Indications and Outcomes of Colon Resection in a Conflict Zone: A Single-Center Experience from a Military Hospital in Yemen

Indications and Outcomes of Colon Resection in a Conflict Zone: A Single-Center Experience from a Military Hospital in Yemen | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Indications and Outcomes of Colon Resection in a Conflict Zone: A Single-Center Experience from a Military Hospital in Yemen Ali Ahmed Albarshi, Yasser Abdurabo Obadiel, Hussam Alkhatab Aldomini, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7096729/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose: Although colon resection is a common procedure, data regarding its indications and outcomes in conflict-affected regions are limited. These environments present unique surgical challenges, driven by the dual burden of acute trauma and advanced-stage chronic diseases. This study aimed to analyze the experience of colon resection at a military hospital in Yemen to identify key risk factors and inform surgical practices in austere settings. Methods: A single-center prospective observational study was conducted on 89 patients who underwent colon resection at a military hospital in Sana'a, Yemen between September 2022 and April 2024. Data on patient demographics, indications, surgical procedures, and postoperative outcomes were collected and analyzed. The primary endpoint was the incidence of adverse outcomes, defined as a composite of significant morbidity and in-hospital mortality. Results: A total of 89 patients were included (mean age 36.9 years; 91.0% male). The predominant indication for surgery was penetrating trauma (78.7%). The procedure-specific anastomotic leak rate for the 55 patients who underwent primary anastomosis was 7.3%. The overall adverse outcome (AE) rate was 19.1%. The strongest predictor of adverse outcomes was hemodynamic instability on admission; patients presenting with shock had an adverse rate of 34.6% compared to 12.7% in stable patients, a trend that approached statistical significance (P = 0.066). No significant difference in outcomes was found between trauma and cancer diagnosis. Conclusion: In this conflict-zone hospital, the patient's initial physiological state was the most critical determinant of postoperative outcomes following colon resection. Despite the austere conditions, the observed anastomotic leak rate was comparable to international standards, suggesting that primary anastomosis is a viable option in carefully selected, hemodynamically stable patients. These findings underscore the need for context-specific guidelines that prioritize aggressive resuscitation and physiological risk stratification to guide surgical decision making. Trial Registration: Not applicable. Colon Resection Colectomy Penetrating Trauma War Surgery Yemen Surgical Outcomes Introduction Colon resection is a fundamental surgical procedure for a wide spectrum of diseases, but the evidence base is dominated by studies from stable, high-income settings [ 1 , 2 ]. Data on low-resource and conflict-affected regions are scarce. Although established guidelines exist for managing colon trauma and cancer, their applicability is uncertain in austere environments, where patient physiology, complex injury patterns, and resource limitations create distinct clinical realities [ 3 , 4 ]. This gap in evidence undermines the development of context-specific surgical protocols for populations undergoing crises. Yemen's protracted conflict has devastated its healthcare system, creating the dual burden of surgical disease. Penetrating abdominal trauma, particularly gunshot wounds, necessitates emergency colon resection [ 5 ]. However, disruptions in healthcare access have led to advanced stages of colorectal cancer, often with complications such as obstruction, which increases the demand for urgent intervention [ 6 ]. The convergence of acute trauma and complex oncologic disease strains an already fragile system; however, the factors that truly drive outcomes in this setting remain poorly characterized. Therefore, this study aimed to analyze the indications, surgical management, and postoperative outcomes of patients who underwent colon resection at a single military hospital in Sana'a, Yemen, Brazil. We sought to identify the primary drivers of adverse outcomes in this high-risk cohort, hypothesizing that initial physiological compromise, specifically hemodynamic instability, would be a more critical determinant of morbidity and mortality than a specific underlying pathology. By elucidating the realities of colectomy in the conflict zone, our findings may inform context-appropriate surgical practices and improve patient care in similar settings. Material and methods Study design and setting This study was a single-center prospective observational analysis of patients undergoing colon resection surgery. All patients were recruited from the surgical department of the Military General Hospital in Sana'a, Yemen. The study period was September 2022 to April 2024. Ethical approval for the study was granted by the Arab Board of Surgery in Yemen and administrative approval was obtained from the Military General Hospital. This study was conducted in accordance with the principles of the Declaration of Helsinki. Patient population Patients admitted to the surgical ward who underwent any form of colon resection (hemicolectomy or segmental resection) were eligible for inclusion. Written informed consent was obtained from all participants or their legal guardians. Patients were excluded if they had incomplete medical records that precluded accurate data extraction, were unwilling to participate in follow-up, or had a terminal illness in which the focus of care was primarily palliative. A total of 89 patients met the inclusion criteria and were enrolled in the study. Data collection and variables Data were collected prospectively using a structured questionnaire supplemented by a thorough review of electronic and paper medical records. The follow-up period for postoperative outcomes was 60 days. The primary variables collected included patient demographics such as age and sex. Clinical data included presenting complaints, findings on physical examination, pre-existing comorbidities, and final diagnosis (confirmed by histopathology with available or intraoperative findings). Surgical data included preoperative investigations (e.g., CT scan and colonoscopy), use of mechanical bowel preparation, type of surgery (elective, urgent, or emergency), specific surgical procedure performed (e.g., right hemicolectomy), and method of bowel management post-resection (primary anastomosis vs. ostomy). Postoperative outcomes included specific postoperative complications, final clinical outcomes (improved, morbid, or death), and total length of hospital stay. Outcome measures and definitions The primary outcome of interest was the incidence of adverse outcomes, and the composite endpoint was