1. Introduction

Worldwide, medical centers try to improve the health care system in its trilogy: care, health, and cost. Patient satisfaction is pointed out as an important clinical indicator for evaluating service quality. However, postoperative nausea and vomiting is still one of the most common and unpleasant side effects following surgeries under general anesthesia, with a mean overall incidence between 30-40% [1].

Perioperative opioid use remains one of the major participants in this issue. Opioids have been the mainstay of pain management for thousands of years, owing to their cost effectiveness in both the inpatient and outpatient settings. Aside from these attributes, opioids have significant side effects associated with nausea, vomiting, constipation, physical dependence, tolerance, and respiratory depression [2].

Morphine, the prototype opiate agent, traces its origin to single plant-the opium poppy. It has been used for centuries for recreation before it became widely used as a pain reliever, particularly in the 1800s. Due to its long analgesic duration of 4-5 hours, low cost, and extensive availability, it is often selected to control postoperative pain [3] preemptively.

Nevertheless, the disadvantages of morphine: slow onset of analgesia (20 min), unsuitability for hemodynamically unstable patients, and several other adverse effects have shed light on recent studies that adopt the use of alternative opioids or combination therapy to tackle this problem [4].

On the other hand, Oxycodone, a semi-synthetic opioid alkaloid derived from Thebaine, is a moderately potent opioid analgesic, developed in 1916 in Germany and has recently been used in Lebanon in an attempt to improve the existing opioids [5].

The recent interest in Oxycodone is based on its favorable pharmacokinetics and pharmacodynamics, especially in the central nervous system [6]. Moreover, relatively high enteral bioavailability allows an easy switch from one drug formulation to another during the course of pain management.

Oxycodone is highly effective and well tolerated in different types of surgical procedures and patient groups. One study conducted at New York University Langone Medical Center in the United States of America showed that the incidence of postoperative nausea and vomiting associated with Oxycodone is 19% [7], which is believed to surpass all the previous opioids, and mainly morphine.

Antiemetic agents were added to reduce one of the well-known side effects of opioids in postoperative settings. Zofran (Ondansetron) is a selective 5-HT3 receptor antagonist, approved by the FDA in 1991, triggers the area postrema in the brainstem [8], with primary effects in the gastrointestinal tract, reducing, therefore, nausea and vomiting within 30 min after IV or IM administration.

Our study aims to add to the previous research that aimed to find the best remedy for postoperative nausea and vomiting to improve patient satisfaction. Alongside pain, PONV is one of the most frequently encountered problems after surgical procedures, and its incidence could reach 30% [1]. While pain management is currently well managed, as well as morbidity and mortality from anesthetic agents, patients' satisfaction is affected by their PONV experience [7]. Patients were sometimes willing to sacrifice by bearing pain, so they would not experience NV [4]. PONV could also affect patients' bills by increasing their length of stay at the PACU. Therefore, recommendations to prevent and manage PONV are currently gaining interest, and research in this field is growing. Nausea and vomiting could be perceived as normal reactions of the body to any emetic stimulus. This includes a variety of stimuli such as food toxins and side effects of drug therapy. The stimulus is first detected by the abdominal vagal afferents, the area posterma, and the vestibular system. This leads to nausea, an unpleasant but nonpainful reaction, which prepares the body to learn either aversion or avoidance. Another reaction to this stimulus detection (that could also be present with it) is vomiting, a reflex reaction that helps to eject the toxins from the gastrointestinal tract. Studies showed that surgery duration, gender, age, smoking, BMI, pain level, and treatment agent were associated with a higher incidence of PONV [1]. A systematic review of the literature summarized evidence levels for all risk factors of PONV. The risk factors are mainly anesthesia dependents, such as volatile anesthetics and nitrous oxide administration, or concern the postoperative and intraoperative administration of opioids.

Prevention of PONV relies first on avoiding its risk factors where possible and preferring less emetic anesthetic agents and pain killers whenever possible. Zofran (Ondansetron) is a selective 5-HT3 receptor antagonist, approved by the FDA in 1991, triggers the area postrema in the brainstem [8], with primary effects in the gastrointestinal tract, reducing, therefore, nausea and vomiting within 30 min after IV administration. Moreover, its administration was known to reduce the incidence of PONV in adults [9] and pediatric population [10]. Besides, the Ondansetron effect with a 4mg dosage was found to be superior to 10 mg of metoclopramide in preventing PONV incidence and giving higher patient satisfaction scores in a systematic review of literature [11].

2. Objectives

2.1. Primary objective

The primary purpose of this study was to compare which combination Zofran and Oxycodone versus Zofran and Morphine is better for the prevention of post-operative nausea and vomiting and improvement of patient satisfaction.

2.2. Secondary objectives

Our study's secondary objectives were to:

• Evaluate the safety, acceptability and effectiveness of Zofran in decreasing post- operative nausea and vomiting.
• Detect the factors that affect the nausea and vomiting severity in our target population.

3. Subjects and methods

3.1. Ethical consideration

First of all, the clearance and approval of the ethical committee at Mount Lebanon Hospital was obtained on November 13, 2018 to be able to start recruitment. All patients willingly participated to the study after signing the informed consent before their surgery. They were informed by the study team about the study, that they will be blinded to the treatment they receive, as well as about their right to drop out from the study at any time. Besides, all data was confidential, patients' identities were to remain only available for their doctors and the treating team during their hospitalization, and no use of any personal information was intended for any purpose other than this research.

3.2. Study design

A prospective, monocentric clinical trial study was conducted at Mont Lebanon Hospital (MLH), between November 2018 and November 2021, to assess the post-operative nausea and vomiting PONV in patients undergoing elective surgeries under general anaesthesia. It was double blinded: study participants and the anesthesiologists collecting and analyzing clinical data were unaware of the assigned treatment. After obtaining written informed consent, the patients were divided into two groups, each receiving a treatment. Patients were thus enrolled on a ratio of 1 to 2 in two groups: the first receiving Oxycodone 5 mg IVP with Zofran 4 mg IVD and the second receiving Morphine 5 mg IVP with Zofran 4mg IVD.

