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

Abstract

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.

Introduction

Armed conflicts generate high-energy penetrating injuries that frequently involve the chest and abdomen, are often combined as thoracoabdominal trauma, and are associated with substantial lethality and complex multi-organ damage patterns [1]. Penetrating cervicothoracic trauma is particularly time-critical because disruption of the airway, major mediastinal vessels, and aerodigestive tract can coexist and rapidly culminate in hypoxemia, exsanguination, or mediastinal/pleural contamination [2, 3]. Within this spectrum, tracheobronchial injury is uncommon but potentially high-impact, with blunt and penetrating trauma, including gunshot wounds, recognized among the principal etiologies and associated with significant morbidity and mortality [4]. Clinically, suspicion for major airway disruption should be heightened by severe respiratory distress, extensive subcutaneous emphysema, pneumothorax/pneumomediastinum, and especially a persistent or large air leak despite a correctly positioned chest tube, including in intubated patients with rising ventilatory resistance [2, 5–7].

Cross-sectional imaging has become central to triage in stable patients: chest CT is superior to radiography for identifying major bronchial rupture, and with modern multidetector techniques CT sensitivity for tracheobronchial injury has been reported as high as approximately 94%, while also delineating associated thoracic injuries [2]. Nevertheless, diagnostic confirmation and injury classification commonly rely on bronchoscopy alongside clinical findings and CT features, particularly when operative planning depends on precise localization and extent [5–7]. Definitive management of traumatic tracheobronchial disruption is most often surgical, whereas conservative strategies are reserved for carefully selected small, localized defects, and airway stents are generally not recommended in this context [5, 8].

Subclavian artery trauma, although infrequent, is feared because exposure is technically demanding and penetrating lesions are frequently accompanied by hemodynamic instability, making timely hemorrhage control and revascularization decisive [6, 9, 10]. Moreover, traumatic esophageal injury is rare, estimated at approximately 0.02–1% of traumatic injuries, yet carries high reported morbidity and mortality, and its presentation may be nonspecific despite described symptom clusters such as pain, fever, dyspnea, crepitus, and dysphagia [3, 11]. Across aerodigestive trauma, operative principles emphasize early source control with debridement, primary repair when feasible, drainage, decompression, and nutritional support, sometimes within damage-control frameworks for critically injured patients [11–14].

In this case series, we report war-related penetrating tracheal, subclavian arterial, and thoracic esophageal injuries managed by urgent operative intervention in a resource-limited military hospital in Syria. In our setting, “resource-limited” refers primarily to limited access to bronchoscopy, Doppler/vascular imaging, endovascular or hybrid operative options, specialized materials, and structured long-term follow-up rather than absence of surgical expertise. The aim is to highlight physiology-driven decision-making, selective use of CT when feasible in borderline but transportable patients, and pragmatic operative adaptations in an austere conflict setting.

Case presentation and series methods

This retrospective case series describes consecutive war-related penetrating cervicothoracic injuries managed at a resource-limited military hospital in Syria between 2015 and 2017. All surgical interventions were performed by a single attending surgeon. Clinical, operative, and imaging data were extracted from emergency department records, operative notes, and radiology reports. Inclusion criteria were penetrating injuries involving the neck or upper chest with intraoperative confirmation of injury to the trachea, major thoracic vessels, or esophagus. Patient identifiers were removed to ensure confidentiality. Written informed consent for publication was obtained from the patients or their legal guardians when applicable.

Case 1 — Tracheal injury

A 28-year-old male was brought to the emergency department of a resource-limited military hospital in Syria approximately 15–30 min after sustaining a penetrating gunshot injury to the left lower cervical region, near the junction of the anterior and posterior cervical triangles, approximately 3–4 cm above the clavicular origin of the sternocleidomastoid muscle. Prehospital care was limited to oxygen supplementation and peripheral intravenous access. On arrival, he was in critical condition with blood pressure 90/50 mmHg, heart rate 120 beats/min, respiratory rate 35 breaths/min, oxygen saturation (SpO₂) 70%, altered consciousness, severe respiratory distress, and extensive subcutaneous emphysema involving the neck and upper chest. No obvious air leak was observed through the cervical wound. Chest examination demonstrated absent breath sounds on the left and markedly reduced breath sounds on the right.

