, the surgeon shall use alternative methods for safe gallbladder removal—the bail-out manoeuver or another method for cystic duct identification. In the setting of acute cholecystitis, the alternative method “fundus-first” has a lower conversion rate and a lower percentage of iatrogenic injuries to the biliary tree [24]. The technique of subtotal cholecystectomy is used as a safe method with minimal risk of injury to the vascular or biliary structures with low conversion volume due to the resection border being out of the risk zone [10]. However, this method has higher amounts of surgical site infections, re-interventions, and rehospitalisations with a longer length of stay [25]. Conversion to open cholecystectomy is an option in difficult cases as well. However, the conversion to OC does not reduce the risk of biliary duct injury as showed in the results of the Belgian multicentre study [26]. In the study of 1089 patients with acute cholecystitis, 116 patients (11.7%) underwent the conversion to open cholecystectomy with the biliary duct injury of 13.7% (16 patients) [26]. Major BDI was present in 6.0% (7 cases) and three cases of the major BDI occurred after the conversion to OC [26]. These results point out the risk of BDI in high-risk patients undergoing cholecystectomy even in cases when the conversion to open gallbladder removal is performed [26]. Therefore, the subtotal cholecystectomy is the preferred choice in surgeons who has low experience with the open cholecystectomy with the exception of large periprocedural haemorrhage, when the method of choice is open cholecystectomy [26]. In the case of complicated cholecystectomy, the intraoperative cholangiography may be a useful method for the identification of anatomical structures and abnormalities with the risk reduction of BDI, although the disadvantage is the need for access to the biliary tree. Another option may be the use of perioperative ultrasonography, which, however, necessitates the need for proper ultrasonography training and knowledge among surgeons.
Intraoperative cholangiography (IOC) can be used intraoperatively for the identification of choledocholithiasis and for visualisation and identification of biliary tree anatomy. The common use of this technique is currently not recommended because of insufficient reduction in complication rate and BDIs during laparoscopic cholecystectomy [27]. The BDIs can appear even in patients in whom the IOC was performed, because of potentially incorrect interpretation of the findings [28]. However, it may be recommended in patients with difficult biliary anatomy and patients, in whom we are unable to perform critical view of safety or there is a perioperative suspicion of a BDI [28]. Importantly, the identification of BDIs with IOC may lead to earlier recognition with a quick therapeutic approach.
Alternatively, the use of indocyanine green fluorescence cholangiography (ICG-C) may be a good option for visualisation of the biliary tree [29]. This method has been suggested by some studies and proved to be effective in acute and chronic gallbladder diseases and in cases, where IOC cannot be used [30].
There is an ongoing controversy about an ideal solution for patients with gallstones and bile duct stones. Historically, the method of choice was the open cholecystectomy with the common bile duct exploration (CBDE), which was replaced due to the progress in the laparoscopic and endoscopic methods. With the improvement of the ERCP, the standard of care for patients with cholecystolithiasis and choledocholithiasis became the preoperative ERCP with the endoscopic sphincterotomy and extraction of the choledocholiths with the subsequent laparoscopic cholecystectomy [31]. It is important to say that the open CBDE was the gold standard during the era of the open cholecystectomies for patients in a need of bile duct stones extraction, with the ERCP being used secondarily. The improvements in the laparoscopy lead to a decline in OC and surgeons started to use and rely more on the ERCP to solve the choledocholithiasis. Laparoscopic CBDE is currently an advanced method and in some centres, it is a method of choice. Although some studies have shown the advantages (lower amount of interventions, lower economic burden, shorter length of stay) of the one-stage procedure (LC + laparoscopic CBDE) in comparison with two-stage procedures (pre- or postoperative ERCP + LC), this practice was not generally accepted [32]. Nowadays, the method of choice is two-stage management with the preoperative ERCP and subsequent LC. Even though the ERCP is considered safe, it is a method with high chances of complications with acute post-ERCP pancreatitis being the most common post-ERCP complication with the high economic burden on healthcare systems [33].
Laparoendoscopic rendezvous (LERV) as a combination of laparoscopy and endoscopy is an attractive method in management of patients with cholecystolithiasis and choledocholithiasis. Recent meta-analysis of eight studies compared LERV with two-stage management (preoperative ERCP + LC) in 1061 patients with gallstones and bile duct stones [34]. A total of 542 patients were treated with LERV technique and 519 patients underwent ERCP with subsequent LC. Between the two groups there were no significant differences in the bile duct clearance (OR 2.20, P = 0.10), postoperative bleeding (OR 0.67, P = 0.37), postoperative cholangitis (OR 0.66, P = 0.53), postoperative bile leak (OR 0.87, P = 0.81), or conversion to different approaches (OR 0.75, P = 0.62) [34]. Total time of surgery was longer in the LERV group (MD = 44.93, P < 0.00001); however, the advantage of the LERV technique was lower incidence of postoperative pancreatitis (OR 0.26, P = 0.0003) and lower overall morbidity (OR 0.41, P < 0.0001) with a shorter length of hospital stay (MD = − 3.52, P < 0.00001) [34]. The authors of the meta-analysis concluded the LERV to be equivalent to standard two-stage management of patients with gallstones and bile duct stones [34].
In current practice, there are clear guidelines by the British Society of Gastroenterology recommending the extraction and clearance of the choledocholiths from the CBD [35]. Although, laparoscopic cholecystectomy is a gold standard for gallstone disease, a consensus on the optimal therapeutic approach in the management of bile duct stones has not been reached. Thanks to the improvements in the laparoscopic technique and surgical skills, the single-stage LC + CBDE has shown its benefits and promise. However, the very limitations are based on the necessity of advanced surgical skills with technical demandingness and the availability of the ERCP rule in favour of the two-stage approaches in the majority of centres [36]. The future may lie with the LERV technique, although as a novel therapeutic approach there are still needed further randomised control trials to decide the optimal therapeutic approach for patients with gallstones and bile duct stones.
Invasive procedures may be complicated by a number of factors related either to the surgeon and his skillset or patient’s characteristics with the clinical findings and anatomical variations. In the case of laparoscopic cholecystectomy, the complications rate varies from 0.5 to 6%:
Biliary duct injury with the incidence 0.1–0.6%
Bleeding and vascular injury with the incidence 0.04–1.22%
Gallbladder perforation 10–30% [37]
Incidence of complication is significantly related to the surgeon’s experience. Some authors estimated 50 performed laparoscopic cholecystectomies to complete the training in this procedure. However, the end of the learning curve for laparoscopic cholecystectomy is somewhat debatable. Some studies have evaluated the decrease in the bile duct injuries or conversion and complication rates, while others focused on operation time, but the definitive criteria are still being formed [38]. Nonetheless, experienced surgeons have the lowest complication rates; therefore, an increasing number of institutions require proof of fundamental skills in laparoscopic surgery.
Patients with acute cholecystitis with inflammatory changes have a higher likelihood for a complication during surgery. Also, a higher rate of complications can be expected in patients with chronic cholecystitis with fibrotic changes in the hepatoduodenal ligament and gallbladder fossa. Choledocholithiasis should be revealed before surgery. Patient’s history and a series of examinations can refer to the presence of bile duct stones. Performing routine preoperative ERCP is not currently recommended [39]. It is reasonable only in cases of suspicion of common bile duct stones (dilatation of common bile ducts, clinical or laboratory picture of pancreatitis, fever, elevated inflammatory markers, jaundice).