3.3. Study population

Our study population consisted of 237 patients who underwent elective surgeries and who had a numerical rating scale (NRS) of 6 /10 or more at the post anesthetic care unit (PACU).

3.4. Inclusion criteria

Subjects must meet the following criteria to be enrolled in the trial:

• Male or female aged between 19 and 65 years.
• Fits the American Society of Anesthesiology ASA1 and ASA2
• Undergoing elective surgery under general anesthesia

3.5 Exclusion criteria

Subjects are excluded from enrolment if any of the following criteria is present:

• Age below 18 or more than 65 years
• Known allergy to opioid or ondansetron
• Known Chronic obstructive pulmonary disease (COPD)
• Known to have moderate to severe hepatic failure
• Known to have Severe renal insufficiency (serum creatinine >1.6 mg/dl)
• Current Pregnancy
• Patient with head injury
• Antiemetic use within 24 hours

3.6. Sample size

Recent studies showed that the incidence of post-operative nausea and vomiting after oxycodone use post general anesthesia was 19% [7] versus 12%-38% for morphine [12]. A 50% decrease in the incidence down to 9% with Zofran was considered clinically significant with alpha=0.05 and beta = 0.2. An intermediate analysis was performed, with a total sample of 237 patients, divided into 2 groups, in whom the informed consent was obtained, and who fitted the eligibility criteria.

4. Material and procedure of data collection

4.1. Material

Zofran 4mg IVD was given systematically to all patients 30 min before the end of the surgery. Oxycodone 5 mg IVD was given in the PACU in the first group of patients. For the second one, Morphine 5 mg IVD was used.

4.2. Procedure

Before induction of anesthesia, all patients were assessed , description of the treatment plan as well as exciting alternatives were explained , and participation in the study was obtained through informed consent . Thirty minutes before the end of the operation, both groups were given 4mg Zofran. All patients were then escorted to the post anesthesia care unit (PACU) and monitoring was standardized for all patients including ECG, pulse oximetry and noninvasive blood pressure (NIBP). Those who had a pain scale more than 6 /10, received morphine or oxycodone and were monitored for the next 2 hours. A questionnaire was filled by the anesthesiologists to assess post-operative nausea and vomiting after oxycodone use vs. morphine, each with the same dose of Zofran 4 mg. All episodes of nausea and emesis were recorded using a severity scale from 0 to 2 under the assessment time frame from 0 to 2 hours:

• T0: PONV immediately after receiving pain killer.
• T1: PONV at 1 hour after receiving pain killer.
• T2: PONV at 2 hours after receiving pain killer.

5. Data analysis

Data entry was done on Excel. Data analysis was done using SPSS version 22. Categorical variables were represented using frequencies and percentages. Pearson's chi square test was used to check the difference between groups for categorical variables. Fisher's Exact test was used instead of it when the cell count wasn't enough to perform Pearson's chi square test. First groups differences were assessed, then the variables affecting the nausea and vomiting (NV) severity were evaluated. Finally, nausea and vomiting incidence at T0, T1, and T2 were evaluated.

6. Results

6.1. Nausea and vomiting incidence in groups

The incidence of nausea and vomiting immediately after the dose is 10% in Oxycodone group and 8.2% in Morphine group, without any statistically significant difference between the two treatment groups (Fisher's Exact Test p-value = 0.636) (Figure 1).

The following figure shows the incidence of nausea and vomiting one hour after the dose: 15% of Oxycodone patients experienced NV, versus 8.9 % in the group who received Morphine, without any statistically significant difference (Pearson's chi square test p-value = 0.187) (Figure 2).

There was a statistically significant (Pearson's chi square test p-value = 0.047 < 0.05) lower nausea and vomiting incidence in the Morphine group (2.5%) compared to the Oxycodone group (8.8% incidence) (Figure 3).

7. Discussion

This monocentric controlled trial was mainly conducted to compare which combination Zofran and oxycodone versus Zofran and morphine is better for the prevention of post-operative nausea and vomiting and improvement of patient satisfaction. It also aimed to evaluate the safety, acceptability and effectiveness of Zofran in decreasing post-operative nausea and vomiting, and to detect the factors that affect the nausea and vomiting severity in our target population. 237 patients were divided into two groups. We assessed the analgesic effects of both treatments by checking the differences in NRS scale. We evaluated Zofran efficacy in reducing the incidence and the severity of PONV. Finally, we evaluated the factors associated with severity of PONV.

Our study showed a statistically significant (p-value = 0.047) lower nausea and vomiting incidence in the Morphine group (2.5%) compared to the Oxycodone group (8.8% incidence). These results match those found in 2013 by Pedersen and his colleagues, who concluded that Morphine had significantly less nausea than Oxycodone (p = 0.03) [13]. However, another study leaded by Lenz in 2009 found no difference between the two drugs in PONV incidence [14]. On the other hand, Oxycodone showed less secondary effects including sedation, when compared to Morphine and other opioids like Fentanyl and Sufentanyl [15]. Therefore, the controversy found in literature highlights the need for solid meta-analysis to get conclusive results about the safety and tolerance of Oxycodone and Morphine in postoperative pain management.

Moreover, our study aimed to assess the efficacy of Zofran for PONV prevention. Recent studies showed that the incidence of post-operative nausea and vomiting after oxycodone use post general anesthesia was 19% [7] vs 12% to 38% for morphine [12]. However, our results showed lower incidence rates of PONV: we found an 8.8% incidence in the Oxycodone group and a 2.5% incidence rate in the Morphine group. Therefore, the use of Zofran injection reduced by almost 2.16 times the incidence of NV in Oxycodone group, and by 4.8 to 15.2 times in the Morphine group. A 50% reduction of NV was considered clinically relevant by the researchers so the results obtained seemed way beyond expected and effectively very suitable for the patients.

