SERATONIN GENE RELATED PEPTIDE IN MIGRAINE. Mazen 1.pdf · BRAIN COMPUTER INTERFACE (BCI) IN STRESS INDUCED LOSS OF COGNITION enhance the life style of the disabled person. The MEG

152 September 2016 International Journal of Health and Rehabilitation Sciences Volume 5 Issue 3

BRAIN COMPUTER INTERFACE (BCI) IN STRESS INDUCED LOSS OF COGNITION

ORIGINAL RESEARCH Effect of Brain Computer Interface (BCI) in

stress induced loss of cognition in hippocampus

of wister albino rats Sivanandan Ramar, Mazen Alqahtani, Anandh Bose, Salameh Al Dajah

Sivanandan Ramar

Associate Prof., Dept. of

Anatomy, Madha Medical

College, Chennai, India

Mazen Alqahtan

Assistant. Prof., Dept. of

Physical therapy, CAMS,

Majmaah University, KSA,

Anandh Bose,

Lecturer, Dept. of

Biomedical, CAMS,

Majmaah University,

KSA,

Salameh Al Dajah

Associate Professor

Physical Therapy Department

Al Isra University, Jordan

Corresponding Author:

Sivanandan Ramar

E-mail:

[email protected]

ABSTRACT

Background: Brain-computer interface (BCI) is a collaboration between a brain and

a device that enables signals from the brain to direct some external activity, which

interface enables a direct communications pathway between the brain and the object

to be controlled. By reading signals from an array of neurons and using computer

chips and programs to translate the signals into action. The Magneto encephalography

(MEG) is to record the firing of the neuron and absorb the brain activity as the

magnetic field travels from region to region with in the brain. It has the potential to

enhance the life style of the disabled person. The MEG Brain Computer Interface

(BCI) impact on medicine and healthcare now may be subtle but is still revolutionary.

Objectives: The purpose of this study was to develop novel methods and systems

for rehabilitation and control of assistive devices using signals from the brain – BCI

on motor coding and on neural plasticity.

Materials and methods: The experiment was carried out in 24 albino rats with

Magneto encephalography (MEG). All the rats underwent BCI procedure except the

first and second group which was exposed to fake intervention. The objective of

this proof of concept closed loop BCI experiment was for the subject to control the

positive movement of a rat in the radial arm maze to take the food even altered

position which was recorded in the system.

Results: An important finding in the present study was the enhancing effect of BCI

against neurodegeneration. It shows that these rats achieve to learn the task. It

suggests that the BCI activated the neurons in the hippocampus and makes it

sufficient for normal acquisition.

Conclusion: Stress induced hippocampal degeneration leads to significant

impairment of cognitive functions especially in calculation, immediate recall and

attention. In this present study, stress induced loss of cognition was studied by

activating the neurons of the hippocampus by grid electrodes of BCI system.

Keywords: Magneto encephalography (MEG), glucocorticoid, hippocampal

formation & grid electrodes.

DOI: 10.5455/ijhrs.0000000113



INTRODUCTION

Brain computer interface (BCI) in learning

and spatial memory is one of the important

ongoing projects in the field of research.

Stress induced deficiency of learning and

memory has been inevitable for the upcoming

generations due to their changing lifestyle.

Chronic stress (CS) extracts a high price from

our bodies as well as our minds 1 . Many

degenerative diseases, as well as premature

aging are associated with chronic nervous

tension. One of the principal cognitive effects

of stress is disruption of learning and

memory. Mainly it leads to significant

impairment of cognitive functions especially

in calculation, immediate recall and attention

2. The documented effect of stress on learning

and memory function raises the question of

what anatomical pathways are impaired,

either transiently or permanently. As far as the

neuropathology associated to stress is

concerned, there will be a defect in cortical

and subcortical centers 3,4,5,6, mainly the

hippocampal formation 7,8,9. The field of

neuroscience has evolved greatly and it is

now clear that the hippocampal formation

plays a pivotal role in learning and memory 10

. A leading thought is that the volume of the

BCI helps to decrease the number and severity

of CS-inhibit the adverse effects of CS on

retention of learned tasks. There is a great

need for safe and effective prevention

strategies to combat the ravages of stress on

our nervous system. The hippocampus is

directly related to memory capability11.

Hippocampus is believed to be particularly

vulnerable to oxidative stress due to a

relatively high rate of oxygen free radical

generation without commensurate level of

antioxidative defenses 12. The cytotoxic

acetaldehyde produced from oxidation of

stress can be further oxidised to acetate by

acetaldehyde dehydrogenase enzyme a n d is

capable of producing reactive oxygen

species 13 and leads to a depletion of the

antioxidant defenses in the hippocampus 14 .

Here in this study, BCI establishes the link

between the human brain and the external

signals. BCI is a smart system that sends

external signals into specific portion of the

brain to enhance its natural activity. BCI’s are

designed to restore sensory function, transmit

sensory information to the brain, or stimulate

the brain through artificially generated

electrical signals. The

Magnetoencephalography (MEG) detects the

tiny magnetic fields created as individual

neurons fire within the brain. It can pinpoint

the active region with a millimeter, and can

follow the movement of brain activity as it

travels from region to region within the brain.

BCI systems use MEG to detect signals from

the brain when it is activated with standard

input signals.



SA SP OD

ES SP SI

SA— Signal Acquisition

SP--- Signal Processing

OD---- Output Display

ES---Electrode System

SI --- Standard Input

FIG.1.BLOCK DIAGRAM OF THE SYSTEM

The objective of this study was with the

help of BCI loop, the subject can control the

positive movement in the radia l arm maze

which allow to t ake the food. I t was

recorded in the system. An important finding

in the present study was the enhancing effect

of BCI against neurodegeneration. It shows

that these rats achieve t o l e a r n the task.

Experimental Procedure

The experiment was carried out in young

adult male wistar albino rats, (body weight

180± 10 gms, aged 2 months) were

maintained in the animal room at a controlled

temperature (26°± 2°C) and a light and dark

cycle (12 hrs light and 12 hrs dark) for 2

months. They were provided with food and

water ad libitum. All experiments were

cleared by institutional ethical committee

(IAEC.No.Ana.M.Sc/002/2010). The animals

are divided into four groups, 6 animals for

each group, so totally 24 rats were used.

No. of groups with description:

Control group:

Group I – The rats were housed in complete

non-stress condition. The control group

animals were housed and maintained for 2

months from the start of the experiment. After

that the animals were sacrificed.

Experimental group:

Experimental animals were divided into 3

groups

(Group II, III and IV).

Group II – Animals induced stress with cold

water (18±2 ºC) for 4 hours for 1 month.

Group III – Animals treated with BCI.

Group IV – Animals subjected to cold stress

for 1 month and then treated with BCI

.

Stress protocol:

The rats were subjected to cold water

swimming stress for 10 minutes, a day

for a period of one month. Animals were

forced to swim in a plastic bucket

(Dimensions 45x20x25 cm in diameter)

filled with of cold water (18±2ºC) under



observation. The s t r e s s period was

selected based on a pilot study to

obtain the maximum percentage of cell

degeneration in the Hippocampal region.

Although habituations were observed in

the general behavior, cell degeneration

was complete 15 .

MATERIALS AND METHODS

The experiment was carried out for a

period of 2 –4 months with 24 albino

rats. Before starting the experiment, the

rats were made to acclimatize to the

laboratory environment for one week.

Then rats were randomly divided into 4

groups of 6 (n=6) animals each. Age: 2

months. All the rats underwent BCI

procedure except the first and second

group which was exposed to fake

intervention. The objective of this

proof of concept closed loop BCI

experiment was for the subject to control

the positive movement of a rat in the

radial arm maze to take the food

which was recorded in the system. The

rat was tasked to alter the position in the

maze by a fixed increment by

respectively engaging into mental

operations increasing cognitive load (e.g

mental arithmetic) or relaxing. The trial

was deemed successful if the rat

managed to manipulate his/her cognitive

load (and thus their alpha power) to

achieve the goal with short latency time.