A left tube thoracostomy was inserted immediately, yielding moderate pneumothorax decompression and approximately 600 mL of blood. Endotracheal intubation was successfully performed. Because portable chest radiography and bronchoscopy were unavailable in the emergency setting, computed tomography (CT) was used as the only immediately available imaging modality despite the patient’s borderline physiologic status. CT demonstrated right pneumothorax, pneumomediastinum, and radiologic suspicion of major tracheal injury (Fig. 1). A right chest tube was subsequently inserted, draining approximately 400 mL of blood with a severe persistent air leak.

Fig. 1.

Case 1 (Tracheal injury). Axial CT images of the cervicothoracic region (mediastinal and lung windows) demonstrating pneumomediastinum with extensive cervical/upper chest subcutaneous emphysema and an associated right pneumothorax, raising suspicion for a major tracheal injury

Given the massive ongoing air leak and progressive deterioration, operative intervention was based primarily on clinical findings, with CT serving as supportive imaging. Initial cervical exploration was performed in the supine position and revealed a severely macerated upper tracheal injury. The patient was then repositioned into lateral decubitus position, and emergency right thoracotomy through the fourth intercostal space was undertaken for definitive exposure. Exploration revealed a longitudinal tracheal laceration approximately 3 cm below the cricoid cartilage extending for nearly 2 cm with disruption and tissue loss involving the tracheal rings. Because of extensive destruction, segmental resection was not feasible.

Repair was achieved using interrupted 3 − 0 polyglactin sutures approximating the membranous and cartilaginous portions. A pedicled intercostal muscle flap harvested from the third intercostal space after partial fourth-rib resection was rotated to reinforce the repair longitudinally, and the mediastinal pleura was closed over the flap (Fig. 2). Bilateral chest drains were left in situ. Both lungs re-expanded satisfactorily after repair, the air leak ceased, and oxygen saturation improved to 93% intraoperatively following resuscitation with crystalloids and one unit of packed red blood cells.

Fig. 2.

Case 1 (Tracheal injury). Intraoperative photographs obtained through right thoracotomy demonstrating surgical exposure and repair of the traumatic tracheal injury, with reinforcement using a pedicled intercostal muscle flap

Case 2 — Subclavian artery injury

A 23-year-old male presented approximately 20 min after a through-and-through gunshot wound with entry at the left supraclavicular fossa and exit near the left acromioclavicular region. Prehospital management consisted only of oxygen administration and peripheral intravenous access. On admission, he was in profound hemorrhagic shock with blood pressure 70/30 mmHg, heart rate 135 beats/min, and oxygen saturation 85%. Physical examination demonstrated absent distal pulses in the left upper extremity and markedly diminished breath sounds over the left hemithorax.

Because Doppler ultrasonography and formal vascular imaging were unavailable in the emergency setting, CT imaging was obtained as the only feasible diagnostic modality despite the patient’s borderline hemodynamic condition. CT demonstrated near-complete opacification of the left hemithorax due to massive hemothorax, mediastinal shift, associated pulmonary collapse, dependent clots, and comminuted scapular fracture related to the projectile trajectory (Figs. 3 and 4).

Fig. 3.

Case 2 (Subclavian artery injury). Chest radiograph showing near-complete opacification of the left hemithorax with mediastinal shift, consistent with a massive left hemothorax/pleural effusion and compressive atelectasis

Fig. 4.

Case 2 (Subclavian artery injury). Axial CT images demonstrating a large left pleural collection (hemothorax) with left lung compression/atelectasis and mediastinal displacement, with associated shoulder-girdle bony injury compatible with the projectile trajectory

Immediate left tube thoracostomy drained approximately 1400 mL of blood. Aggressive resuscitation was initiated with packed red blood cells and crystalloid fluids. Ongoing hemodynamic instability and massive hemothorax prompted emergency operative exploration. The patient was placed in the supine position, and a combined supraclavicular incision with left anterolateral thoracotomy through the fourth intercostal space (“trap-door” approach) was performed to obtain rapid exposure and vascular control of the thoracic outlet vessels (Fig. 5).