Clinical manifestation of biliary duct injury (BDI) can be various and it depends on the kind of injury. BDI can run asymptomatically in cases of small damages to the biliary tree to acute process in cases of transection or occlusion of the common bile duct. Approximately only 25% of cases of BDI are recognised during laparoscopy and the detailed description of the case is very important [40].
Type A—This group represents leakage from the gallbladder bed, minor hepatic ducts, and cystic duct without damage to the biliary tree (Figure 5).
Schematic image of leakage from the gallbladder bed, minor hepatic ducts, and cystic duct without damage to the biliary tree (Type A).
Type B—Occlusion of the aberrant right hepatic duct (Figure 6).
Schematic image of occluded aberrant right hepatic duct (Type B).
Type C—Transection of the aberrant right hepatic duct (Figure 7).
Schematic image of transected aberrant right hepatic duct (Type C).
Cystic dust drainage into an aberrant right hepatic duct is a variation seen in approximately 2% of patients. Injuries type B and C are usually caused by confusion of the aberrant right hepatic duct with the cystic duct. Patients with type B injury may remain asymptomatic for a long period of time. Right upper quadrant pain, fever, elevated liver enzymes, and markers of inflammation can be signs of cholangitis, and ultrasonography (US) will show dilatation of the right part of the biliary tree. The occlusion leads to dilatation of the right part of the biliary tree, fibrotic changes, and finally to lobar atrophy. Type C injury causes biliary leakage.
Type D—This group of injuries represents mural lesions of the common bile duct without interruption of its course (Figure 8). The result of this damage is a biliary leakage and it can progress to a more serious type E injury.
Schematic image of lesion to the common bile duct without interruption of its course (Type D).
Type E—This injuries involve interruptions of the extrahepatic biliary ducts and depending on the location of the injury, they are divided into five subgroups (Bismuth classification) [39].
E1—(Bismuth Type I)—transection more than 2 cm from the confluence of the right and left hepatic ducts (Figure 9).
Schematic image of transected CHD (Type E, Bismuth Type I).
E2—(Bismuth Type II)—transection less than 2 cm from the confluence (Figure 10).
Schematic image of transected CHD (Type E, Bismuth Type II).
E3—(Bismuth Type III)—transection in the confluence (Figure 11).
Schematic image of transected CHD in the confluence (Type E, Bismuth Type III).
E4—(Bismuth Type IV)— separation of major duct from the right and left hepatic duct (Figure 12).
Schematic image of separated major duct from the right and left hepatic duct (Type E, Bismuth Type IV).
E5—(Bismuth Type V)—Interruption of the aberrant right hepatic duct (Type C) combined with the injury in the hilum (Figure 13).
Schematic image of interrupted aberrant right hepatic duct (Type C) combined with the injury in the hilum (Type E, Bismuth Type V).
Bismuth classification of BDI was the first scheme published in 1982 [41]. After this classification, other more complex classification systems were proposed. For clinical use, BDI are usually divided into two groups: minor and major injuries.
Minor BDI are associated with partial lesions without tissue and continuity loss. Major BDI are associated with tissue loss or interruption or occlusion of the main hepatic duct. In a situation when BDI is recognised during laparoscopic surgery, conversion to an open procedure and attempt for a repair is recommended only when the surgeon is skilled in advanced biliary surgery. Non-expert immediate attempts for repair are associated with worse outcomes, and they can compromise later revisions; therefore, an intraoperative consultation of an expert is recommended and patients especially with major BDI should be referred to a hepatobiliary centres with multidisciplinary care [39, 41]. External drainage of the subhepatic space is recommended, and a patient should be referred to the centre early because delayed transfers are associated with a higher rate of complications [42].
In case of intraoperative suspicion of BDI or when patients’ biliary anatomy is unclear, intraoperative cholangiography may be helpful [28]. Currently, it is not generally recommended to perform routine intraoperative cholangiography because it is not associated with a significant reduction of BDI rates and it can lead to BDI itself because of misinterpretation of patients’ anatomy.
This group represents biliary injuries types A, C, D, and E.
Type A leak is localised from the cystic duct or the bile duct Luschka [43]. It can be caused by loosen ligature or dislodged clips because of a frail tissue or obstruction of the cystic duct remnant.
Bile duct of Luschka is a minor accessory bile duct that directly enters the gallbladder in the bed. Clinically, significant leakage from the duct after cholecystectomy is not very common.
Types C and D leaks are related to BDI to aberrant and main ducts.
Clinical presentation depends on the extent of the lesion. Minor lesions with small perihepatic collections may remain asymptomatic for a long time or may resolve spontaneously. Major lesions are followed by massive biliary leakage and affected patients are usually symptomatic. Typical symptoms are abdominal pain, bilious collections or bilious ascites, fever. In this case, jaundice is a variable sign because the serum level of bilirubin can be just slightly elevated. Leucocytosis and elevated serum levels of alkaline phosphatase and gamma-glutamyl transferase are common [39].
If subhepatic drainage during cholecystectomy is performed, bile leakage is usually obvious and the extent of the lesion can be indirectly estimated.
Transabdominal ultrasonography (US) is the basic examination that can describe perihepatic fluid collections and the biliary tree diameter. If the US finding is unclear and the symptomatology is worsening, the CT may be helpful to detect free intraperitoneal fluid or associated vascular injury (triphasic CT) [44].
Large collections or free peritoneal fluid of larger volume can be percutaneously drained and examined for assessment of bilirubin levels. It is recommended to take a sample for microbiological examination and in case of clinical and laboratory proof of sepsis development (elevated inflammatory markers), empiric antibiotic treatment is reasonable, particularly in patients with a history of biliary infections and preoperative ERCP and stenting [44].
Bile leakage can be verified by biliary scintigraphy with hepatobiliary iminodiacetic acid scan (HIDA). It is very sensitive in the diagnosis of an ongoing bile leak, though it cannot anatomically localise the site of the leakage. Major leaks can be obvious on early scans, but if early scans are negative, delayed scans after 3 h from tracer injection are recommended [45].
MRCP is a non-invasive method that can be used for the diagnosis of bile leak and localisation of the leak site. It is particularly important in the case of hilar injury [46].
ERCP is an examination that can determine the side of the BDI and offers a possibility of the insertion of the biliary stents. Stenting across the ampulla can solve the majority of BDI types A and D and reduce the pressure in the biliary tree [39]. Sphincterotomy may be performed without stenting; however, it is recommended in cases of biliary obstruction because of choledocholithiasis [39].
In cases when a minimally invasive approach does not solve patients’ state, if there is biliary peritonitis and evidence of progressive sepsis, an operative exploration and washout are recommended [44].
In type A injuries, stents can be removed endoscopically usually after 2 weeks if there is no ongoing biliary leak on ERCP [39]. In types C and D injuries, repeated HIDA scans are recommended after 2–4 weeks after stent insertion and stents can be removed if there is no leak on a follow-up ERCP [39]. If the leak persists, stents can be replaced or sphincterotomy can be performed to facilitate the bile flow [39]. Patients with type D injuries require close follow-up due to stricture development or progression to type E injuries in case of larger defects of the biliary wall [39]. Also, endoscopic treatment is less effective in the type C injuries because the aberrant right hepatic duct is disconnected from the proximal part of the biliary tree [39].
