Risk Factors for Ischaemic Colitis (Bjorck et al, 1996; Neary et al, 2007; Perry et al, 2008; Becquemin et al, 2008; Levison et al, 1999)
\\n\\n
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Barely three months into the new year and we are happy to announce a monumental milestone reached - 150 million downloads.
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\n\n\n\n\n'}],latestNews:[{slug:"intechopen-supports-asapbio-s-new-initiative-publish-your-reviews-20220729",title:"IntechOpen Supports ASAPbio’s New Initiative Publish Your Reviews"},{slug:"webinar-introduction-to-open-science-wednesday-18-may-1-pm-cest-20220518",title:"Webinar: Introduction to Open Science | Wednesday 18 May, 1 PM CEST"},{slug:"step-in-the-right-direction-intechopen-launches-a-portfolio-of-open-science-journals-20220414",title:"Step in the Right Direction: IntechOpen Launches a Portfolio of Open Science Journals"},{slug:"let-s-meet-at-london-book-fair-5-7-april-2022-olympia-london-20220321",title:"Let’s meet at London Book Fair, 5-7 April 2022, Olympia London"},{slug:"50-books-published-as-part-of-intechopen-and-knowledge-unlatched-ku-collaboration-20220316",title:"50 Books published as part of IntechOpen and Knowledge Unlatched (KU) Collaboration"},{slug:"intechopen-joins-the-united-nations-sustainable-development-goals-publishers-compact-20221702",title:"IntechOpen joins the United Nations Sustainable Development Goals Publishers Compact"},{slug:"intechopen-signs-exclusive-representation-agreement-with-lsr-libros-servicios-y-representaciones-s-a-de-c-v-20211123",title:"IntechOpen Signs Exclusive Representation Agreement with LSR Libros Servicios y Representaciones S.A. de C.V"},{slug:"intechopen-expands-partnership-with-research4life-20211110",title:"IntechOpen Expands Partnership with Research4Life"}]},book:{item:{type:"book",id:"7315",leadTitle:null,fullTitle:"Minerals",title:"Minerals",subtitle:null,reviewType:"peer-reviewed",abstract:'The book "Minerals" offers an important and thorough overview on different geophysical methods including gravity, magnetic and self-potential in mineral exploration, as well as physical and chemical analysis in delineating the minerals. Furthermore, the book describes the different types of minerals such as clay and its minerals, and uranium (which contains radioactive elements) and how to use them in the sector of safe energy. The book also demonstrates the governing law of mineral distribution in bearing rocks and their journey from mining to marketing. This book shall be of great interest to students, geologists, geophysicists, and the mining investment community.',isbn:"978-1-83962-682-1",printIsbn:"978-1-83962-681-4",pdfIsbn:"978-1-83962-683-8",doi:"10.5772/intechopen.74902",price:119,priceEur:129,priceUsd:155,slug:"minerals",numberOfPages:140,isOpenForSubmission:!1,isInWos:null,isInBkci:!1,hash:"f0d5c2a9a5f37e6effcb8486c661d217",bookSignature:"Khalid S. Essa",publishedDate:"November 13th 2019",coverURL:"https://cdn.intechopen.com/books/images_new/7315.jpg",numberOfDownloads:5216,numberOfWosCitations:7,numberOfCrossrefCitations:10,numberOfCrossrefCitationsByBook:1,numberOfDimensionsCitations:20,numberOfDimensionsCitationsByBook:2,hasAltmetrics:1,numberOfTotalCitations:37,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"March 14th 2018",dateEndSecondStepPublish:"August 28th 2018",dateEndThirdStepPublish:"October 27th 2018",dateEndFourthStepPublish:"January 15th 2019",dateEndFifthStepPublish:"March 16th 2019",currentStepOfPublishingProcess:5,indexedIn:"1,2,3,4,5,6,7",editedByType:"Edited by",kuFlag:!1,featuredMarkup:null,editors:[{id:"102766",title:"Prof.",name:"Khalid S.",middleName:null,surname:"Essa",slug:"khalid-s.-essa",fullName:"Khalid S. Essa",profilePictureURL:"https://mts.intechopen.com/storage/users/102766/images/system/102766.jpg",biography:"Dr. Khalid S. Essa obtained his B.Sc. with honors (1997), M.Sc. (2001) and Ph.D. (2004) in Geophysics from the Faculty of Science, Cairo University. He joined the staff of Cairo University (1997) and was appointed a research Professor of potential field methods in the Department of Geophysics (2014). He has undertaken affiliated post-doctoral visits to Strasbourg University, France (2018-2019), Charles University in Prague, Czech (2014-2015) and Western Michigan University, USA (2006-2007). He has authored more than 70 technical papers and served as an Editor and external reviewer for many top journals. He attended several International Geophysical Conferences in USA, Australia and France. He was a member in SEG, AGU, AAPG, EAGE and EGS. Also, he is a member of the National committee for Geodesy and Geophysics, Academy of Scientific Research and Technology, Egypt (2020-2023) and member of the Petroleum and Mineral Resources Research Council, Sector of Quality Councils, Academy of Scientific Research and Technology, Egypt (2018-2021). He has been awarded the Award of Prof. Nasry Matari Shokry in Applied Geology, Academy of Scientific Research & Technology (2017) and the Award of Cairo University for Scientific Excellence in Interdisciplinary, Multidisciplinary and Future Sciences (2017).",institutionString:"Cairo University",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"4",totalChapterViews:"0",totalEditedBooks:"2",institution:{name:"Cairo University",institutionURL:null,country:{name:"Egypt"}}}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,coeditorOne:null,coeditorTwo:null,coeditorThree:null,coeditorFour:null,coeditorFive:null,topics:[{id:"651",title:"Mineralogy",slug:"geology-and-geophysics-mineralogy"}],chapters:[{id:"65826",title:"Introductory Chapter: Mineral Exploration from the Point of View of Geophysicists",doi:"10.5772/intechopen.84830",slug:"introductory-chapter-mineral-exploration-from-the-point-of-view-of-geophysicists",totalDownloads:1662,totalCrossrefCites:3,totalDimensionsCites:3,hasAltmetrics:1,abstract:null,signatures:"Khalid S. Essa and Marc Munschy",downloadPdfUrl:"/chapter/pdf-download/65826",previewPdfUrl:"/chapter/pdf-preview/65826",authors:[{id:"102766",title:"Prof.",name:"Khalid S.",surname:"Essa",slug:"khalid-s.-essa",fullName:"Khalid S. Essa"},{id:"292929",title:"Prof.",name:"Marc",surname:"Munschy",slug:"marc-munschy",fullName:"Marc Munschy"}],corrections:null},{id:"63713",title:"Inversion of Amplitude from the 2-D Analytic Signal of Self-Potential Anomalies",doi:"10.5772/intechopen.79111",slug:"inversion-of-amplitude-from-the-2-d-analytic-signal-of-self-potential-anomalies",totalDownloads:1115,totalCrossrefCites:5,totalDimensionsCites:9,hasAltmetrics:0,abstract:"In the present study, analytic signal amplitude (ASA) or total gradient (TG) inversion of self-potential anomalies has been carried out using very fast simulated annealing (VFSA) global optimization technique. The results of VFSA optimization demonstrate the application and efficacy of the proposed method for idealized synthetic hypothetical models and real single and multiple geological structures. The model parameters deciphered here are the amplitude coefficient (k), horizontal location (x0), depth of the body (z), and shape (q). Inversion of the model parameter suggests that constraining the horizontal location and the shape factor offers the most reliable results. Investigation of convergence rate, histogram, and cross-plot examination suggest that the interpretation method developed for the self-potential anomalies is stable and the model parameters are within the estimated ambiguity. Inversion of synthetic noise-free and noise-corrupted data for single structures and multiple structures in addition to real field information exhibits the viability of the method. The model parameters estimated by the present technique were in good agreement with the real parameters. The method has been used to invert two field examples (Sulleymonkoy anomaly, Ergani, Turkey, Senneterre area of Quebec, Canada) with application of subsurface mineralized bodies. This technique can be very much helpful for mineral or ore bodies investigation of idealized geobodies buried within the shallow and deeper subsurface.",signatures:"Arkoprovo Biswas",downloadPdfUrl:"/chapter/pdf-download/63713",previewPdfUrl:"/chapter/pdf-preview/63713",authors:[{id:"250390",title:"Dr.",name:"Arkoprovo",surname:"Biswas",slug:"arkoprovo-biswas",fullName:"Arkoprovo Biswas"}],corrections:null},{id:"68162",title:"A Review of the Role of Natural Clay Minerals as Effective Adsorbents and an Alternative Source of Minerals",doi:"10.5772/intechopen.87260",slug:"a-review-of-the-role-of-natural-clay-minerals-as-effective-adsorbents-and-an-alternative-source-of-m",totalDownloads:1006,totalCrossrefCites:2,totalDimensionsCites:7,hasAltmetrics:0,abstract:"The minerals with unique properties such as natural clay minerals (NCMs) have promising approach in environmental and industrial sphere. In fact, under some specific conditions the NCMs could be used either as effective adsorbent material or alternative source of minerals. This chapter presents an outline of a general review of factors that affect the application ability of NCMs and a descriptive analysis of NH4+ and REE adsorption behavior and extraction of rare earth elements (REE) by an ion-exchange with NH4+ ions onto NCMs. Clays and NCMs both effectively remove various contaminants from aqueous solution and serve as alternative sources of minerals, as extensively discussed in this chapter. This review compiles thorough literature of current research and highlights the key findings of adsorption (NH4+ and REE) that use different NCMs as adsorbents or alternative sources of minerals (i.e., REE). The review confirmed that NCMs excellently remove different cations pollutants and have significant potential as alternative source of REE. However, modification and further development of NCMs applications for getting the best adsorption and the best extraction of REE onto NCMs, which would enhance pollution control and leaching system is still needed.",signatures:"Aref Alshameri, Xinghu Wei, Hailong Wang, Yang Fuguo, Xin Chen, Hongping He, Chunjie Yan and Feng Xu",downloadPdfUrl:"/chapter/pdf-download/68162",previewPdfUrl:"/chapter/pdf-preview/68162",authors:[{id:"172947",title:"Prof.",name:"Xin",surname:"Chen",slug:"xin-chen",fullName:"Xin Chen"},{id:"250327",title:"Dr.",name:"Aref",surname:"Alshameri",slug:"aref-alshameri",fullName:"Aref Alshameri"},{id:"306625",title:"Dr.",name:"Aref",surname:"Alshameri",slug:"aref-alshameri",fullName:"Aref Alshameri"},{id:"306656",title:"Prof.",name:"Fuguo",surname:"Yang",slug:"fuguo-yang",fullName:"Fuguo Yang"},{id:"306658",title:"Dr.",name:"Wei",surname:"Xinghu",slug:"wei-xinghu",fullName:"Wei Xinghu"},{id:"306660",title:"Prof.",name:"Wang",surname:"Hailong",slug:"wang-hailong",fullName:"Wang Hailong"},{id:"306664",title:"Prof.",name:"Yan",surname:"Chunjie",slug:"yan-chunjie",fullName:"Yan Chunjie"},{id:"306665",title:"Dr.",name:"Xu",surname:"Feng",slug:"xu-feng",fullName:"Xu Feng"},{id:"306671",title:"Prof.",name:"He",surname:"Hongping",slug:"he-hongping",fullName:"He Hongping"}],corrections:null},{id:"63003",title:"Theoretical Studies of the Structural, Mechanical and Raman Spectroscopic Properties of Uranyl-Containing Minerals",doi:"10.5772/intechopen.80360",slug:"theoretical-studies-of-the-structural-mechanical-and-raman-spectroscopic-properties-of-uranyl-contai",totalDownloads:778,totalCrossrefCites:0,totalDimensionsCites:1,hasAltmetrics:0,abstract:"The incipient use of theoretical methods in the research of geomaterials reveals the great power of such methodology in the determination of the mineral properties. These methods provide a safe, accurate and cheap manner of obtaining these properties. Uranium-containing minerals are highly radiotoxic, and their experimental studies demand a careful handling of the samples used. However, theoretical methods are free of such inconveniences and may be used in the complete characterization of this type of minerals. Theoretical methods are not only a complement to the use of other experimental techniques but also a powerful predictive tool. The structural, mechanical and Raman spectroscopic properties of uranyl-containing materials, including rutherfordine soddyite, schoepite and uranophane-α, were studied by means of theoretical solid-state methods based on density functional theory using plane waves and pseudopotentials. A new norm-conserving relativistic pseudopotential for uranium atom developed in recent works was employed. These minerals are among the most important secondary phases arising from corrosion of spent nuclear fuel under the final geological disposal conditions. The computed crystal structures of these materials as well as the corresponding and X-ray powder patterns were found to be in excellent agreement with the experimental information. Therefore, the optimized structures of these minerals were employed to study the mechanical properties and stability of these minerals. These properties were obtained using the finite deformation technique. All these minerals were found to be mechanically stable since the corresponding Born stability conditions were satisfied. A