Fig. 5.

Case 2 (Operative approach). Schematic illustration of the two-incision “trap-door” exposure, combining a left supraclavicular incision with a left anterolateral thoracotomy, to facilitate rapid exposure of the thoracic inlet and proximal/distal control of the subclavian vessels

Intraoperatively, a complete transection of the left subclavian artery approximately 2 cm distal to its origin was identified. Proximal and distal vascular control was achieved using vascular clamps. Reconstruction was performed using an interposition autologous saphenous vein graft because synthetic graft material was unavailable. Continuous 5 − 0 and 6 − 0 polypropylene sutures were used for vascular anastomosis. Estimated blood loss was approximately 4 L. Distal pulses returned immediately after revascularization. No major venous or brachial plexus injury was identified. An associated pulmonary laceration was repaired using absorbable sutures, chest drainage was maintained, and the thoracotomy was closed in standard fashion.

Case 3 — Thoracic esophageal injury

A 30-year-old male arrived approximately 15–30 min after sustaining a penetrating gunshot wound to the right posterior thoracic region at the level of the sixth to seventh intercostal spaces near the scapular area. Initial prehospital care was limited to oxygen supplementation and intravenous access. On admission, he was hypotensive and tachycardic with blood pressure 90/50 mmHg, heart rate 115 beats/min, respiratory rate 24 breaths/min, and oxygen saturation 85%. Examination demonstrated decreased breath sounds over the right hemithorax.

Portable radiography was unavailable, and CT imaging represented the only accessible diagnostic modality. CT demonstrated right pleural effusion, right pneumothorax, pulmonary contusion, and a retained projectile adjacent to the mid-thoracic esophagus (Figs. 6 and 7). A right chest tube drained approximately 200 mL of blood with moderate air leak; notably, food-like enteric material was identified within the drainage system, strongly suggesting esophageal perforation.

Fig. 6.

Case 3 (Esophageal injury). Admission chest radiograph demonstrating a retained projectile projecting over the mid-mediastinum at the expected level of the mid-esophagus, with associated right-sided pleural opacity consistent with pleural effusion/hemothorax (correlating with CT findings)

Fig. 7.

Case 3 (Esophageal injury). Axial CT chest images (mediastinal and lung windows) demonstrating a retained projectile adjacent to the mid-esophagus with associated right pleural effusion/hemothorax, right pneumothorax, and pulmonary contusion, supporting suspected thoracic aerodigestive injury

The patient underwent urgent right posterolateral thoracotomy under general anesthesia with double-lumen endotracheal intubation. Exploration identified a full-thickness longitudinal esophageal tear approximately 4 cm in length involving the right wall of the mid-thoracic esophagus, while the contralateral wall remained intact. The retained metallic fragment was extracted from the esophageal lumen. Devitalized tissue was debrided, and primary repair was performed using interrupted full-thickness 3 − 0 polyglactin sutures. An associated superficial pulmonary laceration was repaired. No dedicated mediastinal drain was inserted because the mediastinal pleura had been opened widely into the pleural cavity, and chest drainage was considered sufficient for mediastinal decompression. Broad-spectrum antimicrobial therapy with meropenem and vancomycin was administered. Oral feeding was resumed after 5 days with no clinical evidence of mediastinitis or early postoperative leak during the limited available follow-up period. A summary of the three cases is provided in Table 1.

Table 1.

