Surgical techniques for prevention of adhesion formation
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",isbn:"978-1-83968-921-5",printIsbn:"978-1-83968-920-8",pdfIsbn:"978-1-83968-922-2",doi:null,price:0,priceEur:0,priceUsd:0,slug:null,numberOfPages:0,isOpenForSubmission:!1,hash:"9528d3b1ff011d68022c4fa750b4bc24",bookSignature:"Dr. Kieran Richard Hickey",publishedDate:null,coverURL:"https://cdn.intechopen.com/books/images_new/8491.jpg",keywords:"Tornadoes Causes, Characteristics, Features, Impacts, Temporal Variability, Spatial Variability, Regional Change, Climate Change, Climatological Context, Trends, Patterns, Projections",numberOfDownloads:null,numberOfWosCitations:0,numberOfCrossrefCitations:0,numberOfDimensionsCitations:null,numberOfTotalCitations:null,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"September 28th 2020",dateEndSecondStepPublish:"October 26th 2020",dateEndThirdStepPublish:"December 25th 2020",dateEndFourthStepPublish:"March 15th 2021",dateEndFifthStepPublish:"May 14th 2021",remainingDaysToSecondStep:"3 months",secondStepPassed:!0,currentStepOfPublishingProcess:4,editedByType:null,kuFlag:!1,biosketch:"Dr. Kieran R. Hickey is currently Head of the Department of Geography and also Head of the School of the Human Environment at the University College Cork, in addition, he is a Fellow of the Royal Meteorology Society and the Royal Geographical Society.",coeditorOneBiosketch:null,coeditorTwoBiosketch:null,coeditorThreeBiosketch:null,coeditorFourBiosketch:null,coeditorFiveBiosketch:null,editors:[{id:"17924",title:"Dr.",name:"Kieran",middleName:"Richard",surname:"Hickey",slug:"kieran-hickey",fullName:"Kieran Hickey",profilePictureURL:"https://mts.intechopen.com/storage/users/17924/images/system/17924.jpg",biography:"Dr. Kieran R. Hickey is a Senior Lecturer in Physical Geography in the School of the Human Environment in University College Cork, Rep. of Ireland where he is currently Head of the Department of Geography and also Head of the School of the Human Environment. He earned his B.A. in Geography and Economics in 1986 and his M.A. in Geography in 1990 from University College Cork, Republic of Ireland and his D.Phil from Coventry University, England in 1997. His research is in storms and hurricanes, climate change, historical climatology and climate disasters. He is a Fellow of the Royal Meteorology Society and the Royal Geographical Society. 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From chapter submission and review, to approval and revision, copyediting and design, until final publication, I work closely with authors and editors to ensure a simple and easy publishing process. I maintain constant and effective communication with authors, editors and reviewers, which allows for a level of personal support that enables contributors to fully commit and concentrate on the chapters they are writing, editing, or reviewing. I assist authors in the preparation of their full chapter submissions and track important deadlines and ensure they are met. I help to coordinate internal processes such as linguistic review, and monitor the technical aspects of the process. As an ASM I am also involved in the acquisition of editors. 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Venkateswarlu",coverURL:"https://cdn.intechopen.com/books/images_new/371.jpg",editedByType:"Edited by",editors:[{id:"58592",title:"Dr.",name:"Arun",surname:"Shanker",slug:"arun-shanker",fullName:"Arun Shanker"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"878",title:"Phytochemicals",subtitle:"A Global Perspective of Their Role in Nutrition and Health",isOpenForSubmission:!1,hash:"ec77671f63975ef2d16192897deb6835",slug:"phytochemicals-a-global-perspective-of-their-role-in-nutrition-and-health",bookSignature:"Venketeshwer Rao",coverURL:"https://cdn.intechopen.com/books/images_new/878.jpg",editedByType:"Edited by",editors:[{id:"82663",title:"Dr.",name:"Venketeshwer",surname:"Rao",slug:"venketeshwer-rao",fullName:"Venketeshwer Rao"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}}]},chapter:{item:{type:"chapter",id:"41907",title:"Adhesion Prevention Strategies in Laparoscopic Surgery",doi:"10.5772/52694",slug:"adhesion-prevention-strategies-in-laparoscopic-surgery",body:'Adhesions are defined as abnormal attachments between tissues and organs [1]. Intra-abdominal adhesions may be classified as congenital or acquired [2]. Congenital adhesions are a consequence of embryological anomaly in the development of the peritoneal cavity. Acquired adhesions result from the inflammatory response of the peritoneum that arises after intra-abdominal inflammatory processes (e.g. acute appendicitis, pelvic inflammatory disease, exposure to intestinal contents and previous use of intrauterine contraceptive devices), radiation and surgical trauma [3]. It has been reported that the majority of acquired adhesions (about 90%) are post-surgical [2].
Factors associated with the formation of post-surgical adhesions include tissue trauma, infection, ischaemia,reaction to foreign bodies (sutures, powder from gloves, gauze particles etc.), haemorrhage, tissue overheating or desiccation and exposure to irrigation fluids [4]. The incidence of intra-abdominal adhesions ranges from 67% to 93% after general surgical abdominal operations and from 60% to 90% after gynecological procedures. Not unexpectedly, adhesion formation is considered one of the most common post-operative complications [2,5]. Post-surgically, many adhesions may be asymptomatic or can lead to a broad spectrum of clinical problems, including intestinal obstruction, chronic pelvic or abdominal pain and female infertility, requiring re-admission and often additional surgery, while at the same time they can complicate future surgical procedures [6]. Adhesion-related re-operations are a common consequence of gynecological procedures and adhesiolysis is followed by a high incidence of adhesion reformation and de-novo adhesion formation [7].
The major strategies for adhesion prevention in gynecological surgery aim at the optimization of surgical technique and use of adhesion-prevention agents. Laparoscopic surgery in gynecology represents the most innovative surgical approach, compared with laparotomy since it has been shown from a large number of clinical, but also experimental studies, that is associated with less development of de novo adhesions. Without any doubt, the most important factor is the operating surgeon, whose attention to proper surgical technique will serve as a mainstay for adhesion formation.
The mechanism of adhesion formation represents a variation of the physiological healing process [8]. The process of peritoneal healing differs from that of other tissues. Peritoneal defects heal by a process of metaplasia from the underlying mesenchyme, partly from migration of epithelial cells from the free peritoneal fluid and minimally through proliferation of epithelial cells from the defect’s edges. Consequently, peritoneal wounds need the same time to heal regardless of their size, in contrast with other tissues, such as the skin, where large injuries take longer to heal than do small injuries [9]. There is no difference between peritoneal healing and adhesion formation for the first 3 days after peritoneal injury. Injuries to the peritoneum cause a disruption of stromal mast cells, resulting in the release of histamine and vasoactive cinins. Also as a response to trauma, various cytokines, such as interleukin (IL)-1, IL-6 and tumor necrosis factor-a (TNF-a) are locally released. The cytokines attract and activate macrophages to secrete vasodilating substances, which in turn, cause an increase in capillary permeability, leading to the formation of fibrous exudate [10]. Platelets are an important component of the inflammatory exudate and have the ability to adhere it to the traumatized surfaces. The platelet degranulation releases adrenaline, transforming growth factor b and serotonin and contribute to the production of prostaglandins and leukotrienes. The chemokines direct the migration of cells to the injury site, while platelets contribute to the initial fibrin clot and to the initiation of the coagulation process [11]. The activation of the coagulation cascade leads to the transformation of the inactive prothrombin into thrombin that triggers the conversion of fibrinogen into monomers of fibrin, which interact and polymerize. The initially soluble polymer becomes insoluble by coagulation factors such as factor XIIIa [12]. The exudate coagulates within 3 h and forms a fibrinous material that plugs the defective area and generates attachments between adjacent tissue surfaces. The presence of blood and post-operative bleeding increases the fibrin deposition. Most of the fibrin depositions will disperse by fibrinolysis. The fibrinous mass that will remain, results in the organization and formation of adhesions [8]. Polymorphonuclear cells, macrophages, fibroblasts and mesothelial cells migrate and proliferate into the fibrinous exudate. Macrophages increase in number, change function and secrete a variety of substances that recruit mesothelial cells onto the injured surfaces. Mesothelial cells form islands, proliferate and cover the injured area. All these cells release a variety of substances such as plasminogen activator, plasminogen activator inhibitor, arachidonic acid metabolites,reactive oxygen species, cytokines, IL-1, IL-6, tumor necrosis factor-a, prostaglandin E2, collagenase, elastase and the transforming growth factors leukotriene B4 a and b(TGFa and TGFb). These factors modulate the process of peritoneal healing and adhesion formation [12-14]. The deposition is the key step for the healing process and the balance between deposition and degradation will determine normal peritoneal healing or adhesion formation. The fibrin absorption is controlled by fibrinolysis. The inactive plasminogen is converted to plasmin through tissue plasminogen activator (tPA) and urokinase type plasminogen activator (uPA). The tPA is present in both mesothelium and submesothelial blood vessels of serosal and peritoneal membranes[12,15]. The fibrinolytic activity normally begins three days after peritoneal injury and increases to a maximum by day 8. Therefore, those adhesions that will be formed are in place by day 8, when mesothelial regeneration has been completed [8]. Normal peritoneum has a high fibrolytic activity in order to prevent adhesion formation between different tissue surfaces. During the inflammatory process, IL-1 and IL-6 stimulate epithelial and inflammatory cells to release plasminogen activator inhibitor 1 and 2 (PAI-1 and PAI-2), which inhibit fibrinolytic activity [16]. Patients with extensive adhesions have been found to have an overexpression of PAI-1 in the peritoneum [17]. Also, the deficient blood supply, the reduced tissue oxygenation and the release of reactive oxygen species that frequently co-exist with surgical trauma, decrease the peritoneal fibrinolytic activity [9,18].
In order to prevent the development and reformation of post-operative intra-abdominal adhesions a variety of surgical techniques and adjuvants have been proposed. Agents, that in theory can modify the mechanism of adhesion formation, have been evaluated in experimental trials and many of them have been advocated for use during surgery in humans. Surgical techniques are focused on the limitation of surgical trauma, prevention of ischaemia and exposure of peritoneal cavity to foreign materials (Table 1). Improvement of surgical techniques can potentially reduce adhesion formation but cannot eliminate it. Anti-adhesive agents can be classified as pharmacological agents, systemic or intra-peritoneal, and intra-peritoneal barriers (solid or liquid). Pharmacological agents (Table 2) target the modification of inflammatory reaction (limitation of fibrin deposition), amplification of fibrin absorption and suppression of fibroblast activity. Barriers (Table 3) are used in order to prevent traumatized peritoneal surface apposition during the healing process so as to prevent tissue adherence [17,19].
Achieving excellent haemostasis and avoiding local ischaemia Avoiding foreign bodies (talc, starch) Avoiding peritoneum suturing or use of fine non-reactive suture Minimizing surgical trauma Minimizing tissue handling Reducing drying or overheating of tissues Reducing infection risk Removing intra-peritoneal blood deposits | \n\t\t
Surgical techniques for prevention of adhesion formation
Fibrinolytic agents \n\t\t\t\t \n\t\t\t\t \n\t\t\t\t \n\t\t\t\t \n\t\t\t\t \n\t\t\t\t \n\t\t\t\t \n\t\t\t\t Anticoagulants \n\t\t\t\t \n\t\t\t\t \n\t\t\t\t Anti-inflammatory agents \n\t\t\t\t \n\t\t\t\t \n\t\t\t\t Antibiotics \n\t\t\t\t \n\t\t\t\t \n\t\t\t\t Other agents \n\t\t\t | \n\t\t\tFibrinolysin Papain Streptokinase, streptodornase Urokinase Hyaluronidase Chymotrypsin, trypsin, pepsin Elastase Recombinant tissue plasminogen activator \n\t\t\t\t Citrates Oxalates Heparin \n\t\t\t\t Corticosteroids Antihistamines Non-steroidal anti-inflammatory drugs \n\t\t\t\t \n\t\t\t\t Tetracycline Cephalosporin \n\t\t\t\t \n\t\t\t\t Progesterone Oestrogens Gonadotrophin-releasing hormone agonists Antiproliferative agents Aromate inhibitors Statins Melatonin \n\t\t\t | \n\t\t
Pharmacological anti-adhesive agents
The development of operative laparoscopy in gynaecology was associated with the expectation of reduced adhesion formation. Therefore, a large number of experimental and human clinical trials has been performed, which have shown that, compared with laparotomy, laparoscopic surgery is associated with less development of adhesions [17,20,21]. Reduction of adhesion formation is facilitated by minimal tissue handling and trauma, avoidance of exposure to foreign bodies (powder from gloves, gauze particles, e.t.c.) and prevention of air pollution in the peritoneal cavity that leads to the reduction of tissue drying. Pneumoperitoneum via increased intra-abdominal pressure has a tamponade effect that facilitates haemostasis, limits the use of diathermy and formation of ischaemic areas. In addition, laparoscopy is associated with a lower incidence of post-operative infection [21,22]. On the other hand, it has been advocated that the beneficial effect of laparoscopy in adhesion formation might be reduced by the use of pneumoperitoneum with CO2 [12]. CO2 pneumoperitoneum is associated with increased intra-abdominal pressure that compresses the splanchnic veins, reducing the blood flow by elevating vascular resistance. This stasis leads to a reduction in tissue oxygenation, anaerobic cell metabolism, acidosis and production of reactive oxygen species. The clinical impact of reactive oxygen species remains unclear but there is evidence that they are associated with increased adhesion formation [23]. Moreover it has been recently proposed that a low intra-peritoneal pressure (IPP) (8 mmHg) may be better than the standard IPP (12 mmHg) to minimize the adverse impact on the surgical peritoneal environment during a CO2 pneumoperitoneum [24].