The position of the food pallet was not

fixed and changed randomly with equal

probability between trials. The

experimental setup is illustrated in fig.1

in that 3 electrodes were placed on the

scalp in the position of P1, O2, and T3.

These were used to record EEG signals

from each subject as well as stimulate in

a common reference montage at a

sampling frequency of 256Hz. The

alpha power for each electrode was

calculated individually using MATLAB

and then averaged to obtain a single

value. The alpha band power was

defined as the power of the EEG data

filtered between 8-13Hz. This value

was calculated once per second. The

mean of the positive activity was

recorded. During this period, the rats

were trained in a 30 min session/day

to study the behaviour for

following 30 days until acquisition of a

stable baseline of responding was

reached.

The rats were treated humanely and in

compliance with the recommendations

of Animal Care Committee. All

experimental procedures were carried

out between 04.00 to 08.00 pm. To

assess hippocampal dependent spatial

learning and memory, all rats were

trained in a complex maze task 16 .

After the induction of stress and BCI

treatment at the end of the 8th week, the

positive behavioral activities were

accessed by performing four times per

day for four weeks. Over the time, rats

tend to run the maze with fewer and

fewer errors, more and more quickly. By

graphing the number of errors over time,

learning and memory of the rats were

assessed. After the scarification

procedure, fixation was done using 4%

paraformaldehyde in 0.1 M phosphate

buffered saline, through transcardiac

perfusion. Fixed tissues are stained

with H&E and counting of neurons were

done by using histomorphometry.



RESULTS AND DISCUSSION

An important finding in the present study was

the enhancing effect of BCI against

neurodegeneration. It shows that these rats

achieve to l e a r n the task. It suggests that

the BCI activated the neurons in the

hippocampus and makes it sufficient for

normal acquisition. So the task acquisition

and memory modulation mediated in

hippocampus was due to neuroprotective &

neurogenesis effect of BCI. In group III,

highly significant effect of BCI was noticed

in normal acquisition and retrieval of

memory. It suggests that BCI not only

reverses amnesia in stress induced rats as

shown in group IV and also it improve the

memory as shown in group III. This suggests

that BCI modulates retention in hippocampus

required for learning the task. An intact

hippocampus was found to be essential for

task acquisition. The retention was

enhanced in group III rats suggests that BCI

strengthened the contribution in

hippocampus makes to a level that could

influence behavior. This interpretation

further suggests that BCI influence and

mediates the modulatory effect of acute stress

on memory.

Table 1: Mean ± SEM of positive behavioral activity (number/count) during the days of training after BCI and/or

stressed rats

The overall mean behavioural activity was

calculated from the above table (n=6). The

above results showed that during stress, the

behavioural activity of group II was

decreased as when compared with all other

groups. But in group III and IV, the overall

positive mean behavioural activity was

increased as compared with all the other

groups. The ANOVA test carried for positive

behavioural activity showed that the

difference in mean values between the groups

were statistically significant (F= 55.21;

P<0.001).

Post- hoc tests revealed that comparing the

mean of positive activity of all the 4 groups,

group IV has higher significant positive

value. This showed that BCI treated group

was better than other groups.

It was proved in the present study that the

beneficial effects of BCI on cognition had

been demonstrated in behavioral studies.

New cells were important for hippocampal

dependent learning, but perhaps only

required for encoding spatial information

in the long term. There was also

Group

Day 1

Day 2

Day 3

Day 4

Group I

1996.1±71.02

2016±51.01

2120±48.02

2428±36.42

Group II

1837±29.51

1625±72.50

1421±49.50

1570±60.10

Group III

2049.91±47.03

2121±59.91

2095±68.02

2327±15.67

Group IV

3599.91±87.03

3121±89.91

3225±58.02

3527±25.67



evidence that the newly-generated cells may

serve specific functions during learning

or recall of certain tasks, distinct from

the function served by mature granule cells.

For example, both cell proliferation and total

cell number in the dentate gyrus was

negatively correlated with a rat’s locomotor

activity in response to exposure to novelty 17.

So, the new cells may serve an important role

in the recognition of novelty and in producing

an appropriate response in a novel context 18.

Table 2: Mean ± SEM of total number of neurons during the days of training after BCI and/or Stressed rats.

(CA – Cornu Ammonis)

The above results showed that during

stress, the total number of neuron was

decreased in group II as when compared

with other groups. But in group IV, it was

increased as compared to all the other

experimental groups. So, this shows that

BCI improved the total number of neurons

in the experimental group. The ANOVA

test done for total number of neuron

which showed that the difference in

overall mean total number of neurons

between the different groups were

statistically significant (F=2.94; P<0.05).

Comparing the mean total number of

all the experimental groups, group III had

significant value. This shows that BCI

treated group was better than other

experimental groups. These findings

compared with previous research

demonstrating the impairment of spatial

learning and memory of stress induced

rats in the radial arm maze 19, 20.

This suggests that these newly formed

cells may serve a function in the encoding

or recall of spatial information that was

distinct from that served by more

mature granule neurons. It was also

possible t h a t the young cells may be

important for encoding information about

the timing of specific memories. The

dentate gyrus allows the differentiation of

similar memories by production of

distinct, non-overlapping representations

in the CA3 region 21. However,

memories that occur temporally close to

each other to remain associated 22. So,

presence of more number of mossy cells

and mature neurons as well as immature

neurons in the hippocampus in fructus

treated group was very much useful in

cognition as well as in depression.

Deficits in spatial ability in stress

exposure mainly in maze studied by

Goodlett and Peterson, et al.,1995.

Group CA1 CA2/3 CA4

Group I 222.9±14.2 271.7±5.7 188±9.5

Group II 192.5±12.2 216.9±9.3 160.8±5.5

Group III 202.7±10.2 261.2±6.8 190±7.5

Group IV

282.7±10.2

291.2±6.8

260±7.5



Although the neural changes underlying

the deficits induced by stress exposure

remain ambiguous. But there were at least

two possible explanations for the

differences in performance group II in the

maze. First, the brain area underlying

spatial cognitive abilities was affected by

stress exposure and secondly, HPA

(Hypothalamo-pituitary-adrenal axis)

hyper responsiveness to stress. So, the

deficits in spatial navigation

demonstrated group II may be

attributable, due to hippocampal damage.

Finally, stress exposure had been shown

to produce alterations in hippocampal

structure and function, changing mossy

fiber branching, arborization and

hippocampal pyramidal cell number in

CA1 as well as in CA3 29,30. It reduces the

affinity of hippocampal NMDA receptors

for binding glutamate 23.

So, finally improved performance in BCI

group in latency time and total path length

appeared to result from neuroprotective

effect of BCI against stress induced

hippocampus and there were significant

differences among groups in latency to

perform the task. The ANOVA test done

for positive activity shows that the

difference in time taken to achieve the

target between the groups were

statistically significant (P<0.05).

Comparing the mean positive activity of

all the 4 groups, group IV had significant

value. This shows that BCI treated group

was better than other groups. So BCI

treated rats performed well in behavioral

and cognitive tasks including conditioned

aversion learning, spatial learning and

memory as well as resulting in decrease in

HPA responsiveness. This shows that BCI

induced the positive behavioral activity

and thereby it improves the learning and

memory. As the set of newly generated

neurons available at the time of encoding

would be similar for memories formed in

close temporal proximity, their

involvement in encoding could help

tie memories together in time 24. Total

number of mature neurons and positive

activity were increased in group II and

IV which proves that BCI had

neuroprotective effect and its estrogen

property. This neuroprotective effect of

BCI increases the pyramidal and granular

cells in hippocampus. This newly borned

cells very much useful in hippocampal

plasticity. So, discovery of adult

hippocampal neurogenesis had stimulated

the efforts to understand the relationship

between newborn cells and hippocampal

dependent learning and memory.