defined as the occurrence of either significant postoperative morbidity or in-hospital mortality. Significant morbidity was defined as a complication requiring major therapeutic intervention or resulting in lasting disability (e.g., necrotizing fasciitis, anastomotic leak requiring re-operation, and osteomyelitis). Statistical analysis All data were analyzed using IBM SPSS Statistics (version 24.0; IBM Corp., Armonk, NY, USA). Descriptive statistics were used to summarize the cohort characteristics; continuous variables (e.g., age and length of stay) were presented as mean ± standard deviation (SD), while categorical variables were presented as frequencies and percentages (n, %). For comparative analysis, Fisher's Exact Test was used to assess the associations between categorical variables given the small sample size. This test was used to compare the rates of adverse outcomes between the different patient groups (e.g., elective vs. non-elective surgery; trauma vs. cancer diagnosis). Differences were considered statistically significant at P < 0.05. Results Patient demographics and diagnostic profile A total of 89 patients who underwent colon resection were included in the final analysis. The cohort was overwhelmingly male (n=81, 91.0%) with a mean age of 36.9 ± 12.1 years. The predominant diagnosis was penetrating abdominal trauma, which accounted for 70 cases (78.7 %). Malignancy was the second most common indication, diagnosed in 14 patients (15.7%). Detailed demographic and diagnostic characteristics are summarized in Table 1. Table 1: Patient demographics and clinical characteristics (N=89) Characteristic Value Total Patients (N) 89 Mean Age (SD), years 36.9 (12.1) Sex, n (%) Male 81 (91.0%) Female 8 (9.0%) Primary Diagnosis, n (%) Penetrating Trauma 70 (78.7%) Cancer 14 (15.7%) Other Benign Conditions 5 (5.6%) Surgical procedures and management Reflecting the acute nature of the presenting pathologies, the vast majority of surgeries were performed on a non-elective basis (n=80, 89.9%). The most common initial surgical strategy was primary anastomosis, which was performed in 55 patients (61.8 %). A primary ostomy was performed in 33 patients (37.1%), most commonly an ileostomy. Right hemicolectomy was the most frequent type of resection (n=33, 37.1%). A summary of surgical management is provided in Table 2. Table 2: Surgical procedures and initial management (N=89) Procedure / Management n (%) Operative Procedure Right Hemicolectomy 33 (37.1%) Left Hemicolectomy 10 (11.2%) Other Resections 46 (51.7%) Initial Post-Resection Management Primary Anastomosis 55 (61.8%) Primary Ostomy 33 (37.1%) Other 1 (1.1%) Postoperative outcomes and complications The overall adverse outcome rate (defined as significant morbidity or mortality) was 19.1% (n=17) with 10 deaths (11.2% mortality). Of the 55 patients who underwent primary anastomosis, four developed a postoperative leak, yielding a procedure-specific anastomotic leak rate of 7.3%. All four leak cases were managed successfully with surgery and the creation of a diverting ileostomy. The most frequent postoperative complication was necrotizing fasciitis, which was observed in five patients (5.6%). A detailed breakdown of the outcomes and complications is presented in Table 3. Table 3: Postoperative complications and final outcomes (N=89) Outcome / Complication n (%) Final Outcome Improved 72 (80.9%) Adverse (Morbid or Death) 17 (19.1%) Mortality 10 (11.2%) Overall Complication Rate 24 (27.0%) Specific Complications¹ Necrotizing Fasciitis (NF) 5 (5.6%) Anastomotic Leak 4 (4.5%) Surgical Site Infection (SSI) 4 (4.5%) Deep Vein Thrombosis (DVT) 2 (2.2%) Other Complications 9 (10.1%) ¹ Some patients experienced more than one complication. Comparative analysis of risk factors for adverse outcomes Comparative analyses were performed to identify the risk factors associated with adverse outcomes. The strongest predictor was the patient's hemodynamic status on admission. Patients presenting with shock experienced an adverse outcome rate of 34.6% (9/26) compared with 12.7% (8/63) in hemodynamically stable patients. This strong clinical trend approached statistical significance (Fisher's Exact Test, P=0.066) and corresponded to a more than three-fold increase in the odds of an adverse outcome (Odds Ratio: 3.47). In contrast, no statistically significant associations with adverse outcomes were found for the diagnosis type (20.0% vs. 7.1%, P=0.428) or surgery urgency (20.0% vs. 11.1%, P=1.000). The results are summarized in Table 4. Table 4: Comparative analysis of factors associated with adverse outcomes (N=89) Factor Group Adverse Outcome, n (%) Improved Outcome, n (%) Total p- value Hemodynamic Status 0.066 Shock 9 (34.6%) 17 (65.4%) 26 Not in Shock 8 (12.7%) 55 (87.3%) 63 Diagnosis Type 0.428 Trauma 14 (20.0%) 56 (80.0%) 70 Cancer 1 (7.1%) 13 (92.9%) 14 Surgery Urgency 1.000 Non-Elective 16 (20.0%) 64 (80.0%) 80 Elective 1 (11.1%) 8 (88.9%) 9 P-values were calculated using the Fisher's Exact Test. Statistical significance was set at P < 0.05. Discussion This study provides a rare and valuable analysis of colon resection in a conflict-zone military hospital, offering critical insights into the surgical realities in an austere environment. These findings confirm that penetrating trauma is the overwhelming driver of this procedure, but more importantly, they reveal a crucial clinical insight: a patient's initial physiological state, specifically the presence of shock, is the most powerful predictor of adverse outcomes. Remarkably, despite this high-risk population, the procedure-specific anastomotic leak rate for primary repair remains within acceptable standards, challenging the dogma that primary anastomosis is universally contraindicated in patients with severe trauma. The most clinically significant finding from our analysis was the profound impact of hemodynamic status on patient outcomes. Patients presenting with shock were more than three times more likely to suffer a major complication or death (OR, 3.47), a finding that approached statistical significance (P = 0.066). This aligns with the bedrock principles of trauma surgery, where physiologic derangement—the "lethal triad" of acidosis, hypothermia, and coagulopathy—is a more potent driver of mortality than the anatomical extent of the injury itself [ 7 ]. This evidence strongly supports the use of stratified surgical approach. For hemodynamically unstable patients, damage control surgery, which prioritizes rapid contamination control and physiological resuscitation over definitive, lengthy repair, should be the default strategy to mitigate the high risk of mortality [ 8 ]. A central and somewhat unexpected finding of our study was the anastomotic leak rate of 7.3% in 55 patients who underwent primary anastomosis. This outcome was highly encouraging. In high-resource settings, the reported leak rates after surgery for penetrating colon trauma range from 5–14% [ 9 ]. A