What is the treatment for an explosion injury with neck trauma, resulting in esophageal and proximal subclavian artery (subclavian artery) injuries, after surgical exploration?

From the Guidelines

The recommended treatment for an explosion with neck injury resulting in esophageal and proximal subclavian artery injury is repair of both structures (option A). This approach provides the best chance for functional recovery and survival, as it maintains blood flow to the upper extremity and restores continuity of the digestive tract, thereby preventing potential complications such as limb loss, mediastinitis, and infection 1. The subclavian artery should be repaired to prevent ischemia, and the esophageal repair is necessary to prevent contamination of surrounding tissues with saliva and food.

Key Considerations

• The repair typically involves debridement of devitalized tissue, primary closure of the esophageal defect (possibly with muscle flap reinforcement), and vascular repair of the subclavian artery using either direct anastomosis or graft interposition.
• Postoperatively, the patient will require broad-spectrum antibiotics, nutritional support (possibly via feeding tube), and close monitoring for complications such as anastomotic leak, infection, or vascular thrombosis.
• While ligation of the subclavian artery or creation of an esophagostomy are sometimes necessary in extreme circumstances with extensive tissue damage or contamination, primary repair of both structures offers the best functional outcome when technically feasible, as supported by the most recent guidelines on esophageal emergencies 1.

Rationale

• The guidelines emphasize the importance of primary repair for esophageal injuries, particularly in the neck, to prevent complications and promote healing 1.
• The subclavian artery repair is crucial to maintain blood flow to the upper extremity and prevent ischemia, which can lead to limb loss or other complications.
• The use of extra-anatomic bypass grafting or other revascularization techniques may be considered in certain cases, but primary repair of both structures is generally the preferred approach, as it offers the best chance for functional recovery and survival 1.

From the Research

Treatment Options for Esophageal and Proximal Subclavian Artery Injuries

• The treatment for esophageal and proximal subclavian artery injuries depends on the extent of the injury and the patient's overall clinical condition 2, 3.
• Primary repair of traumatic injuries is preferred when possible, but if systemic sepsis is present, esophageal resection may become necessary 3.
• In cases of subclavian artery injury, prompt identification and proper surgical approach are crucial for successful management 4.
• The use of median sternotomy with supraclavicular extension can provide adequate exposure for repair of proximal subclavian artery injuries 4.
• For complex injuries involving multiple structures, such as cardiac, esophageal, and arterial injuries, a multidisciplinary approach with rapid identification and operative intervention can lead to good outcomes 5.

Specific Treatment Approaches

• Repair of both esophageal and subclavian artery injuries may be possible in some cases, but the approach depends on the extent of the injury and the patient's condition 2, 4.
• Ligation of the subclavian artery and repair of the esophagus may be an option in certain cases, but this approach is not universally recommended 5, 6.
• Esophagostomy may be necessary in cases where primary repair of the esophagus is not possible, and subclavian artery ligation may be performed to control bleeding 5, 6.