CONCLUSION

BCI improves the behavioral activities of

stress induced hippocampus. Regulating the

cells of the brain in stress induced

hippocampus as well as in normal, BCI can

be used as adjunct for the treatment of

depression. Presence of more number of

neurons reveals that there may be a migration

of progenitor neural stem cells from the

ependymal layer of sub ventricular zone.

Neuronal activity in the hippocampus

declines with age 25. These concurrent events

may precipitate decreased cognitive

functioning with stress and advancement of

age. BCI induced activation of neurons with

resultant induction of an ERK-Akt-CREB-

BDNF signaling pathway mediates

neuroprotection and preservation of cognitive



function BCI. The study thus adds to a

growing literature supporting a potentially

important role of BCI in mediating

neurogenic beneficial effects in the brain.

FUTURE SCOPE

In future, BCI induced neurogenesis may

also be of considerable clinical interest with

the development of neural stem cell

technology for replacing lost neurons. The

results of this study suggest that

administration of BCI had induced

neurogenesis on hippocampus which

suggests that BCI could serve to stabilize

brain morphology and physiology



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Research ArticleCross-Cultural Validation of Urdu Version KOOS in IndianPopulation with Primary Knee Osteoarthritis

Mahamed Ateef,1 Sivachidambaram Kulandaivelan,2 andMazen Alqahtani1

1Department of Physiotherapy, CAMS, Majmaah University, Al Majmaah 11952, Saudi Arabia2Department of Physiotherapy, GJUST, Hisar, Haryana 125001, India

Correspondence should be addressed to Mahamed Ateef; [email protected]

Received 13 May 2017; Revised 13 September 2017; Accepted 3 October 2017; Published 25 October 2017

Academic Editor: Charles J. Malemud

Copyright © 2017 Mahamed Ateef et al.This is an open access article distributed under the Creative CommonsAttribution License,which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Purpose. The primary aim of this study was to translate a self-reported questionnaire (KOOS) from English to Urdu and then to seeits internal consistency, agreement, test-retest reliability, and validity among primary OA knee patients.Methodology. First, KOOSquestionnaire was translated from English language to Urdu through standardized cross-cultural protocol. This translated versionof KOOS was administered to 111 radiographically diagnosed primary OA knee patients at two times with 48-hour interval in-between. Cronbach’s alpha, floor and ceiling effect, intraclass correlation coefficient (ICC), absolute agreement %, and Spearmancorrelation were used to fulfill our objectives. Results. Average time to administer this questionnaire was 20 minutes. There wasgood internal consistency with Cronbach’s alpha ranging from 0.7246 to 0.9139. The absolute agreement of each item between twotests ranged from 81.08% to 98.20%. Test-retest reliability was excellent (“𝑟” ranged from 0.9673 to 0.9782). There was no ceilingeffect; however less than 4% floor effect was seen in two subscales. There was significant difference that existed between differentX-ray grades in all subscales meaning good content validity for disease prognosis. Conclusion. The present results show that KOOSUrdu version is a reliable and valid measure for primary OA knee patients.

1. Introduction

Urdu is spoken by more than 65 million people in the worldwho are predominantly from two Asian countries, that is,India and Pakistan. It is a national language of Pakistanand one of 22 languages recognized by Indian constitution.It is historically associated with Muslims of north Indiansubcontinent [1].

OA knee is one of the most common musculoskeletalproblems in middle and old aged population.The prevalenceof knee OA in Indians aged 30 years or more is approximately20% [2]. Physicians and paramedical staff use various meth-ods/tests for diagnosis and prognosis of knee OA and to seeeffectiveness of interventions, that is, life-style modificationthat includes exercise, medicine, and surgery. The tests usedin knee OA are broadly classified into subjective, that is,health related quality of life (HRQOL) questionnaires, andobjective, that is, 6-minute walk test [3] categories.

Knee osteoarthritis outcome score (KOOS) is one of thedisease specific questionnaires that has been widely used in

literature. It has been translated into 49 languages worldwideso far. Originally developed in Swedish and for young athleteswith knee injury, KOOS is a self-reported questionnaire thatcontains 42 questions in 05 broad domains, that is, symptomsincluding stiffness, pain, activities of daily living (ADL),sports-recreation, and quality of life (QOL). Each questioncontains 5-point Likert scale with “0” being lowest and “4”being highest. Each domain calculated by percentile with “0”means no problem and “100” means maximum problem.

English reading and understanding in India are very lowwhich warrants the translation of self-reported question-naires to regional languages. KOOS has been successfullytranslated into 8 Indian languages so far without any scientificpublications on its validation in Indian population. Thusthe objective of this paper is to translate the KOOS inUrdu language using cross-cultural adaptation followed bymeasuring internal consistency, test-retest reliability, per-centage of agreement, floor–ceiling effect, content validity,and construct/criterion validity of translated version.

HindawiInternational Journal of RheumatologyVolume 2017, Article ID 1206706, 4 pageshttps://doi.org/10.1155/2017/1206706

https://doi.org/10.1155/2017/1206706

2 International Journal of Rheumatology

2. Methodology

The whole protocol was divided into two stages: cross-cultural adaptation and content validation. In first stage, theEnglish version of the KOOS questionnaire was translatedinto Urdu version through standardized procedure recom-mended by Beaton et al. [4] with some modification. Wetranslated and culturally adapted the KOOS according toIndian living standards to adapt/fit and use in Indian UrduspeakingMuslimOsteoarthritis population for the evaluationof self-rated knee functional status. In brief, stage I was doneby the first author with the help of online translation portal.We skipped stages II and III recommended by Beaton et al.[4]. In stage IV, 10 Muslim experts (02 orthopaedicians, 02rheumatologists, 02 English professors, 02 Urdu professors,and 02 religious priests) were volunteered for the review ofquestionnaire developed in stage I. The experts discussedand finalized that questions in sports and recreation shouldbe supplemented by cultural activities; hence SP1 should be“squatting such as floor eating, using Indian toilet (com-mode)” instead of “squatting” and SP5 should be “kneelinglike namas (prayer)” instead of “kneeling.”Overall, Urdu pro-fessors and religious priests simplified the language, whereasmedical experts helped with the medical terminology usedin the questionnaire. In stage V, questionnaire developed atthe end of stage IV was administered to 20 Urdu speakingOA knee patients. All patients understood the questions andresponded correctly; hence there was no modification ofquestionnaire at this stage.

In stage two, we evaluated the clinometric properties andvalidity of translated Urdu version of KOOS on primary OAknee patients. The subjects were all consecutive outpatientsconsulting for knee OA in two orthopaedic hospitals. Theinclusion criteria were patient age of at least 40 to 75 years andprimary knee OA according to the American College ofRheumatology (ACR) criteria [5], again confirmed by radio-graph, and patients should be able to understand and com-plete the self-report questionnaires. The exclusion criteriawere the presence of other significant rheumatic diseasevariants, low back pain, severe inflammatory arthritis asconfirmed by physical examination, and intra-articular useof corticosteroids within the previous 3-month history.

A total of 119 patients (47 males and 72 females) wereasked to complete the KOOS questionnaire in Urdu atoutpatient department (OPD) and instructed to come twodays later to fill it once again (111 patients returned [93.28%compliance rate]: 47 males and 64 females). We requestedorthopaedic physicians to give minimal dose of analgesicsfor two days to prevent medicine effect on pain, symptoms,and ADL subscales. We decided 2-day gap as this is minimalrequirement to avoid recall of answers by patients [6].

Item analysis was done using interitem correlation inwhich consistent values of <0.3 or >0.7 should be consideredfor removal of that item (question) as this indicates itemirrelevance to the group (subscale) [7]. Internal consistencyof individual subscales was measured using Cronbach’s alpha(with less than 0.7, removal should be considered [6, 7]),two-day test-retest reliability using ICC [6, 7], percentageof agreement as absolute and >1 point variation between 1st

Table 1: Descriptive values for KOOS subscales in radiographic OAknee patients (𝑛 = 119).