large amount of relevant mechanical data were reported including bulk, Young and Shear moduli, Poisson ratios, ductility and hardness indices, anisotropy measures as well as longitudinal and transversal wave velocities. The large volume expansion and mechanical stress resulting from the corrosion of spent nuclear fuel during storage emphasize the great relevance of the mechanical information of the waste components. Finally, the computation of vibrational properties of these minerals is studied. The computed Raman spectra of these materials were found to be in good agreement with their experimental counterparts when they were available for comparison. These results demonstrate the power of the theoretical methods in the research of uranium-containing minerals.",signatures:"Francisco Colmenero Ruiz",downloadPdfUrl:"/chapter/pdf-download/63003",previewPdfUrl:"/chapter/pdf-preview/63003",authors:[{id:"252909",title:"Dr.",name:"Francisco",surname:"Colmenero",slug:"francisco-colmenero",fullName:"Francisco Colmenero"}],corrections:null},{id:"68224",title:"Distribution Law for Constituent Minerals and Chemical Components in Rocks and Ores",doi:"10.5772/intechopen.88125",slug:"distribution-law-for-constituent-minerals-and-chemical-components-in-rocks-and-ores",totalDownloads:656,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:"Rocks and Ores comprising of multicomponent of minerals (Group I) contain chemical molecules (Group II) which further contain (Group III). Man has exploited these valuable constituents for industrial, economic, and social growth causing serious depletion of high-grade ores at surface and shallow depths. Sustainable growth now requires exploitation of low-grade ores and those occurring at depth which imply optimal and most efficient mining efforts based on spatial, temporal, and spatiotemporal distribution of these constituents. The optimal decisions resulting in profit maximization is possible by obtaining precise and accurate parameters of these distributions. Sample size required for such estimations must be at least representative elementary volume (REV) of the rocks/ores, but the data matrix is not full-rank for statistical analyses and sample mean (x; 0 < x < 1) must be transformed to Gaussian to apply standard univariate (UND)/multivariate (MND) statistical techniques. A log(x/(1−x)) or ln(x/(1−x)) transform is shown to be an appropriate pre-transformation that eliminates the twin problems of full-rank, and spurious negative correlations as well as makes the distribution Gaussian for major, minor, and trace components. Mining applications using the univariate and/or Multivariate Normal Theory of pre-transformed sample mean (x) in rocks/ores is optimal for anomaly detection, drilling site selection, global reserve and grade estimations, mine planning, ore mineral liberation, blending, sustainable mine developments and maximization of profits computed on net profit value (NPV) basis to present time.",signatures:"Basanta K. Sahu",downloadPdfUrl:"/chapter/pdf-download/68224",previewPdfUrl:"/chapter/pdf-preview/68224",authors:[{id:"248217",title:"Emeritus Prof.",name:"Basanta",surname:"Sahu",slug:"basanta-sahu",fullName:"Basanta Sahu"}],corrections:null}],productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"},subseries:null,tags:null},relatedBooks:[{type:"book",id:"9984",title:"Geophysics and Ocean Waves Studies",subtitle:null,isOpenForSubmission:!1,hash:"271d086381f9ba04162b0dc7cd57755f",slug:"geophysics-and-ocean-waves-studies",bookSignature:"Khalid S. Essa, Marcello Di Risio, Daniele Celli and Davide Pasquali",coverURL:"https://cdn.intechopen.com/books/images_new/9984.jpg",editedByType:"Edited by",editors:[{id:"102766",title:"Prof.",name:"Khalid S.",surname:"Essa",slug:"khalid-s.-essa",fullName:"Khalid S. 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Although the gastrointestinal complications that occur secondary to repair of an aortic abdominal aneurysm (AAA) are uncommon they are associated with a significant increase in patient morbidity and mortality and therefore they warrant discussion. The gastrointestinal complications that we plan to review in detail in this chapter are ischaemic colitis, abdominal compartment syndrome, secondary aorto-enteric fistula, chylous ascites and ileus. We are also going to briefly discuss peptic ulcer disease, acute cholecystitis and acute pancreatitis and their relationship with AAA surgery.
Throughout the chapter we describe the incidence, aetiology, pathology, associated risk factors, diagnosis and management for each potential gastrointestinal complication in an evidence based manner.
Over the last two decades a new technique, endovascular surgery (EVAR), has been introduced as an alternative option for the management of an abdominal aortic aneurysm. The traditional approach, open repair, has long been regarded as a durable, effective procedure that is associated with a low rate of rupture with long-term follow up. However, the evolution of endovascular surgery has promised benefits when compared to the traditional approach. The advantages of the endovascular approach include a faster recovery time post-operatively and a reduction in the morbidity and mortality rates that occur with this condition. It also allows elderly patients and patients with co-morbidities that previously would have been considered unfit for surgery to undergo aneurysm repair in a safe manner. As part of our review of gastrointestinal complications following AAA repair, in this chapter we examine the impact, if any, that endovascular surgery has had on the type and frequency of these complications since its introduction.
Ischaemic colitis is an infrequent but devastating complication following AAA repair. The intestinal mucosa is very sensitive to ischaemia and a sufficient reduction in blood flow can lead to this damaging condition. In ischaemic colitis it is only the mucosa of the bowel that is injured, the full thickness of the bowel wall remains unharmed.
The incidence of ischaemic colitis post open and elective repair of AAA is 1-3% (Van et al, 2000). The incidence following EVAR is similar. However the risk of ischaemic colitis increases to 10% in cases of open repair of a ruptured AAA. If routine post-operative colonoscopy is performed to screen for this condition the rate of detection dramatically rises to 9% for elective repair and has been reported to be found in up to 60% of patients following surgery for a ruptured aneurysm (Chen et al, 1996).
Any reduction in blood flow to the bowel wall mucosa can result in ischaemic colitis. With surgery for an AAA a reduction in blood flow can occur secondary to a reduction in circulating blood volume which can result, for example, due to blood loss or in a state of low cardiac output. Vasoconstriction of the splanchnic circulation occurring as part of the physiological response of the body to shock or due to the administration of vasopressive medication also results in a reduction of blood flowing to the bowel mucosa. Occlusion of the inferior mesenteric artery (IMA) or the internal iliac artery can lead to a reduction in blood flow to the bowel wall. This can arise due to external compression that occurs during operative repair, for example trauma caused by retraction, the intentional occlusion of the IMA that is associated with EVAR, or due to thrombus formation, arthero-embolisation or a haematoma formation.
In endovascular repair it has been proposed that ischaemic colitis could be attributed to the dislodgement of debris from the sac of the aneurysm during wire and graft manipulation. It has been suggested however, that the EVAR approach may reduce the severity of ischaemic colitis but there is currently a lack of conclusive data to support this (Elmarsay et al, 2000). Certainly a recent study has shown that there is at the very least no significant difference in the rates of ischaemic colitis following the open and EVAR approach (Bosch et al, 2010).
During the fasting state the gastrointestinal tract only receives 20% of the overall cardiac output. This increases to 35% post-prandially, and of this, the mucosa receives 70% of the blood supply. The colon differs from the small bowel structurally, a difference that accounts for its greater susceptibility to a reduced blood flow volume. Firstly the sub-mucosal vascular plexuses are much more extensive in the small bowel when compared to the large bowel and secondly the large bowel has no villi and therefore it has no counter-current mechanism. In the case of hypotension or with a low cardiac output the micro-vascular arcades are the ones to suffer as they are (i) the last to get blood and (ii) in cases of shock the physiological response is to shunt blood away from the splanchnic circulation. The splenic flexure in particular is vulnerable to ischaemia as it is part of the “watershed” area – this is the area of the colon where the superior mesenteric artery and IMA both supply but are reliant on collaterals to bridge the gaps in-between. Within a fifteen minute window a reduction in blood flow leading to ischaemia can demonstrate structural changes in the mucosa. After three hours mucosal sloughing will be evident and after six hours transmural necrosis will manifest.
There are two main factors that cause structural damage, (i) hypoxia, due to a reduction in blood flow and (ii) reperfusion injury.
There are three steps in the pathophysiological process leading to ischaemic colitis; fluid loss, reperfusion injury and vasoconstriction of the splanchnic vasculature.
Fluid Loss: The amount of fluid lost during aortic surgery is considerable. Animal experiments have demonstrated that up to a third of circulating fluid (plasma) may be lost after superior mesenteric artery occlusion (Geroulakos & Cherry, 2002). With a reduction in blood flow, the injured bowel loses its absorptive function while the crypt cells are spared and continue to secrete. Intraluminal exudation causes a further reduction in blood volume and distension of the bowel wall. The bowel becomes oedematous and there is transudation of fluid into the peritoneal cavity. When the arterial flow is then restored and blood flow returns to the gastrointestinal tract reactionary haemorrhage can occur into the bowel lumen.
Reperfusion injury: Anaerobic metabolism and acidosis trigger an inflammatory cascade. The main damaging effects of activating this cascade are caused by the production of free radicals (superoxide, peroxide and hydroxyl). The colonic mucosa is rich in the enzyme xanthine dehydrogenase which results in the production of reactive oxygen species and free radicals. The release of these free radicals causes a release of cytokines and platelet activating factor, which in turn activate and stimulate the release of monocytes, neutrophils and endothelin 1 (ET-1), which is a potent vasoconstrictor. The activation of polymorphonuclear leukocytes causes a systemic inflammatory response. The final result is end organ damage affecting the respiratory system, the renal system and leading to bone marrow failure. Further massive losses of fluid volume could result from disseminated intravascular coagulation (DIC) and the widespread increase in vascular permeability that this can bring.
Splanchnic vasoconstriction: Vasoconstriction can persist following revascularisation rendering perfusion inadequate.
The ischaemic colon loses its barrier function rapidly leading to invasion by luminal bacteria and endotoxin absorption. This takes place over a period of at least 24 hours. The mucosa sloughs off into the lumen which causes peristalsis, diarrhoea and bleeding. In the most severe of cases it leads to portal pyaemia and death. Less severe cases result in multi-organ damage and failure.
Three progressive stages of ischemic colitis are described (i) Grade 1: transient mucosal ischaemia, (ii) Grade II: mucosal and muscularis involvement which may result in healing with fibrosis and stricture formation (iii) Grade III: transmural ischaemia and infarction which results in gangrene and perforation. The mortality rate reaches 90% in patients with bowel infarction.
When comparing open surgery to EVAR it is likely that there is a different pathophysiological pattern at play. In EVAR there is no manipulation of the bowel which reduces the risk of trauma. As a result abdominal hypertension and compartment syndrome as a cause of ischaemic colitis is unlikely. Reperfusion injury to the bowel is also unlikely as the period of time during the operation when the aorta is occluded is short. It had been thought that sacrificing the IMA may account for ischaemic colitis in endovascular repair. However, it is now believed that preserving IMA patency may not be as important as previously thought. With EVAR there is a risk of micro-embolisation due to dislodging the thrombus or the artheromatous plaque during wire and graft manipulation and placement.
There are a number of factors that have been established as associated with a greater chance of ischaemic colitis. They can be divided into pre, peri or intra and post-operative risk factors (table 1).
