From the Guidelines
The recommended treatment for an explosion with neck injury resulting in esophageal and proximal subclavian artery injury is option A: Repair of both structures. When faced with injuries to both the esophagus and subclavian artery, primary repair of both structures offers the best chance for functional recovery and prevention of complications. Repairing the esophagus prevents contamination of the surrounding tissues with saliva and gastric contents, which could lead to mediastinitis, sepsis, and death, as highlighted in the guidelines for esophageal emergencies 1. Similarly, repairing the subclavian artery preserves blood flow to the upper extremity, preventing ischemia and potential limb loss. While ligation of the subclavian artery might be considered in unstable patients or with extensive damage, repair is preferred when feasible to maintain perfusion, as discussed in the context of subclavian artery revascularization 1. Esophagostomy is typically reserved for cases where primary repair isn't possible due to extensive tissue damage or when there's a significant delay in treatment with established infection. The combined repair approach addresses both vascular and digestive tract injuries, minimizing the risk of infection spreading from the esophageal injury to the vascular repair site. In cases where damage control surgery is necessary due to the patient's unstable condition, principles of damage control surgery should be applied, including abbreviated source control surgery followed by transfer to the intensive care unit for physiological resuscitation, as outlined in the guidelines for esophageal emergencies 1. However, the primary goal in the management of such injuries should always be to repair both the esophagus and the subclavian artery when possible, to optimize outcomes in terms of morbidity, mortality, and quality of life. Key considerations include:
- Primary repair of the esophagus to prevent leakage and contamination
- Repair of the subclavian artery to maintain blood flow to the upper extremity
- Application of damage control principles in unstable patients
- Minimizing the risk of infection and other complications through appropriate surgical techniques and post-operative care.
From the Research
Treatment Options for Esophageal and Subclavian Artery Injuries
- The treatment for esophageal and subclavian artery injuries depends on the extent of the injury, its anatomic location, and the elapsed time between the injury and repair 2.
- For traumatic subclavian artery injuries, both endovascular and open repairs are effective, with no statistical difference in limb salvage, mortality, and procedure-related complications 3.
- In cases of esophageal injury, a high index of suspicion is crucial for diagnosis and treatment, and various diagnostic modalities should be used judiciously to evaluate the position and extent of the injury 2, 4.
- The management of esophageal injuries secondary to trauma involves a diagnostic and therapeutic algorithm to facilitate diagnosis and management 4.
- In rare cases, an aberrant subclavian artery can be injured during esophageal surgery, and pre-operative diagnosis requires a high index of suspicion 5, 6.
Specific Treatment Approaches
- Repair of both esophageal and subclavian artery injuries may be necessary in some cases, depending on the extent of the injuries.
- Ligation of the subclavian artery and repair of the esophagus may be an option in certain situations.
- Repair of the subclavian artery and esophagostomy may be considered as an alternative approach.
- Subclavian artery ligation and esophagostomy may be performed in cases where repair of both injuries is not feasible.