Subscale name Mean ± SD RangeKOOS-pain 44.68 ± 16.64 14–83KOOS-symptom 51.42 ± 15.91 11–96KOOS-ADL 48.61 ± 14.02 18–94KOOS-sports/rec 35.34 ± 15.41 0–75KOOS-QOL 34.15 ± 18.44 0–69

and 2nd time [8], and floor- [lowest 0%] ceiling [highest100%] effect of individual subscales using percentage [8];content validity was measured by comparing degree ofdisease severity assessed by X-ray using one-way ANNOVA[8]; and construct/criterion validity of pain subscale wascompared with VAS using Spearman (rho) correlation [6, 9].All analysis was done in IBM-SPSS (version 21.0) software.

3. Results

Table 1 shows that themeanKOOS ranged from34.15 to 51.42.There was no ceiling (100%) effect; however 2 and 4 personshave lowest (0%) score in sports and recreation and quality oflife (QOL) subscales, respectively.

Table 2 shows internal consistency and test-retest reli-ability of Urdu KOOS questionnaire in primary knee OApatients. Cronbach’s alpha (CA) ranged from 0.725 for QOLsubscale (95% CI 0.634–0.798) to 0.914 for ADL subscale(95% CI 0.889–0.935). Since all subscale CA is greaterthan 0.7, there is no need of removal of subscale from thequestionnaire. Two-day test-retest reliability of Urdu KOOSquestionnaire ranged from 0.967 for symptom subscale (95%CI 0.952–0.977) to 0.986 for ADL subscale (95% CI 0.979–0.990). This table confirms that there is excellent short termtest-retest reliability for KOOS questionnaire Urdu version.

Item analysis showed that 11%, 38%, 21%, 20%, and16% interitem correlation of pain, symptoms, ADL, sports/recreation, and QOL subscales, respectively, were less than0.3 and none of them were greater than 0.7 (see Sup-plement 1 in the Supplementary Material available onlineat https://doi.org/10.1155/2017/1206706). Subsequent analysisshowed that P1 of pain subscale (involving all 4 pairs), S7 ofsymptom subscale (involving 4 out of 8 pairs), and ADL3 andADL16 of ADL subscale (involving 8 and 10 out of 29 pairs)havemost frequently produced interitem correlation less than0.3 within subscale. 50% of P1, 66% of S7, 50% of ADL3, 63%of ADL16 interitem correlation were less than 0.3.

Absolute agreement between 1st and 2nd visit rangedfrom 88.29% to 99.10% (Supplement II). If 1 point differ-ence was allowed, agreement increased to 98.20% to 100%.Agreement for individual items wasmore consistent in sportsand recreation subscale and more different in symptoms andquality of life subscales. If 1 point difference was allowed,all items in sports and recreation subscale showed 100%agreement, whereas other subscales showed 98.20% to 100%.

Table 3 shows the descriptive statistics along with one-way ANNOVA for five subscales of Urdu version of KOOS in

https://doi.org/10.1155/2017/1206706

International Journal of Rheumatology 3

Table 2: Test-retest reliability and internal consistency of five KOOS subscales in Urdu version (𝑛 = 111).

Subscale Test Retest ICC Cronbach’s alphaMean ± SD Mean ± SD

Pain 44.34 ± 16.08 44.79 ± 15.92 0.9782 0.8799Symptom 51.10 ± 15.22 51.59 ± 14.65 0.9673 0.7889ADL 47.98 ± 12.93 47.94 ± 12.84 0.9855 0.9139Sports/rec 35.59 ± 14.25 35.59 ± 13.80 0.9705 0.7563QOL 34.05 ± 18.51 34.41 ± 18.28 0.9685 0.7246

Table 3: Urdu KOOS subscale score for four radiographic OA knee patient groups based on Kellgren-Lawrence (KL) grading.

Subscales KL grade I(𝑛 = 17)

KL grade II(𝑛 = 15)

KL grade III(𝑛 = 39)

KL grade IV(𝑛 = 40) 𝐹 value (significance)

Pain 63.50 ± 7.36 55.71 ± 8.26 44.15 ± 14.20 30.28 ± 10.90 34.875∗∗∗

Symptom 63.38 ± 7.40 59.93 ± 13.81 51.77 ± 14.82 40.68 ± 13.44 12.641∗∗∗

ADL 59.69 ± 9.63 59.07 ± 10.48 47.13 ± 15.19 40.53 ± 9.69 11.279∗∗∗

Sports/rec 47.50 ± 12.11 45.00 ± 11.27 35.90 ± 11.97 22.88 ± 11.87 22.432∗∗∗

QOL 56.56 ± 6.74 48.71 ± 4.81 33.15 ± 8.32 14.75 ± 8.68 142.18∗∗∗∗∗∗Means 𝑝 < 0.001.

OA knee patients who were classified according to Kellgren-Lawrence (K/L) grades I–IV based on their X-ray. In order tosee the content validity, we hypothesised that as the severityof OA knee increases, KOOS score will decrease which isconfirmed in Table 3. Post hoc analysis showed that meandifference (MD) was −11.56 (95% CI −1.46 to −21.66, 𝑝 =0.014) for K/L3 compared to K/L2 and MD −13.88 (−6.58 to−21.18, 𝑝 < 0.001) for K/L4 compared to K/L3 in KOOS-pain subscale. MD was −11.09 (−2.43 to −19.76, 𝑝 = 0.004)for K/L4 compared to K/L3 in KOOS-symptom subscale.MD was −11.94 (−1.18 to −22.70, 𝑝 = 0.019) for K/L3compared to K/L2 in KOOS-ADL subscale. MD was −13.02(−5.48 to −20.57, 𝑝 < 0.001) for K/L4 compared to K/L3 inKOOS sports subscale. MD was −15.56 (−8.74 to −22.38, 𝑝 <0.001) for K/L3 compared to K/L2 and MD −18.40 (−13.48to −23.33, 𝑝 < 0.001) for K/L4 compared to K/L3 in KOOS-QOL subscale. There was no significant difference betweensubsequent other grades in all subscales, that is, betweenK/L1and K/L2, K/L2 and K/L3, and K/L3 and K/L4. There wassignificant difference that existed between grades II and IIIand grades III and IV in majority of subscales meaning goodcontent validity for disease prognosis and treatment. VASwaswell correlated with KOOS-pain (𝑟 −0.76) subscale meaninggood construct validity.

4. Discussion

The present paper has reported the cross-cultural translationofUrdu version ofKOOS alongwith its reliability and validity.We selected 11 KOOS articles in 10 different languages tocompare our results with them. The languages in whichKOOS has been translated are Portuguese [6], Swedish[8, 10], Dutch [9], Chinese [11], French [12], Persian [13],Japanese [14], Italian [15], Arabic [16], and Polish [17]. Theyused radiographically confirmed OA patients [6, 9, 12, 14]

or pre/post-knee surgery patients [8–12, 17] or other kneeinjuries patients [13–16].

All articles reported test-retest reliability (ICC values)in their cross-cultural validation paper. The gap betweentest and retest varied from minimum 1 week in 6 studies[8, 11, 13–16] to 1 year [17] between the tests. The remaining4 studies used 2–4 weeks between tests [6, 9, 10, 12]. Our test-retest reliability values (ICC 0.967–0.986) are greater thanreported by literature. The possible reasons may be that thegap between the test and retest was short (only two days)and severity of OA knee was less as majority of literatureused patients undergoing surgical intervention. Test-retestreliability values are affected by gap duration between thetests [14–16] and severity of the condition [9]. We choosetwo days between test and retest because analgesics given byphysician would improve pain, function subscales of KOOS.Later responsiveness would result in improvement in KOOSsubscales at 1–3 weeks rather than reliability especially gradeI knee OA patients, but it would have increased the recall biasin patients.