Occlusive BDI of the right hepatic bile duct usually leads to segmental cholestasis, fibrosis, and right lobar atrophy. It can be asymptomatic but some patients can suffer from cholangitis or hepaticolithiasis. US and CT may show dilatated duct of the right part of the liver with focal atrophy of the liver tissue. ERCP and MRCP will show the site of the obstruction of the right hepatic duct. The treatment of this BDI is surgical. In case when fibrosis and atrophy are not advanced, a hepaticojejunostomy should be performed. Significant atrophy may require resection.
Type E injuries are localised at the common hepatic duct and are the most serious. Transections of the common hepatic duct are usually recognised at the time of surgery, because of a biliary leak. If there is only a limited mural lesion of the common bile duct, placing a T-tube drain could be a solution. Primary repair attempts should be avoided, especially in case of normal diameter of the common hepatic duct and tissue loss because the probability for breakdown is high and it can lead to bile duct strictures during the healing process [44]. These attempts, especially if they are performed by an inexperienced surgeon, can make the future revisions more difficult [44]. Significant damage of the common hepatic duct is preferably solved by hepaticojejunostomy [44].
Clinical symptoms depend on the nature of an injury. Occlusive injuries lead to jaundice development and elevated liver function tests. Radiological examinations will show diffuse dilatation of intrahepatic bile ducts, and ERCP will verify complete obstruction of the common hepatic duct. In order to decompress the intrahepatic bile ducts, percutaneous transhepatic drainage (PTD) and percutaneous transhepatic cholangiography (PTC) should be performed. Both liver lobes have to be drained and it can require placing percutaneous drains to both intrahepatic parts of the biliary tree. In cases of strictures due to inappropriately placed clips or ligatures, ERCP with the dilatation and stent insertion may be helpful. Endoscopic treatment is not very effective in cases of complete occlusion and if the length of the stricture is longer than 1 cm. The treatment of choice is surgery and hepaticojejunostomy Roux-en Y [44, 47].
Bleeding from the gallbladder bed is not a rare complication, especially in cases of fibrotic changes in chronic cholecystitis. If laparoscopic attempts for bleeding control fail, it usually requires immediate conversion and ligation [48].
Arterial bleeding is usually caused by the cystic artery transection and can be controlled by clipping, but a surgeon must avoid injury to the right hepatic artery. Injuries of the right hepatic artery require a high level of technical expertise, and the efficiency of reconstruction is questionable. Many right hepatic artery injuries remain unrecognised because its interruption is usually well tolerated [44].
Bleeding from trocar sites should be avoided with direct visualisation after removal.
Bowel injuries are a rare complication. If the bowel injury is recognised intraoperatively, it must be unconditionally repaired. Unspotted bowel injuries may lead to sepsis development after the procedure and require broad-spectrum antibiotic treatment and laparotomy for reparation. Clinical symptoms involve abdominal pain, hypotension with tachycardia with the laboratory picture of leucocytosis or leucopenia, and elevated serum inflammatory markers. In cases when clinical symptoms are mild, a patient does not develop sepsis and an adequate drainage can be achieved, management can be continued as for controlled entercutaneous fistulas [39].
Nowadays, the laparoscopic cholecystectomy is the state-of-the-art surgical therapy for gallstones disease. The primary concept is the safety of the patient; therefore, the surgeon must be aware of the anatomy variations and has to be prepared to react to them. The first thing young residents have to learn is the technique of critical view of safety to reduce the risk of biliary duct injuries. Although we may do every effort to minimise the risks of complications, those will happen nonetheless. Therefore, every surgeon has to be aware of the basics in the management of cholecystectomy complications.
The authors declare no conflict of interest.
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",metaTitle:"Waiver Policy",metaDescription:"We feel that financial barriers should never prevent researchers from publishing their research. With the need to make scientific research more publically available and support the benefits of Open Access, more institutions and funders have dedicated funds to assist their faculty members and researchers cover the APCs associated with publishing in Open Access. Below we have outlined several options available to secure financing for your Open Access publication.",metaKeywords:null,canonicalURL:"/page/waiver-policy",contentRaw:'[{"type":"htmlEditorComponent","content":"At IntechOpen, the majority of OAPFs are paid by an Author’s institution or funding agency - Institutions (73%) vs. Authors (23%).
\\n\\nThe first step in obtaining funds for your Open Access publication begins with your institution or library. IntechOpen’s publishing standards align with most institutional funding programs. Our advice is to petition your institution for help in financing your Open Access publication.
\\n\\nHowever, as Open Access becomes a more commonly used publishing option for the dissemination of scientific and scholarly content, in addition to institutions, there are a growing number of funders who allow the use of grants for covering OA publication costs, or have established separate funds for the same purpose.
\\n\\nPlease consult our Open Access Funding page to explore some of these funding opportunities and learn more about how you could finance your IntechOpen publication. Keep in mind that this list is not definitive, and while we are constantly updating and informing our Authors of new funding opportunities, we recommend that you always check with your institution first.
\\n\\nFor Authors who are unable to obtain funding from their institution or research funding bodies and still need help in covering publication costs, IntechOpen offers the possibility of applying for a Waiver.
\\n\\nOur mission is to support Authors in publishing their research and making an impact within the scientific community. Currently, 14% of Authors receive full waivers and 6% receive partial waivers.
\\n\\nWhile providing support and advice to all our international Authors, waiver priority will be given to those Authors who reside in countries that are classified by the World Bank as low-income economies. In this way, we can help ensure that the scientific work being carried out can make an impact within the worldwide scientific community, no matter where an Author might live.
\\n\\nThe application process is open after your submitted manuscript has been accepted for publication. To apply, please fill out a Waiver Request Form and send it to your Author Service Manager. If you have an official letter from your university or institution showing that funds for your OA publication are unavailable, please attach that as well. The Waiver Request will normally be addressed within one week from the application date. All chapters that receive waivers or partial waivers will be designated as such online.
\\n\\nDownload Waiver Request Form
\\n\\nFeel free to contact us at funders@intechopen.com if you have any questions about Funding options or our Waiver program. If you have already begun the process and require further assistance, please contact your Author Service Manager, who is there to assist you!
\\n\\nNote: All data represented above was collected by IntechOpen from 2013 to 2017.
\\n"}]'},components:[{type:"htmlEditorComponent",content:'At IntechOpen, the majority of OAPFs are paid by an Author’s institution or funding agency - Institutions (73%) vs. Authors (23%).
\n\nThe first step in obtaining funds for your Open Access publication begins with your institution or library. IntechOpen’s publishing standards align with most institutional funding programs. Our advice is to petition your institution for help in financing your Open Access publication.
\n\nHowever, as Open Access becomes a more commonly used publishing option for the dissemination of scientific and scholarly content, in addition to institutions, there are a growing number of funders who allow the use of grants for covering OA publication costs, or have established separate funds for the same purpose.
\n\nPlease consult our Open Access Funding page to explore some of these funding opportunities and learn more about how you could finance your IntechOpen publication. Keep in mind that this list is not definitive, and while we are constantly updating and informing our Authors of new funding opportunities, we recommend that you always check with your institution first.