Solid barriers (membranes, gel) Endogenous tissue \n\t\t\t\t \n\t\t\t\t \n\t\t\t\t Fluid barriers \n\t\t\t\t \n\t\t\t\t \n\t\t\t\t \n\t\t\t\t \n\t\t\t\t \n\t\t\t\t \n\t\t\t\t \n\t\t\t\t Exogenous material | \n\t\t\tOmental grafts Peritoneal grafts Bladder strips Fetal membranes \n\t\t\t\t \n\t\t\t\t Various oils Liquid paraffin Amniotic fluid Dextran Crystalloid solutions Icodextrin 4% Polyglycan esters \n\t\t\t\t \n\t\t\t\t Silicone Vaseline Gelatin Metal foils Elastic and silk foils Expanded polytetrafluoroethylene Oxidized regenerated cellulose Hyaluronic acid Carboxymethylcellulose Polyethylene glycol Polylactide Fibrin, N,Ocarboxymethylchitosan \n\t\t\t | \n\t\t
Anti-adhesive barier methods.
A wide variety of pharmacological agents (Table 2) have been used in attempts to prevent or attenuate the formation of post-surgical adhesions, but none of them has been found to be effective. The use of drugs for adhesion prevention has some obstacles that affect their efficacy. Ischaemia and inadequate blood supply are important factors in adhesion formation and these also decrease systemic drug delivery inhibiting their effectiveness. Peritoneum has an extremely rapid absorption mechanism, that limits the half life and efficacy of many intra-peritoneally administered agents. Anti-adhesion agents must not affect normal wound healing, which has steps in common with adhesion formation (fibrinous exudate, fibrin deposition, fibroblast activity and proliferation) [19,25]. The clinical effectiveness of these agents has been evaluated in a systematic review and meta-analysis that analysed data from relevant randomized controlled trials (RCT) published up to 2005 [26].
Non-steroidal anti-inflammatory drugs (NSAID) affect adhesion formation by several mechanisms. They act by modifying arachidonic acid metabolism and altering cyclooxygenase activities. This results in decreased vascular permeability, platelet aggregation, and coagulation and enhanced macrophage function. A number of locally and systemically administered NSAID have been used in experimental trials.
No relevant clinical trials assessing the effectiveness of NSAID in adhesion prevention have been published to date in patients undergoing gynaecological surgery. Their clinical efficacy is questionable probably because of inadequate concentrations at the sites of surgical trauma or by rapid absorption from the peritoneal membrane [3,19,27].
Corticosteroids alter the inflammatory response by reducing vascular permeability and decreasing cytokine and chemotactic factor secretion. Antihistamines inhibit fibroblast proliferation and stabilize lysosomal membranes and histamine secretion. Corticosteroids have been used alone or plus antihistamines by intra-peritoneal or systemic administration or by flushing through Fallopian tubes post-operatively and were effective in many, but not all, experimental models. In the limited data from RCT [28,29,30], no significant beneficial effect was detected with the use of corticosteroids (systemic, intra-peritoneal or Fallopian tube flushing) in the deterioration of adhesion score at second-look laparoscopy or on the probability of clinical pregnancy. However, limited data suggest that the addition of post-operative steroids to systemic intra-operative steroids might be associated with a favourable outcome both in terms of adhesion score deterioration (increase) or improvement (reduction) [31]. On the other hand, adverse events such as suppression of the pituitary–adrenal axis, immunosuppression and delayed wound healing have been reported with the use of corticosteroids [19,32,33]. Regarding antihistamines, only one RCT has evaluated the role of oral promethazine in the prevention of adhesion formation after pelvic surgery. In that study, no significant difference was detected either in deterioration or improvement of adhesion score in patients who received promethazine as compared with those who did not [31].
Progesterone has been used for the prevention of post-operative adhesions. Administration of progesterone resulted in less adhesion formation in animal models, but does not appear to be effective in humans. Oestrogens have been associated with increased adhesion formation in animal models. It was demonstrated that a hypo-oestrogenic state, produced by gonadotrophin-releasing hormone agonists or aromatase inhibitors such as tamoxifen and anastrazole, decrease development of post-operative adhesions in experimental models [3,34,35]. This hypothesis, however, has never been tested in humans.
Anticoagulants such as heparin can reduce adhesion formation by inhibition of the coagulation cascade and promotion of fibrinolysis [36]. The use of heparin for intra-peritoneal irrigation in a dose that can reduce adhesion formation was associated with haemorrhage and delayed wound healing, but low-dose heparin irrigation showed no benefit in adhesion reduction [3,19,37]. In the only available RCT, heparin delivery with oxidized regenerated cellulose failed to demonstrate a superior effect compared with oxidized regenerated cellulose alone [38]. Furthermore, in experimental trials, the combination of carboxymethylcellulose or 32% dextran 70 plus heparin failed to reduce adhesion formation [38,39,40].
Fibrinolytic agents as streptokinase, elastase and tissue plasminogen activator produced by recombinant DNA techniques (rtPA) can contribute in adhesion prevention directly by reducing the fibrinous mass and indirectly by stimulating plasminogen activator activity. Systemic administration of anticoagulants is impeded by lack of safety. The concentrations of fibrinolytic agents required to prevent adhesion formation are too close to the anticoagulatory concentrations and increase the risk for post-operative haemorrhage and delayed wound healing. Intra-peritoneal administration is ineffective due to rapid absorption by the peritoneal membrane [3,25,41]. The use of carboxymethylcellulose gel and oxidized regenerated cellulose as a carrier to deliver rtPA intra-peritonealy was not associated with a reduction of adhesion formation in animal models [42,43].
A recent study has investigated the impact of gonadotropin-releasing hormone analogue (GnRH-a) on coagulation and fibrinolytic activities and its effectiveness in the prevention of pelvic adhesion after myomectomy in thirty-two infertile women. Patients treated with GnRH-a showed significant decrease in plasminogen activator inhibitorPAI, thrombin activatable fibrinolysis inhibitor (TAFI), factors V, and VIII and increased protein C (PC), but no significant change in plasminogen and α2-antiplasmin levels compared with control group, suggesting a possible critical role of the GnRH-a therapy in preventing postoperative adhesion development [44].
Antibiotics are commonly used for prophylaxis against post-operative infections and hence the inflammatory response that leads to adhesion formation. Peritoneal irrigation with antibiotic solutions does not reduce adhesion formation, while it has been shown that in some cases it may promote them [45].
Many other agents, such as apoprotin, noxytioline, growth factor inhibitors and modulators, phosphatidylcholine, thiazolidinediones, colchicine and calcium channel blockers, have been utilized in experimental trials. The intra-peritoneal administration of noxytioline is the only one of these interventions that has been tested in the context of a RCT and no significant difference was identified in terms of reduction of adhesions and clinical pregnancy rates in patients who were administered intra-peritoneal noxytioline and the control group [29]. There is no data from RCT to support the conclusion that any of the other agents is efficacious in preventing the development of post-operative adhesions [19,46,47].
The failure of pharmacological regimens to prevent adhesion formation has led to the revival of the barrier technique. With the barrier technique, traumatized peritoneal surfaces are kept separated, during mesothelial regeneration, thus precluding adherence of adjacent organs and tissues and reducing the development of adhesions. The separation can be achieved by the use of solid (films or gels) or fluid barriers [19,25]. Anti-adhesive barriers are currently the most useful adjuvant for prevention of post-operative adhesion formation. Numerous substances (Table 3) have been used as mechanical barriers to separate tissue surfaces. Most of these materials are of historical interest only and had no effect or even aggravated adhesion formation [48,49]. An anti-adhesive agent should be effective, safe, economical and easy to use in both open and laparoscopic surgery [50]. The clinical effectiveness of several of these agents has been evaluated in two recent Cochrane reviews [26,51].
Solid barriers are placed over one or between two traumatized surfaces providing a separation that averts tissue apposition during the critical period of fibrin formation and mesothelial regeneration following surgical trauma. It should be noted though, that solid barriers have some significant drawbacks. They are often ineffective in the presence of blood, have a complex preparation and application, do not conform easily to the shape of pelvic organs, need suturing and are difficult to use via laparoscopic surgery. Their benefits are also limited to the site of application and do not prevent the development of adhesions at sites of indirect trauma. So the surgeon has to surmise where adhesions will be formed in order to choose the placement sites and optimize barrier efficacy [52]. Not infrequently, this proves to be a challenging task, since, for example, midline laparotomy initiates a generalized peritoneal response that can lead to adhesion formation distant from surgical trauma [53].
Expanded polytetrafluoroethylene (Preclude, Gore-Tex Surgical Membrane; Johnson and Johnson, Arlington, TX) is a non-absorbable, non-reactive, synthetic material that
inhibits cellular migration and tissue adherence. In the only available RCT, it has been shown to be associated with fewer post-operative de-novo adhesions after myomectomy when compared with no treatment [54]. Moreover, when compared with oxidized regenerated cellulose, Preclude was found to be more effective in terms of adhesion reformation after adhesiolysis [55]. However, in another RCT, no evidence of a beneficial effect of Preclude was demonstrated in the de-novo formation of adhesions after laparoscopic myomectomy when compared to oxidized regenerated cellulose [56]. Expanded polytetrafluoroethylene has the disadvantages that it must be sutured in place, is difficult to use in laparoscopic surgery and, ideally, requires a subsequent surgical procedure for removal after the injury has healed [57]. The use of Preclude in Europe is limited and it has been withdrawn from the market in USA after the development of the absorbable barriers [25].
Oxidized regenerated cellulose (Interceed (TC7); Johnson and Johnson) is the first degradable barrier that was used in clinical practice and represents a modification of its precursor Surgicel, which has been used as a haemostatic agent for a long time. It is a mesh designed to be placed over or between traumatized surfaces. About 8 h after the application in the peritoneal cavity, it becomes a viscous gel and finally it is degraded to monosaccharides and completely absorbed in about 2 weeks [3,22]. Oxidized regenerated cellulose use in laparoscopic surgery is feasible [8]. In order to evaluate the efficacy of oxidized regenerated cellulose in the prevention of the development of post-surgical adhesions, many studies have been carried out. A meta-analysis of 11 relevant RCT [51] has shown that the barrier is safe and reduces significantly the incidence of de-novo adhesions, as well as the reformation of adhesions as compared with no treatment in laparoscopy [58-62]. In laparotomy, the available RCT [63-68], when meta-analysed [51], demonstrated that a significant reduction in the reformation (or mixture) of adhesions can be expected with the use of oxidized regenerated cellulose as compared with the no treatment group. The product is site specific, thus the efficacy is limited to surgical situations where raw surfaces can be completely covered with the mesh and its benefit is limited to the site of barrier placement. The fundamental disadvantage is that it becomes ineffective when the entire area is not completely haemostatic. The presence of small amounts of blood in the peritoneal cavity or post-operative bleeding results in blood permeating the mesh, fibrin deposition and, finally, adhesion formation [8,69,70]. In addition, as reported previously, the combination of oxidized regenerated cellulose plus heparin resulted in a significant reduction of adhesion formation and reformation in experimental models. This improvement in efficacy was not confirmed in clinical trials [36,38,40]. Oxidized regenerated cellulose has been approved by the US Food and Drink Administration (FDA) for use in open surgery in the USA [69].
Hyaluronic acid (HA) is a linear polysaccharide with repeating disaccharide units that are composed of sodium D-glucuronate and N-acetyl-D-glucosamine. It is a naturally occurring component of many body tissues and fluids, where it provides mechanically protective and physically supportive roles [69]. Various combinations of HA have been used for the prevention of adhesion formation. HA and carboxymethylcellulose (Seprafilm; Genzyme, Cambridge, Massachusetts, USA) is an absorbable membrane that dissolves and forms a hydrophilic gel approximately 24 h after placement. It is a site-specific barrier and acts by separating mechanically opposite tissue surfaces and lasts for 7 days. The HA is completely cleared from the body within 4 weeks, but the absorption of carboxymethylcellulose is not well known. It does not conform to the shape of pelvic organs as well as oxidized regenerated cellulose and is usually used to prevent adhesions between the incision of anterior abdominal wall and bowel or omentum [71,72]. Its use in laparoscopic procedures is difficult. In a blind prospective, randomized, multicentre study, the treatment of patients after myomectomy with Seprafilm significantly reduced the extent and area of post-operative uterine adhesions [72]. Potential side effects include induced foreign body reaction, higher incidence of pulmonary emboli and intra-peritoneal abscess formation, but these findings were not statistically significant in the relevant trials [3,73]. High cost is another limitation because, for an effective protection from intestinal obstruction, a mean of 4.5 sheets per patient is required [25]. Seprafilm has been approved by the FDA for use in open surgery in the USA [22]. Ferric hyaluronate 0.5% gel (Intergel; Gynecare, Sommerville, New Jersey, USA) is a viscous gel that provides a broader coverage than previous site-specific agents. It was shown to be easy to use in open and laparoscopic surgery. In relevant prospective randomized trials, ferric hyaluronate was associated with a significant reduction of severity and extent of post-operative adhesions and statistically significant improvement of the American Fertility Society (AFS) and modified AFS scores at second-look laparoscopy [69,74,75]. It was withdrawn from the market in 2003 because of problems with late onset post-operative pain and rare reports of sclerosing peritonitis [25,76]. Low-viscosity 0.04% HA combined with phosphate-buffered saline (Sepracoat; Genzyme) is a bioabsorbable macromolecular dilute solution of HA that is cleared from the body in less than 5 days. The solution is applied in the peritoneal cavity before any tissue manipulation in order to protect peritoneal surfaces from indirect trauma and finally before the end of the procedures [3,77,78]. In a blind, prospective, randomized, placebo-controlled multicentre study, where patients had undergone open gynecological procedures, low-viscosity 0.04% HA resulted in a statistically significant reduction of adhesions, as well as of the mean adhesion score, at second-look laparoscopy. However, it was not effective in reducing post-operative adhesion formation at sites of direct surgical trauma [78]. It has been approved by the FDA for use in open surgery in the USA [22]. HA cross-linked to HA (Hyalobarrier Gel; Baxter, Bracknell, UK) is a site-specific highly viscous gel is considered as easy to use in laparoscopic and open surgery. In a prospective, randomized, controlled study where the rate of post-surgical adhesions after laparoscopic myomectomy was examined, cross-linked HA resulted in significantly more adhesion-free patients [79]. Pregnancy rates at 6 and 12 months after laparoscopic myomectomy were significantly higher in patients treated with cross-linked HA [80]. In another randomized trial, adhesion-free patients after laparoscopic myomectomy were greater in the treatment group but the difference was not statistically significant. The incidence and severity of adhesions was similar in both groups, but a significant reduction of uterine adhesions was found in the treatment group [81]. When the data from the two aforementioned studies were combined, a statistically significant reduction of adhesions during second-look laparoscopy was detected in the group of patients treated with HA-cross-linked HA as compared with the control group. Auto-cross-linked internal ester form of HA (ACP gel; Fidia Advanced Biopolymers, AbanoTerme, Italy) has the biocompatibility of the original polymer but higher viscosity and extended residence. It is a gel that has been shown to be efficacious in reducing abdominal adhesions in experimental models [82,83]. Two prospective randomized controlled trials have been published so far by the same group regarding the use of ACP gel for the prevention of intrauterine adhesions after hysteroscopic surgery. In these studies, ACP gel has been associated with a significant reduction in the incidence and the severity of subsequent intrauterine adhesions [84,85]. A stratified analysis of these two studies confirmed this finding by demonstrating a significant reduction in the proportion of patients with adhesions at second-look hysteroscopy. Cross-linked thiol-modified HA with 4% polyethyleneglycoldiacrylate (Carbylan-S and Carbylan-SX; CarbylanBioSurgery, Palo Alto, CA, USA) is a bioabsorbable solution of HA. Carbylan-S is a hydrogel and Carbylan-SX has two formats, a sprayable gel and a hydrogel film. In animal models, Carbylan- S containing mitomycin C and Carbylan-SX were effective in prevention of post-operative intra-abdominal adhesions [52,86].
