War-related penetrating cervicothoracic trauma managed in a resource-limited hospital in Syria: a case series

BACKGROUND: Penetrating cervicothoracic trauma in war is time-critical because airway, major vascular, and aerodigestive injuries may coexist, rapidly causing hypoxemia, exsanguination, or pleural/mediastinal contamination. CT can support triage and operative planning in transportable patients, while bronchoscopy, vascular imaging, and contrast/endoscopic esophageal studies may further refine assessment when available. CASE PRESENTATION: We reviewed consecutive war-related penetrating neck/upper-chest injuries treated at a military hospital in Syria between 2015 and 2017. Inclusion required intraoperative confirmation of tracheal, major thoracic vascular, or esophageal injury. Three male patients underwent emergency surgery. Case 1 presented with profound hypoxemia, extensive subcutaneous emphysema, pneumomediastinum, and persistent massive air leak after drainage. CT suggested tracheal disruption; right thoracotomy revealed a longitudinal tracheal laceration with tissue loss approximately 3 cm below the cricoid, extending 2 cm. Case 2 arrived in profound shock with absent left upper-limb pulses and massive hemothorax; trap-door exploration identified complete left subclavian artery transection. Case 3 had CT evidence of a retained projectile near the mid-esophagus and right hemopneumothorax; food-like pleural drainage prompted thoracotomy, confirming a 4-cm mid-esophageal tear. CASE DISCUSSION: Management was physiology-driven. The tracheal injury was repaired with interrupted absorbable sutures and intercostal muscle-flap buttress. The subclavian artery was reconstructed with an interposition graft, restoring distal pulses. The esophageal injury underwent primary repair with broad-spectrum antimicrobials. CONCLUSION: In austere conflict settings, CT-informed triage plus decisive operative management can be lifesaving, but imaging should not delay exploration when hard clinical signs persist.