\n\nFor Authors who are unable to obtain funding from their institution or research funding bodies and still need help in covering publication costs, IntechOpen offers the possibility of applying for a Waiver.
\n\nOur mission is to support Authors in publishing their research and making an impact within the scientific community. Currently, 14% of Authors receive full waivers and 6% receive partial waivers.
\n\nWhile providing support and advice to all our international Authors, waiver priority will be given to those Authors who reside in countries that are classified by the World Bank as low-income economies. In this way, we can help ensure that the scientific work being carried out can make an impact within the worldwide scientific community, no matter where an Author might live.
\n\nThe application process is open after your submitted manuscript has been accepted for publication. To apply, please fill out a Waiver Request Form and send it to your Author Service Manager. If you have an official letter from your university or institution showing that funds for your OA publication are unavailable, please attach that as well. The Waiver Request will normally be addressed within one week from the application date. All chapters that receive waivers or partial waivers will be designated as such online.
\n\nDownload Waiver Request Form
\n\nFeel free to contact us at funders@intechopen.com if you have any questions about Funding options or our Waiver program. If you have already begun the process and require further assistance, please contact your Author Service Manager, who is there to assist you!
\n\nNote: All data represented above was collected by IntechOpen from 2013 to 2017.
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The literature source was Web of Science and SSCI, SCI-EXPANDED, A&HCI, CPCI-S, CPCI-SSH, and ESCI indexes. Fifty-two articles were reviewed; however, 14 of them were not been included in the study. As a result, 38 articles were examined. Level of education, field of education, and material types of AR used in education and reported educational advantages of AR have been investigated. All articles are categorized according to target groups, which are early childhood education, primary education, secondary education, high school education, graduate education, and others. AR technology has been mostly carried out in primary and graduate education. “Science education” is the most explored field of education. Mobile applications and marker-based materials on paper have been mostly preferred. The major advantages indicated in the articles are “Learning/Academic Achievement,” “Motivation,” and “Attitude”.",book:{id:"6543",slug:"state-of-the-art-virtual-reality-and-augmented-reality-knowhow",title:"State of the Art Virtual Reality and Augmented Reality Knowhow",fullTitle:"State of the Art Virtual Reality and Augmented Reality Knowhow"},signatures:"Rabia M. Yilmaz",authors:[{id:"225838",title:"Dr.",name:"Rabia",middleName:null,surname:"Yilmaz",slug:"rabia-yilmaz",fullName:"Rabia Yilmaz"}]},{id:"63639",doi:"10.5772/intechopen.81086",title:"Cooperative Learning: The Foundation for Active Learning",slug:"cooperative-learning-the-foundation-for-active-learning",totalDownloads:3475,totalCrossrefCites:18,totalDimensionsCites:24,abstract:"The role of instructors is evolving from the presenter of information to the designer of active learning processes, environments, and experiences that maximize student engagement. The more active a lesson, the more students tend to engage intellectually and emotionally in the learning activities. Cooperative learning is the foundation on which many of the active learning procedures are based. Cooperative learning is the instructional use of small groups so that students work together to maximize their own and each other’s learning. Most of the active learning procedures, such as problem-based learning, team-learning, collaborative learning, and PALS, require that students work cooperatively in small groups to achieve joint learning goals. Cooperative learning is based on two theories: Structure-Process-Outcome theory and Social Interdependence theory. Four types of cooperative learning have been derived: formal cooperative learning, informal cooperative learning, cooperative base groups, and constructive controversy. There is considerable research confirming the effectiveness of cooperative learning. To be cooperative, however, five basic elements must be structured into the situation: positive interdependence, individual accountability, promotive interaction, social skills, and group processing.",book:{id:"6929",slug:"active-learning-beyond-the-future",title:"Active Learning",fullTitle:"Active Learning - Beyond the Future"},signatures:"David W. Johnson and Roger T. Johnson",authors:[{id:"259976",title:"Dr.",name:"David",middleName:null,surname:"Johnson",slug:"david-johnson",fullName:"David Johnson"},{id:"263004",title:"Dr.",name:"Roger",middleName:null,surname:"Johnson",slug:"roger-johnson",fullName:"Roger Johnson"}]},{id:"58060",doi:"10.5772/intechopen.72341",title:"Pedagogy of the Twenty-First Century: Innovative Teaching Methods",slug:"pedagogy-of-the-twenty-first-century-innovative-teaching-methods",totalDownloads:8826,totalCrossrefCites:17,totalDimensionsCites:22,abstract:"In the twenty-first century, significant changes are occurring related to new scientific discoveries, informatization, globalization, the development of astronautics, robotics, and artificial intelligence. This century is called the age of digital technologies and knowledge. How is the school changing in the new century? How does learning theory change? Currently, you can hear a lot of criticism that the classroom has not changed significantly compared to the last century or even like two centuries ago. Do the teachers succeed in modern changes? The purpose of the chapter is to summarize the current changes in didactics for the use of innovative teaching methods and study the understanding of changes by teachers. In this chapter, we consider four areas: the expansion of the subject of pedagogy, environmental approach to teaching, the digital generation and the changes taking place, and innovation in teaching. The theory of education, figuratively speaking, has two levels. At the macro-level, in the “education-society” relationship, decentralization and diversification, internationalization of education, and the introduction of digital technologies occur. At the micro-level in the “teacher-learner” relationship, there is an active mix of traditional and innovative methods, combination of an activity approach with an energy-informational environment approach, cognition with constructivism and connectivism.",book:{id:"5980",slug:"new-pedagogical-challenges-in-the-21st-century-contributions-of-research-in-education",title:"New Pedagogical Challenges in the 21st Century",fullTitle:"New Pedagogical Challenges in the 21st Century - Contributions of Research in Education"},signatures:"Aigerim Mynbayeva, Zukhra Sadvakassova and Bakhytkul\nAkshalova",authors:[{id:"201997",title:"Dr.",name:"Aigerim",middleName:null,surname:"Mynbayeva",slug:"aigerim-mynbayeva",fullName:"Aigerim Mynbayeva"},{id:"209208",title:"Dr.",name:"Zukhra",middleName:null,surname:"Sadvakassova",slug:"zukhra-sadvakassova",fullName:"Zukhra Sadvakassova"},{id:"209210",title:"Dr.",name:"Bakhytkul",middleName:null,surname:"Akshalova",slug:"bakhytkul-akshalova",fullName:"Bakhytkul Akshalova"}]},{id:"59468",doi:"10.5772/intechopen.74344",title:"Virtual and Augmented Reality: New Frontiers for Clinical Psychology",slug:"virtual-and-augmented-reality-new-frontiers-for-clinical-psychology",totalDownloads:2359,totalCrossrefCites:13,totalDimensionsCites:21,abstract:"In the last decades, the applied approach for the use of virtual reality (VR) and augmented reality (AR) on clinical and health psychology has grown exponentially. These technologies have been used to treat several mental disorders, for example, phobias, stress-related disorders, depression, eating disorders, and chronic pain. The importance of VR/AR for the mental health field comes from