Summary of cases

Case	Age/Sex	Time to arrival	Mechanism/Trajectory	Sentinel findings	Key imaging	Operative findings	Repair	Early outcome / short follow-up
1	28/M	~ 15–30 min	GSW neck (left lower cervical/supraclavicular region)	Massive subcutaneous emphysema; severe hypoxemia; persistent massive air leak	CT: right pneumothorax + pneumomediastinum; suspected tracheal injury	Longitudinal tracheal laceration with tissue loss located ~ 3 cm below the cricoid cartilage, extending ~ 2 cm with disrupted tracheal rings	Debridement; membranous-to-cartilaginous approximation with interrupted 3 − 0 polyglactin 910 sutures; pedicled intercostal muscle flap reinforcement; mediastinal pleura closed over flap	SpO2 improved to 93%; bilateral lung re-expansion; air leak ceased; no ongoing hemorrhagic output
2	23/M	~ 20 min	Through-and-through GSW (entry: left supraclavicular fossa; exit: left acromioclavicular region)	Profound hemorrhagic shock; absent left upper-limb pulses; massive hemothorax (1400 mL)	CT: near-complete left hemithorax opacification; massive hemothorax; mediastinal shift; pulmonary collapse; comminuted scapular fracture; dependent clots	Complete transection of left subclavian artery ~ 2 cm distal to origin; associated lung injury	Trap-door approach (supraclavicular incision + left anterolateral thoracotomy through 4th intercostal space); autologous saphenous vein interposition graft with continuous 5 − 0/6 − 0 polypropylene sutures; pulmonary repair	Immediate restoration of distal pulses and limb perfusion
3	30/M	~ 15–30 min	GSW to right posterior thoracic region (6th-7th intercostal level) directed toward mediastinum	Food-like/enteric pleural drainage; right hemopneumothorax	CT: retained projectile near mid-esophagus; right pleural effusion/pneumothorax; pulmonary contusion	Full-thickness longitudinal mid-esophageal tear (~ 4 cm) involving right wall of mid-thoracic esophagus; retained intraluminal fragment	Foreign body extraction; debridement; interrupted full-thickness primary repair using 3 − 0 polyglactin sutures; chest drainage; meropenem + vancomycin	Oral feeding resumed after 5 days; no clinical mediastinitis or early leak during limited follow-up

Follow-up after discharge was limited (approximately one week) because patients returned to distant conflict-affected regions

Discussion

War-related penetrating cervicothoracic trauma concentrates airway, vascular, and aerodigestive injuries within a narrow anatomic corridor; deterioration can therefore be abrupt unless diagnostic and operative decisions are made early and decisively [1–3]. Contemporary combat experience confirms that thoracoabdominal gunshot injuries are often severe, associated with hemopneumothorax, hemorrhagic shock, airway compromise, and multi-organ injury, and that management in deployed or resource-limited hospitals often requires adaptation of standard trauma algorithms to local resources [1]. Several trauma guidelines emphasize that the therapeutic approach should be driven primarily by patient physiology, with airway control, pleural decompression, and hemorrhage control prioritized before exhaustive diagnostic testing in unstable patients [2, 8]. In stable or stabilized patients, modern imaging, particularly multidetector CT and CT angiography where available, can support selective, diagnosis-driven intervention; however, these pathways require modification when bronchoscopy, vascular imaging, endovascular options, or structured follow-up are limited [2, 8, 9, 15].

Our first case demonstrates a classic high-risk pattern for major airway disruption: profound hypoxemia, severe respiratory distress, extensive subcutaneous emphysema/pneumomediastinum, and a persistent massive air leak after tube thoracostomy. Reviews of tracheobronchial injury describe subcutaneous emphysema, pneumomediastinum, pneumothorax, high air leakage, and increased ventilatory resistance as important warning signs, particularly in intubated or critically ill patients [4, 5, 7, 16]. Bronchoscopy remains the definitive diagnostic tool for localizing and characterizing airway injury; however, CT is also well established for initial evaluation when tracheal injury is suspected and can identify pneumomediastinum, pneumothorax, airway wall defects, and associated thoracic injuries [5–7]. In our setting, bronchoscopy was not available, and the patient was physiologically borderline. Therefore, the decision for surgery was driven primarily by clinical deterioration and persistent massive air leak, with CT used as supportive problem-mapping rather than as a prerequisite for intervention. This approach is consistent with guidance that traumatic tracheobronchial injuries with persistent pneumothorax/air leak despite adequate chest drainage should be recognized promptly and surgically managed early when indicated [8].

