Combat-related bowel injuries managed at a civilian level I trauma centre during the Iron Swords War: operative strategies and outcomes.

Abstract

Introduction: War-related bowel trauma poses complex challenges due to destructive injury patterns, physiological derangement and multisystem involvement. This study aimed to characterise injury patterns, operative strategies and outcomes among combat casualties with bowel injuries treated at a civilian level I trauma centre within Israel's integrated civilian-military trauma system during the Iron Swords War.

Methods: We conducted a retrospective cohort study of patients with penetrating bowel injuries sustained during the Iron Swords War from 7 October 2023 to 31 December 2024. Demographics, injury mechanisms, diagnostic accuracy, operative management (primary repair, resection and anastomosis or stoma/diversion) and postoperative outcomes were analysed descriptively.

Results: 21 patients were included; all were male and most (86%) were military personnel. Injuries resulted from high-energy blast or gunshot trauma. Median Injury Severity Score (ISS) was 16 (IQR 9-25), and 81% had injuries in more than one body region. Small and large bowel injuries occurred in 62% and 71%, respectively. 16 (76%) underwent anastomosis, 15 at the index operation and one after damage control, including seven colonic resections with no leaks. Diversion (19%) was reserved for destructive rectal injury or profound physiological compromise (median ISS 30 vs 13); no stoma was created at an index damage-control laparotomy. Complications occurred in three patients; two were major (Clavien-Dindo III-V, 10%)-an intra-abdominal abscess and the single death (5%, day 13, septic shock)-and one was minor (grade II, 5%), a high-output stoma. Median stay was 15 days (IQR 11-23).

Conclusions: In this descriptive cohort within a mature integrated civilian-military trauma system, bowel continuity was restored in most patients without observed leaks; diversion was reserved for destructive rectal injury or profound physiological compromise, with morbidity reflecting injury severity. These hypothesis-generating findings align with civilian guidelines and military experience.