Early Enteral Nutrition and Surgical Outcomes After Repair of Penetrating Bowel Injuries: A Retrospective Cohort Study From the Yemeni Civil War.

introductionPenetrating bowel injuries (PBIs) are the most common serious consequence of abdominal gunshot and blast injuries in conflict zones and remain associated with substantial morbidity. Although international perioperative guidelines endorse early enteral nutrition (EEN), its safety and effectiveness after operative repair of PBIs in resource-limited, war-affected hospitals remain poorly established. We aimed to evaluate the association between the timing of postoperative enteral nutrition and predefined outcomes in adults undergoing operative repair of conflict-related PBIs, including postoperative complications, gastrointestinal recovery, hospital resource utilization, and mortality.

methodsThis was a retrospective single-center cohort study conducted at Al-Safwa Hospital, Taiz, Yemen, between January 2017 and December 2023. Adult patients (≥18 years) with intraoperatively confirmed PBIs who underwent primary repair or resection with anastomosis were included. Patients were stratified by timing of postoperative enteral nutrition into EEN (less than 48 hours) and delayed enteral nutrition (DEN) (more than 48 hours). Primary outcomes included postoperative complications occurring within 30 days, namely, surgical site infection (SSI), anastomotic leak, enterocutaneous fistula, fascial dehiscence, intra-abdominal abscess, pneumonia, sepsis, acute kidney injury (AKI), and mortality; secondary outcomes were gastrointestinal recovery, hospital and intensive care unit (ICU) length of stay, and reoperation. Group comparison used Mann-Whitney U, χ², or Fisher's exact tests. Multivariable logistic regression identified independent predictors of complications.

resultsOf 109 included patients, the median age was 28 years; men constituted n = 102/109 (93.6%). The most common mechanism of gunshot wounds is n = 91/109 (83.5%). Cases who received EEN were n = 94 (86.2%), and those who received DEN were n = 15 (13.8%). EEN was associated with earlier return of bowel sounds (1 vs. 2 days, p = 0.021), lower overall complication rate (n = 20/94, 21.3% vs. n = 9/15, 60.0%; p = 0.003), lower SSI (n = 3/94, 3.2% vs. n = 7/15, 46.7%; p < 0.001), and no mortality (0/94, 0% vs. n = 3/15, 20%; p = 0.002). In an exploratory multivariable logistic regression model adjusted for high American Association for the Surgery of Trauma (AAST) grade, peritoneal contamination, and associated injuries, DEN remained associated with higher odds of postoperative complications (adjusted odds ratio (OR) 3.98, 95% confidence interval (CI) 1.20-13.23; p = 0.024). This estimate should be interpreted cautiously because of the small DEN group and the limited number of events.

conclusionIn this conflict-zone cohort, EEN within 48 hours after PBI repair was feasible and was associated with faster gastrointestinal recovery, fewer postoperative complications, shorter hospital and ICU stays, and lower mortality than delayed feeding. These observational findings support considering EEN when clinically feasible after adequate source control and stabilization, while underscoring the need for prospective multicenter studies with standardized feeding protocols.