Regarding PONV severity, our results showed that only 10% of Oxycodone group patients and 8.9% of Morphine group patients had moderate nausea and vomiting, and none of the groups' patients had severe nausea and vomiting. To our knowledge, no other studies in the literature assessed the severity of NV in patients of our target population. However, since none of the patients reported severe nausea, then it seems that Zofran 4mg injection was effective in lowering the NV severity in the recruited patients (besides reducing its incidence).

Our study showed that neither surgery duration, nor gender, nor age, nor smoking, nor BMI, nor NRS pain level, nor treatment group were statistically associated with severity of nausea and vomiting. However, all the before mentioned were reported in other studies as risk factors of PONV [1,16]. The fact that none of these was detected as aggravating factors of PONV could be explained by the design of our study that included only a certain group of patients where all of them were with high pain levels, all of them receiving opioid injections, all being selected within a predefined age rank, which makes the homogeneity between the patients higher.

7.1. Study strengths

This study is one of few comparing Oxycodone to Morphine, both with Zofran injection and the first in Lebanon, particularly to our knowledge. Besides, this controlled trial was done without a massive budget, with the available standard of care surveillance, comparing frequently used drugs on a daily basis, so no funding was obtained to perform it, and it relied on the devotion of the researchers mainly. Nevertheless, patients were under the best safety measures, with the best surveillance methods in PACU since MLH is a university hospital well equipped for that purpose.

7.2. Study limitations and perspectives

Despite all the strengths, this study had some limitations worth mentioning. Other factors affecting the PONV incidence, such as delayed gastric emptiness, and anesthetic agent used during surgery, were not taken into account in this study. Therefore, it would be interesting to include them in future studies. Finally, only PONV was measured among all opioid side effects, so the evaluation of safety was bound only to PONV in this study. Future studies should consider evaluating the difference between Oxycodone and Morphine with all side effects accounted for in the design.

The study was conducted to find the best remedy to prevent PONV, one of the most common and unpleasant side effects following surgeries. Patients were sometimes willing to sacrifice by bearing pain so they would not experience NV [4]. Based on our results, measures to improve patient outcomes, public health, and health services should be taken, such as recommending the systematic administration of antiemetic agents to prevent or reduce the severity of PONV in patients receiving Oxycodone or Morphine.

8. Conclusion

This monocentric clinical trial was the first in Lebanon to assess the difference between Oxycodone and Morphine coupled with Zofran in reducing PONV incidence. It also aimed to evaluate Zofran's safety, acceptability, and effectiveness in decreasing postoperative nausea and vomiting and to detect the factors affecting the severity of nausea and vomiting in our target population. Two hundred thirty-seven patients were divided into two groups, each receiving a treatment. We assessed the analgesic effects of both treatments by checking the differences on the NRS scale. We evaluated the efficacy of the treatment by assessing the PONV incidence difference. Zofran efficacy was evaluated in reducing the incidence and the severity of PONV. The factors associated with the severity of PONV were also assessed.

Regarding analgesic effects, our results showed that Morphine and Oxycodone seemed to have similar analgesic effects. Our results also showed clinically relevant lower incidence rates of PONV in both Oxycodone and Morphine groups. Moreover, Zofran injection seemed effective in lowering the NV severity. Neither surgery duration, gender, age, smoking, BMI, nor NRS pain level, nor treatment group was statistically associated with the severity of nausea and vomiting.

The study was conducted to find the best remedy to prevent PONV, one of the most common and unpleasant side effects following surgeries. Based on our results, recommending the systematic administration of antiemetic agents to prevent or reduce the severity of PONV in patients receiving Oxycodone or Morphine could enhance patients' satisfaction. Future studies could focus on including all the factors affecting PONV incidence and evaluate all their side effects to accurately estimate the efficacy and safety of Zofran as an antiemetic.

Author Contributions:

All authors contributed equally to the writing of this paper. All authors read and approved the final manuscript.

Conflicts of Interest:

The authors declare no conflict of interest.

1. Introduction

Abnormal uterine bleeding (AUB) is a commonly occurring gynecological complaint characterized by abnormal blood loss, duration of flow and frequency of menstruation [1]. It is evident among 30-35% of all females. The major outcome of AUB is anemia, which greatly impacts females' health quality [2]. Among various causes of abnormal uterine bleeding, dysfunctional menometrorrhagia is a common one. To reach the diagnosis of AUB, a careful history as well as physical examination is required [3]. It is a challenging task among gynecologists. Transvaginal ultrasound may be helpful in up to 60% of cases, and the cause of the bleeding is recognized in only 50-60% of the cases. There can be various causes of AUB, such as physiological, pathological, or pharmacological [4,5].

It has been found to be linked with almost any type of endometrium, ranging from normal endometrium to hyperplasia, irregular ripening, chronic menstrual irregular shedding, and atrophy [6]. Histological variations of the endometrium are useful in detecting various disease patterns. It can be assessed with the help of the age of patients, the phase of the menstrual cycle, and iatrogenic use of hormones[7].

Histological variations of the endometrium can be detected, considering the woman's age, the phase of her menstrual cycle, and iatrogenic use of hormones [8]. It is found that in about 10% of patients, endometrial cancer may be the outcome of abnormal perimenopausal or postmenopausal bleeding [9]. Atypical endometrial hyperplasia is the outcome of endometrial cancer and may progress over time to endometrial cancer in 5-25% of patients[10]. Considering this, we attempted present a study to assess histopathological patterns in the endometrial biopsy of patients presenting with abnormal uterine bleeding.

2. Methodology

A total of one hundred eight females with the complaint of abnormal uterine bleeding was enrolled. Inclusion criteria was females within age group 20-50 years and those giving written consent was enrolled. Those did not wish to participate were excluded from the study. The approval for the study protocol was obtained from institutional ethical clearance committee. All enrolled patients gave written consent for the study.

