Management of Oesophageal and Proximal Subclavian Artery Injuries Following Explosion

Primary Management Approach

The World Journal of Emergency Surgery recommends direct repair of both the oesophageal and proximal subclavian artery injuries as the treatment of choice for patients with explosion-related neck trauma 1, 2
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, 2
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 2, 3

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 4
Two-layer repair with separate suturing of the mucosa and muscle is traditionally recommended to minimize the risk of suture breakdown 4
Buttressing the esophageal repair with surrounding viable tissue decreases the risk of leakage and prevents complications such as tracheo-esophageal fistula 1, 4

Esophagostomy with arterial repair should only be considered if direct esophageal repair is not feasible due to large disruption, delayed surgery, or pre-existing esophageal disease 1, 2

Adequate drainage around the repair site is essential to prevent complications 2
Decompression of the esophagus and stomach via nasogastric tube is recommended 2
Distal enteral nutrition through a feeding jejunostomy should be considered to support healing 2
Close monitoring for complications including infection, respiratory compromise, and wound healing issues is required during the postoperative period 6

In hemodynamically unstable patients, principles of damage control surgery should be applied, with abbreviated source control surgery followed by ICU resuscitation 2, 5
A second-look procedure may be required for definitive management after physiological stabilization 5
Mortality of traumatic esophageal injuries is high, with 92% of deaths occurring within 24 hours, making immediate definitive repair of both structures the optimal approach 5