The internal consistency of present study ranged between0.725 and 0.914 which is similar to [6, 8, 9, 11–14] or lowerthan [15–17] other translated versions. We have not observedany ceiling effect, but less than 5% floor effect was observedin KOOS sports/recreation and QOL subscales. Literaturereported floor effect in either sports/recreation subscale alone[6, 12, 14, 16] or in both sports/recreation and QOL subscales[8–11, 13, 15].

Our findings of agreement between the items are similarto Roos et al. [8]. Our item analysis showed P1, S7, and ADL16as less appropriate (interitem score less than 0.3) for theirrespective subscale which is supported by Xie et al. [11] inChinese version. Our findings on KOOS subscales based onradiographic grading are supported by de Groot et al. [9]who classified patients into 3 groups, that is, mild, moderate,

4 International Journal of Rheumatology

and severe. Their [9] mild group KOOS subscales values aregreater than our grade I; moderate group values are equal toour grade II and severe group values are equal to our gradeIII OA patients.

Strengths of this article include first Indian languagepaper, fairly large sample, and novel statistical treatment forvalidity. Limitations include weak cross-cultural translationprocess; KOOS results are not compared with SF-36 and didnot report the responsiveness (improvement after treatment).

5. Conclusion

Thepresent results show that KOOSUrdu version is a reliableand valid measure for primary OA knee Urdu speakingIndian patients.

Conflicts of Interest

The authors declare that there are no conflicts of interestregarding the publication of this paper.

References

[1] W. N. Hakala, Negotiating Languages, Columbia UniversityPress, New York, NY, USA, 2016.

[2] S. Kulandaivelan, N. Tigdania, M. Ateef et al., “Prevalence ofknee pain and its correlates with specific emphasis on CVDrisk factors in Hisar urban population,” International Journal ofClinical Rheumatology, vol. 12, no. 4, pp. 91–96, 2017.

[3] M. Ateef, S. Kulandaivelan, and S. Tahseen, “Test-retest reliabil-ity and correlates of 6-minute walk test in patients with primaryosteoarthritis of knees,” Indian Journal of Rheumatology, vol. 11,no. 4, pp. 192–196, 2016.

[4] D. E. Beaton, C. Bombardier, F. Guillemin, and M. B. Ferraz,“Guidelines for the process of cross-cultural adaptation of self-report measures,” The Spine Journal, vol. 25, no. 24, pp. 3186–3191, 2000.

[5] R. Altman, E. Asch, D. Bloch et al., “Development of criteria forthe classification and reporting of osteoarthritis. Classificationof osteoarthritis of the knee,” Arthritis & Rheumatology, vol. 29,no. 8, pp. 1039–1052, 1986.

[6] R. S. Goncalves, J. Cabri, J. P. Pinheiro, and P. L. Ferreira, “Cross-cultural adaptation and validation of the Portuguese version ofthe Knee injury and Osteoarthritis Outcome Score (KOOS),”Osteoarthritis and Cartilage, vol. 17, no. 9, pp. 1156–1162, 2009.

[7] J. Rattray and M. C. Jones, “Essential elements of questionnairedesign and development,” Journal of Clinical Nursing, vol. 16, no.2, pp. 234–243, 2007.

[8] E. M. Roos, H. P. Roos, C. Ekdahl, and L. S. Lohmander, “Kneeinjury and Osteoarthritis Outcome Score (KOOS) - Validationof a Swedish version,” Scandinavian Journal of Medicine &Science in Sports, vol. 8, no. 6, pp. 439–448, 1998.

[9] I. B. de Groot, M. M. Favejee, M. Reijman, J. A. N. Verhaar,and C. B. Terwee, “The dutch version of the knee injury andosteoarthritis outcome score: A validation study,” Health andQuality of Life Outcomes, vol. 6, article no. 16, 2008.

[10] E. M. Roos and S. Toksvig-Larsen, “Knee injury and Osteoar-thritis outcome score (KOOS)—validation and comparison tothe WOMAC in total knee replacement,” Health and Quality ofLife Outcomes, vol. 1, article 17, 2003.

[11] F. Xie, S.-C. Li, E. M. Roos et al., “Cross-cultural adaptationand validation of Singapore English and Chinese versions ofthe Knee injury and Osteoarthritis Outcome Score (KOOS) inAsianswith knee osteoarthritis in Singapore,”Osteoarthritis andCartilage, vol. 14, no. 11, pp. 1098–1103, 2006.

[12] P. Ornetti, S. Parratte, L. Gossec et al., “Cross-cultural adap-tation and validation of the French version of the knee injuryand osteoarthritis outcome score (KOOS) in knee osteoarthritispatients,” Osteoarthritis and Cartilage, vol. 16, no. 4, pp. 423–428, 2008.

[13] M. Salavati, M. Mazaheri, H. Negahban et al., “Validation ofa persian-version of knee injury and osteoarthritis outcomescore (KOOS) in Iranians with knee injuries,”Osteoarthritis andCartilage, vol. 16, no. 10, pp. 1178–1182, 2008.

[14] N. Nakamura, R. Takeuchi, T. Sawaguchi, H. Ishikawa, T. Saito,and S. Goldhahn, “Cross-cultural adaptation and validation ofthe Japanese Knee Injury and Osteoarthritis Outcome Score(KOOS),” Journal of Orthopaedic Science, vol. 16, no. 5, pp. 516–523, 2011.

[15] M. Monticone, S. Ferrante, S. Salvaderi et al., “Development ofthe Italian version of the knee injury and osteoarthritis outcomescore for patients with knee injuries: Cross-cultural adaptation,dimensionality, reliability, and validity,” Osteoarthritis and Car-tilage, vol. 20, no. 4, pp. 330–335, 2012.

[16] A. Almangoush, L. Herrington, I. Attia et al., “Cross-culturaladaptation, reliability, internal consistency and validation of theArabic version of the Knee injury and Osteoarthritis OutcomeScore (KOOS) for Egyptian people with knee injuries,” Oste-oarthritis and Cartilage, vol. 21, no. 12, pp. 1855–1864, 2013.

[17] P. T. Paradowski, D.Witonski, R. Keska, and E.M. Roos, “Cross-cultural translation and measurement properties of the Polishversion of the Knee injury and Osteoarthritis Outcome Score(KOOS) following anterior cruciate ligament reconstruction,”Health and Quality of Life Outcomes, vol. 11, no. 1, article no. 107,2013.

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KNOWLEDGE OF THE SEGMENTAL ANATOMY OF LIVER AND ITS IMPORTANCE

ORIGINAL RESEARCH PAPER

Sivanandan Ramar

Asst. Prof., Dept. of Anatomy, Madha Medical College, Chennai, India.

Radha Krishnan Lecturer, Dept. of Physical therapy, CAMS, Majmaah University, Kingdom of Saudi Arabia

Mazen Alqahtani Asst Prof., Dept. of Physical therapy, CAMS, Majmaah University, Kingdom of Saudi Arabia

KEYWORDS:portal pedicle, lobotomy, segments of liver and conservative surgery

INTRODUCTION1Liver is the largest abdominal organ , which lies under cover of right

lower ribs and closely applied to the undersurface of the diaphragm 2which coincides with the costal margin . It is covered by the visceral

3peritoneum of the Glisson's capsule , which thickens into three folds or ligaments connecting it to the abdominal wall. e internal architecture of the liver is composed of series of segments that combine to form sectors separated by scissura containing hepatic

4veins . Essentially the three main hepatic veins, right hepatic vein, middle hepatic vein and the left hepatic vein within the scissurae divide the liver into four sectors each of which receives a portal pedicle. e portal pedicle which is the portal triad that contains of hepatic artery, portal vein and the hepatic duct. e portal pedicle divides into right and left pedicles which enters the respective lobes and subdivide again to form the segmental branches thus dividing

5the sectors into 8 segments . e main portal scissura contains the middle hepatic veins and progresses from the middle of the gall bladder fossa anteriorly to the left of the inferior vena cava

6posteriorly . is forms the right and left lobe of liver both of which are independent in terms of portal and arterial vascularization and of

7,8biliary drainage .