Ruptured AAA | |
Mean systolic blood pressure <80mmHg | |
Length of time spent hypotensive | |
High disease severity score | |
Age | |
Female | |
Blood loss "/>2000ml | |
Operating time "/>4 hours | |
Body temperature <35 degrees | |
Length of time aorta is cross-clamped | |
Hospital case volume | |
Internal iliac artery ligation | |
Aotobifemoral grafting | |
Renal impairment | |
Neutrophilia | |
Metabolic acidosis | |
Ionotropic support | |
Bloody diarrhoea |
Risk Factors for Ischaemic Colitis (Bjorck et al, 1996; Neary et al, 2007; Perry et al, 2008; Becquemin et al, 2008; Levison et al, 1999)
Patients undergoing emergency AAA repair or that develop shock peri-operatively are at the greatest risk of developing ischaemic colitis. Here the incidence increases from 1-3% to 30% (Levison et al, 1999).
The type of surgical approach has not been found to be an independent predictor of ischaemic colitis. This has been challenged in particular with respect to the patency of the IMA. IMA patency has been demonstrated not to be associated with an increased risk of ischaemic colitis (Senekowitsch et al, 2006). This has been shown in open surgery where routine re-implantation of the IMA was compared to no re-implantation and in EVAR where the IMA is routinely blocked off. To date the importance of hypogastric artery patency has not been established in both open and EVAR repair. However, it does seem that it is not emerging as a significant risk factor (Geraghty et al, 2004).
Ischaemic colitis can be seen at the time of open AAA repair. When this occurs a colectomy may need to be performed and the overall outcome for the patient is generally poor.
The mean time to diagnosis ischaemic colitis post-operatively is 5.5 days. In patients where a bowel resection is required there is an overall mortality rate of 80-90%. The sigmoid colon is the most commonly affected segment of large bowel followed by the rectum.
Presenting features are often insidious and include diarrhoea which may or may not be bloody and abdominal pain out of keeping with the clinical signs. The diagnosis often requires a high index of suspicion with specific investigations to confirm it. A high index of suspicion should be had in patients with persistent hypotension post-operatively, an elevated lactate, creatinine, leucocytes and other signs that point towards sepsis.
Features to be aware of on plain abdominal x-ray are non-specific and include; fluid levels, toxic colon dilation, intramural air and free air due to perforation. In severe clinical cases intra-portal air may be present. A barium enema may demonstrate thumb-printing which is present as a result of mucosal oedema. CT (contrast enhanced computed tomography) or MRI scans in the early stages may be normal or may show non-specific signs such as mucosal thickening or oedema. As ischaemic colitis progresses, scanning typically demonstrates a circumferential symmetrical wall thickening with fold enlargement. It may be useful to consider looking at the visceral arteries with MRA.
Endoscopy demonstrates a diagnostic accuracy of 92% (Assadian et al, 2008). But a histological diagnosis is the gold standard. On endoscopy there may be blood visible in the bowel lumen. If there is a suspicion that the colon may be ischaemic biopsies should be taken, even if the mucosa appears normal. In mild cases of ischaemic colitis the mucosa appears pale with petechiae, whereas in severe colitis the mucosa appears blue or black in colour and there may be slough or ulceration. Histological features on biopsy include; hyalinization of the lamina propria, atrophic appearing micro-crypts, lamina propria haemorrhage, full thickness mucosal necrosis and a diffuse distribution of pseudomembranes.
In the acute phase there is necrosis of the superficial epithelium and haemorrhage into the lamina propria. The intestinal crypts are spared. This stage is reversible, but it may progress. In the organising phase there is ulceration and associated granulation tissue formation without the presence of marked inflammatory changes. Iron deposits can be found also. The healed phase demonstrates architectural distortion of the crypts and a transmural fibrosis. Another diagnostic approach is an exploratory laparotomy.
In the setting of ischaemia these patients are at risk of developing pseudomembranous colitis. This is further exacerbated by the administration of prophylactic antibiotics.
Although postoperative clinical assessment with physical examination and laboratory tests is unreliable in predicting ischemic colitis, several intra-operative methods have demonstrated a certain degree of promise. These include inferior mesenteric artery stump pressure measurements, trans-serosal tissue oxygen tension measurements (tPO2), laparoscopy, and tonometry. Pulse oximetry could be another potentially helpful tool to monitor the colon for evidence of ischaemia (Yilmaz et al, 1999). Of these assessments, selective ligation of the IMA on the basis of intraoperative bowel inspection, colonic mesenteric Doppler signals, and IMA stump pressure have been the most encouraging. However, these techniques detect intra-operative changes and they may not accurately reflect or predict subsequent ischemic events.
Colonoscopy remains the diagnostic procedure of choice for assessing ischemic colitis.
Early detection and treatment of ischaemic colitis is very important. The condition if diagnosed in the initial stages can be reversed.
Conservative management of ischaemic colitis can be employed if the ischaemia is not transmural and there is no evidence of multi-organ damage, the patient is clinically stable and they have no signs of peritonitis. Grade I and II bowel ischaemia can be treated with antibiotic therapy, intravenous fluids, bowel rest, and surveillance colonoscopy. Grade III ischaemia warrants an immediate laparotomy in an effort to decrease the mortality associated with this condition (Champagne et al, 2004). At laparotomy the ischaemic segment should be resected with both bowel ends being brought out as stomas. Patients that require an immediate laparotomy and bowel resection do worse in terms of outcome and have a significantly higher mortality risk. Surveillance colonoscopy is very important in the early grades of ischaemia and should be carried out at regular intervals as the ischaemia may become more extensive at any stage.
Although ischaemic colitis may be subclinical and only discovered on colonoscopy and biopsy it is still a significant condition, because despite resolution of the ischaemia, the gut mucosal barrier will have been altered. This allows the passage of bacteria and endotoxins into the portal circulation thereby causing sepsis and multi-organ failure. The true incidence of ischaemic colitis is probably much higher than the clinically evident incidence (Welch et al, 1998). Welch and colleagues performed a study where they scoped patients post-operative AAA repair and they found a very high rate of asymptomatic ischaemic colitis (30%) (Welch et al, 1998).
The monitoring of intra-abdominal pressure post-operatively is justified as an increase in intra-abdominal hypertension is associated with colonic ischaemia (Djavani et al, 2009). This approach can therefore allow early detection and treatment of ischaemic colitis. Another preventative approach, the effectiveness of which remains debatable is the role of re-implanting the IMA (Mitchell & Valentine, 2002). Arguments against this technique include the increased risk of bleeding from the anastomosis, the technically demanding nature of this procedure, and the increase in intra-operative time that it is associated with.
Major cardiac, respiratory and renal complications are associated with ischaemic colitis (Becquemin et al, 2008). Therefore it is easy to understand the seriousness of this gastrointestinal complication following AAA repair. A further complication of ischaemic colitis that presents at a late stage is a stricture of the colon. A stricture typically presents with features of subacute obstruction.
Overall there has been no difference in mortality demonstrated for ischaemic colitis occurring following open repair or endovascular surgery.
Abdominal compartment syndrome (ACS) occurs when a fixed compartment, defined by myofascial elements, becomes subject to increased pressure, leading to ischemia and organ dysfunction. ACS is the worst potential outcome that can occur with an elevation in intra-abdominal pressure (IAP). It is thought to be the most common cause of intestinal hypoperfusion and it also has significance in the setting of AAA repair. The incidence of ACS has been reported to be approximately 5 -18% in patients that do not undergo IAP monitoring and this increases to >10% when IAP is monitored. The incidence seems to be similar irrespective of whether open or EVAR repair is performed (Bjork et al, 2008; Bosch et al, 2010). The incidence is significantly greater in patients following a ruptured AAA (30%) and the associated mortality in this case can be up to 70% (Maker et al, 2009;\n\t\t\t\t\tMehta, 2010). The diagnosis of abdominal compartment syndrome post AAA repair is a recognised prognostic indicator and is associated with an overall mortality rate of greater than 50%.
In open repair of an AAA the most significant contributors to an elevation in intra-abdominal pressure and subsequent development of ACS are manipulation of the intestines and mesenteric retraction occurring as a routine part of surgery.
The aetiology of ACS following endovascular repair is somewhat different. Factors associated with intra-abdominal hypertension following endovascular surgery include; (i) a retroperitoneal hematoma resulting in a space occupying lesion, (ii) continuous bleeding from the lumbar and inferior mesenteric arteries into the disrupted aneurysm sac or surrounding retroperitoneal tissues; this may be exacerbated by the systemic inflammatory response and associated coagulopathy that occurs in patients, in particular, those that have undergone emergency repair due to rupture, and (iii) similarly the increase in microvascular permeability that can lead to visceral and soft tissue oedema following ruptured AAA (Mehta, 2010).
ACS is classified (Grade I-IV) based on the level of intra-abdominal pressure (table 2). In the critically ill patient without an AAA repair a normal IAP is considered to be 5-7mmHg. Grade I and II, where the IAP is between 12 and 20mmHg, can lead to impairment of renal function. This is followed by progressive dysfunction of all other organ systems.
I | 12-15 |
II | 16-20 |
III | 21-25 |
IV | "/>25 |
Grading of Intra-abdominal Pressure according to WSACS Guidelines
A raised IAP of 20mmHg or more results in a reduction in the venous return to the heart and a decreased cardiac output. An increase in abdominal pressure also reduces venous flow to the various intra-peritoneal organs. Overall the outcome is that there is a reduction in perfusion of the various visceral organs resulting in bowel ischaemia. Mild cases of ischaemic colitis create an increase in intestinal permeability but in extreme cases bowel infarction can result.
The risk of increased IAP and therefore ACS has been proposed to be less in cases of endovascular repair. Studies have shown that EVAR is associated with less of a rise in inflammatory markers post-operatively when compared to open repair, a factor that as a consequence reduces the risk of a raised IAP and ACS (Junnarkar et al, 2003).
Risk factors for the development of intra-abdominal hypertension are multiple and can be divided into pre-operative, peri- or intra-operative and post-operative risk factors (table 3).
Studies have demonstrated that on comparing emergency open repair of a ruptured AAA to EVAR for a ruptured AAA, that those patients having open surgery had a significantly higher IAP post-operatively (Maker et al, 2009).\n\t\t\t\t
Ruptured AAA | |
Systolic blood pressure <70mmHg ("/>20 minutes) | |
Haemoglobin <8 g/dl | |
Shock | |
Volume of blood loss | |
Transfusion (platelet/"/>6 units red packed cells) | |
"/>5 litres of intra-venous fluid | |
Temperature <35 degrees | |
Aortic occlusion balloon | |
Time aorta cross-clamped | |
Elevated activated partial thromboplastin time | |
Length of ICU stay | |
PEEP score | |
SIRS score | |
pH <7.3 |
Risk Factors for Intra-abdominal Hypertension
Intra-abdominal pressure typically is at the highest level within 48 hours post-operatively.
Using intra-vesical pressure to monitor for intra-abdominal hypertension is central to the diagnosis of IAP and ACS. Intra-vesical pressure directly corresponds to IAP making this an easy to use diagnostic modality. In monitoring pressure levels readings should be taken on an hourly basis. A standard Foley catheter is placed in the bladder and measurements are taken with volume priming of 25mls of normal saline in the supine position during end expiration. The mid-axillary line serves as the zero reference point. Other parameters that warrant monitoring include the hourly urine output, lactate dehydrogenase levels and other markers of metabolic acidosis and respiratory function.
The management approach for IAP needs to be proactive because if left untreated it may progress to ACS. Once there is a suspicion that ACS may develop prompt and concise management of the condition is warranted.
Some studies have reported avoiding the use of anti-coagulants, such as systemic heparin, in particular after EVAR in an attempt to reduce and limit the on-going bleeding that can occur from collateral vessels as a result of this procedure (Mehta, 2010). The thought process behind this is that continuous bleeding from collateral vessels can lead to a rise in IAP post-operatively. Other factors to consider are care with fluid administration and a trial of neuromuscular blockade in patients with the milder grades of raised IAP as a conservative approach.
Prevention is better than cure, and there is variance in the importance given to IAP monitoring. Certain centres measure IAP both intra-operatively and post-operatively on an hourly basis. With a raised IAP, regardless of the presence of other associated risk factors, there is a drive towards recommending that these patients undergo decompression laparotomy (Mehta, 2010). Other studies have examined the role of leaving the abdomen open as a routine prophylactic measure against ACS. The open abdomen technique post AAA repair to safeguard against ACS was first described by Fietsman (Fietsman et al, 1989). It has a particularly relevant role following open repair for a ruptured aneurysm. Recording an intra-operative abdominal pressure of 12mmHg or above is described as an indication for this (Mayer et al, 2009). Here, it has been shown that in cases of ruptured AAA there is a 30% reduction in mortality associated with ACS using this technique (Mayer et al, 2009).