Polylactide (copolymer of 70:30 poly(L-lactide-CO-D, L-lactide; SurgiWrap, MacroporeBiosurgeryinc., San Diego, USA) is a bioabsorbable film with a long absorption period (up to 6 months). It is metabolized to lactic acid and finally to CO2 and exhaled through the respiratory system. It requires suturing in order to avoid its loss from the site. In preclinical studies, polylactide appears to be effective in the reduction of adhesion formation, but there are no data currently for safety and efficacy in humans [87,88].
Polyethylene glycol (SprayGel; Confluent Surgical, Waltham, Massachusetts, USA). It is a synthetic hydrogel formed when two polyethylene glycol-based liquids are sprayed together with an air assisted sprayer at the target tissue, where they cross-link and form a hydrogel barrier. One liquid is clear and one is coloured with methylene blue in order that facilitate its application. The gel remains intact for approximately 5–7 days and then gradually breaks down by hydrolysis and is cleared through the kidneys [89]. Drawbacks of the product are the intricacy of preparation and application, the time required to cover the target tissue and the high cost. In a prospective randomized controlled phase-III trial, in 40 patients undergoing myomectomy, polylactide resulted in a significant decrease in the mean tenacity score. The extent of adhesions was increased in the control group but the difference was not significant. Also, the proportion of adhesion-free patients at second-look laparoscopy was increased in the treatment group but the difference was not statistically significant [89]. It has been approved for use in laparoscopic and open surgery in Europe, but by the FDA only for use in open surgery in USA [22,25].
Carboxymethylcellulose is a high-molecular-weight polysaccharide, derivative of cellulose. The mechanism of its absorption is not well known. It has been used in combination with rtPA and with HA. A composite gel of carboxymethylcellulose and polyethylene oxide (Oxiplex; FzioMed, San Luis Obispo, CA, USA) is a viscoelastic gel, which acts as a barrier between tissues that inhibits protein deposition and thrombus formation [74]. The gel is absorbed by 6 weeks, but in cases where large amounts of gel were applied in multiple layers to the surgically treated sites or in cases of stage-IV endometriosis, small collections of gelatinous material were noted in areas of gel application or in areas deep in the cul-de-sac [90]. In two blind randomized controlled trials, where patients underwent adnexal surgery, carboxymethylcellulose and polyethylene oxide showed a significant improvement of AFS score in the treated group, but not in all clinical situations. It did not appear to provide this benefit to patients with grade-IV endometriosis [74,91]. Another double-blind prospective randomized controlled trial has shown that the mean AFS score for patients in the treatment group was unchanged, while in control patients an increased AFS score was noted [91]. No statistical pooling was feasible for these three studies, since the data were not analysed and presented per randomization unit (they were analysed per adnexa and not per patient). It is easy to use in laparoscopic surgery and it has been approved in Europe for use in abdominal and pelvic surgery [25].
Fibrin glue (Tissucol; Baxter International, Deerfield, IL, USA) is a biological product. Fibrin glue is made by mixing human fibrinogen with bovine thrombin, calcium and factor XIII [92]. Obviously, the use of human blood products raises a theoretical risk for transmission of infectious diseases. According to the pathogenesis of adhesions, application of fibrin glue at the traumatized peritoneal surfaces should increase adhesion formation. Possibly, fibrin glue application confines fibrin deposition and averts the development of attachments between opposing tissue surfaces. In animal studies, the use of fibrin glue has been shown to decrease adhesion formation and reformation but clinical data are limited. Fibrin glue has not been approved by the FDA for use in USA [22,47]. So far, no relevant data from trials in humans have been published.
N,O-carboxymethylchitosan (Adhes-X, Chitogenics, New Jersey, USA) is a purified derivative of chitin obtained from the exoskeleton of shrimp and has similar structure to hyaluronic acid and carboxymethylcellulose [93]. The product comprises both a clear gel and a solution. The gel is placed initially at the sites of surgical trauma where it is tamped with a laparoscopic instrument and subsequently the solution is placed at the same places. Its efficacy and safety have been confirmed in some animal models. A prospective randomized controlled study, performed on 34 patients undergoing laparoscopy for various gynaecological indications, demonstrated a decrease in the recurrence, extent and severity of adhesions and a decrease of de-novo adhesion formation at second-look laparoscopy, but none of these findings were statistically significant [94].
Fluids constitute an ideal barrier agent because their action is not limited to the site of application. Their function is provided by hydrofloration of intra-peritoneal structures in the liquid that is infused into the peritoneal cavity at the end of the surgical procedure. Hydrofloration provides a temporary separation between raw peritoneal surfaces allowing independent healing without the formation of adhesions. Possibly, fluid circulation in the peritoneal cavity contributes to the prevention of adhesion formation by diluting fibrinous exudates released from traumatized surfaces. Fluid barriers may prevent adhesion formation both at the traumatized area and elsewhere in the pelvis. The instillation of fluids in the peritoneal cavity may be associated with some undesirable side effects, such as leakage from the incision, labial oedema, feeling of fluid moving around, abdominal discomfort, abdominal distension and complications such as pulmonary and peripheral oedema. Large volumes of intra-peritoneal fluids may decrease the peritoneum ability to confront bacterial infections [3,17,76].
Crystalloid solutions (Ringer’s lactate, NaCl 0.9%) are rapidly absorbed by the peritoneal cavity, at a rate of 30–50 ml/h. Consequently, 24 h after the surgery, minimal or no crystalloid solution would be left in the peritoneal cavity. The instillation of crystalloids does not seem to result in decreased adhesion formation. They are commonly used but they are not approved for use as anti-adhesive agents [25,69,95]. Crystalloids have also been used in various combinations with heparin, steroids, antihistamines and other pharmacological agents in randomized controlled trials, but none of them has been found effective in decreasing post-operative adhesion formation or improving pregnancy rates [96].
Dextran (32% dextran 70; Hyskon; Pharmacia, Piscataway, New Jersey, USA) is a 1–6-linked dextrose polymer. A summary [26] of the available data from relevant RCT [37,97-99] demonstrated a decreased proportion of patients with adhesions at second-look laparoscopy in the group that received 32% dextran 70, as compared with the group that did not. However, despite the fact that the patients with improvement and deterioration in the adhesion score at second-look laparoscopy were increased and decreased, respectively, in the treatment group, when compared with the control group, this difference was not statistically significant. In addition, its use was associated with significant side effects as pulmonary and peripheral oedema caused by its osmotic properties, liver function abnormalities, pleural effusion and, rarely, allergic reactions or anaphylactic shock and disseminated intra-vascular coagulation. It has not been approved for use as an anti-adhesive agent [3,17,100,101].
Polyglycanesters (Adcon-P; Gliatech, Cleveland, Ohio) is a viscous bioabsorbable solution. Its prototypes Adcon-L and Adcon-T/N were found effective for adhesion prevention in spinal and neurosurgical procedures. Experimental studies have shown that application of Adcon-P effectively reduces development of post-operative intra-abdominal adhesions. There are no data for the safety and the efficacy of this product in humans [102].
Icodextrin 4% (Adept; Shire Pharmaceuticals, Basingstoke, Hampshire, UK) is a 1–4-linked glucose polymer. Icodextrin 4% is a clear isomolar solution and does not predispose to infection. It is absorbed gradually via the lymphatic system into the systemic circulation, where it is digested to oligosaccharides by amylase. Amylase is absent from the human peritoneal cavity. Preclinical studies had shown significant reduction of post-operative adhesions and confirmed the safety of icodextrin 4%. It was indicated that the agent was more effective in adhesion reduction when used as both an irrigant and post-operative instillate [103]. In a small double-blind prospective randomized multicentre study, icodextrin 4% resulted in the reduction of incidence, severity and extent of adhesions but these results were not statistically significant [104]. However, recently, in the largest prospective randomized double-blind multicentre study for an anti-adhesive agent, icodextrin 4% has been shown to result in a significant reduction of incidence, severity and extent of adhesions and a significant improvement of AFS score. Also the study showed that icodextrin 4% prevents the deterioration of pre-existing adhesions, considering that patients with the higher number of adhesion lysed at initial surgery had the greater reduction in adhesion incidence [95]. A stratified analysis of these two studies revealed a statistically significant effect oficodextrin 4% use on the de-novo formation of adhesions, as well as on the proportion of patients with an improvement of the adhesion score at second-look laparoscopy [105]. Simultaneously with clinical trials, a European patients registry (ARIEL) was created allowing surgeons to record and report the experiences of the use of icodextrin 4% in open and laparoscopic gynaecological and general surgery. The registry provides feedback on routine use in 4620 patients (2882 that underwent gynaecological and 1738 general surgery). The general consensus is that it is easy to use in both open and laparoscopic surgery, it is well tolerated by patients and the incidence of adverse events is considered similar to the control group [76,106]. Low cost is another advantage of icodextrin 4%. Adept (1.5 litre bags) are about half the price of each sheet of Interceed or Seprafilm and it is about four times cheaper than one SprayGel package [50]. Icodextrin 4% has been approved for use in open and laparoscopic surgery in Europe and it was the first anti-adhesive agent that has been approved by the FDA for use in laparoscopic surgery in the USA [25,76,91,95].
Development of post-operative adhesion is a widespread consequence of surgical trauma and healing following open or laparoscopic gynecological surgery and is associated with significant complications. At present, the main strategy to avoid formation and reformation of adhesions is focused on the use of careful surgical techniques and anti-adhesive agents. Reduction of adhesion formation after laparoscopic surgery in comparison to the more conventional approach by laparotomy can be attributed to less tissue manipulation, less tissue drying, avoidance of insertion of foreign bodies such as talc from the surgical gloves, fibers from the gauzes e.t.c. On the other hand pneumoperitoneum during laparoscopy exerts a tamponade effect that facilitates hemostasis, so minimizing the use of electrocautery, which is known that leads to the formation of ischaemic areas and therefore predisposing to adhesion formation. The use of CO2 for pnemoperitoneum may lead to adhesion formation, since its use is associated with reduction in tissue oxygenation, acidosis and release ofreactive oxygen species, which are considered adhesiogenic. Therefore, the addition of oxygen, the heating of the insufflatedCO2 or the alternative use of other gases (i.e. helium) may be beneficial in terms of reduction of de novo adhesion formation. At the end of each operation an «underwater» examination should be used in order to document complete intra-peritoneal hemostasis, since it has been clearly demonstrated that incomplete hemostasis is associated with adhesion formation.
Finally, several anti-adhesive agents are used during laparoscopic intrventions, in order to minimizepostoperative adhesions. These fall into two main categories, which include pharmacological agents and barrier methods. Limited data support the use of the former, either locally or systemically. Barriers, which mechanically separate the opposed serosal surfaces and exert their beneficial action, at least partly, because they remain in place beyond the critical 3-day point, at which competition of fibrinolytic activityandfibrosis will lead to adhesion formation. The tissue separation can be achieved either by the use of solid (films or gel) or fluid barriers. The clinical effectiveness of several of these agents has been thoroughly evaluated in two recent Cochrane reviews by Metwally et al [26] and Ahmad et al [51].
The term stress in plants is defined as the environmental constraint that leads to the inhibition of morphological, physiological, and biochemical functioning of plants adversely affecting their growth and development [1, 2, 3, 4]. The stresses may be biotic (pest, diseases, weed, etc.) or abiotic (soil salinity, radiation, water lodging, drought, extreme temperature, organic and inorganic pollutants, etc.) [4, 5, 6, 7, 8, 9, 10, 11, 12] that may act alone or in combinations, limiting the productivity of crops and food security worldwide. Salt-affected soils (SAS) cause greatest environmental abiotic stresses to plants [13, 14, 15] and cover more than 20% of the cultivated lands throughout the world [16, 17].