Demographic data of each patient was recorded. A detailed history of each patient was recorded. A thorough physical examination was performed. Pelvic ultrasound was performed. Dilatation and curettage were carried out. Specimens thus obtained were stored n 10% formalin. A gross study was done and multiple sections were obtained. The specimens were processed in automated tissue processor. Four to six-micron thick paraffin embedded sections were taken and stained by haematoxylin and eosin. The slides were examined under microscope and the various histopathological patterns assessed. Statistical assessment was carried using MS excel sheet with SPSS version 20.0. The level of significance was set below 0.05.

3. Results

Age group 20-30 years had 48, 30-40 years had 50 and 40-50 years had 10 females. A significant difference was observed (P< 0.05) (Table 1, Figure 1).

Table 1. Age wise distribution.

Age group (years)	Number	P value
20-30	48	0.05
30-40	50
40-50	10

Inflammatory lesions were 28, such as acute endometritis in 12, chronic endometritis in 11, and chorioamnionitis in 5. Proliferative non-neoplastic lesions were 42, such as atypical hyperplasia in 18, typical hyperplasia in 12, and endometrial polyp in 12. Neoplastic lesions in 20 include leiomyoma in 8, a partial mole in 7, a complete mole in 2, and endometroid carcinoma in 3.

Normal endometrium in 18, such as proliferative phase in 12 and secretory phase endometrium in 6. A significant difference was observed (P< 0.05) (Table 2, Figure 2).

Inflammatory lesions were 28, such as acute endometritis in 12, chronic endometritis in 11, and chorioamnionitis in 5. Proliferative non-neoplastic lesions were 42, such as atypical hyperplasia in 18, typical hyperplasia in 12, and endometrial polyp in 12. Neoplastic lesions in 20 include leiomyoma in 8, a partial mole in 7, a complete mole in 2, and endometroid carcinoma in 3.

Normal endometrium in 18, such as proliferative phase in 12 and secretory phase endometrium in 6. A significant difference was observed (P< 0.05) (Table 2, Figure 2).

Table 2. Histopathological diagnosis of endometrial biopsy.

Parameters	Variables	Number	P value
Inflammatory lesions (28)	Acute endometritis	12	<0.05
	Chronic endometritis	11
	Chorioamnionitis	5
Proliferative non-neoplastic lesions (42)	Atypical Hyperplasia	18	>0.05
	Typical Hyperplasia	12
	Endometrial polyp	12
Neoplastic lesions (20)	Leiomyoma	8	<0.05
	Partial mole	7
	Complete mole	2
	Endometroid carcinoma	3
Normal endometrium (18)	Proliferative phase	12	>0.05
	Secretory phase endometrium	6

4. Discussion

Abnormal uterine bleeding, incomplete abortions, and suspected neoplasia are among a few reasons for taking endometrial biopsies [11,12,13]. It may be sampled previously for specific measures to treat infertility to assess the phase of the cycle to direct extra tests or treatments [14,15,16]. The clinical indication shows the protocol to handle any endometrial sampling material for the specimen submission, which may be for evaluation of infertility or preparation for in vitro fertilization (IVF), evaluation of abnormal uterine bleeding, and follow-up of a previous cytological or histological diagnosis. The endometrium may be examined as part of a hysterectomy specimen and may be the site of a primary or secondary neoplastic process [17,18]. The present study assessed histopathological patterns in the endometrial biopsy of patients presenting with abnormal uterine bleeding.

Our study showed that the age group 20-30 years had 48, 30-40 years had 50, and 40-50 years had ten females. Isuzu et al., [19] included 304 cases. Most of the cases of endometrial hyperplasia were typical. Endometritis and chorioamnionitis were the inflammatory conditions seen. It was seen that 23 females had molar pregnancies. The most common cause of abnormal uterine bleeding was retained products of conception.

We observed that inflammatory lesions were 28, such as acute endometritis in 12, chronic endometritis in 11, and chorioamnionitis in 5. Proliferative non-neoplastic lesions were 42, such as atypical hyperplasia in 18, typical hyperplasia in 12, and endometrial polyp in 12. Neoplastic lesions in 20 such as leiomyoma in 8, a partial mole in 7, a complete mole in 2, and endometroid carcinoma in 3. Normal endometrium in 18, such as proliferative phase in 12 and secretory phase endometrium in 6. Doraiswami et al., [20] found that 41-50 years was the most commonly involved age group with abnormal uterine bleeding seen in 33.5%. The most familiar pattern in these patients was normal cycling endometrium seen among 28.4%. The most familiar pathology was a disordered proliferative pattern seen in 20.5%. Other causes identified were complications of pregnancy (22.7%), benign endometrial polyp (11.2%), endometrial hyperplasias (6.1%), carcinomas (4.4%), and chronic endometritis (4.2%). Endometrial causes of AUB and age patterns were statistically significant.

Gunaken et al., [21] in their study, a total of 188 patients were included. The most common histopathological results were endometrial polyp was seen at 26.6%, atrophic endometrium at 22.3%, and surface epithelium at 12.8%. None of the 57 patients without vaginal bleeding had endometrial cancer. In 131 patients with vaginal bleeding, the mean endometrial thickness was 9.8 mm, and the rate of endometrial disorders was 56.5% (74 patients). Endometrial cancer was diagnosed in 19 patients (10.1%), and 36.8% of them had non-endometrioid cancers. The presence of vaginal bleeding was significantly associated with the diagnosis of endometrial cancer and any endometrial disorder.

5. Conclusion

Most common endometrial biopsy revealed proliferative non-neoplastic lesions such as atypical hyperplasia, typical hyperplasia and endometrial polyp.

Author Contributions:

All authors contributed equally to the writing of this paper. All authors read and approved the final manuscript.

Conflicts of Interest:

''The authors declare no conflicts of interest.''

1. Introduction

The main cause of death in closed abdominal trauma is the development of multiple organ failure [1,2,3,4,5,6]. Intra-abdominal hypertension (AHI) syndrome occupies an important place in the pathogenesis of multiple organ failure [7,8,9]. It is known that an increase in AHI contributes to an increase in the mortality rate, primarily in extremely severe patients [10]. The central link in the pathogenetic treatment of AHI syndrome is surgical aid. In connection with the above, this study analyzed the effect of various methods of surgical treatment on changes in the intra-abdominal pressure (IAP) in the postoperative period [11,12,13,14].