Management of ACS involves a decompression laparotomy as a matter of urgency. With this there are a number of different options available for further management. One option is the use of a plastic bag (Bogota bag) and a conventional secondary dressing as a temporary closure measure. Another option for temporary closure is the use of a vacuum-assisted closure (VAC) system (V.A.C., KCI International Inc, Amstelveen, The Netherlands). The exact underlying pathophysiological manner in which vacuum assisted closure devices work is not completely understood. It has been demonstrated that vacuum-assisted closure devices do exert anti-microbial activity (Morykwas et al, 1997) and they also stimulate granulation tissue formation (Moisidis et al, 2004; Morykwas et al, 2001). The device is thought to prevent abdominal wall retraction and as a result adds stability to the abdominal wall. In addition a vacuum-assisted closure device drains the excess intra-peritoneal fluid faster than a Bogota bag and therefore results in a faster decrease in IAP. This assists the patient in their recovery process and it also allows earlier closure of the abdomen.
The decision on the type of temporary closure device to use is made based on factors such as the volume of the intra-abdominal organs protruding from the abdomen following decompression laparotomy and a worry that bowel ischaemia leading to necrosis may occur in the patient. The use of a simple sterile plastic drape or bag allows for direct visualisation of the bowel and other intra-abdominal contents and is a convenient manner of observing for impending bowel ischaemia in a patient where this is a significant concern. A Bogota bag serves the same purpose, however it also has extra reserve capacity in that it allows for further intra-abdominal swelling to take place without impacting on venous return to the heart and general visceral perfusion (Mayer et al, 2009). In cases where a simple plastic bag or drape or the Bogota bag has been employed these temporary closure devices can be changed to a VAC closure device or a zip device at a later stage. This is generally undertaken when the patient is clinically stable, their organ dysfunction is improving and their intra-abdominal pressure remains stable or is decreasing. In patients with a VAC or zip device a high level of monitoring of IAP is required to ensure that the patient doesn’t deteriorate and develop ACS again (Mayer et al, 2009).
The use of temporary closure devices or a staged or delayed closure in general is associated with an increased risk of ventral hernias, incisional hernias and fistulas.
A situation may arise where eventual direct closure of the abdomen is not feasible. This can occur in patients with a prolonged history of unresolving ACS that may have been complicated with infection. The options available at this stage include; the formation of a bilateral anterior rectus abdominus sheath turnover flap (Kushimoto et al, 2007). However, in the vast majority of cases the abdomen can be closed successfully after a median of ten days post laparostomy.
A delay in managing ACS is associated with a high mortality. It is also closely linked with ischaemic colitis. This in itself in patients who require a delayed decompression laparotomy and mesh closure is reported at 40%, compared with 6% in patients with early mesh abdominal closure for open ruptured AAA repair.
Secondary aortoenteric fistula (SAF) is one of the most dreaded of aortic graft complications. The incidence of SAF has increased since the introduction of prosthetic graft materials. It was first described by Brock in 1953 after homograft aortic repair (Walker et al, 1986).
The incidence has been reported as being between 0.3 – 2.0% (Kuestner et al, 1995; Menawat et al, 1997). There is a very high rate of surgical mortality associated with this complication with rates of 25 – 90% reported (Kuestner et al, 1995; Menawat et al, 1997). Heberer is credited with the first successful repair of such a fistula in 1957 (Walker et al, 1986). Overall the outcome associated with this complication is generally poor. It does occur in the endovascular setting but to a lesser extent (Bergqvist et al, 2008).
With open repair of AAA the aetiology is attributed to the formation of a pseudoaneurysm at the graft anastomosis, subclinical graft infection or mechanical factors related to the graft.
In the case of EVAR the formation of a secondary fistula is related to mechanical stent failure, or, distortion or migration of the stent (Janne et al, 2000; Norgren et al, 1998). Endotension has also been described to play a role. It can cause pressure necrosis of the wall of the aneurysm and the small bowel. Endotension, accelerating pressure necrosis, can occur secondary to an undetected or a subclinical endoleak or secondary to the transmission of pressure through a sealed thrombus (Ueno et al, 2006).
SAF is a rarer occurrence after endovascular repair as the adventitia of the aorta remains undisturbed. With EVAR there is no suture line or anastomosis and it is at these points where a fistula typically is found following open surgery.
Injury to the bowel during dissection allows for fibrous contact between the bowel wall and the graft. This can result in a repetitive synchronous pulse traumatic injury. Mechanical erosion of prosthetic material into adjacent bowel most commonly occurs due to the lack of interposed retroperitoneal tissue or it can be associated with the excessive pulsation of a redundantly placed graft (Armstrong et al, 2005). The presence of an underlying graft infection, for example, staph epidermidis biofilm infection, can also lead to inflammatory adhesions and erosion (Bandyk et al, 1984).
The classical position of a SAF is described as being between the proximal aortic graft and the fourth part of the duodenum.
Risk factors for the formation of an aortoenteric fistula include; ruptured AAA repair, haematoma associated with surgical repair, thrombosis and wound infection. Other associated factors are male gender, increasing age and having an inflammatory or mycotic aneurysm.
With EVAR the most common complications are; endoleak and a migrated or kinked stent graft (Haussegser et al, 1999). These complications in turn add to the risk of developing a fistula. Coil embolization of an endoleak has also been reported as causing fistulae (Bertges et al, 2003).
There is often a delay between the presentation and diagnosis of a SAF. The average interval between symptoms and presentation has been reported to be 47 days (range 8 – 180 days) (Armstrong et al, 2005). This is due to most investigative tests being negative or inconclusive. It is therefore very important to have a high index of suspicion for this condition. A poorer outcome is associated with a delay in recognition, diagnosis and definitive management.
There are two main patterns of presentation; bleeding and infection. A high index of suspicion is particularly required if the patient presents with what is known as a herald gastrointestinal bleed. Patients can also present with chronic melena, hematemesis or weight loss. However the typical presentation is with a herald bleed followed by a period of stability and then massive exsanguination and cardiovascular collapse. Patients presenting with symptoms and signs of sepsis can have fever, weight loss, an elevated white blood cell count and c-reactive protein, and abdominal or back pain indicating a retroperitoneal abscess.
Investigations include endoscopy, angiography and contrast studies. Angiography may be negative and at most show a small nipple at the anastomosis. The sensitivity of OGD for diagnosing a secondary aortoenteric fistula is less than 25%. Signs to be aware of on OGD include; fresh blood in the distal duodenum (often a paediatric colonoscope is required to advance this far), and visualising the graft in the base of the duodenal ulcer. To optimise diagnosis from CT investigation a high resolution, spiral, thin slice (3-5 mm) should be performed. On CT examination findings include; an obvious direct communication, loss of retroperitoneal soft tissue interposed between the overlying bowel and the proximal aortic graft, perigraft air and oedema. In patients following endovascular repair it often presents as a re-expanding AAA with associated inflammatory changes around the abdominal aorta (Ueno et al, 2006).
SAF can present as a late complication. The median time from primary operation to presentation has been reported to be two years (Bergqvist et al, 2008). One third of these patients that present late with the condition have been treated for hypovoleamic shock at some stage prior to diagnosis. This again underlines the importance of having a high index of suspicion for this clinical complication.
A number of different operative approaches in the management of this complication have been described. Laparotomy is often performed in an emergent situation with the aim being to control bleeding, repair the fistula site, look for the source of infection and to reconstruct the vasculature. Primary repair may be useful in an elderly patient where you don’t wish to subject them to a prolonged period of ischaemia due to aortic cross clamping. But this course of action doesn’t address the underlying potential problem of a subclinical graft infection.
Traditionally, the management of SAF has involved the creation of an extra-anatomic bypass, with total excision of the graft and over-sewing of the aortic stump (Kuestner et al, 1995). The main objective of this type of surgery is to reduce the risk of infection. The bypass is usually tunnelled through non infected remote tissue planes that are generally axillobifemoral. The procedure itself has associated risks. The mortality rate is high at greater than 40%. There is a risk of a stump blow out rate of 16% and graft loss rates at one year of approximately 60%. Other associated complications include limb loss, and pelvic ischemia. It has also been reported to be the approach associated with the lowest mortality; however, this may be due to confounding factors such as performing the procedure in patients that are relatively heamodynamically stable and with little co-morbidity (Bergqvist et al, 2008).
Endovascular grafting has been successfully reported as a less invasive approach (Suzuki et al, 2005; Schlensak et al, 2000; Chuter et al, 2000). Endovascular grafting has also been successfully used as a temporary measure to control life threatening gastrointestinal bleeding allowing patient stability to be achieved. Endovascular repair is of benefit when the clinical status of the patient or their co-morbidities precludes open surgical intervention. This approach does not solve the underlying problem of the communication tract however. There have been reports on the use of N-butylcyanoacrylate in attempting to obliterate the tract (Finch & Heathcock, 2002). In the setting of an infection it is obviously a questionable method.
Other options that have been reported in the literature are omental patching and homografts. It is queried that both these approaches may have a role in controlling for post-operative infection (Vogt & Turina, 1999;\n\t\t\t\t\tMontgomery & Wilson, 1996). Staged procedures and the more conservative in situ graft replacement with antibiotic coated grafts have also been reported (Kavanagh et al, 2006; Reilly et al, 1987; Kieffer et al, 2004; Walker et al, 1986). In situ repair and revascularisation are associated with better outcomes in comparison to extra-anatomic bypass.
Following operative intervention a course of broad spectrum antibiotics covering for enteric flora is required. This is required in particular after graft replacement. The placement of a feeding jejunostomy at the time of operation should also be considered (Chenu 2009).
The risk of secondary rupture of the abdominal aorta following treatment for an aorto-enteric fistula has been reported as being between 9 and 17% (Kuestner et al, 1995; Menawat et al, 1997; Bergqvist et al, 1996). These figures add to the significant overall mortality risk associated with this complication.
Chylous ascites is an unusual postoperative complication that can lead to significant mechanical, nutritional, and immunologic consequences for the patient. It can present following AAA repair. The incidence of chylous ascites following AAA repair has been reported to be between 0.03 – 0.1% (Pabst et al, 1993). The true incidence of this complication however is unknown as knowledge of it has mainly relied on case reports of which there have been 40 published to date in the literature.
It is hypothesised that dissection around the proximal infra-renal abdominal aorta can cause traumatic damage to the intestinal lymphatics and their recipients; the left lateral-aortic lymph nodes and the cisterna chyli. It is thought that cross clamping of the aorta may also contribute to the traumatic damage of the lymphatic system.
There is a significant variation in the anatomy of the lymphatic channels in the abdomen. This can make it difficult to identify with ease the cisterna chyli and the other lymphatic channels. Identifying the lymphatic channels is made more difficult in the fasting state as there is a minimal amount of lymphatic fluid circulating through them. As a result they are easily lacerated during dissection. This can lead to stasis, fibrosis and rupture of the lymphatic channel into the aneurysmal wall which in turn can lead to the formation of an internal lymphatic fistula between the cisterna chyli or other main lymphatic trunks and the peritoneal cavity. It has been demonstrated that a partial or lateral tear in the cisterna chyli is less likely to heal and more likely to result in chylous ascites when compared to a complete transection, as a complete transection is more likely to spontaneously retract and seal itself off (McKenna & Stevick, 1983).
Chylous ascites occurs in 81% of cases secondary to AAA repair. Risk factors include upper or extensive dissection of the retroperitoneal space, difficult dissection following rupture of an AAA, an inflammatory aneurysm and previous abdominal aortic surgery. The presence of a proximal obstruction to the drainage of lymph from the abdomen is also an associated risk factor.
Chylous ascites typically presents two weeks after AAA repair (Olthof et al, 2008). The mean presentation has been found to be 18.4 days (Sanger et al, 1991, Bahner & Townsend, 1990).