AIM OF THIS STUDYTo study the segmental anatomy of liver by using manual, radiological and ultrasonic method.

MATERIALS AND METHODSis study of segmental anatomy of liver was done in the Department of Anatomy, Kasturba Medical College, Mangalore.

Venue of study1. Department of Anatomy, Kasturba Medical College, Mangalore -

1

2. Department of Forensic Medicine, Kasturba Medical College, Mangalore -1.

3. Department of Radiology, Kasturba Medical College, Mangalore-1.

Collection of specimens e liver specimens with which the study of segmental anatomy was studied were procured from the Department of Forensic Medicine, Kasturba Medical College, Mangalore. All the specimens studied were adult specimens. All the specimens were taken from post – mortem bodies. e cause of death was due to reasons other than liver problems. During the harvesting of the liver specimens no gross anomalies were noted. During the harvesting of the specimens the falciform ligament was retained and a long portal pedicle along with

9the gall bladder was taken . e inferior vena cava was cut at the level little above and below the posterior surface of the liver. is was done to preserve the opening of the hepatic veins into the inferior vena cava. is study of segmental anatomy of liver was conducted in 100 specimens in the following methods.

Materials 1. Cadaveric specimen - 302. Autopsy specimen - 303. Radiological method - 204. Ultrasound method - 20

Methods of studyFollowing methods were used in this study for the segmental anatomy of liver

1. Manual dissection method2. Radiological study by contrast method3. Ultrasound method

INTERNATIONAL JOURNAL OF SCIENTIFIC RESEARCH

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ABSTRACTIntroduction : Liver is composed of series of segments that combine to form sectors each of which receives a portal pedicle. is portal pedicle divides into right and left which enters the respective lobes and subdivide again to form the segmental branches thus dividing the sectors into 8 segments. In the past decades, lobotomies were regularly performed, where a large amount of liver tissue was sacrificed for a small tumor present and the results were poor. With more conservative surgeries and post-operative treatment procedures, the segmental pattern of the liver becomes important.Aim: To study the segmental anatomy of liver by using manual, radiological and ultrasonic method.Material and methods : is study of segmental anatomy of liver was conducted in 100 specimens in the Cadaveric manual dissection method, Radiological method, and Ultrasound methodResults: In this study the three major hepatic veins, the right hepatic vein, left hepatic vein and the middle hepatic vein were observed in all the specimen. Primarily, the middle hepatic vein join with the left hepatic vein which form a common trunk before draining into the inferior vena cava. Secondly, Portal vein had bifurcation pattern of division into right and left portal vein and had segmental division to all the segments of the liver. Discussion : Knowledge of the segmental anatomy very much used for the postoperative treatment mainly the patients posted for lobotomies of liver or segmental surgeries need an intensive nursing care to avoid post-operative complications such as pulmonary complications, deep vein thrombosis, incision hernia, post-operative incision pain and delayed healing of surgical sutures. e variations at this segmental level should be kept in mind to avoid disastrous results. So, the need for more limited resection of the liver has prompted the researchers to look closer into the segmental anatomy of the liver and find more about this organ as well as the anomalies that can spring surprises.

220 International Journal of Scientific Research616 International Journal of Scientific Research

I. MANUAL DISSECTION METHOD1. Cadaveric study e liver specimens with which the study of segmental anatomy was studied in cadavers which was used in dissection hall for study purposes. e study was done on 30% formalin fixed dissecting room cadavers. e mean age of the cadavers was 60 years (Range 45- 75) with a sex distribution of 20 males and 10 females. A midline incision made in the anterior abdominal wall from the xiphi-sternum upto the umbilicus. From the lower end of the incision, a transverse incision was made till the mid axillary line. Skin flap was raised and the rectus abdominis were reflected in the same plane. Peritoneum was opened. Liver and stomach were visualized. e liver was released from its attachments. e collected liver specimens were washed thoroughly and dissected under water to see segments along

10its vascular planes .

2. Autopsy Specimen StudyIn this method of study, 30 adult liver specimens were studied. e specimens taken from the Forensic Medicine Department of Kasturba Medical College and washed thoroughly with running water to remove all the blood that may ooze through the cut veins. en they were kept in 10% formalin solution and allowed to remain in formalin for 10 days. is was done so that the soft friable liver tissue will get fixed making it easy for the dissection to be done. en the specimens were ready for the dissection to see the structures. In this dissection, the hepatic veins and portals veins were studied. e dissection of the hepatic vein was done starting from the inferior vena cava and followed into the liver substance and the three hepatic

11veins were studied . e portal vein was dissected from the portal pedicle from where it was separated from the hepatic artery and bile duct. It was then traced into the liver substance and the branching pattern studied.

II. RADIOLOGICAL STUDY BY CONTRAST METHODIn this method of study of the segmental anatomy of liver, 20 specimens were studied. e liver got from the Forensic Medicine Department was washed in running water thoroughly to remove all the blood. e hepatic artery and the bile duct were flushed with syringe to remove the blood and excess bile which would help in the flow of the contrast agents. e contrast agent used was urograffin which was injected into the bile duct and the hepatic artery and x

12rays were taken .

III. ULTRASOUND METHOD – CLINICAL STUDYis was done at the department of Radiology at Kasturba Medical College, Mangalore. is study was done on 20 patients who had referred for abdominal scan for other reasons other than liver problems. All the patients selected were adult patients. As a routine for abdominal scan the patients were asked to come in empty stomach. Some of the patients could drink sips of water to prevent excessive thirst.

e patients were made to lie in supine position for the scan for liver. Before proceeding for the scan, the abdomen was palpated to exclude any enlargement of liver or pain abdomen. e probe used for the

13liver scan had a transducer of 3.5 MHz . is was selected because at this frequency the penetration was good. But the resolution is always low. e scanning was done in sagittal plane, transverse plane, oblique planes. Intercostals and subcostal views were also seen. In this method, the hepatic veins and its branching pattern, portal vein and its branching and bile ducts were observed.

OBSERVATIONSe study of the segmental anatomy of liver and its clinical importance done at the Department of Anatomy, Kasturba Medical College, is based upon the hepatic veins which divided the liver into lobes and the branching of the portal vein, hepatic artery, and the hepatic duct. In this study the manual dissection method was used to observe the branching pattern of hepatic veins and portal vein. In the radiological method, the urograffin contrast agent was used to study the segmental branching pattern of hepatic artery and the hepatic

duct. In the ultrasound method, which was the easiest to perform and great deal of information was available in short time. In this method, the hepatic veins, portal vein, and the hepatic duct were also observed. In the ultrasound method, the segments of the liver were studied and the findings correlated with the finding of the manual dissection and radiological methods.

e findings observed are given below

Hepatic Veins

Portal vein

Hepatic artery

Bile duct pattern

DISCUSSIONSEGMENTS OF LIVER e importance of more conservative surgery and need for limited resection of liver lead to establish the segmental anatomy of liver where the liver is divided into still smaller functional segments than just lobes.

After the establishment of the major vascular territories of arteries 16and hepatic venous supply , the traditional method of division of the

hepatic segments based on the topographical relation of the liver was dropped and classification based on the vasculature of liver started. In the American system, the liver was divided into four lobes and the importance of the caudate lobe was not considered here but this formed the basis of the four classical types of hepatic resection. In the French system, there are 8 segments and the caudate lobe is considered as independent lobe and this gained popularity and it is now globally accepted by surgeon of the two system of classification

17of segmental anatomy of liver that are present .