landmark multicenter study by Demetriades et al. from the American Association for the Surgery of Trauma (AAST) reported a leak rate of 6.6% in patients undergoing primary repair, forming the basis for a selective approach [ 10 ]. More recently, a large analysis of the U.S. The National Trauma Data Bank found that leak rates remain a significant concern, justifying diversion in high-risk patients [ 11 ]. Our finding of 7.3% is not only comparable but also favorable to many of these benchmarks, especially when considering the austere setting. This provides crucial, context-specific evidence for surgeons operating in similar environments who must weigh the risks of a leak against the known morbidity and resource burden of creating a stoma. Our analysis did not find a statistically significant difference in adverse outcomes between patients with trauma (20.0%) and cancer (7.1%). This does not imply that trauma is without risk; rather, it likely reflects the high-risk nature of our non-trauma cohort, where cancer patients often present late with obstructive emergencies, making them physiologically compromised like many trauma victims [ 12 ]. The overall complication rate remains high, and the incidence of necrotizing fasciitis (5.6%) is a disturbing outlier that underscores the challenges in managing heavily contaminated wounds in this environment [ 13 ]. Limitations This study had several limitations. The sample size of 89, while substantial for a prospective study in this setting, may still lack the statistical power to detect more subtle differences in outcomes, particularly within smaller subgroups such as elective surgeries (n = 9). Second, the single-center design limits the generalizability of our findings to other conflict zones with different injury patterns or resource availability. Finally, the short follow-up period of 60 days precludes the assessment of important long-term outcomes such as stoma reversal rates, chronic pain, or oncologic recurrence. Conclusion In this conflict-zone military hospital, colon resection is a high-risk procedure dictated by the realities of war. The patient's physiological state on arrival was the most critical predictor of outcome. Our findings provide strong context-specific evidence that primary anastomosis can be performed with an acceptable leak rate in carefully selected patients even in this austere setting. Future surgical guidelines for austere environments must emphasize protocols for rapid resuscitation and physiological risk stratification to guide crucial decisions regarding primary repair, damage control surgery, and diversion. Declarations Ethical approval and consent to participate This study was conducted in accordance with the principles of the Declaration of Helsinki. Ethical approval was granted by the institutional review board of the Arab Board of Surgery in Yemen. Administrative approval for this study was obtained from the Military General Hospital of Sana'a. Written informed consent was obtained from all the participants. For patients who could not provide consent because of their clinical condition, consent was obtained from a legally authorized representative. Consent for publication Not applicable. This manuscript does not contain any individual personal data in any form (including individual details, images, or videos), which would require separate consent for publication. Competing interests The authors declare that they have no conflict of interest. Funding This research received no specific grants from any funding agency in the public, commercial, or not-for-profit sector. Author Contribution Study conception and design: A.A.A., H.M.J., Y. A. O. Acquisition of data: A.A.A. and H. A. A. Data analysis and interpretation: A.A.A. and H. M. J. Drafting of the manuscript: A.A.A. and H. M. J. Critical revision of the manuscript: Y.A.O., H.A.A., H.M.J. All authors have read and approved the final manuscript. Acknowledgement We would like to express our sincere gratitude to the patients who participated in this study and the dedicated surgical, nursing, and administrative staff of the Military General Hospital for their invaluable support in data collection and patient care under challenging circumstances. Data Availability The dataset generated and analyzed during the current study is not publicly available because of patient privacy and confidentiality concerns in a conflict-affected region, but is available from the corresponding author upon reasonable request. References Stein DE. Colon resection: background, indications, contraindications. Medscape 2023. https://emedicine.medscape.com/article/1891505-overview (accessed July 5, 2025). Cullinane DC, Jawa RS, Como JJ, Moore AE, Morris DS, Cheriyan J, et al. Management of penetrating intraperitoneal colon injuries: a meta-analysis and practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg 2019;86:505–15. https://doi.org/10.1097/TA.0000000000002146 Awuah WA, Tan JK, Shah MH, Ahluwalia A, Roy S, Ali SH, et al. Addressing abdominal trauma from conflict and warfare in under‐resourced regions: a critical narrative review. Health Sci Rep 2024;7. https://doi.org/10.1002/hsr2.70151 Shahini E, Libânio D, Secco G Lo, Pisani A, Arezzo A. Indications and outcomes of endoscopic resection for non-pedunculated colorectal lesions: a narrative review. World J Gastrointest Endosc 2021;13:275. https://doi.org/10.4253/WJGE.V13.I8.275 Al-Amry A, Obadiel Y, Al-Shehari M, Gailan W, Bajubair M, Jowah H. Early postoperative complications in colorectal cancer patients following colorectal surgery among Yemeni patients: a prospective study. Open Access Surgery 2024;17:81–90. https://doi.org/10.2147/OAS.S465936 Obadiel YA, Albrashi A, Allahabi N, Sharafaddeen M, Ahmed F. Outcomes of nonoperative management of penetrating abdominal trauma injury: a retrospective study. Cureus 2024;16:e58599. https://doi.org/10.7759/cureus.58599 Rotondo MF, Zonies DH. The damage control sequence and underlying logic. Surg Clin North Am 1997;77:761–77. https://doi.org/10.1016/S0039-6109(05)70582-X Cannon JW, Khan MA, Raja AS, Cohen MJ, Como JJ, Cotton BA, et al. Damage control resuscitation in patients with severe traumatic hemorrhage: a practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg 2017;82:605–17. https://doi.org/10.1097/TA.0000000000001333 Sharpe JP, Magnotti LJ, Fabian TC, Croce MA. Evolution of the operative management of colon trauma. Trauma Surg Acute Care Open 2017;2:e000092. https://doi.org/10.1136/tsaco-2017-000092 Demetriades D, Murray JA, Chan L, Ordoñez C, Bowley D, Nagy KK, et al. Penetrating colon injuries requiring resection: diversion or primary anastomosis? An AAST prospective multicenter study. J Trauma 2001;50:765–75. https://doi.org/10.1097/00005373-200105000-00001 Hatch Q, Causey M, Martin M, Stoddard D, Johnson E, Maykel J, et al. Outcomes after colon trauma in the 21st century: an analysis of the U.S. National Trauma Data Bank. Surgery 