What is the treatment for a patient with oesophageal and proximal subclavian artery injuries due to an explosion?

Management of Oesophageal and Proximal Subclavian Artery Injuries Following Explosion

Direct repair of both the oesophageal and proximal subclavian artery injuries is the treatment of choice for this patient with explosion-related neck trauma. 1

Primary Management Approach

• Operative repair is the recommended treatment for traumatic injuries of both the esophagus and major vascular structures, with direct repair being the preferred approach whenever feasible 1
• For cervical esophageal injuries, direct repair of the perforation should be attempted as the first-line treatment, with appropriate management of associated injuries being essential for patient survival 1
• Vascular control of the subclavian artery is paramount, as these injuries are associated with high morbidity and mortality if not promptly addressed 2, 3

Surgical Technique for Esophageal Repair

• The mucosal defect is often longer than the muscular tear; longitudinal myotomy at both ends of the esophageal perforation is useful to expose mucosal edges for appropriate repair 1
• Two-layer repair with separate suturing of the mucosa and muscle is traditionally recommended to minimize the risk of suture breakdown 1
• Buttressing the esophageal repair with surrounding viable tissue (intercostal muscle flap, pleural or pericardic patch) decreases the risk of leakage and prevents complications such as tracheo-esophageal fistula 1

Subclavian Artery Repair Considerations

• Direct repair of the subclavian artery is preferred over ligation when technically feasible, as it preserves limb circulation 3, 4
• Proper surgical exposure is critical for successful repair - midline sternotomy for right subclavian vessels, anterolateral thoracotomy for proximal left subclavian injuries, and claviculectomy for distal subclavian artery injuries 3
• Complete restoration of circulation should be the goal, as limb salvage rates can reach 92-97% with proper vascular repair 4

Why Alternative Options Are Inferior

• Esophagostomy with arterial repair (Option B) should only be considered if direct esophageal repair is not feasible due to large disruption, delayed surgery, or pre-existing esophageal disease 1
• Arterial ligation with esophageal repair (Option C) increases the risk of limb ischemia and should be avoided unless direct arterial repair is technically impossible 3, 4
• Mortality of traumatic esophageal injuries is high (44%), with 92% of deaths occurring within 24 hours, making immediate definitive repair of both structures the optimal approach 1

Critical Adjunctive Measures

• Adequate drainage around the repair site is essential to prevent complications 1
• Decompression of the esophagus and stomach via nasogastric tube is recommended 1
• Distal enteral nutrition through a feeding jejunostomy should be considered to support healing 1
• Close monitoring for complications including infection, respiratory compromise, and wound healing issues is required during the postoperative period 5

Special Considerations for Hemodynamically Unstable Patients

• In hemodynamically unstable patients, principles of damage control surgery should be applied, with abbreviated source control surgery followed by ICU resuscitation 1
• Temporary measures such as endovascular balloon occlusion may be used to obtain vascular control as an adjunct to definitive surgical repair in unstable patients 2
• A second-look procedure may be required for definitive management after physiological stabilization 1