The most common signs and symptoms at presentation are abdominal distension and ascites following resumption of oral diet. The presence of intra-peritoneal fluid is confirmed by abdominal CT or ultrasound. The definitive diagnosis requires paracentesis. This reveals a lypaemic, sterile fluid which is milky in colour. Analysis of the fluid sample should demonstrate an alkaline pH, a total protein level of greater than 3 g/dl, total fat content between 0.4 and 4.0 g/dl and a predominance of lymphocytes on differential white blood count. If the patient is mechanically ventilated the diagnosis should be suspected in the presence of gradually progressing abdominal hypertension.
Other characteristic clinical features include a low serum albumin and a profound decrease in absolute lymphocyte count secondary to sequestration of lymphocytes into the ascitic fluid.
The mortality rate associated with this condition has been reported to be as high as 18.5% (Garrett et al, 1989). However the literature also reports resolution in 60% of cases.
The goal of management is to reduce lymphatic flow. This is achieved with therapeutic paracenetesis combined with either total parenteral nutrition (TPN) or a medium chain triglyceride rich diet. For the first 14 days the patient should be kept nil per mouth and they should receive TPN. This is followed by a diet high in medium chain triglycerides. When this is commenced the TPN is weaned gradually. Abdominal girth measurement can aid monitor patient progress.
Second line treatment consists of placement of a peritoneovenous shunt. The main concern associated with shunt placement is sepsis. Operative ligation of the damaged lymphatic channel is another option. When operative ligation is undertaken it is important to ensure that the exact lymphatic leak is identified. This is difficult if the lymph fluid is clear. The use of dye or feeding the patient cream pre-operatively have both been reported as aiding this process (Uchinami et al, 2005). Both these interventions are usually reserved for patients where conservative management has failed. Successful laparoscopic repair of the damaged lymphatic system has also been reported (Uchinami et al, 2005). The benefit of this approach is that it doesn’t require as invasive surgery as open ligation and it reduces the risk of sepsis associated with shunt placement. Overall chylous ascites typically settles with the appropriate management.
Post-operative ileus is the most common complication to occur following abdominal surgery of any description. It is a problem that is difficult to prevent and is without solution. In the case of abdominal aortic repair it is both the most frequent gastrointestinal complication and overall post-operative complication. It occurs in up to 10% of patients (Sicard et al, 1995). On the other end of the spectrum mechanical obstruction of the small bowel, in particular, the duodenum, after abdominal aortic surgery is rare. Major studies have demonstrated that of patients undergoing AAA repair, small bowel obstruction occurred in 2.9%, with greater than 40% requiring operative intervention (Siporin et al, 1993).
Intra-operative handling of the bowel, and tissue trauma are thought to be the main causes of post-operative ileus. The use of foreign materials for example gauze swabs, the formation of haematomas and aneurysmal sac seromas also contribute. Superior mesenteric artery syndrome, where the duodenum is compressed between the retroperitoneum and the superior mesenteric artery as a result of a retroperitoneal haematoma is associated with ileus. This can also progress to mechanical bowel obstruction if left untreated. Adhesions however, are the most common cause of mechanical bowel obstruction.
Many studies suggest that ileus is the result of an inhibition of intestinal contractility (Smith et al, 1977). Other studies show continued but uncoordinated contractions (Dauchel et al, 1976). The jejunum has been shown to be the main area of small bowel affected by a change in the pattern of bowel contractility following AAA repair (Miedema et al, 2002).
Oedema of the bowel wall results in ileus. The bowel wall becomes oedematous secondary to dissection, manipulation trauma and direct handling of the small bowel intra-operatively. This in turn stimulates an inflammatory cascade which is thought to cause an increase in the sympathetic response to the gastrointestinal tract.
There are two approaches the surgeon can take in open repair of an AAA; transabdominal and retroperitoneal. The transabdominal approach has been reported to be associated with a greater percentage of prolonged ileus and bowel obstruction post-operatively (Kudo et al, 2004) when compared with the retroperitoneal approach.
Studies have demonstrated that the longer the operative time and the greater the volume of intra-operative blood loss the greater the correlation with post-operative ileus and specifically the delayed passage of flatus (Miedema et al, 2002). Other factors that have also been found to be associated with post-operative ileus include hypoalbuminea, hypoproteinaemia and the presence of additional gastro-intestinal pathologies such as pancreatitis post-operatively. The length of the abdominal skin incision for abdominal aortic aneurysm repair has been determined to impact on the presence of ileus and time to return to normal diet. Hiromatsu and colleagues established that those patients with a skin incision of less than 15cm had a significantly smaller incidence of ileus when compared to a group of patients that had a skin incision of greater than 20cm (Hiromatsu et al, 2007). Laparoscopic repair has also demonstrated a shorter period of ileus and a quicker return to diet when compared to open repair (Coggia et al, 2005).
Postoperative ileus is classically characterized by impaired intestinal motility and transit, absence of the passage of flatus, diminished bowel sounds, abdominal distension and intestinal dilatation. A patient with ileus typically presents with abdominal pain, nausea, and vomiting. On examination the abdomen is often distended and tender. The signs and symptoms typically are present within 24-48 hours post-operatively or when the patient attempts a return to fluids and diet. It can also present up to two weeks post the procedure.
Imaging such as plain x-rays of the abdomen and contrast studies aid in determining the extent of the ileus or obstruction. In the case of a non-resolving ileus or a suspected bowel obstruction a CT scan allows the underlying cause to be determined. If on CT scanning a cause is not found then it is most likely an adhesion that is causing the problem (Tessier et al, 2003).
A prolonged post-operative ileus is a significant contributor to postoperative morbidity and mortality (Johnson, 1989). This is particularly true of non-ruptured AAA repair. The presence of post-operative ileus slows the patients return to normal function. It results in a delayed discharge and is associated with the risk of other morbidities.
Initial management should be conservative and involves the placement of a nasogastric (NG) tube which is left on free drainage and intravenous hydration. The patient should remain nil per mouth until the symptoms settle and drainage from the NG is minimal.
Determining the underlying cause can aid in planning management. If a specific cause is known for example, a haematoma, this should be drained or treated to allow resolution of symptoms. Where the symptoms do not settle after a period of greater than two weeks, typically operative intervention is required. Often the procedure is adhesiolysis. This in turn however increases the risk of wound infection and dehiscence, general sepsis and fistula formation post-operatively.
Some surgeons place a NG tube at the time of surgery in an effort to reduce nausea and vomiting. This is not evidence based but more associated with traditional practice.
Studies have examined the use of novel bioresorbable materials made from chemically modified hyaluronate acid and carboxymethylcellulose. These materials form a physicochemical barrier to prevent adhesion between adjacent tissue surfaces for up to seven days after surgery (Kudo et al, 2004).
The vast majority of patients (>80%) that are managed conservatively settle within a two week window and do not require surgical intervention (Tessier et al, 2003). Patients that ultimately require surgical intervention do so after a median duration of ten days conservative management (Tessier et al, 2003).
Acute pancreatitis is a rare but recognised complication of AAA surgery. The true incidence of this condition is unknown and has been reliant on the reporting of case series in the surgical literature. It has been stated that the incidence is approximately 0.7% in open repair (Hashimoto & Walsh, 1999). In the presence of diabetes the incidence increases to 5% (Ryan et al, 2002). There has only been one case report, which the authors are aware of, to date with EVAR (James et al, 2008). One of the factors affecting the under-reporting of this complication is the often associated lack of a rise in amylase levels that can be found in particular with severe cases of pancreatitis.
The aetiology of acute pancreatitis specifically following AAA repair is not clear. One proposed theory is that of micro-emboli entering the pancreatic circulation leading to ischemia of the pancreas post-operatively (James et al, 2008). Another proposed aetiology is whereby aortic cross clamping, especially at the level of the supra-renal aorta, can result in peri-operative trauma which in turn leads to trauma and an inflammatory response.
The spectrum of acute pancreatitis that has been described following AAA repair has varied from mild pancreatitis to more severe cases that are associated with pancreatic necrosis and a high mortality rate. In greater than 75% of known cases the pancreatitis was mild and the patients experienced a full recovery. Those patients however, that develop severe pancreatitis have been reported in one review as having a 100% mortality (Hashimoto & Walsh, 1999). This was due to multi-organ dysfunction and pancreatic necrosis. Conversely, as a point of interest, abdominal aortic aneurysms have been diagnosed following acute pancreatitis. This phenomenon is thought to be related to the release of enzymes such as elastase that cause lysis of the elastic component of the arterial vessel wall.
There are two known associated risk factors; (i) emergency surgery following a ruptured AAA and (ii) having diabetes mellitus (Ryan et al, 2002).
The diagnosis of acute pancreatitis post-operatively is frequently associated with a delay. A raised amylase level often is just seen in mild cases of pancreatitis. In more severe cases of acute pancreatitis the amylase level can remain normal. Severe cases are usually picked up after a period of unexplained sepsis in a clinically deteriorating patient (Hashimoto & Walsh, 1999). On average severe cases of acute pancreatitis are diagnosed approximately two weeks following the initial aortic aneurysm surgery. Therefore a high index of suspicion is required for this complication in patients that develop signs and symptoms of sepsis post-operatively. The diagnosis is made using CT imaging. Features seen on CT include; diffuse or segmental pancreatic enlargement, irregularity or heterogeneity and lobularity of the pancreas, and obliteration of the peri-pancreatic fat planes. CT also allows areas of pancreatic necrosis to be detected. The presence of necrosis significantly impacts on the prognosis for the patient and is associated with a high rate of mortality.
The management of acute pancreatitis following AAA repair adheres to the general supportive treatment protocol of bowel rest and intravenous fluid therapy, analgesia and nutritional support. Close monitoring for sepsis and multi-organ failure is also of importance. Regular CT scanning should be employed to monitor for disease progression and to screen for pancreatic necrosis. Assessment of severity should be carried out using pre-defined criteria such as Ranson and APACGE II severity scores. This allows modification of management protocols and risk stratification.
The mortality rate has been reported as ranging from 40% to an absolute level of 100% in severe cases of acute pancreatitis (Hashimoto & Walsh, 1999). With respect to preventing the development of acute pancreatitis post-operatively one proposition has been to perform an incidental cholecystectomy in patients with known cholelithiasis at the time of AAA repair (Hashimoto & Walsh, 1999). However, this intervention may be somewhat excessive as overall, acute pancreatitis, is a rare gastrointestinal complication of AAA surgery.
The incidence of acute cholecystitis has been reported as varying between 0.3 – 18% (Cadot et al, 2002). Overall acute cholecystitis complicating AAA repair is accepted to be a rare event.
Cholesterol crystallisation occurs in association with atherosclerotic disease. Patients with an AAA often will have atherosclerosis and therefore are predisposed to cholesterol gallstones. Often these are asymptomatic and therefore undiagnosed pre AAA repair. Embolization of cholesterol crystals can lead to ischaemia of the gallbladder which in turn is a cause of cholecystitis. Low flow states, such as hypovolaemia, may also cause gallbladder wall ischaemia and therefore cholecystitis. Following AAA surgery patients may also be at risk of developing acalculus cholecystitis.
Cholecystitis may occur secondary to the presence of gallstones which can obstruct the cystic duct or other parts of the biliary tree or it may occur in the absence of calculi (acalculus choleystitis). Acalculus cholecystitis is more commonly found in critically ill patients and has a higher morbidity and mortality rate associated with it when compared to gallstone disease. It is also associated with a higher incidence of gallbladder perforation and gangrene. In the setting of AAA surgery the main pathophysiological process is thought to be due to bile stasis and the increased lithogenicity of bile. AAA patients are more predisposed to acalculus cholecystitis because of increased bile viscosity due to dehydration and blood loss. In patients that have a prolonged recovery where there is a delay in the return to normal diet a decrease in cholecystokinin-induced gallbladder contractions may result leading to bile stasis and a risk of cholecystitis.
Male gender, increasing age, emergency surgery, post-operative sepsis and hypotension or hypovolaemia are risk factors for acalculus cholecystitis. The presence of gallstones pre-operatively is a risk factor for calculus acute cholecystitis.