2013;154:397–403. https://doi.org/10.1016/J.SURG.2013.05.011 Mohd Suan MA, Tan WL, Soelar SA, Ismail I, Abu Hassan MR. Intestinal obstruction: predictor of poor prognosis in colorectal carcinoma? Epidemiol Health 2015;37:e2015017. https://doi.org/10.4178/epih/e2015017 Singh Y, Motilall S, Khulu BL, Jackson BS. The impact of colon injuries on the outcome of gunshot wounds to the abdomen. Langenbecks Arch Surg 2023;408:328. https://doi.org/10.1007/s00423-023-03067-0 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7096729","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":497572594,"identity":"be33586a-23d2-4f27-9849-4e47bc45bc1d","order_by":0,"name":"Ali Ahmed Albarshi","email":"","orcid":"","institution":"Military General Hospital","correspondingAuthor":false,"prefix":"","firstName":"Ali","middleName":"Ahmed","lastName":"Albarshi","suffix":""},{"id":497572595,"identity":"4b57d2b5-6b4b-4edb-b832-15fb3350da5e","order_by":1,"name":"Yasser Abdurabo Obadiel","email":"","orcid":"","institution":"Sana'a University","correspondingAuthor":false,"prefix":"","firstName":"Yasser","middleName":"Abdurabo","lastName":"Obadiel","suffix":""},{"id":497572596,"identity":"e01076ab-bfe9-4b5b-886d-28b9d993b469","order_by":2,"name":"Hussam Alkhatab Aldomini","email":"","orcid":"","institution":"Military General Hospital","correspondingAuthor":false,"prefix":"","firstName":"Hussam","middleName":"Alkhatab","lastName":"Aldomini","suffix":""},{"id":497572597,"identity":"d82a4656-8f1c-4b71-9166-8bedfdef5b8c","order_by":3,"name":"Haitham Mohammed Jowah","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAzUlEQVRIiWNgGAWjYBACAwaGBCB1QA7M4yFFizFJWkDgQGID0VrMGRgePuapuZM+f0YC44O3bQyJ/YS0WDYwJBvzHHuWu+FGArPhXKCWmQ2EHHaAIU06h+1w7gaJBDZpXqCWDQeI0vLvcLr8jAT23yAt+4nSktt2OIHhRgIbM9gWQn4xOAz0y9++w4YbzjxslpxzTsJ4BkFbjvckPpzx7bC8fHvywQ9vymxk+xsIWcPMkwBlMYLUSjgS1MHAwI7qEHvCOkbBKBgFo2CkAQCEAUMIrb03fgAAAABJRU5ErkJggg==","orcid":"","institution":"Sana'a University","correspondingAuthor":true,"prefix":"","firstName":"Haitham","middleName":"Mohammed","lastName":"Jowah","suffix":""}],"badges":[],"createdAt":"2025-07-11 01:38:09","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7096729/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7096729/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":88746744,"identity":"bc3e36d9-2754-4229-aa7a-f44044461f9d","added_by":"auto","created_at":"2025-08-11 04:35:53","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":779649,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7096729/v1/1b0c7b4c-df47-4b38-8253-a6a63f4610c0.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Indications and Outcomes of Colon Resection in a Conflict Zone: A Single-Center Experience from a Military Hospital in Yemen","fulltext":[{"header":"Introduction","content":"\u003cp\u003eColon resection is a fundamental surgical procedure for a wide spectrum of diseases, but the evidence base is dominated by studies from stable, high-income settings [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Data on low-resource and conflict-affected regions are scarce. Although established guidelines exist for managing colon trauma and cancer, their applicability is uncertain in austere environments, where patient physiology, complex injury patterns, and resource limitations create distinct clinical realities [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. This gap in evidence undermines the development of context-specific surgical protocols for populations undergoing crises.\u003c/p\u003e\u003cp\u003eYemen's protracted conflict has devastated its healthcare system, creating the dual burden of surgical disease. Penetrating abdominal trauma, particularly gunshot wounds, necessitates emergency colon resection [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. However, disruptions in healthcare access have led to advanced stages of colorectal cancer, often with complications such as obstruction, which increases the demand for urgent intervention [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. The convergence of acute trauma and complex oncologic disease strains an already fragile system; however, the factors that truly drive outcomes in this setting remain poorly characterized.\u003c/p\u003e\u003cp\u003eTherefore, this study aimed to analyze the indications, surgical management, and postoperative outcomes of patients who underwent colon resection at a single military hospital in Sana'a, Yemen, Brazil. We sought to identify the primary drivers of adverse outcomes in this high-risk cohort, hypothesizing that initial physiological compromise, specifically hemodynamic instability, would be a more critical determinant of morbidity and mortality than a specific underlying pathology. By elucidating the realities of colectomy in the conflict zone, our findings may inform context-appropriate surgical practices and improve patient care in similar settings.\u003c/p\u003e"},{"header":"Material and methods","content":"\u003cp\u003e\u003cb\u003eStudy design and setting\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThis study was a single-center prospective observational analysis of patients undergoing colon resection surgery. All patients were recruited from the surgical department of the Military General Hospital in Sana'a, Yemen. The study period was September 2022 to April 2024. Ethical approval for the study was granted by the Arab Board of Surgery in Yemen and administrative approval was obtained from the Military General Hospital. This study was conducted in accordance with the principles of the Declaration of Helsinki.\u003c/p\u003e\u003cp\u003e\u003cb\u003ePatient population\u003c/b\u003e\u003c/p\u003e\u003cp\u003ePatients admitted to the surgical ward who underwent any form of colon resection (hemicolectomy or segmental resection) were eligible for inclusion. Written informed consent was obtained from all participants or their legal guardians. Patients were excluded if they had incomplete medical records that precluded accurate data extraction, were unwilling to participate in follow-up, or had a terminal illness in which the focus of care was primarily palliative. A total of 89 patients met the inclusion criteria and were enrolled in the study.\u003c/p\u003e\u003cp\u003e\u003cb\u003eData collection and variables\u003c/b\u003e\u003c/p\u003e\u003cp\u003eData were collected prospectively using a structured questionnaire supplemented by a thorough review of electronic and paper medical records. The follow-up period for postoperative outcomes was 60 days. The primary variables collected included patient demographics such as age and sex. Clinical data included presenting complaints, findings on physical examination, pre-existing comorbidities, and final diagnosis (confirmed by histopathology with available or intraoperative findings). Surgical data included preoperative investigations (e.g., CT scan and colonoscopy), use of mechanical bowel preparation, type of surgery (elective, urgent, or emergency), specific surgical procedure performed (e.g., right hemicolectomy), and method of bowel management post-resection (primary anastomosis vs. ostomy). Postoperative outcomes included specific postoperative complications, final clinical outcomes (improved, morbid, or death), and total length of hospital stay.