three main concepts: (1) VR/AR as an imaginal technology, people can feel “as if they are” in a reality that does not exist in external world; (2) VR/AR as an embodied technology, the experience to feel user’s body inside the virtual environment; and (3) VR/AR as connectivity technology, the “end of geography’. In this chapter, we explore the opportunities provided by VR/AR as technologies to improve people’s quality of life and to discuss new frontiers for their application in mental health and psychological well-being promotion.",book:{id:"6543",slug:"state-of-the-art-virtual-reality-and-augmented-reality-knowhow",title:"State of the Art Virtual Reality and Augmented Reality Knowhow",fullTitle:"State of the Art Virtual Reality and Augmented Reality Knowhow"},signatures:"Sara Ventura, Rosa M. Baños and Cristina Botella",authors:[{id:"106036",title:"Dr.",name:"Rosa Maria",middleName:null,surname:"Baños",slug:"rosa-maria-banos",fullName:"Rosa Maria Baños"},{id:"227763",title:"Ph.D.",name:"Sara",middleName:null,surname:"Ventura",slug:"sara-ventura",fullName:"Sara Ventura"},{id:"229056",title:"Dr.",name:"Cristina",middleName:null,surname:"Botella",slug:"cristina-botella",fullName:"Cristina Botella"}]},{id:"64583",doi:"10.5772/intechopen.81714",title:"Evaluating a Course for Teaching Advanced Programming Concepts with Scratch to Preservice Kindergarten Teachers: A Case Study in Greece",slug:"evaluating-a-course-for-teaching-advanced-programming-concepts-with-scratch-to-preservice-kindergart",totalDownloads:1419,totalCrossrefCites:13,totalDimensionsCites:18,abstract:"Coding is a new literacy for the twenty-first century, and as a literacy, coding enables new ways of thinking and new ways of communicating and expressing ideas, as well as new ways of civic participation. A growing number of countries, in Europe and beyond, have established clear policies and frameworks for introducing computational thinking (CT) and computer programming to young children. In this chapter, we discuss a game-based approach to coding education for preservice kindergarten teachers using Scratch. The aim of using Scratch was to excite students’ interest and familiarize them with the basics of programming in an open-ended, project-based, and personally meaningful environment for a semester course in the Department of Preschool Education in the University of Crete. For 13 weeks, students were introduced to the main Scratch concepts and, afterward, were asked to prepare their projects. For the projects, they were required to design their own interactive stories to teach certain concepts about mathematics or physical science to preschool-age students. The results we obtained were more satisfactory than expected and, in some regards, encouraging if one considers the fact that the research participants had no prior experiences with computational thinking.",book:{id:"6936",slug:"early-childhood-education",title:"Early Childhood Education",fullTitle:"Early Childhood Education"},signatures:"Stamatios Papadakis and Michail Kalogiannakis",authors:null}],mostDownloadedChaptersLast30Days:[{id:"58060",title:"Pedagogy of the Twenty-First Century: Innovative Teaching Methods",slug:"pedagogy-of-the-twenty-first-century-innovative-teaching-methods",totalDownloads:8818,totalCrossrefCites:17,totalDimensionsCites:21,abstract:"In the twenty-first century, significant changes are occurring related to new scientific discoveries, informatization, globalization, the development of astronautics, robotics, and artificial intelligence. This century is called the age of digital technologies and knowledge. How is the school changing in the new century? How does learning theory change? Currently, you can hear a lot of criticism that the classroom has not changed significantly compared to the last century or even like two centuries ago. Do the teachers succeed in modern changes? The purpose of the chapter is to summarize the current changes in didactics for the use of innovative teaching methods and study the understanding of changes by teachers. In this chapter, we consider four areas: the expansion of the subject of pedagogy, environmental approach to teaching, the digital generation and the changes taking place, and innovation in teaching. The theory of education, figuratively speaking, has two levels. At the macro-level, in the “education-society” relationship, decentralization and diversification, internationalization of education, and the introduction of digital technologies occur. At the micro-level in the “teacher-learner” relationship, there is an active mix of traditional and innovative methods, combination of an activity approach with an energy-informational environment approach, cognition with constructivism and connectivism.",book:{id:"5980",slug:"new-pedagogical-challenges-in-the-21st-century-contributions-of-research-in-education",title:"New Pedagogical Challenges in the 21st Century",fullTitle:"New Pedagogical Challenges in the 21st Century - Contributions of Research in Education"},signatures:"Aigerim Mynbayeva, Zukhra Sadvakassova and Bakhytkul\nAkshalova",authors:[{id:"201997",title:"Dr.",name:"Aigerim",middleName:null,surname:"Mynbayeva",slug:"aigerim-mynbayeva",fullName:"Aigerim Mynbayeva"},{id:"209208",title:"Dr.",name:"Zukhra",middleName:null,surname:"Sadvakassova",slug:"zukhra-sadvakassova",fullName:"Zukhra Sadvakassova"},{id:"209210",title:"Dr.",name:"Bakhytkul",middleName:null,surname:"Akshalova",slug:"bakhytkul-akshalova",fullName:"Bakhytkul Akshalova"}]},{id:"61746",title:"Facilitation of Teachers’ Professional Development through Principals’ Instructional Supervision and Teachers’ Knowledge- Management Behaviors",slug:"facilitation-of-teachers-professional-development-through-principals-instructional-supervision-and-t",totalDownloads:3378,totalCrossrefCites:2,totalDimensionsCites:2,abstract:"With the rise of global competition and the focus on teacher quality, teacher professional development is becoming increasingly crucial, and the stress and challenges for principals are more severe than ever. Teachers can improve their professional abilities through principals’ instructional supervision and their own knowledge-management (KM) behaviors to benefit students. Thus, this chapter analyzes the relationship among principals’ instructional supervision, teachers’ KM, and teachers’ professional development. The author believes that principals’ instructional supervision and effective KM can facilitate the professional development of teachers. The author also believes the readers can know the relationships among them, and teachers’ professional development can be improved through principal’s instructional supervision and teachers’ KM behaviors.",book:{id:"6674",slug:"contemporary-pedagogies-in-teacher-education-and-development",title:"Contemporary Pedagogies in Teacher Education and Development",fullTitle:"Contemporary Pedagogies in Teacher Education and Development"},signatures:"Chien-Chin Chen",authors:[{id:"232569",title:"Ph.D.",name:"Chien Chih",middleName:null,surname:"Chen",slug:"chien-chih-chen",fullName:"Chien Chih Chen"}]},{id:"75908",title:"From the Classroom into Virtual Learning Environments: Essential Knowledge, Competences, Skills and Pedagogical Strategies for the 21st Century Teacher Education in Kenya",slug:"from-the-classroom-into-virtual-learning-environments-essential-knowledge-competences-skills-and-ped",totalDownloads:515,totalCrossrefCites:0,totalDimensionsCites:0,abstract:"As teachers in Kenya begin to migrate from the classroom to virtual learning spaces following COVID 19 pandemic, there is pressing need to realign Teacher Education to requisite Knowledge, competences, skills, and attitudes that will support online teaching. This chapter explores these needs using a combination of lived experiences and literature review that captured a meta-analysis of research trends on e-learning. While trends in Teacher Education indicate progression towards adoption of technology, there are disparities between the theory and practice. Evidence from recent research and reports; and the recollected experiences confirmed knowledge, competence, skills