Patients classically complain of right upper quadrant pain, nausea, vomiting and fever and on examination have abdominal tenderness, deranged liver function tests and an elevated white blood cell count. Having a high index of suspicion for acalculus disease is important as this complication has a worse prognosis and requires a more aggressive approach to treatment. The imaging modality of choice is ultrasound scanning. Features of gallbladder disease include; thickening of the gallbladder wall (>3mm), the presence of stones and pericholecystitic fluid.
Acute acalculous cholecystitis is the most common postoperative biliary complication after aortic surgery. The diagnosis should be entertained in patients with signs of abdominal sepsis after aortic surgery, especially those with a complicated postoperative course. Even if acute acalculous cholecystitis is diagnosed with ease, mortality remains high (Hagino et al, 1997).
Acute cholecystitis is managed with intravenous fluid therapy, antibiotics and analgesia. The definitive treatment involves either (i) removal of the gallstones through ERCP or surgical removal of the gallbladder or (ii) the performance of a percutaneous cholecystostomy, which may be the treatment method of choice in patients that are otherwise too ill for surgical intervention.
There are centres that recommend a pre procedure cholecystectomy in patients with known cholelithiasis. The reasoning for this is that symptomatic gallbladder disease post-operatively is a significant contributor to morbidity and mortality when it occurs in a patient post AAA repair (D’Angelo et al, 1999).
The incidence of peptic ulcer disease (PUD) directly related to AAA repair is rare to begin with (0.9%) and its incidence has been further reduced by the routine incorporation of proton pump inhibitors (PPI’s) into the management protocols of patients following AAA surgery (Achouh et al, 2006). In the literature there is a paucity of information on peptic ulcer disease associated with AAA, with the majority of reports having being published before the new millennium.
PUD after AAA surgery is theorized to be associated with (i) a decrease in gastric mucosal blood flow and (ii) the consumptive coagulopathy that can occur due to blood loss and the systemic inflammatory response that results from an AAA (Konno et al, 1991). This is particularly true following emergency surgery for a ruptured aneurysm and in patients with underlying co-morbidities pre-operatively.
It has been found that a reduction in blood flow to the gastric mucosa and a rise in the prostaglandin content of the gastric mucosa both contribute to the development of PUD post AAA repair (Konno et al, 1994).
Risk factors include; previously treated PUD, ruptured AAA repair, coagulopathy (such as thrombocytopenia, altered thromboplastin time, reduction in fibrinogen levels), the volume of blood lost and the presence of DIC or SIRS post-operatively.
In a patient with suspected PUD an OGD should be performed allowing direct visualisation of the peptic ulcer. At OGD biopsies should be taken to test for H. Pylori bacteria. OGD also allows for complications of PUD such, as bleeding, to be effectively managed.
Symptomatic PUD, where the patient complains of epigastric pain, reflux symptoms and nausea can be treated with a course of PPI’s. If H. Pylori is found to be present the patient requires a course of triple therapy. Active bleeding from a peptic ulcer needs to be expediently managed. This can be done at endoscopy using the injection of adrenaline to control bleeding. Surgical intervention is nowadays rarely necessary.
In the era before the regular use of PPI’s, PUD in the setting of AAA repair was associated with a significant mortality, with reports of a mortality rate up to 30% (Achouh et al, 2006). Thankfully, although PUD may complicate the post-operative recovery pathway of the patient its overall morbidity and mortality has been significantly reduced.
All of the gastrointestinal complications discussed in this chapter require us, as physicians, to have a high index of suspicion for and knowledge of, following repair of an AAA. Although some of the complications we have detailed are rare in incidence they impact significantly on patient outcome, morbidity and mortality. The key gastrointestinal complications to be aware of following AAA surgery are ischaemic colitis, abdominal compartment syndrome and ileus. The introduction of EVAR has had a positive impact on the rate of some gastrointestinal complications, in other cases it has led to different pathophysiological pathways. As our knowledge base relies on literature reports it remains as yet to be seen what the full impact of endovascular surgery will have on outcomes following AAA repair in both the elective and emergent setting.
Vibriosis is a bacterial disease caused by
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This is one of the severe systemic diseases caused by bacteria, which affects shrimps and exhibits the symptoms such as lethargic, show abnormal swimming behavior, expansion of chromatophores, followed by reddish color change in the pleopods which can be seen in the abdominal musculature. In chronic cases, the gill covers appear flared up and eroded along with the melanized black blisters on the carapace and abdomen. The disease caused by
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Shrimps affected by Necrosis 1.
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Members of the microorganism genus
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Unfavorable environment such as poor soil and water quality.
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Usage of poor quality feeds with low protein content.
Accumulation of sludge in the pond bottom due to the presence of unutilized feed.
Presence of gut micro flora and numerous virulent pathogens in the pond.
Bacteriophage therapy acts as a prophylactic alternative instead of antibiotics usage in shrimp industry. These are viruses that kill only specific disease causing pathogens and acts as therapeutic agents in pathogenic infections. Unlike antibiotics, bacteriophage therapy has no residual issues and has advantages of being specific to their host bacteria, without harming other micro-organisms [10]. In aquaculture hatcheries, bacterial diseases often cause considerable economic loss across globe for hatchery operators. Bacteriophages and their lytic enzymes are in use for therapy of bacterial infections in human and animals, as biocontrol agents for food protection also as tools in molecular biology, the penentration of phage DNA inside a bacteria is promoted by lysossome produced by the phage. In yellow tail fish, a pathogen named
Bacteriophage attached to bacterial cell 1.
Herbs act as antibiotic for controlling or reduce the infection of pathogen in aquaculture sector and also increases the survival rate of organisms, during outbreak of disease managements. In
Probiotics gaining more attention in recent scenario in all sectors including aquaculture, agriculture and animal husbandry when considering other remedies probiotics acts as a better option rather than incorporating antibiotics to control pathogens in aquaculture. The term probiotic has been defined as a mono or mixed culture of live microorganisms which can be applied to animal or human to enhance the immune system. The animal health is then improved by the removal or decrease in population density of pathogens and by improving water quality through more rapid degradation of waste organic matter (sludge). Environmental microbiology and biotechnology have advanced in the past decade, to the point that commercial products and technologies are available for treating large areas of water and land to enhance population densities of desired microbial species or biochemical activities. The practice of bioremediation is applied in many areas of interest, but success rate varies in different areas, depending on the environmental conditions, nature of products and the method of usage by the consumer, the probiotic that are added must be selected for specific functions. Bioaugmentation and the use of probiotics are significant tools for aquaculture but their efficiency depends on understanding the nature of competition between disease causing pathogens and desired strains of bacteria.
The disease control programmers in aquaculture must include examination of diseases and mortalities in a holistic manner and consider various factors such as stocking densities, environment (turbidity, temperature, pH, salinity, dissolved oxygen, H2S,NH3,NO2, etc. of water and redox potential of soil), rate of water exchange, presence of toxic bottom dwelling algae, the type of feed and its FCR ratio by the shrimps, phytoplankton bloom, physiological status of shrimps, etc. [13]. Most of the disease control methods are based on preventive measures. They are,
Better husbandry practices,
Use of balanced nutritional supplement,
Implementing nursery setup to avoid mortality in culture ponds,
Use of GMO stocks for culture,
Use of herbal extracts as antibiotics and
Use of vaccines or drugs.
Diseases can be prevented by adapting better animal handling practices and providing adequate amount of nutrient rich feed [14]. Vibriosis is controlled by rigorous water management through ROS systems and sanitation to prevent the entry of vibrio in the culture water and to reduce stress on the shrimps. Good site selection, pond design and pond preparation are also important. An increase in daily water exchanges and a reduction in pond biomass by partial harvesting are recommended to reduce mortalities caused by Vibriosis. Draining, drying and administering lime/dolomite to ponds following harvest is also recommended [15].
In spite of all these recent advancements to eradicate all the bacterial diseases in shrimps, still there is a void for complete eradication of these diseases. Various techniques and medicines are introduced to cure these bacterial infections, but still there are certain side effects for consumers, by introducing antibiotics and other medicines for respective infections. So when it comes to large scale like commercial farming, the efficacy of the above mentioned techniques for prevention and cure of cultured shrimps from bacterial diseases is low when compared to laboratory conditions.
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He has been listed among the top 2% of scientists in the world for the last three consecutive years, 2019 to 2021 as per studies conducted by the Stanford University, USA.",institutionString:"Praxis Business School",institution:null},{id:"320071",title:"Dr.",name:"Sidra",middleName:null,surname:"Mehtab",slug:"sidra-mehtab",fullName:"Sidra Mehtab",position:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0033Y00002v6KHoQAM/Profile_Picture_1584512086360",biography:"Sidra Mehtab has completed her BS with honors in Physics from Calcutta University, India in 2018. She has done MS in Data Science and Analytics from Maulana Abul Kalam Azad University of Technology (MAKAUT), Kolkata, India in 2020. Her research areas include Econometrics, Time Series Analysis, Machine Learning, Deep Learning, Artificial Intelligence, and Computer and Network Security with a particular focus on Cyber Security Analytics. Ms. Mehtab has published seven papers in international conferences and one of her papers has been accepted for publication in a reputable international journal. She has won the best paper awards in two prestigious international conferences – BAICONF 2019, and ICADCML 2021, organized in the Indian Institute of Management, Bangalore, India in December 2019, and SOA University, Bhubaneswar, India in January 2021. Besides, Ms. Mehtab has also published two book chapters in two books. Seven of her book chapters will be published in a volume shortly in 2021 by Cambridge Scholars’ Press, UK. Currently, she is working as the joint editor of two edited volumes on Time Series Analysis and Forecasting to be published in the first half of 2021 by an international house. Currently, she is working as a Data Scientist with an MNC in Delhi, India.",institutionString:"NSHM College of Management and Technology",institution:{name:"Association for Computing Machinery",country:{name:"United States of America"}}},{id:"226240",title:"Dr.",name:"Andri Irfan",middleName:null,surname:"Rifai",slug:"andri-irfan-rifai",fullName:"Andri Irfan Rifai",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/226240/images/7412_n.jpg",biography:"Andri IRFAN is a Senior Lecturer of Civil Engineering and Planning. He completed the PhD at the Universitas Indonesia & Universidade do Minho with Sandwich Program Scholarship from the Directorate General of Higher Education and LPDP scholarship. He has been teaching for more than 19 years and much active to applied his knowledge in the project construction in Indonesia. His research interest ranges from pavement management system to advanced data mining techniques for transportation engineering. He has published more than 50 papers in journals and 2 books.",institutionString:null,institution:{name:"Universitas Internasional Batam",country:{name:"Indonesia"}}},{id:"314576",title:"Dr.",name:"Ibai",middleName:null,surname:"Laña",slug:"ibai-lana",fullName:"Ibai Laña",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/314576/images/system/314576.jpg",biography:"Dr. Ibai Laña works at TECNALIA as a data analyst. He received his Ph.D. in Artificial Intelligence from the University of the Basque Country (UPV/EHU), Spain, in 2018. He is currently a senior researcher at TECNALIA. His research interests fall within the intersection of intelligent transportation systems, machine learning, traffic data analysis, and data science. He has dealt with urban traffic forecasting problems, applying machine learning models and evolutionary algorithms. He has experience in origin-destination matrix estimation or point of interest and trajectory detection. Working with large volumes of data has given him a good command of big data processing tools and NoSQL databases. He has also been a visiting scholar at the Knowledge Engineering and Discovery Research Institute, Auckland University of Technology.",institutionString:"TECNALIA Research & Innovation",institution:{name:"Tecnalia",country:{name:"Spain"}}},{id:"314575",title:"Dr.",name:"Jesus",middleName:null,surname:"L. Lobo",slug:"jesus-l.