\u003c/p\u003e\u003cp\u003e\u003cb\u003eOutcome measures and definitions\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe primary outcome of interest was the incidence of adverse outcomes, and the composite endpoint was defined as the occurrence of either significant postoperative morbidity or in-hospital mortality. Significant morbidity was defined as a complication requiring major therapeutic intervention or resulting in lasting disability (e.g., necrotizing fasciitis, anastomotic leak requiring re-operation, and osteomyelitis).\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStatistical analysis\u003c/h2\u003e\u003cp\u003eAll data were analyzed using IBM SPSS Statistics (version 24.0; IBM Corp., Armonk, NY, USA). Descriptive statistics were used to summarize the cohort characteristics; continuous variables (e.g., age and length of stay) were presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (SD), while categorical variables were presented as frequencies and percentages (n, %). For comparative analysis, Fisher's Exact Test was used to assess the associations between categorical variables given the small sample size. This test was used to compare the rates of adverse outcomes between the different patient groups (e.g., elective vs. non-elective surgery; trauma vs. cancer diagnosis). Differences were considered statistically significant at P\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003ch2\u003e\u003cstrong\u003ePatient demographics and diagnostic profile\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eA total of 89 patients who underwent colon resection were included in the final\u0026nbsp;analysis.\u0026nbsp;The\u0026nbsp;cohort\u0026nbsp;was\u0026nbsp;overwhelmingly\u0026nbsp;male\u0026nbsp;(n=81,\u0026nbsp;91.0%)\u0026nbsp;with\u0026nbsp;a\u0026nbsp;mean\u0026nbsp;age\u0026nbsp;of 36.9 \u0026plusmn; 12.1 years. The predominant diagnosis was penetrating abdominal trauma, which accounted for 70 cases (78.7 %). Malignancy was the second most common indication, diagnosed in 14 patients (15.7%). Detailed demographic and diagnostic characteristics are summarized in Table 1.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1: Patient demographics and clinical characteristics (N=89)\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 68.612%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCharacteristic\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.388%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eValue\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 68.612%;\"\u003e\n \u003cp\u003eTotal\u0026nbsp;Patients (N)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.388%;\"\u003e\n \u003cp\u003e89\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 68.612%;\"\u003e\n \u003cp\u003eMean\u0026nbsp;Age\u0026nbsp;(SD), years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.388%;\"\u003e\n \u003cp\u003e36.9 (12.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 68.612%;\"\u003e\n \u003cp\u003eSex,\u0026nbsp;n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.388%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 68.612%;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.388%;\"\u003e\n \u003cp\u003e81 (91.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 68.612%;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.388%;\"\u003e\n \u003cp\u003e8 (9.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 68.612%;\"\u003e\n \u003cp\u003ePrimary\u0026nbsp;Diagnosis,\u0026nbsp;n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.388%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 68.612%;\"\u003e\n \u003cp\u003ePenetrating Trauma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.388%;\"\u003e\n \u003cp\u003e70 (78.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 68.612%;\"\u003e\n \u003cp\u003eCancer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.388%;\"\u003e\n \u003cp\u003e14 (15.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 68.612%;\"\u003e\n \u003cp\u003eOther\u0026nbsp;Benign Conditions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.388%;\"\u003e\n \u003cp\u003e5 (5.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003ch2\u003e\u003cstrong\u003eSurgical procedures and management\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eReflecting the acute nature of the presenting pathologies, the vast majority of surgeries were performed on a non-elective basis (n=80, 89.9%). The most common initial surgical strategy was primary anastomosis, which was performed in 55 patients (61.8 %). A primary ostomy was performed in 33 patients (37.1%), most commonly an ileostomy. Right hemicolectomy was the most frequent type of resection (n=33, 37.1%).\u0026nbsp;A\u0026nbsp;summary of surgical management is provided in Table 2.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable\u0026nbsp;2:\u0026nbsp;Surgical\u0026nbsp;procedures\u0026nbsp;and\u0026nbsp;initial\u0026nbsp;management (N=89)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 78.2334%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eProcedure\u0026nbsp;/ Management\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.7666%;\"\u003e\n \u003cp\u003e\u003cstrong\u003en (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 78.2334%;\"\u003e\n \u003cp\u003eOperative Procedure\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.7666%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 78.2334%;\"\u003e\n \u003cp\u003eRight\u0026nbsp;Hemicolectomy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.7666%;\"\u003e\n \u003cp\u003e33 (37.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 78.2334%;\"\u003e\n \u003cp\u003eLeft Hemicolectomy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.7666%;\"\u003e\n \u003cp\u003e10 (11.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 78.2334%;\"\u003e\n \u003cp\u003eOther\u0026nbsp;Resections\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.7666%;\"\u003e\n \u003cp\u003e46 (51.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 78.2334%;\"\u003e\n \u003cp\u003eInitial\u0026nbsp;Post-Resection Management\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.7666%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 78.2334%;\"\u003e\n \u003cp\u003ePrimary Anastomosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.7666%;\"\u003e\n \u003cp\u003e55 (61.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 78.2334%;\"\u003e\n \u003cp\u003ePrimary Ostomy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.7666%;\"\u003e\n \u003cp\u003e33 (37.