Claude de Couinaud a French surgeon and anatomist proposed the new segmental anatomy of liver. He divided the liver into 8 segments. He described that the right lobe is divided into two sectors namely anteromedial and posterolateral. e anteromedial sector was

14. divided into segment V anterior and segment VIII posterior e posterolateral sector was divided into segment VI anterior and

segment VII posterior. He divided the left lobe into three segments and named them segment II posterior and segment III anterior and

ISSN No 2277 - 8179 | IF : 4.176 | IC Value : 78.46VOLUME-6 | ISSUE-5 | MAY - 2017

617International Journal of Scientific Research

S. No. Various pattern observed

Number of specimens Percentage %

1 Right hepatic vein is larger than the middle & left hepatic veins

80 100%

2 Middle hepatic vein observed to join the left hepatic vein

70 87%

3 A single vein was seen draining the caudate lobe of the liver

80 100%

S. No. Various pattern observed Number of

specimens Percentage %

1 Bifurcation pattern 71 88%2 Trifurcation pattern 7 8%3 Accessory portal vein 2 4%



1 Arising from the coeliac axis 20 100%2 Hepatic artery divides into

right & left hepatic artery20 100%

3 Right hepatic artery divides into superior & inferior

20 100%



1 Triple confluence 2 10%

segment IV medial to umbilical fissure. e Spigelian lobe or the caudate lobe or the segment I is considered as an autonomous

segment.In this study, all the specimens studied were found to have 8 segments that corresponded to the Couinaud segments.

HEPATIC VEINS With the establishment of relationships between the portal venous

1 7system and hepatic venous systems , (Glisson 1659) the nomenclature for major branching of intrahepatic portal vein and for major hepatic veins.

Couinaud description of the segments was based upon the division of liver into eight segments following the distribution of the portal pedicles and the location of three hepatic veins. He had put forward that the middle hepatic vein separates the whole liver into right and left lobe. e right hepatic vein further separates the right liver into right posterior sector and right anterior sector and left hepatic vein separates the left liver into the left anterior sector and left posterior sector. In the drainage of hepatic veins observed, in 75% of specimens the left hepatic vein joining with the middle hepatic vein to empty

18into the inferior vena cava .

L. H. Blumgart in his description says that the hepatic veins drain directly from the upper part of the posterior surface of the liver at

19somewhat oblique angle directly into the inferior vena cava . e right hepatic vein somewhat larger than the left vein. e middle hepatic veins have short extra hepatic course. e left and middle hepatic veins may drain separately into the inferior vena cava but frequently joined after a short extra hepatic course to form a common venous channel. He also describes that there are also other short hepatic veins that drain into the inferior vana cava.

Peter I Williams (38th edition) Grays anatomy states that there are three hepatic veins drain into inferior vena cava. e most commonly

20the middle hepatic vein joining with the left hepatic vein. In a majority of cases, the diameters of the right and left hepatic veins were between 7 mm and 13 mm. No gender differences were found in the study by Sharma D Deshmukh A, Rains VK (2001) and they have observed that in 96 % of cases the middle and left hepatic veins

21form a common trunk . Variations in the drainage pattern of hepatic 22veins have been reported from time to time. ese include accessory

right hepatic veins, (Van Leewwen et al., 1994, De Cecchis et al, 2000) significant accessory hepatic veins (Marcos et al., 2000) and accessory suprahepatic veins (Bach et al 1994-95). e knowledge of this accessory vein is important for the operating surgeon.

In the present study, the right hepatic vein, left hepatic vein and the middle hepatic vein were seen in all the specimens, and in 51 0f 58 specimens studied the middle hepatic vein was seen joining with the left hepatic vein. is coincides with the observations of (H. Bismuth and Peter I Williams) there were no accessory veins observed

PORTAL VEIN Supplying almost two third of the blood to the liver, this portal vein was important not only for the digestive purpose by bringing all the splanchnic blood, it was also important for the segmentation of liver. It was Looten (1908) who claimed vascular independence of right and left lobes based on the portal vein branching. en it was Segell (1923) studied by injecting radio opaque gelatin into vessels of human liver obtained by autopsy. He gave general information of the 4 systems – portal vein, hepatic Artery, hepatic vein and hepatic duct.

Couinauds in 1953 described the division of liver into sectors by the hepatic veins. e anteromedial sector is divided into segment V anterior and segment VIII posterior. e posterolateral sector is divided into segment VI anterior and segment VII posterior. Left lobe of liver divided into segment III anterior, segment II posterior and segment IV medial to the umbilical fissure. e Spegelian lobe or segment I considered as an autonomous segment since it receives vascularization both form right and left branch of portal vein and its

venous drainage directly into inferior vena cava.

ere are 3 patterns of portal vein branching described by Couinauds

Pattern I: Immediate trifurcation of main portal trunk into right anterior right posterior and left portal branches was observed in 8/103 specimens studied.

Pattern II: Right posterior segmental branch arises directly from the main portal trunk and seen in 6/103 specimens (5.8%) studied

Pattern III: e origin of the right anterior segmental branch form left portal vein was seen in 3/103 specimens (2.9%)

Studying the left branch of portal vein, it was described that the left branch of the portal vein curved laterally at the root of the ligamentum teres and along with the hepatic artery it gave feedback vessels to the medial segment IV i.e., the quadrate lobe (Goldsmith and Woodburne 1957). In anatomical record (Hans Ekuas 1952) stated that the intrahepatic portal venous system presente a constant "skeleton" for the liver. It was represented as "Trellis". With the non- invasive method of investigation like the ultrasound and computerised tomography it became easy to study the vascular pattern which also threw light on variations in pattern of branching. In ultrasound examination, the portal branches to the four segments of each lobe are letter "H" as was described by Lafortune. Margeret et al (1990) reported in colour Doppler study a large aberrant branch from the anterior segmental branch to the medial segment of the left lobe. Osamu matsui et al., (1997) reported a branch from right portal vein distributed to posterior aspect of segment IV.

In the present study, the portal vein was seen to have a normal bifurcation pattern and division into the segmental branches correlating with the Couinauds observation that the trifurcation pattern was observed in less than 8% of cases. e segmental branching of portal vein was observed in the typical H pattern in all the specimens studied correlating with the Lafortune description. In 2 specimens, accessory vein were given to the segment IV i.e., the quadrate lobe from the anterior segmental branch of the right branch of the portal vein.

is correlates with the observations made by Margaret et al and Osamu Matsui et al.

HEPATIC ARTERY e importance of good knowledge of the hepatic artery not only helps in the hepatobiliary surgeries, but is also useful in selective embolization for the control of tumor growth.

Michels (1966) stated that despite variations in origin and occurrence of accessory vessels, the hepatic arterial system consists of end arteries.

Variations of the arterial anatomy are common (Bismuth) and among the most frequent are

1. e presence of supplementary hepatic artery to the right lobe or of a replaced hepatic artery. 2. Left hepatic artery originated from the left gastric artery may be found in the lesser omentum.

In the study of the arterial supply of left hemi liver done by Mlakar B et al the observed that the left hemi liver was supplied by one artery

23 in 53 % of cases, by two arteries in 40 % and by three arteries in 7%.e left hepatic artery, which originated from the proper hepatic

artery, supplied all three left segments in 39% of specimens. e replacing left hepatic artery, which originated from the left gastric artery supplied the whole left hemi liver in 30 % of cases.

In this present study, hepatic artery was seen arising from the coeliac

220 International Journal of Scientific Research618 International Journal of Scientific Research


24axis correlating with the observation by Decker & Du Plessis 1986. e hepatic artery was seen dividing into right and left hepatic arteries. No variations in origin or branching was noted. e right hepatic artery divided into right anterior segmental branch which divided into superior and inferior branches to supply the segment VIII and segment V. Left posterior segmental branch dividing into the superior and inferior branches to supply the segment VI and segment VII.

BILE DUCTS e aberrant hepatic biliary segmental anatomy was studied using Magnetic Resonance cholangiographic method by Koenraad J. Mortele et al (2001) the most common anatomic variants in the branching of the biliary tree involved the right posterior duct and its

25fusion with the right anterior or left hepatic duct . Another common variant (11%) of the main hepatic biliary branching is the so called triple confluence. e branching pattern of intra hepatic ducts was

26atypical in 37% of cases was observed by Jin Woo Choie in 2003 . e two most common variations were drainage of the right posterior segmental duct into the left hepatic duct (11%) and triple confluence of the right anterior segmental duct, right posterior segmental duct and left hepatic duct (10%).