-lobo",fullName:"Jesus L. Lobo",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/314575/images/system/314575.png",biography:"Dr. Jesús López is currently based in Bilbao (Spain) working at TECNALIA as Artificial Intelligence Research Scientist. In most cases, a project idea or a new research line needs to be investigated to see if it is good enough to take into production or to focus on it. That is exactly what he does, diving into Machine Learning algorithms and technologies to help TECNALIA to decide whether something is great in theory or will actually impact on the product or processes of its projects. So, he is expert at framing experiments, developing hypotheses, and proving whether they’re true or not, in order to investigate fundamental problems with a longer time horizon. He is also able to design and develop PoCs and system prototypes in simulation. He has participated in several national and internacional R&D projects.\n\nAs another relevant part of his everyday research work, he usually publishes his findings in reputed scientific refereed journals and international conferences, occasionally acting as reviewer and Programme Commitee member. Concretely, since 2018 he has published 9 JCR (8 Q1) journal papers, 9 conference papers (e.g. ECML PKDD 2021), and he has co-edited a book. He is also active in popular science writing data science stories for reputed blogs (KDNuggets, TowardsDataScience, Naukas). Besides, he has recently embarked on mentoring programmes as mentor, and has also worked as data science trainer.",institutionString:"TECNALIA Research & Innovation",institution:{name:"Tecnalia",country:{name:"Spain"}}},{id:"103779",title:"Prof.",name:"Yalcin",middleName:null,surname:"Isler",slug:"yalcin-isler",fullName:"Yalcin Isler",position:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRyQ8QAK/Profile_Picture_1628834958734",biography:"Yalcin Isler (1971 - Burdur / Turkey) received the B.Sc. degree in the Department of Electrical and Electronics Engineering from Anadolu University, Eskisehir, Turkey, in 1993, the M.Sc. degree from the Department of Electronics and Communication Engineering, Suleyman Demirel University, Isparta, Turkey, in 1996, the Ph.D. degree from the Department of Electrical and Electronics Engineering, Dokuz Eylul University, Izmir, Turkey, in 2009, and the Competence of Associate Professorship from the Turkish Interuniversity Council in 2019.\n\nHe was Lecturer at Burdur Vocational School in Suleyman Demirel University (1993-2000, Burdur / Turkey), Software Engineer (2000-2002, Izmir / Turkey), Research Assistant in Bulent Ecevit University (2002-2003, Zonguldak / Turkey), Research Assistant in Dokuz Eylul University (2003-2010, Izmir / Turkey), Assistant Professor at the Department of Electrical and Electronics Engineering in Bulent Ecevit University (2010-2012, Zonguldak / Turkey), Assistant Professor at the Department of Biomedical Engineering in Izmir Katip Celebi University (2012-2019, Izmir / Turkey). He is an Associate Professor at the Department of Biomedical Engineering at Izmir Katip Celebi University, Izmir / Turkey, since 2019. In addition to academics, he has also founded Islerya Medical and Information Technologies Company, Izmir / Turkey, since 2017.\n\nHis main research interests cover biomedical signal processing, pattern recognition, medical device design, programming, and embedded systems. He has many scientific papers and participated in several projects in these study fields. He was an IEEE Student Member (2009-2011) and IEEE Member (2011-2014) and has been IEEE Senior Member since 2014.",institutionString:null,institution:{name:"Izmir Kâtip Çelebi University",country:{name:"Turkey"}}},{id:"339677",title:"Dr.",name:"Mrinmoy",middleName:null,surname:"Roy",slug:"mrinmoy-roy",fullName:"Mrinmoy Roy",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/339677/images/16768_n.jpg",biography:"An accomplished Sales & Marketing professional with 12 years of cross-functional experience in well-known organisations such as CIPLA, LUPIN, GLENMARK, ASTRAZENECA across different segment of Sales & Marketing, International Business, Institutional Business, Product Management, Strategic Marketing of HIV, Oncology, Derma, Respiratory, Anti-Diabetic, Nutraceutical & Stomatological Product Portfolio and Generic as well as Chronic Critical Care Portfolio. A First Class MBA in International Business & Strategic Marketing, B.Pharm, D.Pharm, Google Certified Digital Marketing Professional. Qualified PhD Candidate in Operations and Management with special focus on Artificial Intelligence and Machine Learning adoption, analysis and use in Healthcare, Hospital & Pharma Domain. Seasoned with diverse therapy area of Pharmaceutical Sales & Marketing ranging from generating revenue through generating prescriptions, launching new products, and making them big brands with continuous strategy execution at the Physician and Patients level. Moved from Sales to Marketing and Business Development for 3.5 years in South East Asian Market operating from Manila, Philippines. Came back to India and handled and developed Brands such as Gluconorm, Lupisulin, Supracal, Absolut Woman, Hemozink, Fabiflu (For COVID 19), and many more. In my previous assignment I used to develop and execute strategies on Sales & Marketing, Commercialization & Business Development for Institution and Corporate Hospital Business portfolio of Oncology Therapy Area for AstraZeneca Pharma India Ltd. Being a Research Scholar and Student of ‘Operations Research & Management: Artificial Intelligence’ I published several pioneer research papers and book chapters on the same in Internationally reputed journals and Books indexed in Scopus, Springer and Ei Compendex, Google Scholar etc. Currently, I am launching PGDM Pharmaceutical Management Program in IIHMR Bangalore and spearheading the course curriculum and structure of the same. I am interested in Collaboration for Healthcare Innovation, Pharma AI Innovation, Future trend in Marketing and Management with incubation on Healthcare, Healthcare IT startups, AI-ML Modelling and Healthcare Algorithm based training module development. I am also an affiliated member of the Institute of Management Consultant of India, looking forward to Healthcare, Healthcare IT and Innovation, Pharma and Hospital Management Consulting works.",institutionString:null,institution:{name:"Lovely Professional University",country:{name:"India"}}},{id:"310576",title:"Prof.",name:"Erick Giovani",middleName:null,surname:"Sperandio Nascimento",slug:"erick-giovani-sperandio-nascimento",fullName:"Erick Giovani Sperandio Nascimento",position:null,profilePictureURL:"https://intech-files.s3.amazonaws.com/0033Y00002pDKxDQAW/ProfilePicture%202022-06-20%2019%3A57%3A24.788",biography:"Prof. Erick Sperandio is the Lead Researcher and professor of Artificial Intelligence (AI) at SENAI CIMATEC, Bahia, Brazil, also working with Computational Modeling (CM) and HPC. He holds a PhD in Environmental Engineering in the area of Atmospheric Computational Modeling, a Master in Informatics in the field of Computational Intelligence and Graduated in Computer Science from UFES. He currently coordinates, leads and participates in R&D projects in the areas of AI, computational modeling and supercomputing applied to different areas such as Oil and Gas, Health, Advanced Manufacturing, Renewable Energies and Atmospheric Sciences, advising undergraduate, master's and doctoral students. He is the Lead Researcher at SENAI CIMATEC's Reference Center on Artificial Intelligence. In addition, he is a Certified Instructor and University Ambassador of the NVIDIA Deep Learning Institute (DLI) in the areas of Deep Learning, Computer Vision, Natural Language Processing and Recommender Systems, and Principal Investigator of the NVIDIA/CIMATEC AI Joint Lab, the first in Latin America within the NVIDIA AI Technology Center (NVAITC) worldwide program. He also works as a researcher at the Supercomputing Center for Industrial Innovation (CS2i) and at the SENAI Institute of Innovation for Automation (ISI Automação), both from SENAI CIMATEC. He is a member and vice-coordinator of the Basic Board of Scientific-Technological Advice and Evaluation, in the area of Innovation, of the Foundation for Research Support of the State of Bahia (FAPESB). He serves as Technology Transfer Coordinator and one of the Principal Investigators at the National Applied Research Center in Artificial Intelligence (CPA-IA) of SENAI CIMATEC, focusing on Industry, being one of the six CPA-IA in Brazil approved by MCTI / FAPESP / CGI.br. He also participates as one of the representatives of Brazil in the BRICS Innovation Collaboration Working Group on HPC, ICT and AI. He is the coordinator of the Work Group of the Axis 5 - Workforce and Training - of the Brazilian Strategy for Artificial Intelligence (EBIA), and member of the MCTI/EMBRAPII AI Innovation Network Training Committee. He is the coordinator, by SENAI CIMATEC, of the Artificial Intelligence Reference Network of the State of Bahia (REDE BAH.IA). He leads the working group of experts representing Brazil in the Global Partnership on Artificial Intelligence (GPAI), on the theme \"AI and the Pandemic Response\".",institutionString:"Manufacturing and Technology Integrated Campus – SENAI CIMATEC",institution:null},{id:"1063",title:"Prof.",name:"Constantin",middleName:null,surname:"Volosencu",slug:"constantin-volosencu",fullName:"Constantin Volosencu",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/1063/images/system/1063.png",biography:"Prof. Dr. Constantin Voloşencu graduated as an engineer from\nPolitehnica University of Timișoara, Romania, where he also\nobtained a doctorate degree. He is currently a full professor in\nthe Department of Automation and Applied Informatics at the\nsame university. Dr. Voloşencu is the author of ten books, seven\nbook chapters, and more than 160 papers published in journals\nand conference proceedings. He has also edited twelve books and\nhas twenty-seven patents to his name. He is a manager of research grants, editor in\nchief and member of international journal editorial boards, a former plenary speaker, a member of scientific committees, and chair at international conferences. His\nresearch is in the fields of control systems, control of electric drives, fuzzy control\nsystems, neural network applications, fault detection and diagnosis, sensor network\napplications, monitoring of distributed parameter systems, and power ultrasound\napplications. He has developed automation equipment for machine tools, spooling\nmachines, high-power ultrasound processes, and more.",institutionString:'"Politechnica" University Timişoara',institution:null},{id:"221364",title:"Dr.",name:"Eneko",middleName:null,surname:"Osaba",slug:"eneko-osaba",fullName:"Eneko Osaba",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/221364/images/system/221364.jpg",biography:"Dr. Eneko Osaba works at TECNALIA as a senior researcher. He obtained his Ph.D. in Artificial Intelligence in 2015. He has participated in more than twenty-five local and European research projects, and in the publication of more than 130 papers. He has performed several stays at universities in the United Kingdom, Italy, and Malta. Dr. Osaba has served as a program committee member in more than forty international conferences and participated in organizing activities in more than ten international conferences. He is a member of the editorial board of the International Journal of Artificial Intelligence, Data in Brief, and Journal of Advanced Transportation. He is also a guest editor for the Journal of Computational Science, Neurocomputing, Swarm, and Evolutionary Computation and IEEE ITS Magazine.",institutionString:"TECNALIA Research & Innovation",institution:{name:"Tecnalia",country:{name:"Spain"}}},{id:"275829",title:"Dr.",name:"Esther",middleName:null,surname:"Villar-Rodriguez",slug:"esther-villar-rodriguez",fullName:"Esther Villar-Rodriguez",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/275829/images/system/275829.jpg",biography:"Dr. Esther Villar obtained a Ph.D. in Information and Communication Technologies from the University of Alcalá, Spain, in 2015. She obtained a degree in Computer Science from the University of Deusto, Spain, in 2010, and an MSc in Computer Languages and Systems from the National University of Distance Education, Spain, in 2012. Her areas of interest and knowledge include natural language processing (NLP), detection of impersonation in social networks, semantic web, and machine learning. Dr. Esther Villar made several contributions at conferences and publishing in various journals in those fields. Currently, she is working within the OPTIMA (Optimization Modeling & Analytics) business of TECNALIA’s ICT Division as a data scientist in projects related to the prediction and optimization of management and industrial processes (resource planning, energy efficiency, etc).",institutionString:"TECNALIA Research & Innovation",institution:{name:"Tecnalia",country:{name:"Spain"}}},{id:"49813",title:"Dr.",name:"Javier",middleName:null,surname:"Del Ser",slug:"javier-del-ser",fullName:"Javier Del