Salt-affected soils are grouped into saline, sodic, and saline-sodic and exhibit stresses to plants differently through various mechanisms. The principle mechanisms of salt stress in plants include osmotic effect, ionic toxicity, and nutritional imbalances [4, 15]. The increase in the uptake of Na and Cl caused by the salt constraint is attributed to the reduction in N and P concentrations that may be due to the antagonistic relations of Na and Cl with ammonium (NH4+), nitrate (NO3−), and phosphate (H2PO4−) [18, 19]. The salt stress adversely affects plant growth by inhibiting various steps of N metabolism such as uptake, assimilation, and amino acid and protein synthesis [20]. High concentrations of Na ions at the root surface have detrimental effects on the uptake of K [21]. Because of the similar chemical nature of Na and K ions, Na has an adverse effect on K uptake by the root specifically through high-affinity potassium transporters (HKTs) and nonselective cation channels (NSCCs) [22, 23]. Similar to K, the uptake and transport of Ca and Mg can also be adversely affected by the high concentrations of Na commonly found in saline soils, resulting in lower Ca:Na and Mg:Na ratios in plants [24]. The concentration of micronutrients in plants may be increased, decreased, or remain unaffected under salt stress depending on the plant type, tolerance of plants to salinity, macro- and micronutrient concentrations in soil, pH of the soil solution, the adsorption phenomena on the surface complexes of mineral and organic particles, and different environmental conditions [1, 25].
The approaches for the management of SAS include removal of salts from the root zone through leaching, incorporation of organic and inorganic amendments, mulching, maintaining groundwater table, and cultivating crops tolerant to salt stress [26, 27]. In salt-affected areas, different methods are applied to remove excess soluble salts from the root zone of plants to improve crop growth and production. Scraping, flushing, and leaching are most commonly used, but these methods are found to be very expensive [28]. The application of organic amendments is effectively being practiced to ameliorate physical, chemical, and microbial complications associated with SAS. Organic amendments help to flocculate mineral particles to organic polymers because of their bonding or adhesion properties [29], resulting in a good structural stability, which is a precondition to maintain an appropriate soil structure. The application of organic matter to SAS can improve the aggregate stability and porosity, resulting in increased Na leaching and decreased exchangeable sodium percentage (ESP) and electrical conductivity (EC) values [30]. Several studies reported a significant increase in the soil microbial and enzymatic activities in SAS as a result of organic matter incorporation [31, 32, 33]. Salt-affected areas are increasing globally with the intervention of human activities and natural events. With the increase in salt-affected areas and population worldwide, the net cultivable land is decreasing, pushing enormous pressure on food security. It is pertinent to study how SAS harms plant growth and productivity as well as the strategies to ameliorate SAS by improving their physical, chemical, and biological conditions for the sustainable production of crops. Therefore, this chapter is arranged by compiling the existing knowledge in the literature in such a way that will demonstrate plant responses to salt stress, especially the uptake and accumulation of essential nutrient elements. Besides, different approaches that can be practiced for the amelioration of SAS have been discussed with the aim to improve soil health and boost up crop production in sustainable ways for ensuring food security worldwide.
Understanding the differences in properties among SAS is important for proper reclamation and management. Salt-affected soils are categorized into saline, sodic, and saline-sodic groups based on the amount of total soluble salts (TSS) (measured by EC), sodium adsorption ratio (SAR; the ratio of Na+ to Ca2+ and Mg2+ on the exchange sites of soil), exchangeable sodium percentage [ESP; the relative amount of the Na+ ion expressed as a percentage (%) to the cation exchange capacity (CEC) or the sum of exchangeable bases], and soil pH. Based on these criteria, the classification of SAS is given in Table 1.
Types of SAS | pH | EC (dS/m) | SAR | ESP | Major cations and anions and their relative concentrations |
---|---|---|---|---|---|
Saline | <8.5 | >4.0 | <13 | <15 | Cl− > SO42− > HCO3− > CO32− Na+ > Ca2+ + g2+ > K+ |
Saline-sodic | <8.5 | >4.0 | >13 | >15 | High content of Na+ on exchange sites as well as in soil solution |
Sodic | <8.5 | >4.0 | >13 | >15 | High Na+ on exchange site of soil particles with little amount in soil solution |
Classes of SAS.
The pH of sodic soils is usually greater than 8.5, which may rise as high as 10.5. The high pH of sodic soils may be due to a greater extent of hydrolysis of exchangeable Na compared to more strongly held ions such as Ca and Mg. Upon hydrolysis, exchangeable Na contributes to high soil pH according to the following phenomenon [26]:
The increase in the concentration of OH− ion contributes to the increase in soil pH. The limited hydrolysis of CaCO3 and MgCO3 causes low solubility of these salts, resulting in soil pH no higher than 8.5, while soils containing Na2CO3 have a pH of more than 8.5 or even 10 to 10.5 due to their higher solubility [26, 34, 35].
The processes by which saline soils are formed are known as salinization, whereas the processes that are responsible for the formation of sodic soils are called as sodification. The causes of salinization and sodification are multifactorial, and one factor that affects the salinization and/or sodification may influence the others [36]. Soil salinization and sodification are interrelated with such factors as soil characteristics; the amount and composition of salts in the soil; and the quantity, quality, and methods of irrigation [37]. Salt-affected soils are formed either by natural processes or anthropogenic activities. Natural processes are known as primary salinization/sodification, whereas human-induced processes are known as secondary salinization/sodification [38]. The main sources of soluble salts under natural and anthropogenic factors involving the development of SAS are summarized in Figure 1.
Natural and anthropogenic sources of salts in soils.
Soil salinity and sodicity have contributed to the changes in land use/land cover features over the years, which are directly related to land degradation and results in many changes in the environment [39]. More than 20% of the total agricultural lands are affected by high salinity [38, 40, 41, 42], which accounts for more than 7% of the world’s total land area [23, 43]. It has been reported that the majority of the SAS occur mainly in the arid and semiarid regions of Asia, Australia, and South America, covering an estimated 1 billion ha [36]. Data summarized from Abrol et al. [34] and Szabolcs [44] give an account that globally about 932 million ha areas are occupied by SAS. There are sporadic studies on the estimates in the global distribution of salt-affected areas in recent years. For the establishment of better management strategies of SAS, it is important to identify their extent and distribution in systematic ways. However, different countries assess the extent and severity of their SAS at national levels.
Soil salinity can be determined by measuring either the total soluble salts (TSS) by evaporation of a soil-water extract or by determining the EC of a soil-water suspension. In the laboratory, EC as an indicator of soil salinity can be measured by analyzing the soil suspension either in a 1:5 soil:distilled water dilution (EC1:5) or in a saturated paste extract (ECe). The measurement of EC1:5 is most commonly employed from an unfiltered 1:5 soil-water suspension prepared by taking a unit of 2-mm sieved soil (usually, 5 g) and 5 units of distilled water (25 ml). The suspension is shaken for 30 min to dissolve the soluble salts and left for 15 min to settle down the soil particles, followed by the EC measurement using EC meter after necessary calibration [45].
Though all soils invariably contain soluble salts, under saline and sodic conditions, excess salts in the root zone deteriorate the physical, chemical, and biological properties of soils to such an extent that the crop growth is adversely affected [46]. The adverse effects of salinity on plant growth depend on plant factors such as growth stage, species, and variety; soil factors such as temperature and moisture, degree of salinity, and presence of heavy metals; and environmental factors such as growing season, temperature, humidity, light, pollutants in the atmosphere, etc. [47, 48, 49, 50, 51, 52]. Based on the degree of salinity and associated effects on the plant growth, the saline soils can be classified from nonsaline to very strongly saline (Table 2).
Classes of saline soils | ECe (dS/m) | Salinity effects on plant | Yield loss (%) |
---|---|---|---|
Nonsaline | 0–2 | Salt effects are negligible | 0 |
Slightly saline | 2–4 | Yields of only sensitive crops may be restricted, and the yields of most of the crops are not likely to be affected | 20–30 |
Moderately saline | 4–8 | The yields of most of the crops are likely to be hampered | 30–60 |
Strongly saline | 8–16 | Most of the crops are likely to be affected, while the yields of only tolerant crops are satisfactorily | 60–100 |
Very strongly saline | >16 | Only limited tolerant plants can sustain | 100 |
Soil salinity classes and associated effects on plants.
Adapted and modified from Shin et al. [53].
The mechanisms of how the SAS distress plant growth are shown in Figure 2. Under saline environment, the inhibition of growth is mainly induced by the physiological and biochemical disturbances resulting from osmotic stress; changes in the uptake of mineral nutrients such as N, P, K, Ca, and Mg; and specific ion toxicities such as Na and Cl [54, 55, 56, 57]. Plants containing approximately 0.25–0.5% Na in leaf tissues on dry weight basis may exhibit toxicity symptoms such as necrosis and burns of leaf edges [1, 58]. When the salt concentration in the soil is equal to that of the plant, there is no net movement of water. But when the salt concentration in the soil solution is greater than that of the plant, water moves from the plant into the soil causing physiological drought [59, 60]. To counteract the low osmotic potential of the soil solution, plants accumulate organic and inorganic solutes to reduce the osmotic potential inside the cell. Maintenance of such osmotic adjustment requires a considerable expenditure of energy, resulting in reduced growth [35]. Besides direct effects of SAS through osmotic stress and nutritional imbalances, the growth of plants may be adversely affected by a high content of exchangeable Na relative to Ca and Mg on soil particles which leads to the breakdown of soil structure, resulting in decreased porosity, permeability, hydraulic conductivity, and aeration in the vicinity of plant root [35, 41].
Mechanism of salt stress in plants.
The adverse effects of salts are first expressed by the inhibition of growth and other physiological symptoms. Salt stress has been found to negatively affect the biomass of cabbage, Brassica oleracea [19]; cotton, Gossypium hirsutum [61]; Jerusalem artichoke, Helianthus tuberosus [62]; pistachio, Pistacia vera [63]; poacea, Catapodium rigidum [15]; rice, Oryza sativa [64]; saltmarsh grass, Spartina alterniflora [65]; strawberry, Fragaria ananassa [66]; tomato, Lycopersicon esculentum [64]; and wheat, Triticum aestivum [67].
The capacity of roots to transport nutrients and water to shoots is restricted due to abiotic stress, adversely affecting the functional balance between roots and shoots, which results in lower shoot:root ratio [68]. The leaves of plants are the most sensitive organs and greatly affected, while the roots are reasonably less affected when exposed to high salinity [69]. However, all plants do not respond to salinity to the same extent. Different crops exhibit a broad spectrum of responses to salt stress.
Though the most common cations found in SAS are Na+, Ca2+, and Mg2+, accompanied by anions Cl−, SO42−, and HCO3−, these soils are mainly dominated by Na+ and Cl− [35, 45, 70]. Nitrogen, P, K, Ca, and Mg play important physiological functions in plants, and their replacement by Na and Cl may lead to nutritional imbalances [47]. For the optimum growth and yield of crops, an adequate and balanced supply of mineral nutrients is essential [42]. High contents of Na and Cl in the rhizosphere can interfere with the uptake of essential elements, leading to their deficiencies or imbalances [71, 72] through the processes of fixation, adsorption, and transformation in soil [18]. The effects of high concentrations of Na and Cl on the uptake of essential elements by plants are outlined in the following subsections.
Nitrogen is a major constituent of the nucleotides and proteins of all micro-and macroorganisms [9, 73]. It is considered as one of the limiting factors and is required in large quantities compared to other essential nutrients for the growth, yield, and quality of crops [74, 75, 76, 77]. In general, the total N content in the plow layer of mineral soils ranges from 0.05 to 0.2% corresponding to approximately 1750 to 7000 kg N/ha, and in plants, it ranges from 1 to 4% on dry matter basis [77]. Nitrogen rarely exists in the lithosphere in rock deposits, and more than 90% of the total N comes from the soil organic matter [35]. It is principally taken up by plants in the forms of NO3− and NH4+ [61]. As a consequence of high salinity, the uptake and assimilation of NH4+ and NO3− are inhabited by excessive concentrations of Na and Cl. The uptake of other essential nutrients may be disturbed due to the inhibition of N metabolism as the presence of N in the growth medium stimulates the uptake and assimilation of other essential nutrients [77]. Decreases in N uptake may be a physiological response of plants under salt stress [78].
Salt stress was found to strongly inhibit the uptake and accumulation of N in different plant parts of green chireta, Andrographis paniculata [14]; cabbage, Brassica oleracea [19]; canola, Brassica napus [78]; cotton, Gossypium hirsutum [61]; gray poplar, Populus × canescens [20]; saltmarsh grass, Spartina alterniflora [65]; sesame, Sesamum indicum [79]; and wheat, Triticum aestivum [67]. However, the uptake and accumulation of N in response to salt stress depend on different plant and soil factors [80]. Kanagaraj and Desingh [79] observed variations in foliar N among different varieties of sesame, where the maximum reduction was found at the highest dose of NaCl.
The decline in the uptake of N by plants could be due to the increased uptake and accumulation of Cl. The antagonistic relationship between the uptake of NO3− and Cl− was found in rice, Oryza sativa [64]; cabbage, Brassica oleracea [19]; and barley, Hordeum vulgare [81, 82]. High soil salinity was found to increase the concentration of Cl in the different plant parts of cotton, Gossypium hirsutum [47]; cowpea, Vigna unguiculata [72]; and poacea, Catapodium rigidum [15]. However, the accumulation of Cl is regulated by the duration of salt stress as well as the phase of the plant life cycle [83]. As a consequence of high salinity, the uptake of NH4+ can also be reduced. It was observed that the decreased uptake of NH4+ in plants was accompanied by an increased Na+:NH4+ ratio in the growth medium [20].
Several studies reported inhibited accumulation of nutrients with decreasing water uptake under salt stress [15, 64]. The effect of salt stress on N metabolism varies depending on the forms of N applied [20]. Botella et al. [67] reported that the increased concentration of NaCl in the root medium decreased the net uptake of N more profoundly in NO3− compared to the NH4+ form when their compounds were incorporated as the source of N, which was assumed to be a reason for the greater affinity for NH4+ compared to NO3− under the saline environment. Similarly, Saud et al. [84] found higher N content, N isotope abundance, and relative water content in both roots and leaves of Kentucky bluegrass, Poa pratensis, in 15NH4+ compared to the 15NO3 treatment under abiotic stress. By contrast, Dluzniewska et al. [20] observed that the net uptake of NH4+ decreased in poplars when exposed to increased NaCl concentrations, resulting in decreased whole-plant N content in comparison to control. Hofman and Cleemput [77] stated that NH4+ is more preferably taken up by plants in comparison to other forms as it does not require to be reduced before incorporation into plant compounds. On the other hand, Dai et al. [61] found better root growth and low Na content in NO3-fed compared to NH4-fed cotton seedlings, and they reported the superiority of NO3-N relative to the NH4-N source in the uptake of N under salt stress. The high salt content in soil may also interrupt the synthesis of protein in plants. Chakraborty et al. [85] observed that the uptake of N of the Brassica spp. decreased due to the high salt content, which reflected in the low protein levels in seeds. The physiological drought of plants, which is caused by the low osmotic potential of soil solution, is attributed to the reduced metabolism of N [18] that may result in the low protein content under saline condition.