The operative strategy in the tracheal case also reflects accepted principles for penetrating airway trauma. Penetrating airway injuries generally require operative exploration, limited dissection, debridement, and direct repair, unlike selected iatrogenic membranous lacerations that may be managed conservatively or endoluminally [5]. Conservative treatment is generally reserved for carefully selected patients with stable vital signs, no esophageal injury, no difficulty with ventilation, and no progressive subcutaneous or mediastinal emphysema [6]. These criteria were not present in our patient. Open repair through a right thoracic approach is consistent with thoracic airway injury recommendations, and airway trauma reviews support absorbable sutures and vascularized tissue reinforcement when tissue quality is poor or when contamination/fistula risk is a concern [5, 6]. In our case, the intercostal muscle flap provided a pragmatic, locally available buttress for a macerated tracheal defect with tissue loss, and bilateral lung re-expansion with cessation of the air leak after repair supported central airway disruption as the dominant pathophysiologic problem.

The second case illustrates the intersection of hemorrhage control and limb salvage in proximal upper-extremity vascular trauma. Major vascular trauma reviews emphasize that the two immediate goals are bleeding control and restoration of perfusion, and that hard signs such as pulselessness, ischemia, expanding hematoma, or shock warrant expedited invasive treatment rather than delayed confirmation [9]. Subclavian artery injuries are particularly difficult because surgical exposure is constrained by the clavicle, first rib, and thoracic inlet, and penetrating subclavian injuries are often associated with hemodynamic instability and severe noncompressible hemorrhage [9, 17]. In modern centers, CTA is generally preferred for vascular trauma because it localizes injury, demonstrates extravasation or thrombosis, and supports operative or endovascular planning; nevertheless, its practical use depends on patient transportability and institutional resources [9]. In our case, Doppler ultrasonography, formal CTA, and endovascular capability were not available; therefore, absent pulses, hemorrhagic shock, and massive hemothorax were sufficient clinical triggers for immediate open exploration.

The reviewer’s concern regarding high-volume hemothorax is important. Current chest-trauma guidance notes that older numeric thresholds such as initial chest tube output greater than 1500 mL or persistent loss around 250 mL/hour for several hours have historically been used as indications for thoracotomy, but modern recommendations emphasize physiology and ongoing relevant blood loss rather than volume alone [8]. This distinction is clinically relevant in subclavian artery injury: rapid decompression of a large hemothorax may remove a tamponade effect, alter intrathoracic pressure, and unmask or worsen arterial bleeding. Accordingly, in our patient, tube thoracostomy, transfusion, and operative exposure were treated as linked steps rather than separate sequential endpoints. The trap-door approach allowed access to both the pleural space and thoracic outlet, enabling proximal and distal control of the transected left subclavian artery. Although prosthetic conduits are often used for larger subclavian defects when contamination is not present, autologous greater saphenous vein may be used when prosthetic material is unavailable or contamination/infection risk is a concern [9]. The immediate return of distal pulses after interposition grafting supports the effectiveness of this resource-adapted open reconstruction.

The third case highlights the diagnostic vulnerability of thoracic esophageal trauma. Esophageal injury is rare but potentially catastrophic because the esophagus lacks a serosal layer and has segmental blood supply, allowing rapid contamination of the mediastinum and pleural space after perforation [11]. Clinical findings may be nonspecific, and delay in diagnosis increases morbidity [11, 18]. In stable patients, recommended diagnostic pathways may include CT, CT esophagography, esophagoscopy, and/or contrast esophagography depending on location and available expertise [11, 12, 18]. However, Western Trauma Association guidance emphasizes that unstable patients with penetrating thoracic injury should proceed directly to operative management, and that diagnostic algorithms must be adapted to patient condition, personnel, institutional resources, and situational factors [18]. In our case, CT localized the retained projectile near the mid-esophagus, but the decisive finding was food-like enteric material in the chest tube, a bedside sign consistent with pleural contamination from esophageal perforation [11]. Because advanced contrast studies and endoscopy were unavailable and would have delayed source control, urgent thoracotomy was appropriate.