Ser",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/49813/images/system/49813.png",biography:"Prof. Dr. Javier Del Ser received his first PhD in Telecommunication Engineering (Cum Laude) from the University of Navarra, Spain, in 2006, and a second PhD in Computational Intelligence (Summa Cum Laude) from the University of Alcala, Spain, in 2013. He is currently a principal researcher in data analytics and optimisation at TECNALIA (Spain), a visiting fellow at the Basque Center for Applied Mathematics (BCAM) and a part-time lecturer at the University of the Basque Country (UPV/EHU). His research interests gravitate on the use of descriptive, prescriptive and predictive algorithms for data mining and optimization in a diverse range of application fields such as Energy, Transport, Telecommunications, Health and Industry, among others. In these fields he has published more than 240 articles, co-supervised 8 Ph.D. theses, edited 6 books, coauthored 7 patents and participated/led more than 40 research projects. He is a Senior Member of the IEEE, and a recipient of the Biscay Talent prize for his academic career.",institutionString:"Tecnalia Research & Innovation",institution:{name:"Tecnalia",country:{name:"Spain"}}},{id:"278948",title:"Dr.",name:"Carlos Pedro",middleName:null,surname:"Gonçalves",slug:"carlos-pedro-goncalves",fullName:"Carlos Pedro Gonçalves",position:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRcmyQAC/Profile_Picture_1564224512145",biography:'Carlos Pedro Gonçalves (PhD) is an Associate Professor at Lusophone University of Humanities and Technologies and a researcher on Complexity Sciences, Quantum Technologies, Artificial Intelligence, Strategic Studies, Studies in Intelligence and Security, FinTech and Financial Risk Modeling. He is also a progammer with programming experience in:\n\nA) Quantum Computing using Qiskit Python module and IBM Quantum Experience Platform, with software developed on the simulation of Quantum Artificial Neural Networks and Quantum Cybersecurity;\n\nB) Artificial Intelligence and Machine learning programming in Python;\n\nC) Artificial Intelligence, Multiagent Systems Modeling and System Dynamics Modeling in Netlogo, with models developed in the areas of Chaos Theory, Econophysics, Artificial Intelligence, Classical and Quantum Complex Systems Science, with the Econophysics models having been cited worldwide and incorporated in PhD programs by different Universities.\n\nReceived an Arctic Code Vault Contributor status by GitHub, due to having developed open source software preserved in the \\"Arctic Code Vault\\" for future generations (https://archiveprogram.github.com/arctic-vault/), with the Strategy Analyzer A.I. module for decision making support (based on his PhD thesis, used in his Classes on Decision Making and in Strategic Intelligence Consulting Activities) and QNeural Python Quantum Neural Network simulator also preserved in the \\"Arctic Code Vault\\", for access to these software modules see: https://github.com/cpgoncalves. He is also a peer reviewer with outsanding review status from Elsevier journals, including Physica A, Neurocomputing and Engineering Applications of Artificial Intelligence. Science CV available at: https://www.cienciavitae.pt//pt/8E1C-A8B3-78C5 and ORCID: https://orcid.org/0000-0002-0298-3974',institutionString:"University of Lisbon",institution:{name:"Universidade Lusófona",country:{name:"Portugal"}}},{id:"241400",title:"Prof.",name:"Mohammed",middleName:null,surname:"Bsiss",slug:"mohammed-bsiss",fullName:"Mohammed Bsiss",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/241400/images/8062_n.jpg",biography:null,institutionString:null,institution:null},{id:"276128",title:"Dr.",name:"Hira",middleName:null,surname:"Fatima",slug:"hira-fatima",fullName:"Hira Fatima",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/276128/images/14420_n.jpg",biography:"Dr. Hira Fatima\nAssistant Professor\nDepartment of Mathematics\nInstitute of Applied Science\nMangalayatan University, Aligarh\nMobile: no : 8532041179\nhirafatima2014@gmal.com\n\nDr. Hira Fatima has received his Ph.D. degree in pure Mathematics from Aligarh Muslim University, Aligarh India. Currently working as an Assistant Professor in the Department of Mathematics, Institute of Applied Science, Mangalayatan University, Aligarh. She taught so many courses of Mathematics of UG and PG level. Her research Area of Expertise is Functional Analysis & Sequence Spaces. She has been working on Ideal Convergence of double sequence. She has published 17 research papers in National and International Journals including Cogent Mathematics, Filomat, Journal of Intelligent and Fuzzy Systems, Advances in Difference Equations, Journal of Mathematical Analysis, Journal of Mathematical & Computer Science etc. She has also reviewed few research papers for the and international journals. She is a member of Indian Mathematical Society.",institutionString:null,institution:null},{id:"414880",title:"Dr.",name:"Maryam",middleName:null,surname:"Vatankhah",slug:"maryam-vatankhah",fullName:"Maryam Vatankhah",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Borough of Manhattan Community College",country:{name:"United States of America"}}},{id:"414879",title:"Prof.",name:"Mohammad-Reza",middleName:null,surname:"Akbarzadeh-Totonchi",slug:"mohammad-reza-akbarzadeh-totonchi",fullName:"Mohammad-Reza Akbarzadeh-Totonchi",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Ferdowsi University of Mashhad",country:{name:"Iran"}}},{id:"414878",title:"Prof.",name:"Reza",middleName:null,surname:"Fazel-Rezai",slug:"reza-fazel-rezai",fullName:"Reza Fazel-Rezai",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"American Public University System",country:{name:"United States of America"}}},{id:"426586",title:"Dr.",name:"Oladunni A.",middleName:null,surname:"Daramola",slug:"oladunni-a.-daramola",fullName:"Oladunni A. Daramola",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Federal University of Technology",country:{name:"Nigeria"}}},{id:"357014",title:"Prof.",name:"Leon",middleName:null,surname:"Bobrowski",slug:"leon-bobrowski",fullName:"Leon Bobrowski",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Bialystok University of Technology",country:{name:"Poland"}}},{id:"302698",title:"Dr.",name:"Yao",middleName:null,surname:"Shan",slug:"yao-shan",fullName:"Yao Shan",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Dalian University of Technology",country:{name:"China"}}},{id:"354126",title:"Dr.",name:"Setiawan",middleName:null,surname:"Hadi",slug:"setiawan-hadi",fullName:"Setiawan Hadi",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Padjadjaran University",country:{name:"Indonesia"}}},{id:"125911",title:"Prof.",name:"Jia-Ching",middleName:null,surname:"Wang",slug:"jia-ching-wang",fullName:"Jia-Ching Wang",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"National Central University",country:{name:"Taiwan"}}},{id:"332603",title:"Prof.",name:"Kumar S.",middleName:null,surname:"Ray",slug:"kumar-s.-ray",fullName:"Kumar S. Ray",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Indian Statistical Institute",country:{name:"India"}}},{id:"415409",title:"Prof.",name:"Maghsoud",middleName:null,surname:"Amiri",slug:"maghsoud-amiri",fullName:"Maghsoud Amiri",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Allameh Tabataba'i University",country:{name:"Iran"}}},{id:"357085",title:"Mr.",name:"P. Mohan",middleName:null,surname:"Anand",slug:"p.-mohan-anand",fullName:"P. Mohan Anand",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Indian Institute of Technology Kanpur",country:{name:"India"}}},{id:"356696",title:"Ph.D. Student",name:"P.V.",middleName:null,surname:"Sai Charan",slug:"p.v.-sai-charan",fullName:"P.V. Sai Charan",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Indian Institute of Technology Kanpur",country:{name:"India"}}},{id:"357086",title:"Prof.",name:"Sandeep K.",middleName:null,surname:"Shukla",slug:"sandeep-k.-shukla",fullName:"Sandeep K. Shukla",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Indian Institute of Technology Kanpur",country:{name:"India"}}}]}},subseries:{item:{id:"14",type:"subseries",title:"Cell and Molecular Biology",keywords:"Omics (Transcriptomics; Proteomics; Metabolomics), Molecular Biology, Cell Biology, Signal Transduction and Regulation, Cell Growth and Differentiation, Apoptosis, Necroptosis, Ferroptosis, Autophagy, Cell Cycle, Macromolecules and Complexes, Gene Expression",scope:"The Cell and Molecular Biology topic within the IntechOpen Biochemistry Series aims to rapidly publish contributions on all aspects of cell and molecular biology, including aspects related to biochemical and genetic research (not only in humans but all living beings). We encourage the submission of manuscripts that provide novel and mechanistic insights that report significant advances in the fields. Topics include, but are not limited to: Advanced techniques of cellular and molecular biology (Molecular methodologies, imaging techniques, and bioinformatics); Biological activities at the molecular level; Biological processes of cell functions, cell division, senescence, maintenance, and cell death; Biomolecules interactions; Cancer; Cell biology; Chemical biology; Computational biology; Cytochemistry; Developmental biology; Disease mechanisms and therapeutics; DNA, and RNA metabolism; Gene functions, genetics, and genomics; Genetics; Immunology; Medical microbiology; Molecular biology; Molecular genetics; Molecular processes of cell and organelle dynamics; Neuroscience; Protein biosynthesis, degradation, and functions; Regulation of molecular interactions in a cell; Signalling networks and system biology; Structural biology; Virology and microbiology.",coverUrl:"https://cdn.intechopen.com/series_topics/covers/14.jpg",hasOnlineFirst:!0,hasPublishedBooks:!0,annualVolume:11410,editor:{id:"165627",title:"Dr.",name:"Rosa María",middleName:null,surname:"Martínez-Espinosa",slug:"rosa-maria-martinez-espinosa",fullName:"Rosa María Martínez-Espinosa",profilePictureURL:"https://mts.intechopen.com/storage/users/165627/images/system/165627.jpeg",biography:"Dr. Rosa María Martínez-Espinosa has been a Spanish Full Professor since 2020 (Biochemistry and Molecular Biology) and is currently Vice-President of International Relations and Cooperation development and leader of the research group 'Applied Biochemistry” (University of Alicante, Spain). Other positions she has held at the university include Vice-Dean of Master Programs, Vice-Dean of the Degree in Biology and Vice-Dean for Mobility and Enterprise and Engagement at the Faculty of Science (University of Alicante). She received her Bachelor in Biology in 1998 (University of Alicante) and her PhD in 2003 (Biochemistry, University of Alicante). She undertook post-doctoral research at the University of East Anglia (Norwich, U.K. 2004-2005; 2007-2008).\nHer multidisciplinary research focuses on investigating archaea and their potential applications in biotechnology. She has an H-index of 21. She has authored one patent and has published more than 70 indexed papers and around 60 book chapters.\nShe has contributed to more than 150 national and international meetings during the last 15 years. Her research interests include archaea metabolism, enzymes purification and characterization, gene regulation, carotenoids and bioplastics production, antioxidant\ncompounds, waste water treatments, and brines bioremediation.\nRosa María’s other roles include editorial board member for several journals related\nto biochemistry, reviewer for more than 60 journals (biochemistry, molecular biology, biotechnology, chemistry and microbiology) and president of several organizing committees in international meetings related to the N-cycle or respiratory processes.",institutionString:null,institution:{name:"University of Alicante",institutionURL:null,country:{name:"Spain"}}},editorTwo:null,editorThree:null,series:{id:"11",title:"Biochemistry",doi:"10.5772/intechopen.72877",issn:"2632-0983"},editorialBoard:[{id:"79367",title:"Dr.",name:"Ana Isabel",middleName:null,surname:"Flores",slug:"ana-isabel-flores",fullName:"Ana Isabel Flores",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRpIOQA0/Profile_Picture_1632418099564",institutionString:null,institution:{name:"Hospital Universitario 12 De Octubre",institutionURL:null,country:{name:"Spain"}}},{id:"328234",title:"Ph.D.",name:"Christian",middleName:null,surname:"Palavecino",slug:"christian-palavecino",fullName:"Christian Palavecino",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0033Y000030DhEhQAK/Profile_Picture_1628835318625",institutionString:null,institution:{name:"Central University of Chile",institutionURL:null,country:{name:"Chile"}}},{id:"186585",title:"Dr.",name:"Francisco Javier",middleName:null,surname:"Martin-Romero",slug:"francisco-javier-martin-romero",fullName:"Francisco Javier Martin-Romero",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bSB3HQAW/Profile_Picture_1631258137641",institutionString:null,institution:{name:"University of Extremadura",institutionURL:null,country:{name:"Spain"}}}]},onlineFirstChapters:{paginationCount:26,paginationItems:[{id:"83087",title:"Role of Cellular Responses in Periodontal Tissue Destruction",doi:"10.5772/intechopen.106645",signatures:"Nam Cong-Nhat Huynh",slug:"role-of-cellular-responses-in-periodontal-tissue-destruction",totalDownloads:8,totalCrossrefCites:0,totalDimensionsCites:0,authors:null,book:{title:"Periodontology - New Insights",coverURL:"https://cdn.intechopen.com/books/images_new/11566.jpg",subseries:{id:"1",title:"Oral Health"}}},{id:"82654",title:"Atraumatic Restorative Treatment: More than a Minimally Invasive Approach?",doi:"10.5772/intechopen.105623",signatures:"Manal A. 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