The ''gold standard'' for indirect measurement of intra-abdominal hypertension is the use of the bladder. Since the wall of the bladder is well stretchable and elastic with a volume of no more than 25 ml, it acts as a passive membrane and shows intra-abdominal pressure until it is true [15,16,17,18].

The purpose of the study was the timely prediction of the development of AHI syndrome in patients with closed abdominal trauma.

Material and research methods: All patients with closed abdominal trauma underwent measurement of intra-abdominal pressure and abdominal perfusion pressure (APP), for which a urethral catheter connected to a water pressure gauge of the Waldman apparatus was used. In this case, the IAP was examined every 6 hours. The APP was calculated by subtracting the IAP from the mean arterial pressure (MAP). SBP was determined using the following formula: SBP = (2 * diastolic blood pressure + systolic blood pressure) / 3.

The World Society developed the classification system for the Study of Abdominal Compartment Syndrome for AHI. Classification of AHI by degrees is as follows:

Grade I: IAD 12-15 mm Hg.;

II degree: IAD 16-20 mm Hg.;

III degree: IAD 21-25 mm Hg.;

IV degree: IAD> 25 mm Hg.

A normal APD is 60 mmHg. or higher.

2. Materials and methods

All patients were divided into the following groups depending on the method of completing the surgery. Group-I corresponded to the patients of the control group, which included 208 patients in whom the laparotomy was completed by traditional suturing of the wound tightly with drainage of the abdominal cavity. Group-II (main) was divided into two subgroups: the first subgroup (IIa) included 152 patients in whom laparotomy ended with the temporary closure of the surgical wound; the second subgroup (IIB) included 87 patients whose surgical wound was not sutured at the end of the operation, and a laparostomy was applied. All groups of patients under consideration were matched by sex, age, and severity of the condition according to the APACHE II scale and the scale for determining the severity of injury (ISS).

3. Results and discussion

AHI of I degree was observed in 271 (56.7%) patients, II degree - in 167 (35.0%), III degree - in 28 (5.8%), and IV degree - in 12 (2.5%) patients. ... In patients with concomitant abdominal trauma, a decrease in APD was noted below 80 mm Hg. Art. in 70.3% of cases, while the APD level is less than 65 mm Hg. Art. was noted in 28.9% of cases. In all groups of victims with concomitant abdominal trauma in the postoperative period, we analyzed the results of studying the dynamics of APD and IAP.

On the first day of the postoperative period, the patients of group I (traditional tactics, Figure 1) had a second-degree AHI with a critical increase in the level of intra-abdominal pressure by day 4 (20.9 \(\pm\) 3.8 mm Hg). At the same time, APD values remained low, reaching the minimum values (62.8 \(\pm\) 8.7 mm Hg) by day 3 of the postoperative period. In the dynamics against treatment background in the first week, in 58.7% of cases, there was a gradual decrease in IHD and normalization of APD indicators. In 94 (45.2%) patients, various complications developed (incompetence of the inner intestinal anastomosis, eventration of the abdominal organs, enclosed abscesses of the abdominal cavity), gastroduodenal bleeding, early adhesive obstruction), which were the reason for the reoperation.

In subgroups IIa and IIb of groups (damage control surgery, Figures 2 and 3), a statistically significant decrease in IAP were observed on the initial day of the postoperative period: up to 10.9 \(\pm\) 7.8 mm Hg. Art. in subgroup IIa and up to 7.8 \(\pm\) 3.5 mm Hg. Art. in subgroup IIb (p> 0.05). There is an improvement in APD indicators - up to 77.5 \(\pm\) 5.8 mm Hg. Art. and 84.5 \(\pm\) 4.2 mm Hg. Art. respectively (p> 0.05), which shows an improvement in microcirculation processes in the main group's victims. Moreover, the increase in IAP in the IIa subgroup of patients on the third day of the postoperative period to 12.3 \(\pm\) 3.7 mm Hg. Art. should not be misleading since this depends on the second stage of surgical tactics and the final closure of the surgical wound.

The frequency of the development of multiple organ failure according to the criteria and the assessment on the SOFA scale were compared on the second day of the postoperative period since it was during this period that the most significant difference in IAP indicators was revealed between I and IIa, and I and IIb groups (Table 1).

Table 1. Multiple organ failure and SOFA score in victims on the 2nd day of the postoperative period.

Groups Systems	Group I, n = 208	Subgroup IIa, n = 152	Subgroup IIb, n = 87
The cardiovascular system	22.5\% *	55.6%	33.3%
urinary system	45% *	22.2%	22.2%
Respiratory system	85%	one hundre	63.0%
Liver	-	-
Coagulating system	10%	22.2%	3.7%
Metabolic dysfunction	32.5% *	11.1%	7.40%
CNS	87.5%	77.8%	17.4%
SOFA, score	7.3 \(\pm\) 1.8 *	3.4 \(\pm\) 1.5	3.7 \(\pm\) 1.8

* - significant differences between I and IIa, I and IIb subgroups of patients.

The high incidence of acute cerebral failure in all groups is explained by the nature of the trauma, that is, abdominal trauma was almost always combined with craniocerebral trauma, which was the cause of neurological deficit on the Glasgow coma scale. Manifestations of hepatic impairments were not observed in any of the cases, and impairments of the coagulating system were also rare and did not differ significantly among the groups. But nevertheless, in the first group there were significantly more patients with disorders in the cardiovascular, urinary, and metabolic disorders. This group of patients really needed more inotropic therapy. The result of the SOFA assessment showed a truly higher score in the severity of organ disorders in the first group.

The overall mortality rate in patients with abdominal injuries and associated severe trauma was 67.8%. The number of deaths among the patients of the first group was 119 out of 208 (57.21%), in the second group - 88 out of 270 (32.59%). Differences between IIa and IIb subgroups are not significant (p < 0.05). However, the differences in indicators I and IIa, I and IIb by subgroups are significant (\(p < 0.05\)).