Phosphorus is the second most essential nutrient requiring 0.3–0.5% of the dry matter for the optimal growth of plants [86]. It is an integral part of nucleic acids and membrane lipids [73]. In contrast to N, the main sources of P in the lithosphere are the rock deposits [77]. Phosphorus exists in the soil solution as orthophosphate ions such as H2PO4−, HPO42−, and PO43− [87] and plants take up P from the soil solution in the form of H2PO4− and HPO42−, although H2PO4− is taken up to a greater extent [88, 89]. Exposure to high salinity resulted in significant decrease in P levels in green chireta, Andrographis paniculata [14]; cabbage, Brassica oleracea [19]; canola, Brassica napus [78]; pistachio, Pistacia vera [63]; saltmarsh grass, Spartina alterniflora [65]; and spinach, Ipomoea aquatica [90]. The salt stress had been found to magnify the adverse effects on the uptake of P by plants in several studies when plants were exposed simultaneously to both salinity and drought [19, 65]. The reduction in P concentration under high salinity may be due to the competition between H2PO4− and Cl− ions [18]. The accumulation of P in plants exposed to salt stress varies with the plant organs. Silva et al. [72] found a greater P content in leaves compared to roots. Conversely, Shahriaripour et al. [63] reported that the translocation of P from root to shoot was inhibited under a high saline environment.
The evidence of increased P under high salinity had also been reported in several studies. The presence of NaCl in nutrient solution resulted in an increased concentration of P content in leaves [72, 83]. Zribi et al. [15], however, demonstrated that salinity had no significant effect on both P concentration and acquisition efficiency (PAE), and they also found a higher concentration of Cl in the shoot when subjected to both salt stress and P treatment compared to salt stress only.
The uptake of P by plants under salt stress is influenced by the plant species, plant stage, degree and extent of stress, temperature, moisture, soil pH, and the prevailing soil P level [55, 83, 89]. The solubility of P may also be influenced by strong sorption-desorption processes with divalent cations such as Ca2+, Mg2+, and Fe3+ at different pH ranges because of their high sorption capacity regulating the uptake by plants [5, 87, 91].
Potassium is an important and abundant mineral nutrient that comprises 2.6% of the earth’s crust [92] and 1–10% of the plant tissue on a dry weight basis [92, 93]. It contributes to important physiological, biochemical, and biophysical roles such as photosynthesis, osmotic adjustment, and turgor maintenance [94, 95], regulating the growth and development of plants. The concentration of K in the growth medium determines the net uptake of K [13]. The seldom deficiency of K in most soils is believed due to comparatively high concentration and greater mobility [96, 97]. However, in the condition of salt stress, the plants may suffer from K deficiency as a result of Na toxicity. Both Na and K are monovalent cations with similar physicochemical properties. The hydrated ion radius of Na ion is 0.358 nm, while that of K ion is 0.331 nm [23]. Due to similar ionic radius and cationic competition for entry into the plant cells, high concentrations of Na can adversely affect the uptake and accumulation of K in plants.
Salt-affected soils led to a significant influence on K in plant tissues, either increasing or decreasing its concentration. The reduction in K content in plant tissues is one of the primary responses of plants to high Na, which ultimately causes nutrient imbalances [98]. High salt stress with increased concentrations of NaCl was found to decrease the total K and cause an increase in the Na content in Aloe vera, Aloe vera [99]; barley, Hordeum vulgare [100]; bean, Phaseolus vulgaris and P. acutifolius [54]; cabbage, Brassica oleracea [19]; cotton, Gossypium hirsutum [47]; green chireta, Andrographis paniculata [14]; maize, Zea mays [101]; pistachio, Pistacia vera [63]; poacea, Catapodium rigidum [15]; rice, Oryza sativa [102]; saltmarsh grass, Spartina alterniflora [65]; strawberry, Fragaria ananassa [66]; and tomato, Lycopersicon esculentum [13, 103, 104]. A positive relation of salt-tolerance capacity with Na and a negative relationship with that of K was found in saltbush, Atriplex canescens [105]. Besides, there is evidence that both the contents of Na and K in plants increased with the increase of salinity. The concentrations of Na and K in the above-ground and below-ground portions of Jerusalem artichoke, Helianthus tuberosus, were found to increase with the increasing amount of seawater application in a greenhouse experiment [62]. Similarly, the concentrations of Na and K in the leaves of cowpea, Vigna unguiculata, increased in salt-stressed condition and the responses differed depending on the duration of stress and leaf age [83]. Al-karaki [13] found higher translocation of K from root to shoot in tomato plants to a greater extent in the saline environment in comparison to nonsaline conditions, with the increase of K concentration in medium.
The higher concentration of Na restricts the transport of K by impairing the route AKT1 (hyperpolarization-activated inward-rectifying K channel) used for the uptake of K and, in this way, reduce the uptake of K [106]. The inhibitory effect of Na on the transport of K through channels in the membranes is probably more important in the phase of uptake of K from the soil solution than in the phase of K transport to the xylem [107]. Besides, the inhibitory effect of Na on K translocation depends on the concentration of K in solution. The effect is lower with low Na and high K levels in the medium [13, 108, 109]. However, the effects of Na on the uptake and accumulation of K can vary among species and even between varieties within such same species of Aloe vera, Aloe vera [99]; bean, Phaseolus vulgaris [110]; cotton, Gossypium hirsutum [111]; green chireta, Andrographis paniculata [14]; mustard, Brassica nigra [112]; tomato, Lycopersicon esculentum [104, 113]; and wheat, Triticum aestivum [109]. Salt-tolerant species were found to maintain a high concentration of K and low concentration of Na. High concentration of K and low concentration of Na in plants under saline environment can be considered as a good indicator for salinity tolerance [114]. The plant parts also differently respond to salt stress. Generally, a higher concentration of Na in roots relative to leaves in various plant species was explained by the high tolerance in roots in addition to reduced translocation of Na from root to leaf [1]. Different authors reported lower content of K as a result of salt stress to a greater extent in stems in comparison to leaves and roots [99, 110]. A high concentration of K in leaves is important to maintain constant photosynthesis and leaf stomatal conductance [54].
Calcium is the fifth most plentiful element, whereas Na is the sixth most abundant element comprising, respectively, about 3 and 2.6% of the earth’s crust. Because of the greater charge density of Ca2+ compared to Na+, it attracts more water, resulting in a greater hydrated ionic radius of 0.44 nm [48]. Calcium is an essential inorganic nutrient and plays a vital role in maintaining the structural and functional integrity of cell wall and membrane because of its ability to form intermolecular linkages [98, 113]. Considering the importance of external Ca in enduring K transport and K:Na selectivity in plants under Na stress condition, a large number of research was carried out on Na:Ca interactions. The deficiency of Ca in plants is a common indication of Na toxicity [115]. The Na:Ca ratio of plants is a good indication used to express the extent to which a plant can survive under salt stress [69]. A high concentration of Na can decrease the uptake of Ca and Mg by inhabiting their influx through roots, decreasing the extracellular binding sites of Ca and Mg in the plasma membranes [69, 116], decreasing the osmotic potential [19] under saline condition.
Increased level of Na was found to significantly decrease the concentrations of Ca and Mg in saltmarsh grass, Spartina alterniflora [65]. Significant negative correlations were also found between salt stress and the contents of Ca and Mg, where the ratios of Ca:Na and Mg:Na in the leaves and roots of cabbage, Brassica oleracea, decreased with the increasing salinity levels [19]. Similar results were reported by other authors where the salt stress resulted in an increased accumulation of Na and Cl and decreased the contents of Ca and Mg in plants [18, 117]. On the other hand, Chen et al. [47] found both higher Na and Ca in cotton leaf with increasing salt stress. Rahimi and Biglarifard [66] observed that the Ca and Mg concentrations decreased in the shoot and increased in the root of strawberry, Fragaria ananassa, with the increase in salinity. There were evidences from several studies that the supplemental addition of Ca increased the concentration of Ca in rapeseed, Brassica napus [114], and in tomato, Lycopersicon esculentum [113] under high salinity levels. However, the effects of salinity had been found more detrimental in conditions having different levels of drought stress [19, 65, 118].
The influx of Ca and Mg in the root and transport to the shoot can vary with the amount of Na as well as genotypes. The uptake of Ca had been found to be higher in a salt-sensitive variety of wheat, Triticum aestivum, at a low level of Na and the transport became lower as the concentration increased [115]. Furthermore, tolerant varieties of green chireta, Andrographis paniculata, contained high concentrations of Ca and Mg and low concentration of Na in comparison to sensitive accessions under high salinity [14].
Micronutrients are involved in various important physiological and biochemical functioning of plants, including enzyme activation, chlorophyll formation, protein synthesis, carbohydrates, and lipids and nucleic acids metabolism [119]. Different authors reported differently in the uptake and accumulation of micronutrients such as Fe, Mn, Zn, and Cu in salt-stressed condition. Though the exact mechanism in the literature is scarce, different soil, plant, and environmental factors are believed to influence the uptake and accumulation of micronutrients in different plant parts under salt stress. The response of micronutrient concentrations in plants under salt stress was found to be variable in previous studies. The plants grown in saline soils often showed the deficiency of micronutrients such as Fe, Zn, Mn, and Cu, which was assumed to be the result of their low solubility and availability [120]. A negative relationship was found between the salt content and Cu, Mn, and Fe concentration in tissues of Avicennia marina (Forssk.) Vierh [49]. Chakraborty et al. [85] found a reduced accumulation of Fe, Mn, and Zn in different parts of Brassica spp. at the flowering and post-flowering stages when exposed to high salt concentration. Similarly, salt stress had been found to decrease the concentrations of Fe and Zn in the roots and leaves of cabbage, Brassica oleracea [19]. On the other hand, the concentrations of Fe, Zn, and Cu in green chireta, Andrographis paniculata, significantly increased though the Mn content decreased under high salinity [14]. The concentrations of Fe, Mn, and Zn increased in the above-ground part of strawberry, Fragaria ananassa, while their contents did not change in the root when plants were exposed to salt stress. On the other hand, while Cu content did not change in the aerial part, the concentration increased in the root as a result of salt stress [121]. Significant reduction in the Fe content in both root and shoot of strawberry was observed, while Zn, Cu, and Mn concentrations remained unaffected under salt stress [66]. The change in concentrations of Fe, Zn, and Mn was not found as a limiting factor for the growth of wheat, Triticum aestivum, and their contents in plants were not much affected by salt stress [25]. The response of micronutrient concentrations under salt stress differed among varieties in green chireta, Andrographis paniculata [14]; Brassica spp. [85]; and strawberry, Fragaria ananassa [121].
To make SAS productive, integrative soil, water and agronomic reclamation, and management approaches can be practiced. Saline and sodic soils differ in their reclamation and management practices because of their unlike complications. The problem of saline soils is mainly oriented with high soluble salt content, whereas sodic soils are associated with high exchangeable Na. The suitability of approaches depends on such considerations as cost of reclamation, the time required, the extent of the salinity or sodicity problem, soil properties, availability of technology, and other environmental factors [26]. This section will mainly focus on the existing information in the literature on various aspects, including the effectiveness and downsides of the leaching approach for removing salts as well as the application of organic and inorganic amendments as ameliorative for the restoration of SAS.
Removing salts from the root zone is the first requirement to restore productivity of saline areas. However, saline-sodic and sodic soils cannot be reclaimed only by the leaching approach. Thus, to improve the growth and yield performance of crops in saline soils, the harmful concentration of salts must first be washed out from the root zone, which can be achieved by leaching, the most effective procedure for removing excess soluble salts. The efficiency of leaching to remove the salts from the soil profile depends on such factors as the initial salt content, nature of soluble salts, desired EC of soil after leaching, properties of soil, quality of water to be used for leaching, etc. [34]. The key to leaching of soluble salts is to provide an appropriate amount of water at the proper time with adequate drainage. A reliable estimate of the favorable soil moisture content is essential to alleviate the harmful effects of salinity by leaching. In general, depth of water equal to the depth of soil removes 70–80% of the soluble salts for continuous ponding, that is, 15 cm of water is required to reduce the salt content by 70–80% in the upper 15 cm of soil. However, as continuous ponding leads to reduced soil aeration and quick loss of water in coarse-textured soils, intermediate ponding or sprinkler irrigation is preferred for more efficient leaching of salts through increasing contact time of salts with water [122]. On the other hand, prolonged drying may increase the concentration of salts in soil solution, resulting in lower osmotic potential of the soil solution. Due to high permeability and less workability, a large volume of water can be leached over a shorter period in coarse-textured soils. Fine-textured soils having high CEC and organic matter require more water to remove the salts from the soil profile [123]. The desalinization of soils through leaching also depends upon the drainage condition of the soil. The application of leaching with surface drainage at shallow groundwater levels may further exacerbate salinity problems, while the subsurface drainage can sustain the groundwater depth and prevent additional salinization [124]. The role of organic amendments on the reclamation of SAS through improvements in physical properties found in the literature has been presented later in the organic amendment section. Soils having a good structure and internal drainage favor the leaching process [125]. Therefore, a judicious application of water having proper drainage at the right time is important to prevent irrigated lands from becoming saline. The leaching process is accomplished by either natural precipitation and/or artificial irrigation water containing minimum salt content and allowing the water to drain out. The salinity problem of the agricultural land may become worse if saline water is used for leaching purpose because of considerable quantities of such cations as Na+, Ca2+, Mg2+, and K+ and such anions as Cl−, HCO3−, and SO42− in saline water [126, 127].