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 78.2334%;\"\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.7666%;\"\u003e\n \u003cp\u003e1 (1.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003ch2\u003e\u003cstrong\u003ePostoperative outcomes and complications\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eThe overall adverse outcome rate (defined as significant morbidity or mortality) was 19.1% (n=17) with 10 deaths (11.2% mortality). Of the 55 patients who underwent primary\u0026nbsp;anastomosis,\u0026nbsp;four\u0026nbsp;developed\u0026nbsp;a\u0026nbsp;postoperative\u0026nbsp;leak,\u0026nbsp;yielding\u0026nbsp;a\u0026nbsp;procedure-specific anastomotic leak rate of 7.3%. All four leak cases were managed successfully with surgery and the creation of a diverting ileostomy. The most frequent postoperative complication was necrotizing fasciitis, which was observed in five patients (5.6%). A detailed breakdown of the outcomes and complications is presented in Table 3.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3: Postoperative complications and final outcomes (N=89)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 77.7603%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOutcome / Complication\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22.2397%;\"\u003e\n \u003cp\u003e\u003cstrong\u003en (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 77.7603%;\"\u003e\n \u003cp\u003eFinal\u0026nbsp;Outcome\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22.2397%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 77.7603%;\"\u003e\n \u003cp\u003eImproved\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22.2397%;\"\u003e\n \u003cp\u003e72 (80.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 77.7603%;\"\u003e\n \u003cp\u003eAdverse\u0026nbsp;(Morbid\u0026nbsp;or Death)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22.2397%;\"\u003e\n \u003cp\u003e17 (19.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 77.7603%;\"\u003e\n \u003cp\u003eMortality\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22.2397%;\"\u003e\n \u003cp\u003e10 (11.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 77.7603%;\"\u003e\n \u003cp\u003eOverall\u0026nbsp;Complication Rate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22.2397%;\"\u003e\n \u003cp\u003e24 (27.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 77.7603%;\"\u003e\n \u003cp\u003eSpecific Complications\u0026sup1;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22.2397%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 77.7603%;\"\u003e\n \u003cp\u003eNecrotizing\u0026nbsp;Fasciitis (NF)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22.2397%;\"\u003e\n \u003cp\u003e5 (5.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 77.7603%;\"\u003e\n \u003cp\u003eAnastomotic Leak\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22.2397%;\"\u003e\n \u003cp\u003e4 (4.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 77.7603%;\"\u003e\n \u003cp\u003eSurgical\u0026nbsp;Site\u0026nbsp;Infection (SSI)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22.2397%;\"\u003e\n \u003cp\u003e4 (4.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 77.7603%;\"\u003e\n \u003cp\u003eDeep Vein\u0026nbsp;Thrombosis (DVT)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22.2397%;\"\u003e\n \u003cp\u003e2 (2.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 77.7603%;\"\u003e\n \u003cp\u003eOther\u0026nbsp;Complications\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 22.2397%;\"\u003e\n \u003cp\u003e9 (10.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026sup1; Some patients experienced more than one complication.\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003eComparative analysis of risk factors for adverse outcomes\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eComparative analyses were performed to identify the risk factors associated with adverse outcomes. The strongest predictor was the patient\u0026apos;s hemodynamic status on admission. Patients presenting with shock experienced an adverse outcome rate of 34.6% (9/26) compared with 12.7% (8/63) in hemodynamically stable patients. This strong clinical trend \u0026nbsp;approached \u0026nbsp;statistical \u0026nbsp;significance \u0026nbsp;(Fisher\u0026apos;s \u0026nbsp;Exact \u0026nbsp;Test, \u0026nbsp;P=0.066) and corresponded to a more than three-fold increase in the odds of an adverse outcome (Odds Ratio: 3.47). In contrast, no statistically significant associations with adverse outcomes were found for the diagnosis type (20.0% vs. 7.1%, P=0.428) or surgery urgency (20.0% vs. 11.1%, P=1.000). The results are summarized in Table 4.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4: Comparative analysis of factors associated with adverse outcomes (N=89)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eFactor Group\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAdverse\u0026nbsp;Outcome,\u0026nbsp;n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eImproved\u0026nbsp;Outcome,\u0026nbsp;n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003evalue\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHemodynamic Status\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.066\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eShock\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e9 (34.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e17 (65.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNot\u0026nbsp;in Shock\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e8 (12.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e55 (87.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eDiagnosis Type\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.428\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTrauma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e14 (20.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e56 (80.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCancer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1 (7.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e13 (92.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSurgery Urgency\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNon-Elective\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e16 (20.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e64 (80.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eElective\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1 (11.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e8 (88.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eP-values were calculated using the Fisher\u0026apos;s Exact Test. Statistical significance was set at P \u0026lt; 0.05.