Once identified, the management of the esophageal injury followed accepted operative principles. Reviews and algorithms emphasize early broad-spectrum antibiotics, nil per os status, gastric/esophageal decompression when feasible, debridement of devitalized tissue, primary repair when possible, and adequate drainage [11–13, 18]. Primary repair is widely supported when healthy tissue can be approximated without tension, and single- or double-layer repair with absorbable or nonabsorbable sutures may be used because no definitive comparative evidence proves superiority of one technique [18]. For thoracic esophageal injuries, right posterolateral thoracotomy is recommended for upper and middle thoracic lesions, while lower thoracic lesions are generally approached from the left [12]. Our patient had a right-sided full-thickness mid-esophageal injury with the contralateral wall intact; therefore, foreign-body extraction, debridement, interrupted full-thickness repair, broad-spectrum antibiotics, and pleural drainage were consistent with these principles. No separate mediastinal drain was placed because the mediastinal pleura was widely opened into the pleural cavity, allowing chest drainage to function as the available route for mediastinal decompression.

Across the three cases, the term “damage-control surgery” should be interpreted carefully. These patients were not managed uniformly by staged abbreviated laparotomy/thoracotomy followed by delayed definitive reconstruction. Rather, management combined damage-control principles—rapid control of airway failure, hemorrhage, contamination, and physiology—with definitive emergency repair when feasible during the index operation. This is particularly true for the esophageal case, in which primary repair was performed during the first operation. Therefore, the most accurate framing of this series is physiology-driven urgent operative management of war-related penetrating cervicothoracic trauma in a resource-limited setting. The resource limitations in our hospital did not reflect lack of surgical expertise, but rather limited access to bronchoscopy, Doppler/vascular imaging, endovascular or hybrid operating capability, specialized materials, and long-term follow-up infrastructure. If available, bronchoscopy could have refined airway localization, vascular imaging or endovascular tools could have supported subclavian planning, and esophagoscopy or contrast esophagography could have further characterized the esophageal injury. Nonetheless, none of these modalities should delay intervention in patients with life-threatening clinical triggers.

This series has important limitations. It includes only three patients and is subject to selection and survivorship bias because only patients who reached the operating room are represented. Prehospital documentation was limited, and follow-up after discharge was short, approximately one week, because patients returned to distant conflict-affected areas. Consequently, delayed complications such as airway stenosis, recurrent air leak, graft thrombosis, infection, esophageal leak, stricture, or late mediastinitis could not be reliably assessed. Despite these limitations, the cases illustrate transferable lessons for similar austere environments: prioritize physiology over diagnostic completeness, use CT selectively when patients are borderline but transportable, proceed to open exploration when hard clinical signs mandate action, and adapt repair techniques using available autologous tissue, open exposure, drainage, and antimicrobial coverage.

Conclusion

In austere conflict settings, penetrating cervicothoracic trauma requires rapid recognition and physiology-driven operative management because airway disruption, major hemorrhage, and mediastinal contamination may coexist and deteriorate within minutes. This case series illustrates that prioritizing airway control, pleural decompression, hemorrhage control, and early source control can be lifesaving even when bronchoscopy, vascular imaging, endovascular options, and structured follow-up resources are limited. Cross-sectional imaging can help map injury patterns and guide operative planning in borderline but transportable patients, but it should not delay exploration when hard clinical signs mandate intervention. Overall, adaptable emergency surgical strategies, meticulous primary repair, vascularized reinforcement when needed, adequate drainage/decompression, and broad-spectrum antimicrobial therapy can achieve favorable early outcomes in selected high-risk injuries, although longer follow-up is needed to assess delayed complications.

Author contributions

1. Issam Alkhayer: Supervision; Investigation (operating surgeon); Methodology; Writing, review & editing. 2. Mohammad Alaa Aldakak: Conceptualization; Data curation; Writing original draft; Writing, review & editing. 3. Youssef Abbas: Investigation; Data curation; Resources; Writing, review & editing.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Data availability

De-identified data and analysis outputs are available from the corresponding author on reasonable request.

Declarations

Ethical approval

According to local institutional policy, formal IRB approval was not required for this retrospective de-identified case series.

Patient consent

Written informed consent was obtained from the patients for publication and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Competing interests

The authors declare no competing interests.