and pedagogical gaps in the implementation of online learning, that have been exacerbated by COVID-19. The researcher recommends that teacher education should sensitize and train teacher trainees on how to access, analyze and use new knowledge emerging with technology; they also should be coached on how learners learn with technology and on fundamentals of the communication process. Particularly the course on educational technology, should focus on how to create and manage online courses. The 5-stage E-Moderator Model and Universal Design for Learning (UDL) are recommended as effective pedagogical scaffold for online teaching.",book:{id:"10229",slug:"teacher-education-in-the-21st-century-emerging-skills-for-a-changing-world",title:"Teacher Education in the 21st Century",fullTitle:"Teacher Education in the 21st Century - Emerging Skills for a Changing World"},signatures:"Catherine Adhiambo Amimo",authors:[{id:"333482",title:"Dr.",name:"Catherine Adhiambo",middleName:null,surname:"Amimo",slug:"catherine-adhiambo-amimo",fullName:"Catherine Adhiambo Amimo"}]},{id:"75224",title:"Decoding the Digital Gap in Teacher Education: Three Perspectives across the Globe",slug:"decoding-the-digital-gap-in-teacher-education-three-perspectives-across-the-globe",totalDownloads:583,totalCrossrefCites:0,totalDimensionsCites:4,abstract:"Educational use of technology is regularly assessed, and results often show a gap between educational policies and what is actually practiced. This chapter will help clarify how teacher educators experience the changing educational contexts due to the digital revolution, how their meaning-making shifts, and how outside forces influence those processes. The results are based on comparative international studies. Central for this study is practitioners’ professional digital competence, their attitudes towards digital technology and the use of digital technology in education. We found that the influence and contribution of digital practice is carried out quite differently across the globe. Our research questions were: How do practitioners experience teaching in a rapidly changing context? How do attitudes change due to top-down governing of education? and What motivates teacher educators to implement digital technology?",book:{id:"10229",slug:"teacher-education-in-the-21st-century-emerging-skills-for-a-changing-world",title:"Teacher Education in the 21st Century",fullTitle:"Teacher Education in the 21st Century - Emerging Skills for a Changing World"},signatures:"Steinar Thorvaldsen and Siri Sollied Madsen",authors:[{id:"332624",title:"Associate Prof.",name:"Siri Sollied",middleName:null,surname:"Madsen",slug:"siri-sollied-madsen",fullName:"Siri Sollied Madsen"},{id:"332626",title:"Prof.",name:"Steinar",middleName:null,surname:"Thorvaldsen",slug:"steinar-thorvaldsen",fullName:"Steinar Thorvaldsen"}]},{id:"75416",title:"Self-Study Research: Challenges and Opportunities in Teacher Education",slug:"self-study-research-challenges-and-opportunities-in-teacher-education",totalDownloads:763,totalCrossrefCites:0,totalDimensionsCites:0,abstract:"This article aims to describe what self-study research is, why self-study can be a good approach to teacher educators’ professional development and improvements in practice and highlight some challenges and opportunities in this research approach. In addition, the article will shed light on some methodological aspects related to self-study. Self-study refers to teacher educators who in an intentionally and systematically way examine their practice to improve it, based on a deeper understanding of practice, as well as the context practice takes place. 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His research interests include epidemiological patterns and molecular analysis of antimicrobial resistance and modulation and vaccine development against animal pathogens of public health concern.",institutionString:"Cholistan University of Veterinary and Animal Sciences",institution:{name:"University of Agriculture Faisalabad",country:{name:"Pakistan"}}},{id:"333753",title:"Dr.",name:"Rais",middleName:null,surname:"Ahmed",slug:"rais-ahmed",fullName:"Rais Ahmed",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/333753/images/20168_n.jpg",biography:null,institutionString:null,institution:{name:"University of Agriculture Faisalabad",country:{name:"Pakistan"}}},{id:"62900",title:"Prof.",name:"Fethi",middleName:null,surname:"Derbel",slug:"fethi-derbel",fullName:"Fethi Derbel",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/62900/images/system/62900.jpeg",biography:"Professor Fethi Derbel was born in 1960 in Tunisia. He received his medical degree from the Sousse Faculty of Medicine at Sousse, University of Sousse, Tunisia. He completed his surgical residency in General Surgery at the University Hospital Farhat Hached of Sousse and was a member of the Unit of Liver Transplantation in the University of Rennes, France. He then worked in the Department of Surgery at the Sahloul University Hospital in Sousse. Professor Derbel is presently working at the Clinique les Oliviers, Sousse, Tunisia. His hospital activities are mostly concerned with laparoscopic, colorectal, pancreatic, hepatobiliary, and gastric surgery. He is also very interested in hernia surgery and performs ventral hernia repairs and inguinal hernia repairs. He has been a member of the GREPA and Tunisian Hernia Society (THS). During his residency, he managed patients suffering from diabetic foot, and he was very interested in this pathology. For this reason, he decided to coordinate a book project dealing with the diabetic foot. Professor Derbel has published many articles in journals and collaborates intensively with IntechOpen Access Publisher as an editor.",institutionString:"Clinique les Oliviers",institution:null},{id:"300144",title:"Dr.",name:"Meriem",middleName:null,surname:"Braiki",slug:"meriem-braiki",fullName:"Meriem Braiki",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/300144/images/system/300144.jpg",biography:"Dr. Meriem Braiki is a specialist in pediatric surgeon from Tunisia. She was born in 1985. She received her medical degree from the University of Medicine at Sousse, Tunisia. She achieved her surgical residency training periods in Pediatric Surgery departments at University Hospitals in Monastir, Tunis and France.\r\nShe is currently working at the Pediatric surgery department, Sidi Bouzid Hospital, Tunisia. Her hospital activities are mostly concerned with laparoscopic, parietal, urological and digestive surgery. She has published several articles in diffrent journals.",institutionString:"Sidi Bouzid Regional Hospital",institution:null},{id:"229481",title:"Dr.",name:"Erika M.",middleName:"Martins",surname:"de Carvalho",slug:"erika-m.-de-carvalho",fullName:"Erika M. de Carvalho",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/229481/images/6397_n.jpg",biography:null,institutionString:null,institution:{name:"Oswaldo Cruz Foundation",country:{name:"Brazil"}}},{id:"186537",title:"Prof.",name:"Tonay",middleName:null,surname:"Inceboz",slug:"tonay-inceboz",fullName:"Tonay Inceboz",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/186537/images/system/186537.jfif",biography:"I was graduated from Ege University of Medical Faculty (Turkey) in 1988 and completed his Med. PhD degree in Medical Parasitology at the same university. I became an Associate Professor in 2008 and Professor in 2014. I am currently working as a Professor at the Department of Medical Parasitology at Dokuz Eylul University, Izmir, Turkey.\n\nI have given many lectures, presentations in different academic meetings. I have more than 60 articles in peer-reviewed journals, 18 book chapters, 1 book editorship.