Postoperative morbidity among survivors of emergency war trauma surgery in a conflict setting: a descriptive cohort study.

Abstract

Background: Evidence on surgical outcomes in active conflict settings remains limited, particularly regarding postoperative morbidity and its relationship to injury severity among civilians with severe war-related injuries. This study describes the pattern of postoperative morbidity following emergency surgery for conflict-related abdominal and thoracic trauma.

Methods: We conducted a cohort study of patients undergoing emergency war trauma surgery at a single surgical unit during the 2024 Gaza conflict. Data were collected prospectively and supplemented through retrospective review when needed. To avoid conflating early postoperative death with an absence of morbidity, postoperative morbidity was described only among patients who survived to hospital discharge.

Results: Seventy-nine patients were included. Five patients (6%) died intraoperatively and were excluded from postoperative analysis. Of the remaining 74 patients, 20 (27%) died during the index admission and 54 (73%) survived to discharge; non-survivors had substantially higher Injury Severity Scores than survivors (median ISS 32 vs 16) and were less often haemodynamically stable on arrival (12% vs 67%). Among the 54 survivors, postoperative morbidity occurred in 46 (85%), mainly due to infectious complications (81%), particularly surgical site infection (74%). Descriptive comparison of survivors with and without morbidity showed similar injury severity between groups (median ISS 16 vs 16.5), suggesting that once patients survived long enough to be at risk of complications, morbidity was common across the injury-severity spectrum rather than concentrated among the most severely injured.

Conclusions: Postoperative morbidity after conflict-related emergency surgery was high among survivors and was largely driven by infectious complications. Mortality, rather than morbidity, was most closely related to injury severity. These findings support the need for consistent injury severity assessment, improved infection prevention strategies, and cautious interpretation of morbidity data in conflict cohorts where early mortality limits the population at risk of developing recorded complications.