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

Management of Explosion-Related Oesophageal and Proximal Subclavian Artery Injuries

Direct repair of both the oesophageal and proximal subclavian artery injuries (option A) is the treatment of choice for patients with explosion-related neck trauma. 1

Primary Management Approach

The management of combined oesophageal and subclavian artery injuries requires immediate and definitive intervention due to the high risk of mortality and morbidity:

• Direct operative repair of both structures is the recommended first-line treatment whenever feasible, as it provides the best outcomes for patient survival 1
• Mortality of traumatic oesophageal injuries is extremely high, with 92% of deaths occurring within 24 hours, making immediate definitive repair critical 1
• For cervical oesophageal injuries specifically, direct repair of the perforation should be attempted as the primary approach 1, 2

Surgical Technique for Combined Injuries

Oesophageal Repair:

• Two-layer repair with separate suturing of the mucosa and muscle is recommended to minimize suture breakdown risk 1
• Longitudinal myotomy at both ends of the oesophageal perforation helps expose mucosal edges for appropriate repair 1
• Buttressing the oesophageal repair with surrounding viable tissue decreases leakage risk and prevents complications such as tracheo-oesophageal fistula 1, 2

Subclavian Artery Repair:

• Direct repair of the subclavian artery is preferred over ligation whenever possible 1, 3
• Proper surgical exposure is critical - midline sternotomy for right subclavian injuries and anterolateral thoracotomy for proximal left subclavian injuries 3
• Temporary hemostatic control may be achieved with endovascular balloon occlusion as an adjunct to surgical repair in cases of severe hemorrhage 4

When to Consider Alternative Approaches

Alternative approaches (options B, C, or D) should only be considered in specific circumstances:

• Esophagostomy with arterial repair (option B) should only be considered if direct oesophageal repair is not feasible due to large disruption, delayed surgery, or pre-existing oesophageal disease 1
• Subclavian artery ligation (options C or D) is generally avoided due to the high risk of limb ischemia, but may be necessary in extreme circumstances where repair is technically impossible 5
• In hemodynamically unstable patients, damage control principles may be applied with abbreviated source control surgery followed by ICU resuscitation and a second-look procedure 1

Critical Adjunctive Measures

• Adequate drainage around the repair site is essential to prevent complications 1
• Decompression of the oesophagus 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 1, 2

Prognostic Factors and Complications

• Predictors of poor outcomes include hemodynamic instability on arrival, multiple associated injuries, and gunshot mechanisms 5, 6
• Associated brachial plexus injury accounts for the majority of long-term morbidity in survivors 5
• Complications are more common in patients presenting with initial systolic blood pressure less than 90 mmHg 6