Appropriate nutritional management is often considered feasible and cost-effective, which can lead to the better performance of plants grown in contrasting environments by reducing the adverse effects [128, 129, 130]. The application of organic manures as amendments to reclaim SAS is considered highly sustainable and commonly practiced over the last few years [29, 131]. Due to the high cost and quick release of nutrients involved in chemical fertilizers, the application of organic amendments as the substitute of chemical fertilizers or in a combination with chemical fertilizer has gained worldwide acceptance from the farmers [132]. Besides, the extensive application of inorganic fertilizer contributes to groundwater pollution due to leaching loss, and the global climate change is caused due to the emission of potent greenhouse gas such as nitrous oxide from agricultural lands [133, 134]. Though inorganic fertilizers provides easily available nutrients for plant, these are quickly lost from the soil. On the other hand, organic manures contribute to the physical and biological improvements of soil with a gradual release of nutrients. The incorporation of organic manures along with the chemical fertilizers is considered as an effective and sustainable approach for enhancing the resistance of crops to abiotic stress [135, 136, 137, 138]. Different sources of organic materials originating from plant and animal residues such as green manure, cattle manure, poultry manure, food processing wastes, etc. are used to augment the organic matter content and nutrient status. The role of organic amendments on physical, chemical, and biological properties of soils having salinity and sodicity problems is shown in Table 3.
Sources of organic amendments | Rate | Soil condition (pH, EC, and ESP/SAR) | Effects on soil properties | Reference |
---|---|---|---|---|
Farmyard manure, and sewage sludge | 5 and 10 t/ha | Different sites having variable PH and EC | Decreased bulk density, increased available water and hydraulic conductivity, decrease in pH, and increased organic matter and available macronutrients | [139] |
Biochar, green waste compost (GWC), and municipal sewage sludge | 1.0, 2.5 and 5.0% | pH: 4.04 EC1:10: 4.91 ESP: 67.62 | Increase in pH, total organic carbon, and CEC; decrease in EC, ESP, and SAR; and increase in catalase activity and acid-and alkaline phosphatase activity | [140] |
Vermicompost and compost | 5 and 10 Mg/ha | pH: 7.3 ECe: 4.26 | Decrease in pH and EC, exchangeable Na+; increase in organic carbon, CEC, exchangeable K+, Ca2+ and Mg2+; and increased microbial C and N, and basal soil respiration | [32] |
Municipal solid waste and palm waste | 50, 100, and 150 t/ha | pH: 7.97 ECe: 5.13 | Increased organic carbon and N; increased microbial biomass and enzymatic activities | [141] |
Cow dung, and paddy husk | 1 g/kg | pH: 7.86 ECe: 24.35 SAR: 26.53 | Decreased bulk density; decreased EC and SAR; and increased exchangeable Ca2+ | [142] |
Cotton gin crushed compost and poultry manure | 5 and 10 t/ha | pH: 8.0 EC1:5: 9.1 ESP: 15.7 | Decreased bulk density and ESP; increased soil microbial biomass, respiration, carbohydrate, and enzymatic activities | [33] |
Green waste compost (GWC), sedge peat (SP), furfural residue (FR), and a mixture of GWC, SP, and FR (GSF) (1:1:1 by volume). | 4.5 kg/m3 | pH: 7.75 EC1:5: 3.69 ESP: 15.8 | Decreased bulk density; increased total porosity; increased CEC, organic carbon, and available nutrients (N, P, and K); and decreased EC and ESP | [30] |
Cattle dung, vermicompost, biofertilizer, and their combinations | 1.8, 3.7, and 5 t/ha | pH: 7.39 EC1:5: 7.44 | Decreased EC; increased organic matter and available nutrients; and increased microbial biomass carbon | [143] |
Pig manure, cattle dung, chicken manure, rapeseed meal, and biochar | 50 g/kg | pH: 8.29 EC1:5: 19.35 ESP: 67.62 | Decrease in pH; increase in organic carbon, K, Ca, and Mg; and increased enzyme activities such as catalase, urease, alkaline phosphatase, and saccharase | [144] |
Poultry manure, commercially available organic fertilizer, reed straw, and fresh reed straw with green leaves | 15 g/kg | pH: 8.44 EC1:5: 11.61 | Decreased bulk density; increased available N, water-soluble organic carbon; decreased SAR; and increased soil respiration | [145] |
Straw, composted straw, fresh reed, and chicken manure | 15 g/kg | pH: 7.82 EC1:5: 6.59 ESP: 36.17 | Decreased pH, ESP; increased organic carbon, CEC, macronutrient concentration; and increased soil respiration | [146] |
Effects of organic amendments on the physical, chemical, and biological properties of SAS.
Organic amendments have profound influences on soil’s physical properties. Several studies revealed that the application of organic manures decreased the bulk density [33, 147, 148, 149] and penetration resistance [149], whereas it increased the aggregate stability [150, 151, 152], total porosity [152, 153], hydraulic conductivity, and permeability [150, 154]. Soil organic matter is an important attribute of soil quality and aggregate stability, which is influenced by the inherent properties of soil such as soil type and texture [155, 156] as well as agronomic factors such as management, inputs, and nature of the organic matter [157]. Improvement in the aggregate stability is related to increased soil porosity and decreased bulk density. As a consequence of good aggregation with a concomitant increase in porosity and decrease in bulk density, soil water infiltration is facilitated causing the soluble salts to leach down, and an adequate oxygen supply is maintained in the root zone which is necessary for crop production in SAS.
The incorporation of organic amendments had also been found to improve chemical properties such as decrease in pH [27, 147, 158, 159], EC [27, 158, 160], ESP [33, 158], and SAR [27], while there is an increase in the soil organic matter [153, 161], organic carbon [132, 147, 151, 152, 159, 162, 163, 164], CEC [152, 162], total nutrients [32, 151, 161], and available nutrients [32, 132, 147, 149, 153, 159, 162, 164, 165].
The decline in soil pH resulting from the incorporation of organic amendments reported in several studies can be explained by the acidic nature of the amendments. Microbial activities resulting from the incorporation of organic materials release carbon dioxide that reacts with water to form carbonic acid, and thus contribute to lowering of the soil pH [166]. The pH of soils was also found to be increased by the addition of organic amendments in several studies [30, 33, 141, 143, 167]. Roy and Kashem [132] found that the addition of organic amendments slightly increased the soil pH initially which thereafter declined significantly with time. However, the change in pH with the addition of organic amendments depends on the initial pH of the original soil, nature of organic materials, and rate of organic matter application [32, 141]. The increase in pH is explained by the mineralization of carbon (C) and the subsequent production of OH− ions by ligand exchange and release of such basic ions such as K, Ca, and Mg [167]. The decrease in EC due to the application of organic amendments might be a result of Na displacement from the exchange sites and washing out with soluble salts through the leaching process. Organic amendments substantially contain Ca, Mg, and K [30, 131]. The presence of Ca can contribute to the low ESP of SAS due to increased exchange of Na by Ca at the cation exchange sites of soil particles, allowing greater leaching of exchanged Na with percolating water [32, 168]. Moreover, the presence of soluble and exchangeable K can limit the entry of Na into the exchange complex due to a similar ionic balance resulting in lower ESP [169]. Furthermore, Ca improves the aggregation of soil by cationic bridges between the soil organic matter and clay particles, and thus increases the soil porosity. The greater the total porosity, the greater the leaching of the soluble and exchangeable Na ions, and the greater the subsequent reduction in soil sodicity and salinity as expressed by the ESP and EC values, respectively [30]. Salt adsorbing ability of organic amendments is also known to be considered in lowering the EC of soils [140]. The incorporation of different organic amendments in soils had often contributed to a slight increase in EC depending on the rate and duration of incorporation [139, 146]. The increase in EC after the application of organic manures could be attributed to the presence of high amounts of K and Ca [141]. The role of organic matter in increasing the CEC has already been established. Hue [170] reported the decrease in Na in soil solution due to greater CEC resulting from incorporation of organic matter. The removal of organic matter had also been found to increase the CEC of a specific soil, which could be due to the exposure of the permanent charge of the montmorillonitic clay that was blocked by the interaction of the organic matter with the clay [171].
Several studies reported a significant increase in the soil microbial and enzymatic activities as a result of organic matter incorporation. The incorporation of organic amendments resulted in enhanced enzymatic activities [31, 33, 140, 161, 164, 172], microbial biomass C [32, 143, 161, 164, 173], microbial biomass N [32, 161], soil microbial activity as expressed by basal respiration [32, 174], and nematode abundance [143]. However, the response of microbial and enzymatic activities to organic amendments differs depending on the kinds of amendments, rates of incorporation, the types of crops grown, etc. The rate of microbial respiration was found to be highest in poultry manure-amended soils compared to reed-, composted straw-, and straw-treated soils, and all the amended soils resulted in a rapid increase in respiration rate in the beginning of incorporation that decreased gradually with time [163]. Tejada et al. [33] also observed the highest soil microbial biomass C and cumulative C-CO2 in soils amended with a maximum dose of poultry manure that was 37% higher compared to cotton gin crushed compost-amended soils. Similarly, the urease, protease, b-glucosidase, phosphatase, arylsulfatase, and dehydrogenase activities were found to be increased by 34, 18, 37, 39, 40, and 30%, respectively, in poultry manure-amended soils compared to the cotton gin crushed compost-amended soils. In another study, Liang et al. [31] found that the urease activity increased by 62.3 and 117.4%, respectively, in pig manure- and rice straw plus pig manure-amended soils in comparison to rice straw treatment alone. The author also observed that the addition of rice straw, poultry manure, and their combination increased the urease activity by 21, 96, 163%, respectively, in rice, whereas by 57.4, 93.1, and 152.5%, respectively, in barley compared to the control. On the other hand, Zhang et al. [164] found dual effects where the application of vermicompost increased the activities of dehydrogenase, urease, and phosphatases by 37–68%, 22–107%, and 3.4–56%, respectively, while vermicompost addition decreased the activities of β-1,4-glucosidase and β-1,4-N-acetylglucosaminidase by 17–53% and 24–42%, respectively. Easily decomposable organic substances such as biosolids, swine manure, and chicken manure may likely be retained in the soil over short periods, resulting in an intense and short effect, while recalcitrant, lignin-rich amendments such as woody biomass have a smaller but long-lasting effect on these soil properties [131, 175].
Several studies reported the beneficial effects of phytohormones and plant growth-promoting rhizobacteria in modifying the physiological and metabolic responses of plants to salt stress, enhancing their tolerance as well as growth and yield [2, 176, 177, 178]. Egamberdieva [179] found that the indoleacetic acid producing bacterial strains significantly increased the seedling root growth of wheat up to 52% compared to control under conditions of soil salinity. However, in different studies, the morphological and physiological growth and yield attributes of crops were found to be increased under abiotic stress when several plant growth regulators were applied in combination compared to their single dose [180, 181].
The beneficial effects of the organic amendments on physical, chemical, and biological properties of SAS greatly influence the growth, nutrient uptake, and accumulation of plants under salt stress. The application of organic amendments in SAS is considered a useful and effective way to increase soil fertility and enhance crop growth [31, 157]. The application of organic amendments in SAS increased the biomass yield of alfalfa, Medicago sativa [182]; barley, Hordeum vulgare [31]; cotton, Gossypium hirsutum [143]; maize, Zea mays [32, 159, 183]; onion, Allium cepa [142]; rice, Oryza sativa [31, 153, 184]; seepweed, Suaeda salsa [185]; sweet fennel, Foeniculum vulgare [186]; tomato, Solanum lycopersicum [187]; and wheat, Triticum aestivum [139]. The quantitative and qualitative improvements in the growth and yield attributes of crops as affected by abiotic stresses in the presence of different additives might be due to the enhanced photosynthesis, cholorophyll contents, stomatal conductance, water-use efficiency, and synthesis of metabolites [137, 188, 189, 190, 191].
Organic manure incorporation into the SAS also increased the N, P, and K contents in rice, Oryza sativa, barley, Hordeum vulgare [31], and sweet fennel, Foeniculum vulgare [186]; K content in rice, Oryza sativa [184, 192]; and K and Ca contents in tomato, Solanum lycopersicum [187], while it decreased the Na uptake [31, 184, 186, 187]. Improved soil physical conditions, availability of macro- and micronutrients, and enhanced microbial activities in soil resulting from the incorporation of organic amendments lead to better growth and yield of crops under salt stress [30, 175]. Maintaining a high K:Na ratio as a result of organic manure incorporation is an important mechanism of plants to resist the harmful effects of salts and perform better growth [31, 186]. Decreased uptake of Na may be due to the action of organic matter which acts as salt-ion chelating agents detoxifying the toxic ions, especially Na and Cl [184]. The C:N ratio also determines the growth of plants by influencing the availability of nutrients, especially N. Incorporation of organic amendments having a lower C:N ratio attributes to higher N availability [147].
As saline soils are usually good in structure, removal of excess salts can be obtained merely by the leaching process, and in most cases, the application of inorganic amendments is unnecessary. However, in the case of saline-sodic and sodic soils, exchangeable Na must first be removed from the exchange sites of soil particles and then leached to wash out from the root zone. As sodic soils are characterized by poor soil structure and limited infiltration rate, in addition to organic materials, various inorganic amendments are used to improve the soil structure and facilitate the leaching process. The application of Ca containing salt especially gypsum along with the organic amendments in SAS, in order to replace exchangeable Na, improves the physical condition of the soil, facilitates leaching of salts, and increases crop yield, which has been previously been reported in several studies [142, 184]. The application of gypsum followed by leaching of soils enhanced the reclamation and decreased the salinity as well as the sodicity levels [193]. Khattak et al. [194] observed a decrease in the pH, EC, and SAR of leached soils and an increase in the yield of rice and wheat by 9.8–25.3% and 10–80%, respectively, in salt-affected soil as a result of gypsum application. Khosla et al. [195] reported that the use of additional quantities of water can be minimized by the application of gypsum to achieve a reduced SAR value to a greater extent. The amount of gypsum required to reclaim saline-sodic and sodic soils is based on the amount of exchangeable Na, soil texture, leaching rate, crop to be sown, solubility, and reaction rates of the amendments [34, 125]. Abdel-Fattah et al. [193] studied the effects of different size fractions of gypsum (<0.5, 0.5–1, and 1.0–2.0 mm) on the efficiency of the reclamation of SAS and found that the salinity and sodicity decreased with the increasing fineness of gypsum. Gypsum is usually required to spread uniformly in the field and is incorporated into the upper 10–15 cm of soil by 2–3 shallow plowings at least 10–15 days before planting [34].