Blumgart (1988) has studied the hepatic duct confluence and concluded that the most common variations was drainage of the right anterior or right posterior segment into common hepatic duct in 16 % and the triple confluence in 12 % of the cases. In the present study two specimens out of 20 studied by radiological method showed the triple confluence of the hepatic duct thus correlating with the previous studies (Blumgart / Choi / Koenraad J. Mortele)

27which showed it as one of the common variations .

SUMMARYIn this study the hepatic vasculature was studied first, as this forms the basis of the segmental pattern of the liver and the functional anatomy. In this study the three major hepatic veins, the right hepatic vein, left hepatic vein and the middle hepatic vein were observed in all the specimen. In 87 % of observation the middle hepatic vein joined with the left hepatic vein and formed a common trunk before draining into the inferior vena cava. A single vein was seen draining the caudate lobe the liver. In all the 80 specimens studied the portal vein had bifurcation pattern of division into right and left portal vein and had segmental division to all the segments of the liver. e caudate lobe was seen to receive portal blood from both the right and left portal vein. A single variation was observed in one specimen where an accessory portal vein was seen from the right anterior division of portal vein to the quadrate lobe.

No variations were seen in the hepatic artery pattern of segmental branching. Triple confluence of the hepatic ducts was seen in one specimen. All the segments were seen in all the 80 liver specimens observed. is observation on the segmental anatomy of the liver and its variations has great importance to the opening surgeon because a neat surgery is the gateway to successful results. In the past decades, lobotomies were regularly performed, where a large amount of liver tissue was sacrificed for a small tumor present and the results were poor. With more conservative surgeries the segmental pattern of the liver becomes important. e variations at this segmental level should be kept in mind to avoid disastrous results.

So, knowledge of the segmental anatomy very much used for the postoperative treatment mainly the patients posted for lobotomies of liver or segmental surgeries need an intensive nursing care to avoid post-operative complications such as pulmonary complications, deep vein thrombosis, incision hernia, post-operative incision pain and delayed healing of surgical sutures. Physical therapy exercises advised to patients after the surgery reduces these complications and minimizes losses in lung function and improves the strength of

28respiratory muscles and shortens the period of hospital stay . e more recent studies document that the use of elasticized abdominal binders will improve walk performance, controlling pain and

29 30distress, and improving patients' experience , .

References1. W.P. Longmire, R.K. Tompkins (2012) “Manual of Liver Surgery” Springer Science &

Business Media. P. 154.2. William R. Jarnagin (2012) “Blumgart's Surgery of the Liver, Pancreas and Biliary

Tract.”(5th edition). Elsevier, Saunders.3. Ronald S. Chamberlain, L. H. Blumgart (2000) “Hepatobiliary Surgery” Landes

Bioscience, the University of Michigan.4. Ronald S. Chamberla in (2013) “Essential Functional Hepatic and Biliary Anatomy for

the Surgeon” Chapter (2). Hepatic Surgery", Hesham Abdeldayem.5. Pietro Majno et.al (2013) “Anatomy of the liver: An outline with three levels of

complexity – A further step towards tailored territorial liver resections.” European Association for the Study of the Liver, Elsevier B.V. March 2014 ,Volume 60, Issue 3, Pages 654–662.

6. F. Charles Brunicardi, Dana K. Andersen, Timothy R. Billiar, David L. Dunn, John G. Hunter, Jeffrey B. Matthews, Raphael E. Pollock (2015 ).” Schwartz's Principles of Surgery”, 10e.

7. Sjaak Pouwels.et.al “Preoperative exercise therapy for elective major abdominal surgery: A systematic review”. International Journal of Surgery,Volume 12, Issue 2, February 2014, Pages 134–140.

8. Roberta Munhoz Manzano,” Chest physiotherapy during immediate postoperative period among patients undergoing upper abdominal surgery: randomized clinical trial”.Sao Paulo Med J. 2008;126(5):269-73.

9. Margaret Farquharson, James Hollingshead, Brendan Moran (2014 ).Farquharson's Textbook of Operative General Surgery, 10th Edition.CRC press,Taylor and Francis Group.

10. Camran Nezhat.(2000),Operative Gynecologic Laparoscopy: Principles and Techniques,2edition.Mc Graw Hill.

11. Edward R. Howard (1991).” Surgery of liver disease in children”, Butterworth-Heinemann.

12. Henrik omsen, Robert N. Muller, Robert F. Mattrey (2012). “Trends in Contrast Media ”.Springer.

13. Ellen J. Hagopian, Junji Machi (2014). “Abdominal Ultrasound for Surgeons” .Springer.14. Angela D. Levy, Koenraad J. Mortele, Benjamin M. Yeh – 2015.” Gastrointestinal

Imaging.Oxford publications.15. Robin Smithuis and Eduard E. de Lange. (2006) “Anatomy of the liver segments”.16. C.Couinaud (1999). “ Liver Anatomy: Portal (and Suprahepatic) or Biliary

Segmentation”. Dig Surg 1999;16:459–467.17. Mavrides E1.et al. (2001)“e anatomy of the umbilical, portal and hepatic venous

systems in the human fetus at 14-19 weeks of gestation.” Ultrasound Obstet Gynecol. Dec; 18(6):598-604.

18. H Bismuth. Surgical anatomy and anatomical surgery of the liver. World J surg. 1982;6:3–9.

19. Blumgart LH, Belghiti J. Surgery of the liver, biliary tract, and pancreas. 3rd edition. Philadelphia: Saunders Elsevier; 2007. pp. 3–30.

20. Peter L. Williams - Gray's Anatomy: Churchill Livingstone; 38 edition (January 8, 1995).21. Sharma D.et.al “Surgical anatomy of retrohepatic inferior vena cava and hepatic veins:

a quantitative assessment. Indian J Gastroenterol. 2001 Jul-Aug;20(4):136-9.22. Van Leeuwen .et.al(1994) : Variations in venous and segmental anatomy of the liver :

two and three dimensional MR imaging in healthy volunteers. American Journal of Roentgenology 162 (6): 1337-45

23. Mlakar B.et.al “ Anatomical variations of the cystic artery”. Eur J Morphol. 2003 Feb;41(1):31-4.

24. Decker,G.A.G and du Plessis, D.J. Lee McGregor’s Synopsis of Surgical Anatomy: e liver and biliary system. 12th Edn. John Wright & Sons Ltd. Bristol. pp 86-87 (1986)

25. Mortele KJ, Wiesner W, Ji H, Ros PR. Scientific Teaching Exhibit: Usual and Unusual Causes of Extrahepatic Cholestasis: Assessment with Magnetic Resonance Cholangiography (MRC) and ultrafast MR imaging. 2001.

26. Jin Woo Choi, et.al.Anatomic Variation in Intrahepatic Bile Ducts: an Analysis of Intraoperative Cholangiograms in 300 Consecutive Donors for Living Donor Liver Transplantation. Korean J Radiol. 2003 Apr-Jun; 4(2): 85–90.

27. Koenraad J. Mortelé .et.al. “Anatomic variants of biliary tree MR cholangiographic finding and clinical applications.American Journal of Roentgenology ,Volume 177, Issue 2 ,Anatomic Variants Of e Biliary Tree. August 2001, Volume 177,

28. Dronkers J. et.al “Prevention of pulmonary complications after upper abdominal surgery by preoperative intensive inspiratory muscle training: a randomized controlled pilot study. Clin Rehabil. 2008;22(2):134-42).

29. omas J. Hoogeboom.et.al. “Merits of exercise therapy before and after major surgery”.,a Curr Opin Anaesthesiol. 2014 Apr; 27(2): 161–166

30. Oren Cheifetz.et.al “e Effect of Abdominal Support on Functional Outcomes in Patients Following Major Abdominal Surgery: A Randomized Controlled Trial” Physiother Can. 2010 Summer; 62.

619International Journal of Scientific Research


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