SURGICAL STRATEGIES FOR CERVICOTHORACIC INJURY WITH PENETRATING INJURY TO THE RIGHT COMMON CAROTID ARTERY, TRACHEA AND ESOPHAGUS Dulaev A.K., Demko A.E., Taniya S.Sh., Babich A.I.
Saint Petersburg I.I. Dzhanelidze Institute of Emergency Medicine,
Saint Petersburg, Russia
Cervicothoracic wounds present the actual problem in modern urgent surgery. It is associated with rare incidence of this type of wounds (< 1 % of all injuries) and with poor results of treatment − complications appear during treatment in 80 % of patients, and the mortality reaches 45 % in big modern surgery centers [1-4].
The highest experience with cervicothoracic wounds in the Russian Federation has been accumulated in Sklifosofsky Research Institute of Emergency Aid (123 patients). The common carotid artery damage was identified in only 3.8 % of cases (4 patients) [5]. Moreover, we have not found any cases of treatment of patients with combination of injuries to the common carotid artery and the esophagus in its intrathoracic part with trachea injury in domestic and foreign literature. Therefore, discussion of this clinical case is important.
Objective − to discuss the features of surgical strategies in a patient with a cervicothoracic stab wound with an injury to the right common carotid artery, trachea and esophagus.
The study was conducted in compliance with Helsinki Declare and the order of Health Ministry of Russia from April 1, 2016 "About confirmation of rules of clinical practice". The patient gave the informed consent for publication of the clinical case.
CLINICAL CASE
The patient, male, age of 52, was admitted by the emergency medical team to the anti-shock surgery room of the emergency unit of Saint Petersburg Dzhanelidze Research Institute on April 13, 2016. The duration of the prehospital stage was 45 minutes. The patient suffered from an injury during domestic conflict. He called to emergency service immediately after the injury. The patient was in awake during examination on the accident site. He was in alcohol intoxication. Arterial pressure (AP) was 70 and 40 mm Hg. The heart rate (HR) was 100 per minute, the respiratory rate − 22 per minute. External blood loss was high. At the prehospital stage, two peripheral veins were catheterized, infusion of 1,000 ml of crystalloid solutions was carried out, and the aseptic dressing was applied.
The patient was awake and agitated during admission to the anti-shock surgical room (CGS − 14). The skin was pale. AP was 80/40 mm Hg, HR − 96 per minute, RR − 18 per minute. There was a stab wound (2 cm) on the anterior surface of the neck, 1 cm above the right sternal clavicular junction in the first zone of the neck to the right. A handle of a cutting tool was visible in the wound (Fig. 1). Moreover, there was a superficial stab wound in the second zone of the neck to the right. Auscultation showed breathing in all regions of the lungs. Breathing was not weak. No other injuries were found.
Figure 1
Photo of the wound upon admission
In conditions of the anti-shock surgery room, the protocol of short examination of the patient was carried out. No abnormalities were found in ultrasonic examination (FAST) of abdominal organs, pleural cavities and pericardium. Frontal X-ray examination of the chest (Fig. 2) identified a fork, which was the injuring object. The fork was in transaxial direction. Moreover, a mediastinum hematoma was found. The general clinical analysis of the blood: hemoglobin − 93 g/l, red blood cells − 2.2 × 1012/l. Blood gas analysis: base excess (BE) − -5 mmol/l. Considering the unstable hemodynamics, the cervicothoracic wound and mediastinum hematoma, longitudinal middle sternotomy (Babich A.I.) was conducted in conditions of general anesthesia with tracheal intubation and artificial lung ventilation, without removal of the injuring object, in the anti-shock surgery room (Fig. 3). The Buford rake retractor was installed. The revision showed a penetrating wound of the right common carotid artery − it was put onto the fork in the site of its origin from brachiocephalic trunk. Moreover, there was a penetrating injury to the trachea and right esophageal wall (intrathoracic part). Proximal and distal control of bleeding was performed. The brachiocephalic trunk, the right subclavian artery and right common carotid artery (more proximally from its injury) were ligated. The fork was removed (Fig. 4). Due to extensive injury to the right common carotid artery, it was resected and replanted into the brachiocephalic trunk with continuous twisted suture with prolen 6/0 (Khomchuk I.A., Babich A.I.) (Fig. 5). Duration of ligation of the right common carotid artery was 8 minutes. Tracheal and esophageal injuries were sutured with separate interrupted sutures with vicryl 3/0 (Fig. 6). Control of hemostasis did not show any blood. There were not any foreign bodies. Z-shaped sutures were paced onto the sternum with metal surgical wire, separate interrupted sutures − with capron 3/0. The diagnosis was confirmed after surgery: "The deep cervicothoracic stab wound with the penetrating injury to the right common carotid artery of trachea and esophagus. Severe acute blood loss. Severe alcohol intoxication (3.2 ‰ in the blood).
Figure 2
Chest X-ray image (direct projection)
Figure 3
Sternotomy (fork not removed)
Figure 4
Proximal and distal control before replantation of the right common carotid artery
Figure 5
Replanted right common carotid artery
Figure 6
Stitched trachea and esophagus
In the postsurgical period, the patient was extubated and switched to independent breathing in 2 hours after completion of surgical intervention. The period of stay in the surgical intensive care unit was 2 days. The patient was discharged in satisfactory condition on 7th day after admission. The sutures were removed on 12th days in the clinic according to place of residence. After 60 days from surgery, the control examination showed satisfactory condition. The patient returned to his normal life.
DISCUSSION
In case of admission of patients with neck wounds and unstable hemodynamics it is necessary to perform examination in special anti-shock surgery rooms. Unstable hemodynamics (systolic arterial pressure 90 mm Hg) in presence of a wound usually means severe blood loss and a potential lethal injury [2, 6]. According to most researchers, such cases require for revision, search and treatment of an injury [1, 4, 5, 7]. The presented patient received short examination: FAST and chest X-ray imaging. These procedures were sufficient for making a decision on necessity of surgical intervention. Additional examination − spiral computer tomography with intravenous contrasting, fibrobronchoscopy, fibroesophagoscopy − was inappropriate for this patient owing to severe condition. Most authors share our position in relation to the accepted strategic decision [1-3, 5-7]. Longitudinal middle sternotomy is the optimal approach if some injuries to anterior mediastinum, and transaxial injuries are suspected [5, 6]. Such surgical approach is appropriate for adequate proximal and distal control of bleeding. If necessary, direct heart massage can be performed, and if a complex vascular injury exists, which cannot be corrected with beating heart, it is possible to switch artificial blood circulation device without additional surgical approaches. The important moment of the surgical intervention was non-removal of the injuring object up to the moment of vascular control [5, 6]. Removal of the injuring object before sternotomy, ligation and clamping of vessels above and below the injury site would result in development of uncontrolled intensive bleeding that would significantly worsen the severity of the patient's condition. One should note that the selected strategy of treatment would provide good immediate results of treatment and absence of complications in the postsurgical period.
CONCLUSION
Patients with cervicothoracic wounds and unstable hemodynamics should receive examination in conditions of the anti-shock surgery room with shortened algorithm including chest X-ray imaging and FAST-examination. The optimal surgical approach for correction of damages in transaxial injuries to the mediastinum is longitudinal middle sternotomy, which provide conditions for adequate temporary and final hemostasis, as well as for correction of esophageal and tracheal injuries.
Information on financing and conflict of interests
The study was conducted without sponsorship. The authors declare the absence of any clear and potential conflicts of interests relating to publication of this article.