Treatment results were studied in absolutely all patients with different IAP parameters during admission to the ICU. The average IAP in those patients who survived was 8.5 \(\pm\) 3.2 mm Hg, and in deceased patients - 24.2 \(\pm\) 1.8 mm Hg. (p < 0.05). But in this case, a natural dynamics of an increase in the mortality rate with an increase in IAP was noted.

When analyzing the relationship between AHI, APD, the frequency of multiple organ failure and the general severity of the condition of the victims, a statistically significant correlation was confirmed between the IAP and the severity of the patient's condition according to the SOFA and APACHE II scales (\(p < 0.05\)). The increase in IAP level corresponded to the worsening of the severity of the condition of the victims according to the SOFA and APACHE II scales, which was confirmed by the progress of the clinical picture of multiple organ failure.

4. Conclusion

Thus, in order to timely predict the development of AHI syndrome in patients with closed abdominal trauma, it is necessary to monitor the IAP level. IBH syndrome develops in patients with concomitant abdominal trauma and is characterized by relatively high mortality rates. A statistically significant correlation was established between the level of AHI, APD, the frequency of development of a picture of multiple organ failure and the severity of the patient's condition according to the SOFA and APACHE II scales (p < 0.05). A sudden increase and persistence of a high IAP level for a long time in patients with a closed abdominal trauma is an indication for the use of active surgical tactics to perform decompression.

Author Contributions:

All authors contributed equally to the writing of this paper. All authors read and approved the final manuscript.

Conflicts of Interest:

''The authors declare no conflicts of interest.''

1. Introduction

Subaxial cervical spine injuries carry high mortality and morbidity. These comprise facet joint fractures and disruption of joint capsule [1]. Subaxial cervical spine injuries involve either anterior column injuries such as those involving body fractures, middle column injuries such as facets injuries, or posterior column injuries such as laminar injuries and posterior osteoligamentous injuries [2]. In the case of anterior column injuries, compression and comminuted fracture injuries of the vertebral body are common [3]. It is indicated when there is evidence of spinal canal compression resulting from a fractured segment breaching into the spinal canal [4]. Correction of the kyphotic deformity occurred due to wedge fracture. Posterior column injuries comprise injuries of the lamina and various ligaments [5,6].

Various treatment modalities have emerged over the period of time regarding the treatment of traumatic axial cervical spine injuries. Both anterior and posterior approaches with the help of autologous and synthetic bone grafts for fixation have been tried by Neurosurgeons [7,8]. There is variation in the management of traumatic subaxial cervical spine injuries. Stabilization of facet joint either by immobilization or fixation of levels above and below the level of fracture is the main treatment option [9].

Considering this, we attempted present a retrospective, observational study to assess traumatic axial cervical spine injuries in 84 patients.

2. Methodology

A sum total of eighty- four patients with traumatic axial cervical spine injuries of either gender. They became part of the study with their written consent. Ethical clearance was obtained from the review and clearance committee.

The demographic profile of each patient was entered in the case history proforma. All cases were managed in casualty with primary resuscitation with trauma protocol and spine immobilization. They underwent clinical and radiological investigations. Magnetic imaging resonance (MRI) was performed in all. Conservative treatment was given to those with minimal no bony injuries with or without spinal cord contusion, and decompression and fixation were performed in moderate to severe bony injuries with spinal cord compression. Patients were treated for anterior fixation, i.e., corpectomy with either autologous bone graft or a titanium cage and plate fixation and with corpectomy with tricorticate graft. Results were compiled and spread along an MS excel sheet for correct inference. SPSS version 18.0 with Chi-square test was performed for comparison with the level of significance set below 0.05.

3. Results

Out of 84 patients, males comprised 54 (64.2%) and females had 30 (35.8%) (Table 1, Figure 1).

Table 1. Patients distribution.

Gender	Frequency	Percentage
Male	54	64.2%
Female	30	35.8%

Aetiology in present found to be assault in 9, road traffic accident in 48, sports injury in 17 and work place injury in 10 cases. A significant difference was observed (P< 0.05) (Table 2, Figure 2).

Table 2. Aetiology of injury.

Aetiology	Number	P value
Assault	9	<0.05
Road traffic accident	48
Sports injury	17
Work place injury	10

Body fracture was evident in 24 and ligamentous injury in 60 patients. The difference found to be significant (P< 0.05) (Table 3, Figure 3).

Table 3. Type of injury noted in patients.

Type of injury	Number	P value
Body	24	<0.05
Discoligamentous	60

Type of body fractures was C3 in 3, C4 in 2, C5 in 12, C6 in 3 and C7 in 4 patients. The difference found to be significant (P< 0.05) (Table 4, Figure 4).

Table 4. Type of body fractures.

Body fractures	Number	P value
C3	3	<0.05
C4	2
C5	12
C6	3
C7	4

Management performed was corpectomy with tricorticate graft in 26 cases and corpectomy with fixation with titanium cage and plate/screws in 58 cases. The difference was significant (P< 0.05) (Table 5).

Table 5. Management performed in cases.

Management	Number	P value
Corpectomy with tricorticate graft	26	0.05
Corpectomy with fixation with titanium cage and plate/screws	58

4. Discussion

Spinal cord injuries (SCIs) are a major cause of disability and mortality in the modern world [10]. Cervical spine injuries occur in 2% to 3% of all blunt trauma [11,12]. The permanent disability and lack of societal and vocational integration associated with SCI make it a burden on the patient and the family [13,14]. Since quadriplegia or quadriparesis resulting from cervical spine injuries cause significant disability, it becomes more critical to promptly manage these injuries in the hope of a better functional recovery [15,16]. The retrospective observational study assessed traumatic axial cervical spine injuries in 84 patients. Out of 84 patients, males comprised 54 (64.2%) and females had 30 (35.8%).