\n\nMy research interests are Echinococcus granulosus, Echinococcus multilocularis (diagnosis, life cycle, in vitro and in vivo cultivation), and Trichomonas vaginalis (diagnosis, PCR, and in vitro cultivation).",institutionString:"Dokuz Eylül University",institution:{name:"Dokuz Eylül University",country:{name:"Turkey"}}},{id:"71812",title:"Prof.",name:"Hanem Fathy",middleName:"Fathy",surname:"Khater",slug:"hanem-fathy-khater",fullName:"Hanem Fathy Khater",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/71812/images/1167_n.jpg",biography:"Prof. Khater is a Professor of Parasitology at Benha University, Egypt. She studied for her doctoral degree, at the Department of Entomology, College of Agriculture, Food and Natural Resources, University of Missouri, Columbia, USA. She has completed her Ph.D. degrees in Parasitology in Egypt, from where she got the award for “the best scientific Ph.D. dissertation”. She worked at the School of Biological Sciences, Bristol, England, the UK in controlling insects of medical and veterinary importance as a grant from Newton Mosharafa, the British Council. Her research is focused on searching of pesticides against mosquitoes, house flies, lice, green bottle fly, camel nasal botfly, soft and hard ticks, mites, and the diamondback moth as well as control of several parasites using safe and natural materials to avoid drug resistances and environmental contamination.",institutionString:null,institution:{name:"Banha University",country:{name:"Egypt"}}},{id:"99780",title:"Prof.",name:"Omolade",middleName:"Olayinka",surname:"Okwa",slug:"omolade-okwa",fullName:"Omolade Okwa",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/99780/images/system/99780.jpg",biography:"Omolade Olayinka Okwa is presently a Professor of Parasitology at Lagos State University, Nigeria. She has a PhD in Parasitology (1997), an MSc in Cellular Parasitology (1992), and a BSc (Hons) Zoology (1990) all from the University of Ibadan, Nigeria. She teaches parasitology at the undergraduate and postgraduate levels. She was a recipient of a Commonwealth fellowship supported by British Council tenable at the Centre for Entomology and Parasitology (CAEP), Keele University, United Kingdom between 2004 and 2005. She was awarded an Honorary Visiting Research Fellow at the same university from 2005 to 2007. \nShe has been an external examiner to the Department of Veterinary Microbiology and Parasitology, University of Ibadan, MSc programme between 2010 and 2012. She is a member of the Nigerian Society of Experimental Biology (NISEB), Parasitology and Public Health Society of Nigeria (PPSN), Science Association of Nigeria (SAN), Zoological Society of Nigeria (ZSN), and is Vice Chairperson of the Organisation of Women in Science (OWSG), LASU chapter. She served as Head of Department of Zoology and Environmental Biology, Lagos State University from 2007 to 2010 and 2014 to 2016. She is a reviewer for several local and international journals such as Unilag Journal of Science, Libyan Journal of Medicine, Journal of Medicine and Medical Sciences, and Annual Research and Review in Science. \nShe has authored 45 scientific research publications in local and international journals, 8 scientific reviews, 4 books, and 3 book chapters, which includes the books “Malaria Parasites” and “Malaria” which are IntechOpen access publications.",institutionString:"Lagos State University",institution:{name:"Lagos State University",country:{name:"Nigeria"}}},{id:"273100",title:"Dr.",name:"Vijay",middleName:null,surname:"Gayam",slug:"vijay-gayam",fullName:"Vijay Gayam",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/273100/images/system/273100.jpeg",biography:"Dr. Vijay Bhaskar Reddy Gayam is currently practicing as an internist at Interfaith Medical Center in Brooklyn, New York, USA. He is also a Clinical Assistant Professor at the SUNY Downstate University Hospital and Adjunct Professor of Medicine at the American University of Antigua. He is a holder of an M.B.B.S. degree bestowed to him by Osmania Medical College and received his M.D. at Interfaith Medical Center. His career goals thus far have heavily focused on direct patient care, medical education, and clinical research. He currently serves in two leadership capacities; Assistant Program Director of Medicine at Interfaith Medical Center and as a Councilor for the American\r\nFederation for Medical Research. As a true academician and researcher, he has more than 50 papers indexed in international peer-reviewed journals. He has also presented numerous papers in multiple national and international scientific conferences. His areas of research interest include general internal medicine, gastroenterology and hepatology. He serves as an editor, editorial board member and reviewer for multiple international journals. His research on Hepatitis C has been very successful and has led to multiple research awards, including the 'Equity in Prevention and Treatment Award” from the New York Department of Health Viral Hepatitis Symposium (2018) and the 'Presidential Poster Award” awarded to him by the American College of Gastroenterology (2018). He was also awarded 'Outstanding Clinician in General Medicine” by Venus International Foundation for his extensive research expertise and services, perform over and above the standard expected in the advancement of healthcare, patient safety and quality of care.",institutionString:"Interfaith Medical Center",institution:{name:"Interfaith Medical Center",country:{name:"United States of America"}}},{id:"93517",title:"Dr.",name:"Clement",middleName:"Adebajo",surname:"Meseko",slug:"clement-meseko",fullName:"Clement Meseko",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/93517/images/system/93517.jpg",biography:"Dr. Clement Meseko obtained DVM and PhD degree in Veterinary Medicine and Virology respectively. He has worked for over 20 years in both private and public sectors including the academia, contributing to knowledge and control of infectious disease. Through the application of epidemiological skill, classical and molecular virological skills, he investigates viruses of economic and public health importance for the mitigation of the negative impact on people, animal and the environment in the context of Onehealth. \r\nDr. Meseko’s field experience on animal and zoonotic diseases and pathogen dynamics at the human-animal interface over the years shaped his carrier in research and scientific inquiries. He has been part of the investigation of Highly Pathogenic Avian Influenza incursions in sub Saharan Africa and monitors swine Influenza (Pandemic influenza Virus) agro-ecology and potential for interspecies transmission. He has authored and reviewed a number of journal articles and book chapters.",institutionString:"National Veterinary Research Institute",institution:{name:"National Veterinary Research Institute",country:{name:"Nigeria"}}},{id:"158026",title:"Prof.",name:"Shailendra K.",middleName:null,surname:"Saxena",slug:"shailendra-k.-saxena",fullName:"Shailendra K. Saxena",position:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRET3QAO/Profile_Picture_2022-05-10T10:10:26.jpeg",biography:"Professor Dr. Shailendra K. Saxena is a vice dean and professor at King George's Medical University, Lucknow, India. His research interests involve understanding the molecular mechanisms of host defense during human viral infections and developing new predictive, preventive, and therapeutic strategies for them using Japanese encephalitis virus (JEV), HIV, and emerging viruses as a model via stem cell and cell culture technologies. His research work has been published in various high-impact factor journals (Science, PNAS, Nature Medicine) with a high number of citations. He has received many awards and honors in India and abroad including various Young Scientist Awards, BBSRC India Partnering Award, and Dr. JC Bose National Award of Department of Biotechnology, Min. of Science and Technology, Govt. of India. Dr. Saxena is a fellow of various international societies/academies including the Royal College of Pathologists, United Kingdom; Royal Society of Medicine, London; Royal Society of Biology, United Kingdom; Royal Society of Chemistry, London; and Academy of Translational Medicine Professionals, Austria. He was named a Global Leader in Science by The Scientist. He is also an international opinion leader/expert in vaccination for Japanese encephalitis by IPIC (UK).",institutionString:"King George's Medical University",institution:{name:"King George's Medical