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study provides a rare and valuable analysis of colon resection in a conflict-zone military hospital, offering critical insights into the surgical realities in an austere environment. These findings confirm that penetrating trauma is the overwhelming driver of this procedure, but more importantly, they reveal a crucial clinical insight: a patient's initial physiological state, specifically the presence of shock, is the most powerful predictor of adverse outcomes. Remarkably, despite this high-risk population, the procedure-specific anastomotic leak rate for primary repair remains within acceptable standards, challenging the dogma that primary anastomosis is universally contraindicated in patients with severe trauma.\u003c/p\u003e\u003cp\u003eThe most clinically significant finding from our analysis was the profound impact of hemodynamic status on patient outcomes. Patients presenting with shock were more than three times more likely to suffer a major complication or death (OR, 3.47), a finding that approached statistical significance (P\u0026thinsp;=\u0026thinsp;0.066). This aligns with the bedrock principles of trauma surgery, where physiologic derangement\u0026mdash;the \"lethal triad\" of acidosis, hypothermia, and coagulopathy\u0026mdash;is a more potent driver of mortality than the anatomical extent of the injury itself [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. This evidence strongly supports the use of stratified surgical approach. For hemodynamically unstable patients, damage control surgery, which prioritizes rapid contamination control and physiological resuscitation over definitive, lengthy repair, should be the default strategy to mitigate the high risk of mortality [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eA central and somewhat unexpected finding of our study was the anastomotic leak rate of 7.3% in 55 patients who underwent primary anastomosis. This outcome was highly encouraging. In high-resource settings, the reported leak rates after surgery for penetrating colon trauma range from 5\u0026ndash;14% [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. A landmark multicenter study by Demetriades et al. from the American Association for the Surgery of Trauma (AAST) reported a leak rate of 6.6% in patients undergoing primary repair, forming the basis for a selective approach [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. More recently, a large analysis of the U.S. The National Trauma Data Bank found that leak rates remain a significant concern, justifying diversion in high-risk patients [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Our finding of 7.3% is not only comparable but also favorable to many of these benchmarks, especially when considering the austere setting. This provides crucial, context-specific evidence for surgeons operating in similar environments who must weigh the risks of a leak against the known morbidity and resource burden of creating a stoma.\u003c/p\u003e\u003cp\u003eOur analysis did not find a statistically significant difference in adverse outcomes between patients with trauma (20.0%) and cancer (7.1%). This does not imply that trauma is without risk; rather, it likely reflects the high-risk nature of our non-trauma cohort, where cancer patients often present late with obstructive emergencies, making them physiologically compromised like many trauma victims [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. The overall complication rate remains high, and the incidence of necrotizing fasciitis (5.6%) is a disturbing outlier that underscores the challenges in managing heavily contaminated wounds in this environment [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e\u003cb\u003eLimitations\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThis study had several limitations. The sample size of 89, while substantial for a prospective study in this setting, may still lack the statistical power to detect more subtle differences in outcomes, particularly within smaller subgroups such as elective surgeries (n\u0026thinsp;=\u0026thinsp;9). Second, the single-center design limits the generalizability of our findings to other conflict zones with different injury patterns or resource availability. Finally, the short follow-up period of 60 days precludes the assessment of important long-term outcomes such as stoma reversal rates, chronic pain, or oncologic recurrence.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn this conflict-zone military hospital, colon resection is a high-risk procedure dictated by the realities of war. The patient's physiological state on arrival was the most critical predictor of outcome. Our findings provide strong context-specific evidence that primary anastomosis can be performed with an acceptable leak rate in carefully selected patients even in this austere setting. Future surgical guidelines for austere environments must emphasize protocols for rapid resuscitation and physiological risk stratification to guide crucial decisions regarding primary repair, damage control surgery, and diversion.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eEthical approval and consent to participate\u003c/h2\u003e\n\u003cp\u003eThis study was conducted in accordance with the principles of the Declaration of Helsinki. Ethical approval was granted by the institutional review board of the Arab Board of Surgery in Yemen. Administrative approval for this study was obtained from the Military General Hospital of Sana\u0026apos;a. Written informed consent was obtained from all the participants. For patients who could not provide consent because of their clinical condition, consent was obtained from a legally authorized representative.\u003c/p\u003e\n\u003ch2\u003eConsent for publication\u003c/h2\u003e\n\u003cp\u003eNot applicable. This manuscript does not contain any individual personal data in any form (including individual details, images, or videos), which would require separate consent for publication.\u003c/p\u003e\n\u003ch2\u003eCompeting interests\u003c/h2\u003e\n\u003cp\u003eThe authors declare that they have no conflict of interest.\u003c/p\u003e\n\u003ch2\u003eFunding\u003c/h2\u003e\n\u003cp\u003eThis research received no specific grants from any funding agency in the public, commercial, or not-for-profit sector.\u003c/p\u003e\n\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\n\u003cp\u003eStudy conception and design: A.A.A., H.M.J., Y. A. O. Acquisition of data: A.A.A. and H. A. A. Data analysis and interpretation: A.A.A. and H. M. J. Drafting of the manuscript: A.A.A. and H. M. J. Critical revision of the manuscript: Y.A.O., H.A.A., H.M.J. All authors have read and approved the final manuscript.\u003c/p\u003e\n\u003ch2\u003eAcknowledgement\u003c/h2\u003e\n\u003cp\u003eWe would like to express our sincere gratitude to the patients who participated in this study and the dedicated surgical, nursing, and administrative staff of the Military General Hospital for their invaluable support in data collection and patient care under challenging circumstances.