When someone is badly hurt, the general rule is to get the patient to surgery immediately. But Israeli surgeons who – in a great humanitarian effort in several hospitals in this country – treated thousands of civilians wounded in the Syrian civil war between 2013 and 2018 have learned that delaying surgery may actually be beneficial. 

Following the Israel government’s decision to help the wounded even though this country had no involvement in the civil war, the Israel Defense Forces and its Medical Corps, along with the health care system and hospitals in northern Israel joined together to provide medical treatment to large numbers of wounded Syrians. The logistics of evacuating the injured from the battlefield and transferring them to Israeli territory often took considerable time because Israel and Syria are defined as enemy states.

Most of the wounded were brought to the Galilee Medical Center (GMC) in Nahariya. Some were admitted within 24 hours of injury, but for others, it took as long as two to four weeks to reach Israel from the combat zone.

The delay in beginning treatment provided medical professionals and researchers from the hospital’s otolaryngology (ear, nose and throat) and oral and maxillofacial surgery departments with a rare window of opportunity to observe and evaluate how this lapse in time impacted the outcome of treatment.

In a study recently published in the journal Scientific Reports under the title “The impact of delayed surgical intervention following high velocity maxillofacial injuries,” the researchers found that – quite surprisingly – patients injured in the facial bones by high-speed fire and operated on approximately 14 to 28 days weeks after the injury suffered fewer post-operative complications compared to wounded who underwent immediate surgical treatment (within 72 hours). 

The researchers suggested that this is due to a critical period of time before surgery that speeds up healing and the formation of new blood vessels in the area of the injury and subsequently an improvement in the blood and oxygen supply and a reduction in the incidence of complications. 

Prof. Samer Srouji, a member of the Azrieli Faculty of Medicine of Bar-Ilan University in Ramat Gan near Tel Aviv and chief of the oral and maxillofacial institute at the Galilee Medical Center and his team coined the term Critical Revascularization Period (CRP) to explain this phenomenon.

Weapon injuries, he said, are generally categorized as low-velocity or high-velocity depending on the speed of impact from the weapon. War injuries are commonly induced by high-velocity weapons such as machine guns, improvised explosive devices, and missiles. High-velocity injuries are significantly less common than those inflicted by low speeds, leading to comparatively less research available as to the proper surgical management of injuries sustained from high-velocity weapons. His hospital had unique opportunities to evaluate, treat, and study these high-velocity weapons injuries sustained by hundreds of the 3,200 Syrian patients who have arrived in the midst of the Syrian civil war.

“We believe that this benefit stems from neovascularization, the formation and repair – over time – of blood vessels in the injured region, which improves the supply of blood and oxygen to the area and, in turn, leads to smoother healing and fewer complications following surgery,” he said. “This study also highlights the important interface between bedside and basic research in the lab. We are currently working on 3D organ printing methods to develop artificial organ scaffold optimized for ideal oxygenation bone construction and rapid wound healing.”

Treating the wounded civilians also provided insight into injuries caused by sniper fire and high-velocity injuries unique to a battlefield. The researchers have developed a laboratory model that simulates shooting injuries and they continue to collect and process data from the period of treatment of the wounded from the Syrian civil war.

The findings in this study, said the team, may lead to a reassessment of protocols for the treatment of high-speed head and facial injuries. It is not yet possible to draw unequivocal conclusions concerning the ideal time for surgical treatment, but the research findings suggest that delayed treatment with an opportunity for maxillofacial revascularization can improve the results of surgery while cutting complications after surgery.