Ann Thorac Surg 2007;83:382
© 2007 The Society of Thoracic Surgeons
Original Articles: General Thoracic
Invited commentary
Kenneth Mattox, MD
Department of Surgery, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030
(Email: kmattox2{at}aol.com).
Burack and associates [1] have analyzed 20 patients with mediastinal traverse injuries from a cohort of 207 patients with penetrating wounds to the mediastinum, with entry from the front, cephalad, or side. The 20 mediastinal traverse patients were those at greatest risk for tracheal, bronchial, or esophageal injury, and historically have posed one of the great challenges for surgeons—determining which such patients should receive additional endoscopic or contrast studies.
All the unstable patients in this group (35%) either died in the emergency center or had operative intervention, where two esophageal injuries and no tracheal injuries were discovered at direct exploration. Among the stable patients (65%), 7 had mediastinal traverse, and 1 was found to have a tracheal injury. None were found to have esophageal injury at endoscopy or esophagoscopy. Among this group of 7 patients, the analysis of aerodigestive injuries is most helpful, as the unstable patients had direct evaluation at the time of surgery.
Although the stable cohort available for such an analysis is very small, it appears that an algorithm based on the computed tomography (CT) determined trajectory in penetrating mediastinal and mediastinal traverse injuries can be beneficial. When CT demonstrates the trajectory in stable patients is not specifically in the area of the trachea or the esophagus, bronchoscopy, esophagoscopy, or esophagography are apparently not required.
Esophageal injury can be caused by caustic ingestion, iatrogenic perforation, blunt trauma, foreign body perforation, and mediastinal penetrating trauma. It is in the area of mediastinal traverse that the clinician has historically had the most difficulty determining the exact diagnostic modality and planning for an operation. This article, with its small numbers of mediastinal traverse patients provides some guidance.
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- Burack JH, Kandil E, Sawas A, et al. Triage and outcome of patients with mediastinal penetrating trauma Ann Thorac Surg 2007;83:377-382.[Abstract/Free Full Text]
Related Article
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Triage and Outcome of Patients with Mediastinal Penetrating Trauma
- Joshua H. Burack, Emad Kandil, Ahmed Sawas, Patricia A. O’Neill, Salvatore J.A. Sclafani, Robert C. Lowery, and Michael E. Zenilman
Ann. Thorac. Surg. 2007 83: 377-382.
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