Aetiology in the present found to be assault in 9, road traffic accident in 48, sports injury in 17, and workplace injury in 10 cases. Dhakal et al., [17] in their study, 30 subaxial cervical trauma patients were divided into four groups based on the timing of surgery: within two days, 3 to 7 days, 8 to 30 days, and >31 days. There were 27 male and three female patients. Forty-four had an injury due to a fall. No patients were treated within the first 48 hours; only nine were treated between 3 and 7 days, 16 between 8 and 30 days, and five a month later. The major delay was finance and operating room availability. Thirteen patients had a C6C7 involvement, followed by C5C6 in 6 patients. Seven patients had complete neurological deficit, while 18 patients had an incomplete deficit. A total of 46.7% improved their neurology in 6 months. No neurological recovery was observed in complete deficit patients.

Our results showed that body fracture was evident in 24 and ligamentous injury in 60 patients. Type of body fractures was C3 in 3, C4 in 2, C5 in 12, C6 in 3, and C7 in 4 patients. Ulrich et al., [18]. Coe et al., [19] tested several implants in cadaver and bovine spines. They concluded that the posterior approach is far better than the anterior one, especially in associated ligamental injuries. Ulrich et al., [18] said an additional external immobilization should be combined with anterior fixation, whereas Coe et al., [19] recommended posterior wiring techniques.

Management performed was corpectomy with tricorticate graft in 26 cases and a corpectomy with fixation with a titanium cage and plate/screws in 58 cases. Venkati et al., [20] conducted a study on 172 patients with subaxial cervical spine injuries, of which 44 patients suffered from vertebral body fracture. In comparison, 108 patients had spinal canal compromise due to other injuries. Sixteen patients had quadriplegia, 24 had grade 4 power in upper and lower extremities, and roots were involved in 46 patients. In 44 patients complete corpectomy was performed with the placement of a tricorticate graft taken from the fibula. This graft was fixed in place with a titanium plate and four screws.

Asher et al., [21] conducted a study on 452 patients, of which 69.7% were males, and 30.3% were females. 52.4% patients were between the age group 30-60 years of age, and about 56.1% had hospital stays lasting < 10 days. 46.6% of patients exhibited road traffic accidents as the primary common mechanism of injury. Neck pain was the most common symptom, and cervical spine straightening was the most common radiological abnormality. The injuries were more severe in patients who were not restrained by a seat belt or wearing a helmet.

The shortcoming of the present study is that a small sample size was included. In addition, we did not include those who died during the treatment.

5. Conclusion

Discoligamentouswas major type of injury and road traffic accident was main cause of injury among patients with subaxial cervical spine injuries.

Author Contributions:

All authors contributed equally to the writing of this paper. All authors read and approved the final manuscript.

Conflicts of Interest:

''The authors declare no conflicts of interest.''

1. Introduction

Abdominal injuries account for 1.5 to 36.5% of peacetime injuries, but their frequency and severity continue to increase. According to A.N. Tulupov[1,2], in severe concomitant trauma, injuries to the abdominal organs are present in almost 30% of victims. Due to the severity of damage to internal organs and difficulties in diagnosis, such an injury is characterized by a high rate of complications and mortality, which, according to various authors, ranges from 25 to 65%. According to Shapot [3,4] and Afonina [5], with an isolated injury of one abdominal cavity, the lethality ranges from 5.1 to 20.4%, and with a combined injury - from 18.3 to 64% [6,7,8,9,10,11,12,13].

Closed abdominal injuries are accompanied by a large number of complications and high mortality due to difficulties in diagnosis and frequent combination with injuries to other organs, and systems [14,15,16,17,18,19,20,21]. A particular problem is the diagnosis and treatment of concomitant closed trauma of the abdominal organs, accompanied by shock. Hospital mortality in this variant of the pathology ranges from 17.3 to 72.7% [22,23,24,25,26]. For example, over the past five years, the mortality rate from road accidents in Russia has increased by 65%, and the death toll reaches 33-35 thousand people per year [27,28,29].

In the literature, several terms define multiple injuries to various areas of the body in severe trauma [30,31]. In the Russian literature, the term severe concomitant injury (TTS) is most often used. However, in the big medical encyclopedia [32] there is the following definition: polytrauma - simultaneous damage to several anatomical areas in one victim.

Concomitant injuries are simultaneous damage to several different systems or organs. TCT as a model of an extreme condition, is damage to two or more anatomical regions of the body. Concomitant injury, defined as the simultaneous injury of two or more of the body's seven anatomical regions, is a complex multifactorial and severe type of injury characterized by numerous pathological syndromes, a frequent change in the dominant factor, a large number of complications, and a high mortality rate. In the diagnosis, the authors recommend indicating the leading injury. Thus, the analysis of scientific literature indicates that the choice of the volume of surgical intervention in patients with severe concomitant abdominal trauma against the background of traumatic and hemorrhagic shock is still an unsolved problem [33,34,35].

The purpose of the study

Improvement of the results of surgical treatment of damage to the abdominal organs in concomitant trauma by improving and introducing new methods of diagnosis and rational surgical tactics, depending on the severity of the injury.

Materials and methods

Treatment of victims with severe concomitant abdominal injuries was carried out in the conditions of round-the-clock emergency surgical care in the Samarkand branch of the RSCEMP.

For the period from 2009-2019. Two thousand six hundred forty-five patients with concomitant trauma of the abdominal cavity and retroperitoneal space were admitted to the Samarkand branch of the RSCEMP, of which 447 (16.9%) patients were operated on with concomitant abdominal trauma.

Our study consisted of two stages - a retrospective one based on the results of studying the case histories of 208 patients with shock-related mechanical trauma and a prospective one based on analyzing the treatment results of 270 critically ill patients hospitalized with concomitant trauma.

The criteria for inclusion in the research were the following attitudes: 1) shock-related concomitant mechanical trauma to the abdominal organs; 2) the age of the victims is from 18 to 89 years. The exclusion criteria were: 1) clinically significant comorbidities (oncological diseases and chronic diseases in the decompensated stage at the time of admission); 2) combined trauma of severe degree.

The study included 478 patients aged 18 to 89 years, among them - 306 men (64.0%) and 172 women (36.0%) - Figure 1.