Zeolite (CaAl2Si4O12·nH2O), an aluminosilicate, had also been studied as an inorganic amendment with the aims to reclaim SAS and enhance plant growth. Zeolite can enhance plant growth and nutrient uptake by mitigating salt stress. In an experiment, Al-Busaidi [196] studied 1 and 5% rates of zeolite and found that the application of zeolite resulted in a significant increase in the biomass of barley, Hordeum vulgare, and increased concentration of Ca, Mg, and K in postharvest soils. Application of zeolite in the soil also increased fresh and dry weights of shoots and roots, fruit weight, and the number of achenes of strawberry, Fragaria ananassa, as well as the available N, P, K, Ca, and Mg of the medium [197]. Milosevic and Milosevic [198] found higher amounts of humus, total N, and available P and K in soil along with a significant increase in the shoot length and trunk cross-sectional area by the application of zeolite in combination with cattle manure and inorganic fertilizer. Zeolite is characterized by large sorption and ion-exchange capacity. As a sorbent, it has an important effect on the mobilization of heavy metals as well as micronutrients and macronutrients [199]. In the structure of zeolite, the negative charges developed through the replacement of quadri-charged silicon cations by triply charged aluminum can be balanced by the adsorption of Na under salt stress conditions. Besides, the three-dimensional framework of zeolite is made up of [SiO4]4− and [AlO4]5− tetrahedra, which are bonded together by sharing the oxygen atoms located at the corner of each tetrahedron in such a way that the framework develops voids or pores in the form of cages and channels between the tetrahedra [200]. The incorporation of zeolite into SAS thus can lead to the adsorption of Na on the surfaces or entrapment in the void spaces, resulting in decreased uptake by plants. Moreover, zeolite plays an important source of Ca (CaO, 16.0%) to the soil-plant system. The release of Ca in the root media from the Ca-type zeolite can maintain a high Ca:Na ratio in the shoot and root by decreasing the Na while increasing the Ca uptake [201]. While using zeolite as an amendment to reclaim SAS, the concentration of Na should be taken into consideration. The application of zeolite contributed to a substantial increase of Na in soil and plant [196]. Besides, in soils having low pH (below 4.2), decomposition of zeolite and concomitant placement of Al3+ and Mn2+ ions in the sorption complex may lead to increased leaching of Mg and Ca, root damage, deficiency of Mg and P, toxicity of Mn and Fe, and restricted plant growth [199].
Plants are subjected to various abiotic and biotic stresses due to natural or human interferences. Among the abiotic factors, the problems of soil salinity and sodicity occurring in arid, humid, coastal, and even in irrigated agricultural lands possess great threats to sustainable food security worldwide. Due to differences in properties of saline, sodic, and saline-sodic soils, their ways of stresses to plants as well as amelioration approaches are different. The adverse effects of salt stress on the uptake of essential nutrients by plants vary depending on the genotype, growth stage, concentration of salts in medium, etc. While salinity can be reclaimed by leaching of salts through good quality water together with a proper drainage system, saline-sodic and sodic soils cannot be reclaimed merely by leaching. The application of inorganic and organic amendments is often required to reclaim the saline-sodic and sodic soils. The incorporation of organic amendments is beneficial to reclaim saline as well as saline-sodic and sodic soils. Organic amendments contribute to the physical, chemical, and biological improvements of saline, saline-sodic, and sodic soils, enhancing the magnitude of their reclamation. Besides, organic amendments act as important sources of essential plant nutrients. Therefore, application of organic amendments in combination with the judicious application of inorganic amendments can be a better approach to improve the properties of SAS and the plant’s response to salt stress for sustainable crop production and food security.
The authors declare no conflict of interest.
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",metaTitle:"Advantages of Publishing with IntechOpen",metaDescription:"We have more than a decade of experience in Open Access publishing. \n\n ",metaKeywords:null,canonicalURL:null,contentRaw:'[{"type":"htmlEditorComponent","content":"We have more than a decade of experience in Open Access publishing. The advantages of publishing with IntechOpen include:
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\n\nOur platform – IntechOpen is the world’s leading publisher of OA books, built by scientists, for scientists.
\n\nOur reputation – Everything we publish goes through a two-stage peer review process. We’re proud to count Nobel laureates among our esteemed authors. We meet European Commission standards for funding, and the research we’ve published has been funded by the Bill and Melinda Gates Foundation and the Wellcome Trust, among others. IntechOpen is a member of all relevant trade associations (including the STM Association and the Association of Learned and Professional Society Publishers) and has a selection of books indexed in Web of Science's Book Citation Index.
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\n\nOur services – The support we offer our authors and editors is second to none. Each book in our program receives the following:
\n\nOur end-to-end publishing service frees our authors and editors to focus on what matters: research. We empower them to shape their fields and connect with the global scientific community.
\n\n"In developing countries until now, advancement in science has been very limited, because insufficient economic resources are dedicated to science and education. These limitations are more marked when the scientists are women. In order to develop science in the poorest countries and decrease the gender gap that exists in scientific fields, Open Access networks like IntechOpen are essential. Free access to scientific research could contribute to ameliorating difficult life conditions and breaking down barriers." Marquidia Pacheco, National Institute for Nuclear Research (ININ), Mexico
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She performed (inter)national tasks as vice-president of the Concilium Anaesthesia and related committees. \nShe performed research in several fields, with over 100 publications in (inter)national journals and numerous papers on scientific conferences. \nShe received several awards and is a member of Honour of the Dutch Society of Anaesthesia.",institutionString:null,institution:{name:"Albert Schweitzer Hospital",country:{name:"Gabon"}}},{id:"83089",title:"Prof.",name:"Aaron",middleName:null,surname:"Ojule",slug:"aaron-ojule",fullName:"Aaron Ojule",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"University of Port Harcourt",country:{name:"Nigeria"}}},{id:"295748",title:"Mr.",name:"Abayomi",middleName:null,surname:"Modupe",slug:"abayomi-modupe",fullName:"Abayomi Modupe",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/no_image.jpg",biography:null,institutionString:null,institution:{name:"Landmark University",country:{name:"Nigeria"}}},{id:"94191",title:"Prof.",name:"Abbas",middleName:null,surname:"Moustafa",slug:"abbas-moustafa",fullName:"Abbas Moustafa",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/94191/images/96_n.jpg",biography:"Prof. Moustafa got his doctoral degree in earthquake engineering and structural safety from Indian Institute of Science in 2002. He is currently an associate professor at Department of Civil Engineering, Minia University, Egypt and the chairman of Department of Civil Engineering, High Institute of Engineering and Technology, Giza, Egypt. He is also a consultant engineer and head of structural group at Hamza Associates, Giza, Egypt. Dr. Moustafa was a senior research associate at Vanderbilt University and a JSPS fellow at Kyoto and Nagasaki Universities. He has more than 40 research papers published in international journals and conferences. He acts as an editorial board member and a reviewer for several regional and international journals. His research interest includes earthquake engineering, seismic design, nonlinear dynamics, random vibration, structural reliability, structural health monitoring and uncertainty modeling.",institutionString:null,institution:{name:"Minia University",country:{name:"Egypt"}}},{id:"84562",title:"Dr.",name:"Abbyssinia",middleName:null,surname:"Mushunje",slug:"abbyssinia-mushunje",fullName:"Abbyssinia Mushunje",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"University of Fort Hare",country:{name:"South Africa"}}},{id:"202206",title:"Associate Prof.",name:"Abd Elmoniem",middleName:"Ahmed",surname:"Elzain",slug:"abd-elmoniem-elzain",fullName:"Abd Elmoniem Elzain",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Kassala University",country:{name:"Sudan"}}},{id:"98127",title:"Dr.",name:"Abdallah",middleName:null,surname:"Handoura",slug:"abdallah-handoura",fullName:"Abdallah Handoura",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"École Supérieure des Télécommunications",country:{name:"Morocco"}}},{id:"91404",title:"Prof.",name:"Abdecharif",middleName:null,surname:"Boumaza",slug:"abdecharif-boumaza",fullName:"Abdecharif Boumaza",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Abbès Laghrour University of Khenchela",country:{name:"Algeria"}}},{id:"105795",title:"Prof.",name:"Abdel Ghani",middleName:null,surname:"Aissaoui",slug:"abdel-ghani-aissaoui",fullName:"Abdel Ghani Aissaoui",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/105795/images/system/105795.jpeg",biography:"Abdel Ghani AISSAOUI is a Full Professor of electrical engineering at University of Bechar (ALGERIA). He was born in 1969 in Naama, Algeria. He received his BS degree in 1993, the MS degree in 1997, the PhD degree in 2007 from the Electrical Engineering Institute of Djilali Liabes University of Sidi Bel Abbes (ALGERIA). He is an active member of IRECOM (Interaction Réseaux Electriques - COnvertisseurs Machines) Laboratory and IEEE senior member. He is an editor member for many international journals (IJET, RSE, MER, IJECE, etc.), he serves as a reviewer in international journals (IJAC, ECPS, COMPEL, etc.). He serves as member in technical committee (TPC) and reviewer in international conferences (CHUSER 2011, SHUSER 2012, PECON 2012, SAI 2013, SCSE2013, SDM2014, SEB2014, PEMC2014, PEAM2014, SEB (2014, 2015), ICRERA (2015, 2016, 2017, 2018,-2019), etc.). His current research interest includes power electronics, control of electrical machines, artificial intelligence and Renewable energies.",institutionString:"University of Béchar",institution:{name:"University of Béchar",country:{name:"Algeria"}}},{id:"99749",title:"Dr.",name:"Abdel Hafid",middleName:null,surname:"Essadki",slug:"abdel-hafid-essadki",fullName:"Abdel Hafid Essadki",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"École Nationale Supérieure de Technologie",country:{name:"Algeria"}}},{id:"101208",title:"Prof.",name:"Abdel Karim",middleName:"Mohamad",surname:"El Hemaly",slug:"abdel-karim-el-hemaly",fullName:"Abdel Karim El Hemaly",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/101208/images/733_n.jpg",biography:"OBGYN.net Editorial Advisor Urogynecology.\nAbdel Karim M. A. El-Hemaly, MRCOG, FRCS � Egypt.\n \nAbdel Karim M. A. El-Hemaly\nProfessor OB/GYN & Urogynecology\nFaculty of medicine, Al-Azhar University \nPersonal Information: \nMarried with two children\nWife: Professor Laila A. Moussa MD.\nSons: Mohamad A. M. El-Hemaly Jr. MD. Died March 25-2007\nMostafa A. M. El-Hemaly, Computer Scientist working at Microsoft Seatle, USA. \nQualifications: \n1.\tM.B.-Bch Cairo Univ. June 1963. \n2.\tDiploma Ob./Gyn. Cairo Univ. April 1966. \n3.\tDiploma Surgery Cairo Univ. Oct. 1966. \n4.\tMRCOG London Feb. 1975. \n5.\tF.R.C.S. Glasgow June 1976. \n6.\tPopulation Study Johns Hopkins 1981. \n7.\tGyn. Oncology Johns Hopkins 1983. \n8.\tAdvanced Laparoscopic Surgery, with Prof. Paulson, Alexandria, Virginia USA 1993. \nSocieties & Associations: \n1.\t Member of the Royal College of Ob./Gyn. London. \n2.\tFellow of the Royal College of Surgeons Glasgow UK. \n3.\tMember of the advisory board on urogyn. FIGO. \n4.\tMember of the New York Academy of Sciences. \n5.\tMember of the American Association for the Advancement of Science. \n6.\tFeatured in �Who is Who in the World� from the 16th edition to the 20th edition. \n7.\tFeatured in �Who is Who in Science and Engineering� in the 7th edition. \n8.