University",country:{name:"India"}}},{id:"94928",title:"Dr.",name:"Takuo",middleName:null,surname:"Mizukami",slug:"takuo-mizukami",fullName:"Takuo Mizukami",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/94928/images/6402_n.jpg",biography:null,institutionString:null,institution:{name:"National Institute of Infectious Diseases",country:{name:"Japan"}}},{id:"233433",title:"Dr.",name:"Yulia",middleName:null,surname:"Desheva",slug:"yulia-desheva",fullName:"Yulia Desheva",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/233433/images/system/233433.png",biography:"Dr. Yulia Desheva is a leading researcher at the Institute of Experimental Medicine, St. Petersburg, Russia. She is a professor in the Stomatology Faculty, St. Petersburg State University. She has expertise in the development and evaluation of a wide range of live mucosal vaccines against influenza and bacterial complications. Her research interests include immunity against influenza and COVID-19 and the development of immunization schemes for high-risk individuals.",institutionString:'Federal State Budgetary Scientific Institution "Institute of Experimental Medicine"',institution:null},{id:"238958",title:"Mr.",name:"Atamjit",middleName:null,surname:"Singh",slug:"atamjit-singh",fullName:"Atamjit Singh",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/238958/images/6575_n.jpg",biography:null,institutionString:null,institution:null},{id:"252058",title:"M.Sc.",name:"Juan",middleName:null,surname:"Sulca",slug:"juan-sulca",fullName:"Juan Sulca",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/252058/images/12834_n.jpg",biography:null,institutionString:null,institution:null},{id:"191392",title:"Dr.",name:"Marimuthu",middleName:null,surname:"Govindarajan",slug:"marimuthu-govindarajan",fullName:"Marimuthu Govindarajan",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/191392/images/5828_n.jpg",biography:"Dr. M. Govindarajan completed his BSc degree in Zoology at Government Arts College (Autonomous), Kumbakonam, and MSc, MPhil, and PhD degrees at Annamalai University, Annamalai Nagar, Tamil Nadu, India. He is serving as an assistant professor at the Department of Zoology, Annamalai University. His research interests include isolation, identification, and characterization of biologically active molecules from plants and microbes. He has identified more than 20 pure compounds with high mosquitocidal activity and also conducted high-quality research on photochemistry and nanosynthesis. He has published more than 150 studies in journals with impact factor and 2 books in Lambert Academic Publishing, Germany. He serves as an editorial board member in various national and international scientific journals.",institutionString:null,institution:null},{id:"274660",title:"Dr.",name:"Damodar",middleName:null,surname:"Paudel",slug:"damodar-paudel",fullName:"Damodar Paudel",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/274660/images/8176_n.jpg",biography:"I am DrDamodar Paudel,currently working as consultant Physician in Nepal police Hospital.",institutionString:null,institution:null},{id:"241562",title:"Dr.",name:"Melvin",middleName:null,surname:"Sanicas",slug:"melvin-sanicas",fullName:"Melvin Sanicas",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/241562/images/6699_n.jpg",biography:null,institutionString:null,institution:null},{id:"322007",title:"Dr.",name:"Maria Elizbeth",middleName:null,surname:"Alvarez-Sánchez",slug:"maria-elizbeth-alvarez-sanchez",fullName:"Maria Elizbeth Alvarez-Sánchez",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Universidad Autónoma de la Ciudad de México",country:{name:"Mexico"}}},{id:"337443",title:"Dr.",name:"Juan",middleName:null,surname:"A. Gonzalez-Sanchez",slug:"juan-a.-gonzalez-sanchez",fullName:"Juan A. 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The applications of this research cover many related fields, such as biotechnology and medicine, where, for example, Bioinformatics contributes to faster drug design, DNA analysis in forensics, and DNA sequence analysis in the field of personalized medicine. Personalized medicine is a type of medical care in which treatment is customized individually for each patient. Personalized medicine enables more effective therapy, reduces the costs of therapy and clinical trials, and also minimizes the risk of side effects. Nevertheless, advances in personalized medicine would not have been possible without bioinformatics, which can analyze the human genome and other vast amounts of biomedical data, especially in genetics. The rapid growth of information technology enabled the development of new tools to decode human genomes, large-scale studies of genetic variations and medical informatics. The considerable development of technology, including the computing power of computers, is also conducive to the development of bioinformatics, including personalized medicine. In an era of rapidly growing data volumes and ever lower costs of generating, storing and computing data, personalized medicine holds great promises. Modern computational methods used as bioinformatics tools can integrate multi-scale, multi-modal and longitudinal patient data to create even more effective and safer therapy and disease prevention methods. Main aspects of the topic are: Applying bioinformatics in drug discovery and development; Bioinformatics in clinical diagnostics (genetic variants that act as markers for a condition or a disease); Blockchain and Artificial Intelligence/Machine Learning in personalized medicine; Customize disease-prevention strategies in personalized medicine; Big data analysis in personalized medicine; Translating stratification algorithms into clinical practice of personalized medicine.",coverUrl:"https://cdn.intechopen.com/series_topics/covers/7.jpg",hasOnlineFirst:!0,hasPublishedBooks:!0,annualVolume:11403,editor:{id:"351533",title:"Dr.",name:"Slawomir",middleName:null,surname:"Wilczynski",slug:"slawomir-wilczynski",fullName:"Slawomir Wilczynski",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0033Y000035U1loQAC/Profile_Picture_1630074514792",biography:"Professor Sławomir Wilczyński, Head of the Chair of Department of Basic Biomedical Sciences, Faculty of Pharmaceutical Sciences, Medical University of Silesia in Katowice, Poland. His research interests are focused on modern imaging methods used in medicine and pharmacy, including in particular hyperspectral imaging, dynamic thermovision analysis, high-resolution ultrasound, as well as other techniques such as EPR, NMR and hemispheric directional reflectance. Author of over 100 scientific works, patents and industrial designs. Expert of the Polish National Center for Research and Development, Member of the Investment Committee in the Bridge Alfa NCBiR program, expert of the Polish Ministry of Funds and Regional Policy, Polish Medical Research Agency. Editor-in-chief of the journal in the field of aesthetic medicine and dermatology - Aesthetica.",institutionString:null,institution:{name:"Medical University of Silesia",institutionURL:null,country:{name:"Poland"}}},editorTwo:null,editorThree:null,series:{id:"7",title:"Biomedical Engineering",doi:"10.5772/intechopen.71985",issn:"2631-5343"},editorialBoard:[{id:"5886",title:"Dr.",name:"Alexandros",middleName:"T.",surname:"Tzallas",slug:"alexandros-tzallas",fullName:"Alexandros Tzallas",profilePictureURL:"https://mts.intechopen.com/storage/users/5886/images/system/5886.png",institutionString:"University of Ioannina, Greece & Imperial College London",institution:{name:"University of Ioannina",institutionURL:null,country:{name:"Greece"}}},{id:"257388",title:"Distinguished Prof.",name:"Lulu",middleName:null,surname:"Wang",slug:"lulu-wang",fullName:"Lulu Wang",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRX6kQAG/Profile_Picture_1630329584194",institutionString:"Shenzhen Technology University",institution:{name:"Shenzhen Technology University",institutionURL:null,country:{name:"China"}}},{id:"225387",title:"Prof.",name:"Reda R.",middleName:"R.",surname:"Gharieb",slug:"reda-r.-gharieb",fullName:"Reda R. 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