\u003c/p\u003e\n\u003ch2\u003eData Availability\u003c/h2\u003e\n\u003cp\u003eThe dataset generated and analyzed during the current study is not publicly available because of patient privacy and confidentiality concerns in a conflict-affected region, but is available from the corresponding author upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eStein DE. Colon resection: background, indications, contraindications. Medscape 2023. https://emedicine.medscape.com/article/1891505-overview (accessed July 5, 2025).\u003c/li\u003e\n\u003cli\u003eCullinane DC, Jawa RS, Como JJ, Moore AE, Morris DS, Cheriyan J, et al. Management of penetrating intraperitoneal colon injuries: a meta-analysis and practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg 2019;86:505\u0026ndash;15. https://doi.org/10.1097/TA.0000000000002146\u003c/li\u003e\n\u003cli\u003eAwuah WA, Tan JK, Shah MH, Ahluwalia A, Roy S, Ali SH, et al. Addressing abdominal trauma from conflict and warfare in under‐resourced regions: a critical narrative review. Health Sci Rep 2024;7. https://doi.org/10.1002/hsr2.70151\u003c/li\u003e\n\u003cli\u003eShahini E, Lib\u0026acirc;nio D, Secco G Lo, Pisani A, Arezzo A. Indications and outcomes of endoscopic resection for non-pedunculated colorectal lesions: a narrative review. World J Gastrointest Endosc 2021;13:275. https://doi.org/10.4253/WJGE.V13.I8.275\u003c/li\u003e\n\u003cli\u003eAl-Amry A, Obadiel Y, Al-Shehari M, Gailan W, Bajubair M, Jowah H. Early postoperative complications in colorectal cancer patients following colorectal surgery among Yemeni patients: a prospective study. Open Access Surgery 2024;17:81\u0026ndash;90. https://doi.org/10.2147/OAS.S465936\u003c/li\u003e\n\u003cli\u003eObadiel YA, Albrashi A, Allahabi N, Sharafaddeen M, Ahmed F. Outcomes of nonoperative management of penetrating abdominal trauma injury: a retrospective study. Cureus 2024;16:e58599. https://doi.org/10.7759/cureus.58599\u003c/li\u003e\n\u003cli\u003eRotondo MF, Zonies DH. The damage control sequence and underlying logic. Surg Clin North Am 1997;77:761\u0026ndash;77. https://doi.org/10.1016/S0039-6109(05)70582-X\u003c/li\u003e\n\u003cli\u003eCannon JW, Khan MA, Raja AS, Cohen MJ, Como JJ, Cotton BA, et al. Damage control resuscitation in patients with severe traumatic hemorrhage: a practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg 2017;82:605\u0026ndash;17. https://doi.org/10.1097/TA.0000000000001333\u003c/li\u003e\n\u003cli\u003eSharpe JP, Magnotti LJ, Fabian TC, Croce MA. Evolution of the operative management of colon trauma. Trauma Surg Acute Care Open 2017;2:e000092. https://doi.org/10.1136/tsaco-2017-000092\u003c/li\u003e\n\u003cli\u003eDemetriades D, Murray JA, Chan L, Ordo\u0026ntilde;ez C, Bowley D, Nagy KK, et al. Penetrating colon injuries requiring resection: diversion or primary anastomosis? An AAST prospective multicenter study. J Trauma 2001;50:765\u0026ndash;75. https://doi.org/10.1097/00005373-200105000-00001\u003c/li\u003e\n\u003cli\u003eHatch Q, Causey M, Martin M, Stoddard D, Johnson E, Maykel J, et al. Outcomes after colon trauma in the 21st century: an analysis of the U.S. National Trauma Data Bank. Surgery 2013;154:397\u0026ndash;403. https://doi.org/10.1016/J.SURG.2013.05.011\u003c/li\u003e\n\u003cli\u003eMohd Suan MA, Tan WL, Soelar SA, Ismail I, Abu Hassan MR. Intestinal obstruction: predictor of poor prognosis in colorectal carcinoma? Epidemiol Health 2015;37:e2015017. https://doi.org/10.4178/epih/e2015017\u003c/li\u003e\n\u003cli\u003eSingh Y, Motilall S, Khulu BL, Jackson BS. The impact of colon injuries on the outcome of gunshot wounds to the abdomen. Langenbecks Arch Surg 2023;408:328. https://doi.org/10.1007/s00423-023-03067-0\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Colon Resection, Colectomy, Penetrating Trauma, War Surgery, Yemen, Surgical Outcomes","lastPublishedDoi":"10.21203/rs.3.rs-7096729/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7096729/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose: \u003c/strong\u003eAlthough colon resection is a common procedure, data regarding its indications and outcomes in conflict-affected regions are limited. These environments present unique surgical challenges, driven by the dual burden of acute trauma and advanced-stage chronic diseases. This study aimed to analyze the experience of colon resection at a military hospital in Yemen to identify key risk factors and inform surgical practices in austere settings.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eA single-center prospective observational study was conducted on 89 patients who underwent colon resection at a military hospital in Sana'a, Yemen between September 2022 and April 2024. Data on patient demographics, indications, surgical procedures, and postoperative outcomes were collected and analyzed. The primary endpoint was the incidence of adverse outcomes, defined as a composite of significant morbidity and in-hospital mortality.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eA total of 89 patients were included (mean age 36.9 years; 91.0% male). The predominant indication for surgery was penetrating trauma (78.7%). The procedure-specific anastomotic leak rate for the 55 patients who underwent primary anastomosis was 7.3%. The overall adverse outcome (AE) rate was 19.1%. The strongest predictor of adverse outcomes was hemodynamic instability on admission; patients presenting with shock had an adverse rate of 34.6% compared to 12.7% in stable patients, a trend that approached statistical significance (P = 0.066). No significant difference in outcomes was found between trauma and cancer diagnosis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eIn this conflict-zone hospital, the patient's initial physiological state was the most critical determinant of postoperative outcomes following colon resection. Despite the austere conditions, the observed anastomotic leak rate was comparable to international standards, suggesting that primary anastomosis is a viable option in carefully selected, hemodynamically stable patients. These findings underscore the need for context-specific guidelines that prioritize aggressive resuscitation and physiological risk stratification to guide surgical decision making.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTrial Registration:\u003c/strong\u003e \u0026nbsp;Not applicable.\u003c/p\u003e","manuscriptTitle":"Indications and Outcomes of Colon Resection in a Conflict Zone: A Single-Center Experience from a Military Hospital in Yemen","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-11 04:19:49","doi":"10.21203/rs.3.rs-7096729/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"05b1dc45-21cd-4e82-9c5d-7a0ba1efc3b1","owner":[],"postedDate":"August 11th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-08-11T04:19:49+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-11 04:19:49","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7096729","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7096729","identity":"rs-7096729","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}