\tMember of the Egyptian Fertility & Sterility Society. \n9.\tMember of the Egyptian Society of Ob./Gyn. \n10.\tMember of the Egyptian Society of Urogyn. \n\nScientific Publications & Communications:\n1- Abdel Karim M. El Hemaly*, Ibrahim M. Kandil, Asim Kurjak, Ahmad G. Serour, Laila A. S. Mousa, Amr M. Zaied, Khalid Z. El Sheikha. \nImaging the Internal Urethral Sphincter and the Vagina in Normal Women and Women Suffering from Stress Urinary Incontinence and Vaginal Prolapse. Gynaecologia Et Perinatologia, Vol18, No 4; 169-286 October-December 2009.\n2- Abdel Karim M. El Hemaly*, Laila A. S. Mousa Ibrahim M. Kandil, Fatma S. El Sokkary, Ahmad G. Serour, Hossam Hussein.\nFecal Incontinence, A Novel Concept: The Role of the internal Anal sphincter (IAS) in defecation and fecal incontinence. Gynaecologia Et Perinatologia, Vol19, No 2; 79-85 April -June 2010.\n3- Abdel Karim M. El Hemaly*, Laila A. S. Mousa Ibrahim M. Kandil, Fatma S. El Sokkary, Ahmad G. Serour, Hossam Hussein.\nSurgical Treatment of Stress Urinary Incontinence, Fecal Incontinence and Vaginal Prolapse By A Novel Operation \n"Urethro-Ano-Vaginoplasty"\n Gynaecologia Et Perinatologia, Vol19, No 3; 129-188 July-September 2010.\n4- Abdel Karim M. El Hemaly*, Ibrahim M. Kandil, Laila A. S. Mousa and Mohamad A.K.M.El Hemaly.\nUrethro-vaginoplasty, an innovated operation for the treatment of: Stress Urinary Incontinence (SUI), Detursor Overactivity (DO), Mixed Urinary Incontinence and Anterior Vaginal Wall Descent. \nhttp://www.obgyn.net/urogyn/urogyn.asp?page=/urogyn/articles/ urethro-vaginoplasty_01\n\n5- Abdel Karim M. El Hemaly, Ibrahim M Kandil, Mohamed M. Radwan.\n Urethro-raphy a new technique for surgical management of Stress Urinary Incontinence.\nhttp://www.obgyn.net/urogyn/urogyn.asp?page=/urogyn/articles/\nnew-tech-urethro\n\n6- Abdel Karim M. El Hemaly, Ibrahim M Kandil, Mohamad A. Rizk, Nabil Abdel Maksoud H., Mohamad M. Radwan, Khalid Z. El Shieka, Mohamad A. K. M. El Hemaly, and Ahmad T. El Saban.\nUrethro-raphy The New Operation for the treatment of stress urinary incontinence, SUI, detrusor instability, DI, and mixed-type of urinary incontinence; short and long term results. \nhttp://www.obgyn.net/urogyn/urogyn.asp?page=urogyn/articles/\nurethroraphy-09280\n\n7-Abdel Karim M. El Hemaly, Ibrahim M Kandil, and Bahaa E. El Mohamady. Menopause, and Voiding troubles. \nhttp://www.obgyn.net/displayppt.asp?page=/English/pubs/features/presentations/El-Hemaly03/el-hemaly03-ss\n\n8-El Hemaly AKMA, Mousa L.A. Micturition and Urinary\tContinence. Int J Gynecol Obstet 1996; 42: 291-2. \n\n9-Abdel Karim M. El Hemaly.\n Urinary incontinence in gynecology, a review article.\nhttp://www.obgyn.net/urogyn/urogyn.asp?page=/urogyn/articles/abs-urinary_incotinence_gyn_ehemaly \n\n10-El Hemaly AKMA. Nocturnal Enuresis: Pathogenesis and Treatment. \nInt Urogynecol J Pelvic Floor Dysfunct 1998;9: 129-31.\n \n11-El Hemaly AKMA, Mousa L.A.E. Stress Urinary Incontinence, a New Concept. Eur J Obstet Gynecol Reprod Biol 1996; 68: 129-35. \n\n12- El Hemaly AKMA, Kandil I. M. Stress Urinary Incontinence SUI facts and fiction. Is SUI a puzzle?! http://www.obgyn.net/displayppt.asp?page=/English/pubs/features/presentations/El-Hemaly/el-hemaly-ss\n\n13-Abdel Karim El Hemaly, Nabil Abdel Maksoud, Laila A. Mousa, Ibrahim M. Kandil, Asem Anwar, M.A.K El Hemaly and Bahaa E. El Mohamady. \nEvidence based Facts on the Pathogenesis and Management of SUI. http://www.obgyn.net/displayppt.asp?page=/English/pubs/features/presentations/El-Hemaly02/el-hemaly02-ss\n\n14- Abdel Karim M. El Hemaly*, Ibrahim M. Kandil, Mohamad A. Rizk and Mohamad A.K.M.El Hemaly.\n Urethro-plasty, a Novel Operation based on a New Concept, for the Treatment of Stress Urinary Incontinence, S.U.I., Detrusor Instability, D.I., and Mixed-type of Urinary Incontinence.\nhttp://www.obgyn.net/urogyn/urogyn.asp?page=/urogyn/articles/urethro-plasty_01\n\n15-Ibrahim M. Kandil, Abdel Karim M. El Hemaly, Mohamad M. Radwan: Ultrasonic Assessment of the Internal Urethral Sphincter in Stress Urinary Incontinence. The Internet Journal of Gynecology and Obstetrics. 2003. Volume 2 Number 1. \n\n\n16-Abdel Karim M. El Hemaly. Nocturnal Enureses: A Novel Concept on its pathogenesis and Treatment.\nhttp://www.obgyn.net/urogynecolgy/?page=articles/nocturnal_enuresis\n\n17- Abdel Karim M. El Hemaly. Nocturnal Enureses: An Update on the pathogenesis and Treatment.\nhttp://www.obgyn.net/urogynecology/?page=/ENHLIDH/PUBD/FEATURES/\nPresentations/ Nocturnal_Enuresis/nocturnal_enuresis\n\n18-Maternal Mortality in Egypt, a cry for help and attention. The Second International Conference of the African Society of Organization & Gestosis, 1998, 3rd Annual International Conference of Ob/Gyn Department � Sohag Faculty of Medicine University. Feb. 11-13. Luxor, Egypt. \n19-Postmenopausal Osteprosis. The 2nd annual conference of Health Insurance Organization on Family Planning and its role in primary health care. Zagaziz, Egypt, February 26-27, 1997, Center of Complementary Services for Maternity and childhood care. \n20-Laparoscopic Assisted vaginal hysterectomy. 10th International Annual Congress Modern Trends in Reproductive Techniques 23-24 March 1995. Alexandria, Egypt. \n21-Immunological Studies in Pre-eclamptic Toxaemia. Proceedings of 10th Annual Ain Shams Medical Congress. Cairo, Egypt, March 6-10, 1987. \n22-Socio-demographic factorse affecting acceptability of the long-acting contraceptive injections in a rural Egyptian community. Journal of Biosocial Science 29:305, 1987. \n23-Plasma fibronectin levels hypertension during pregnancy. The Journal of the Egypt. Soc. of Ob./Gyn. 13:1, 17-21, Jan. 1987. \n24-Effect of smoking on pregnancy. Journal of Egypt. Soc. of Ob./Gyn. 12:3, 111-121, Sept 1986. \n25-Socio-demographic aspects of nausea and vomiting in early pregnancy. Journal of the Egypt. Soc. of Ob./Gyn. 12:3, 35-42, Sept. 1986. \n26-Effect of intrapartum oxygen inhalation on maternofetal blood gases and pH. Journal of the Egypt. Soc. of Ob./Gyn. 12:3, 57-64, Sept. 1986. \n27-The effect of severe pre-eclampsia on serum transaminases. The Egypt. J. Med. Sci. 7(2): 479-485, 1986. \n28-A study of placental immunoreceptors in pre-eclampsia. The Egypt. J. Med. Sci. 7(2): 211-216, 1986. \n29-Serum human placental lactogen (hpl) in normal, toxaemic and diabetic pregnant women, during pregnancy and its relation to the outcome of pregnancy. Journal of the Egypt. Soc. of Ob./Gyn. 12:2, 11-23, May 1986. \n30-Pregnancy specific B1 Glycoprotein and free estriol in the serum of normal, toxaemic and diabetic pregnant women during pregnancy and after delivery. Journal of the Egypt. Soc. of Ob./Gyn. 12:1, 63-70, Jan. 1986. Also was accepted and presented at Xith World Congress of Gynecology and Obstetrics, Berlin (West), September 15-20, 1985. \n31-Pregnancy and labor in women over the age of forty years. Accepted and presented at Al-Azhar International Medical Conference, Cairo 28-31 Dec. 1985. \n32-Effect of Copper T intra-uterine device on cervico-vaginal flora. Int. J. Gynaecol. Obstet. 23:2, 153-156, April 1985. \n33-Factors affecting the occurrence of post-Caesarean section febrile morbidity. Population Sciences, 6, 139-149, 1985. \n34-Pre-eclamptic toxaemia and its relation to H.L.A. system. Population Sciences, 6, 131-139, 1985. \n35-The menstrual pattern and occurrence of pregnancy one year after discontinuation of Depo-medroxy progesterone acetate as a postpartum contraceptive. Population Sciences, 6, 105-111, 1985. \n36-The menstrual pattern and side effects of Depo-medroxy progesterone acetate as postpartum contraceptive. Population Sciences, 6, 97-105, 1985. \n37-Actinomyces in the vaginas of women with and without intrauterine contraceptive devices. Population Sciences, 6, 77-85, 1985. \n38-Comparative efficacy of ibuprofen and etamsylate in the treatment of I.U.D. menorrhagia. Population Sciences, 6, 63-77, 1985. \n39-Changes in cervical mucus copper and zinc in women using I.U.D.�s. Population Sciences, 6, 35-41, 1985. \n40-Histochemical study of the endometrium of infertile women. Egypt. J. Histol. 8(1) 63-66, 1985. \n41-Genital flora in pre- and post-menopausal women. Egypt. J. Med. Sci. 4(2), 165-172, 1983. \n42-Evaluation of the vaginal rugae and thickness in 8 different groups. Journal of the Egypt. Soc. of Ob./Gyn. 9:2, 101-114, May 1983. \n43-The effect of menopausal status and conjugated oestrogen therapy on serum cholesterol, triglycerides and electrophoretic lipoprotein patterns. Al-Azhar Medical Journal, 12:2, 113-119, April 1983. \n44-Laparoscopic ventrosuspension: A New Technique. Int. J. Gynaecol. Obstet., 20, 129-31, 1982. \n45-The laparoscope: A useful diagnostic tool in general surgery. Al-Azhar Medical Journal, 11:4, 397-401, Oct. 1982. \n46-The value of the laparoscope in the diagnosis of polycystic ovary. Al-Azhar Medical Journal, 11:2, 153-159, April 1982. \n47-An anaesthetic approach to the management of eclampsia. Ain Shams Medical Journal, accepted for publication 1981. \n48-Laparoscopy on patients with previous lower abdominal surgery. Fertility management edited by E. Osman and M. Wahba 1981. \n49-Heart diseases with pregnancy. Population Sciences, 11, 121-130, 1981. \n50-A study of the biosocial factors affecting perinatal mortality in an Egyptian maternity hospital. Population Sciences, 6, 71-90, 1981. \n51-Pregnancy Wastage. Journal of the Egypt. Soc. of Ob./Gyn. 11:3, 57-67, Sept. 1980. \n52-Analysis of maternal deaths in Egyptian maternity hospitals. Population Sciences, 1, 59-65, 1979. \nArticles published on OBGYN.net: \n1- Abdel Karim M. El Hemaly*, Ibrahim M. Kandil, Laila A. S. Mousa and Mohamad A.K.M.El Hemaly.\nUrethro-vaginoplasty, an innovated operation for the treatment of: Stress Urinary Incontinence (SUI), Detursor Overactivity (DO), Mixed Urinary Incontinence and Anterior Vaginal Wall Descent. \nhttp://www.obgyn.net/urogyn/urogyn.asp?page=/urogyn/articles/ urethro-vaginoplasty_01\n\n2- Abdel Karim M. El Hemaly, Ibrahim M Kandil, Mohamed M. Radwan.\n Urethro-raphy a new technique for surgical management of Stress Urinary Incontinence.\nhttp://www.obgyn.net/urogyn/urogyn.asp?page=/urogyn/articles/\nnew-tech-urethro\n\n3- Abdel Karim M. El Hemaly, Ibrahim M Kandil, Mohamad A. Rizk, Nabil Abdel Maksoud H., Mohamad M. Radwan, Khalid Z. El Shieka, Mohamad A. K. M. El Hemaly, and Ahmad T. El Saban.\nUrethro-raphy The New Operation for the treatment of stress urinary incontinence, SUI, detrusor instability, DI, and mixed-type of urinary incontinence; short and long term results. \nhttp://www.obgyn.net/urogyn/urogyn.asp?page=urogyn/articles/\nurethroraphy-09280\n\n4-Abdel Karim M. El Hemaly, Ibrahim M Kandil, and Bahaa E. El Mohamady. Menopause, and Voiding troubles. \nhttp://www.obgyn.net/displayppt.asp?page=/English/pubs/features/presentations/El-Hemaly03/el-hemaly03-ss\n\n5-El Hemaly AKMA, Mousa L.A. Micturition and Urinary\tContinence. Int J Gynecol Obstet 1996; 42: 291-2. \n\n6-Abdel Karim M. El Hemaly.\n Urinary incontinence in gynecology, a review article.\nhttp://www.obgyn.net/urogyn/urogyn.asp?page=/urogyn/articles/abs-urinary_incotinence_gyn_ehemaly \n\n7-El Hemaly AKMA. Nocturnal Enuresis: Pathogenesis and Treatment. \nInt Urogynecol J Pelvic Floor Dysfunct 1998;9: 129-31.\n \n8-El Hemaly AKMA, Mousa L.A.E. Stress Urinary Incontinence, a New Concept. Eur J Obstet Gynecol Reprod Biol 1996; 68: 129-35. \n\n9- El Hemaly AKMA, Kandil I. M. Stress Urinary Incontinence SUI facts and fiction. Is SUI a puzzle?! http://www.obgyn.net/displayppt.asp?page=/English/pubs/features/presentations/El-Hemaly/el-hemaly-ss\n\n10-Abdel Karim El Hemaly, Nabil Abdel Maksoud, Laila A. Mousa, Ibrahim M. Kandil, Asem Anwar, M.A.K El Hemaly and Bahaa E. El Mohamady. \nEvidence based Facts on the Pathogenesis and Management of SUI. http://www.obgyn.net/displayppt.asp?page=/English/pubs/features/presentations/El-Hemaly02/el-hemaly02-ss\n\n11- Abdel Karim M. El Hemaly*, Ibrahim M. Kandil, Mohamad A. Rizk and Mohamad A.K.M.El Hemaly.\n Urethro-plasty, a Novel Operation based on a New Concept, for the Treatment of Stress Urinary Incontinence, S.U.I., Detrusor Instability, D.I., and Mixed-type of Urinary Incontinence.\nhttp://www.obgyn.net/urogyn/urogyn.asp?page=/urogyn/articles/urethro-plasty_01\n\n12-Ibrahim M. Kandil, Abdel Karim M. El Hemaly, Mohamad M. Radwan: Ultrasonic Assessment of the Internal Urethral Sphincter in Stress Urinary Incontinence. The Internet Journal of Gynecology and Obstetrics. 2003. Volume 2 Number 1. \n\n13-Abdel Karim M. El Hemaly. Nocturnal Enureses: A Novel Concept on its pathogenesis and Treatment.\nhttp://www.obgyn.net/urogynecolgy/?page=articles/nocturnal_enuresis\n\n14- Abdel Karim M. El Hemaly. 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