Sorting of victims with abdominal injuries in cases of combined trauma by gender in the control and main groups is illustrated in Figure 2.

The average age of hospitalized patients was 33.8 \(\pm\) 13.4 years, and most of them were people of working age, which also emphasizes the relevance of the problem under study (Figure 3).

As seen in Figure 5, over ten years, the number of victims hospitalized in the SFRNCEMP increased six times. The overwhelming majority were delivered by ambulance teams - 416 (87%), who were provided with appropriate assistance at the scene of the accident to maintain the body's vital functions and prevent the development of life-threatening conditions. However, 62 victims (13%) were admitted by gravity without providing the necessary assistance (Figure 4)

Among 478 victims, 447 (93.5%) were operated on. Of these, a lethal outcome was observed in the control group - out of 208 in 119 (57.21%), and in the main group - out of 270 - 88 (32.59%) - Figure 6. Thirty-one (11.48%) patients with abdominal injuries (liver in 25 and spleen in 6) underwent conservative therapy in the presence of concomitant injury.

In most cases, the cause of injury was a road traffic accident (n = 358 - 74.89%), in 51 (10.67%) victims, the cause of injury was the result of striking the abdomen, in 61 (12.76%) catatrauma (Figure 7).

Alcohol intoxication was observed in 257 (53.77%) victims.

The severity of shock was assessed using the Algover-Gruber index (shock index).

Sorting of victims according to the degree of hemorrhagic shock is presented in Table 1. The data in the table indicate that 478 (100%) patients undergoing examination were admitted in a state of hemorrhagic shock (I, II, III and IV degrees).

Table 2. Sorting of victims with concomitant trauma of the abdominal organs according to the severity of hemorrhagic shock upon admission.

Index Algovera-Gruber	Shock degrees	Number of victims, n = 478		Total died
		I gr.	II gr.	I gr.	II gr.
Up to 1.0	I	101	5	15	-
1.0 to 1.5	II	20	60	18	10
1.5 to 2.0	III	31	164	30	57
2.1 and more	IV	56	41	56	21
Total		208	270	119(57.21%)	88(32.59%)

Attention should be paid to the fact that in the control group, even with the development of hemorrhagic shock of the 1st degree, there were cases of lethal outcome; with the development of hemorrhagic shock of II, III, and IV degrees, almost 100% mortality was noted (Figure 8).

With the use of improved surgical tactics in the leading group, lethality significantly decreased, with no lethal outcome in the case of grade I hemorrhagic shock, and 49% of patients with grade IV shock survived (Figure 9).

The following Figure 10 shows the terms of hospitalization of the victims in the hospital from the moment of injury. Most of the patients were hospitalized for 3 hours from the moment of injury (n = 292, 61.1%). Moreover, in the first hour after the injury - only 60 (12.55%) patients.

We also analyzed the frequency of damage to various anatomical areas of the body in victims with associated trauma (Figure 11). The largest group consisted of injuries to the head and limbs (62.0% and 58.9%, respectively), injuries to the chest organs - 40.5%, the spine - 27.2%, the pelvic bones, and urogenital organs - 22.9%, abdominal cavity - 21.2%.

Among 478 patients with concomitant abdominal trauma, in 261 cases (54.6%), the predominant injury was abdominal trauma, in 131 cases (27.4%) - craniocerebral (TBI), in 60 patients (12.5%) - chest trauma and combined injuries were found in 26 (5.5%) cases.

Most often, abdominal injuries were associated with TBI and chest trauma (n = 271; 56.7% of cases).

It is important to note that in 94.1% of cases, injuries of two or more anatomical areas were detected.

The total number of abdominal and retroperitoneal injuries detected in 478 patients is 880. Among the abdominal injuries, injuries of parenchymal organs were predominantly encountered (Figure 12).

Damage to the parenchymal organs (506) of the abdominal cavity and retroperitoneal space prevailed over injuries to the hollow organs (374) of the abdominal cavity (Figure 13).

In addition, 275 patients had extra-abdominal injuries (Figure 14), which were characterized by damage to the skeleton, soft tissues and chest organs.

2. Results and discussion

In these observations, we noted two prevailing syndromes: developing peritonitis syndrome and intra-abdominal bleeding syndrome. The syndrome of developing peritonitis was encountered with injuries to the hollow organs.

The intra-abdominal bleeding syndrome was observed in the case of damage to the parenchymal organs or blood vessels of the mesentery and omentum, retroperitoneal space. At the same time, changes in hemodynamics were characteristic, as well as a decrease in several hematological parameters (hemoglobin, hematocrit, the number of erythrocytes), oliguria, and leukocytosis with the ruptured spleen (in 167).

We adhere to the following treatment tactics: with a distinct clinic for intra-abdominal bleeding and acute peritonitis - emergency operation (in 232 patients). In the absence of confidence in the presence of intra-abdominal bleeding and peritonitis, together with anti-shock therapy, such diagnostic methods are performed as pleural puncture (in 31), laparocentesis (in 40), laparoscopy (in 127), R-graph: skull (in 51), pelvis (in 30), spine (in 37), retrograde cystography (in 15), ultrasound (in 201) and computed tomography (in 40 patients).

The most common combined abdominal trauma was damage to the parenchymal organs in combination with damage to the intestine, bladder, and kidney. It is considered that trauma to the liver, spleen, kidney, and extensive retroperitoneal hematomas were more often observed with damage to the chest, pelvis, and spine. On admission, symptoms of internal bleeding were noted in 250 (52.3%) patients and 48 (10.0%) patients with symptoms of peritonitis.

3. Conclusion

The main cause of death among 478 patients was a combination of injuries in 127 victims (26.56%), as well as the development of complications. Among patients with injuries of the abdominal organs, they were observed in 80 (16.73%) in the postoperative period.

Author Contributions:

All authors contributed equally to the writing of this paper. All authors read and approved the final manuscript.

Conflicts of Interest:

''The authors declare no conflicts of interest.''