Elsevier

Surgery

Volume 128, Issue 1, July 2000, Pages 54-58
Surgery

Original Communications
Transmediastinal gunshot injuries*

https://doi.org/10.1067/msy.2000.106463Get rights and content

Abstract

Background: Transmediastinal gunshot injuries are a rarely reported injury. Until recently, assessment of the thoracic aorta by angiography preceded the investigation of the esophagus. This order has been recently debated. Methods: There were 118 patients with potential transmediastinal injuries included in this retrospective study. Unstable patients who were unresponsive to resuscitation were taken to the operating room without previous investigation. Stable patients were routinely investigated initially for injury of the aorta and then for injury of the esophagus. Results: There were 51 patients who underwent urgent thoracotomy/sternotomy. In 27, the hemorrhage was of mediastinal origin; 17 of these patients died of intraoperative bleeding. Eight of the patients had aortic injury, and only one of this group survived. There were 57 stable patients who were investigated initially for injury of the aorta by angiography. It was positive in only one patient who underwent an operation with good results. An investigation of the esophagus followed and revealed esophageal injury in 17 patients. All of them were treated operatively, 15 of them with satisfactory outcome. Conclusions: Angiography should at present precede esophageal investigations. There is a need for shortening the time between admission and operation. Other modalities that could expedite the investigation of the thoracic aorta and the esophagus should be prospectively evaluated in multi-center studies. (Surgery 2000;128:54-8.)

Section snippets

Patients and methods

Baragwanath hospital with 3000 beds is the largest teaching hospital attached to the University of the Witwatersrand. From January 1993 to June 1998, a retrospective study was undertaken of all patients with potentially transmediastinal gunshot injuries. This group of patients included: (1) patients in whom the bullet entered one hemithorax and exited on the opposite side; (2) patients in whom the bullet was seen on chest x-ray film lodged in the mediastinum or the opposite hemithorax. Patients

Results

In 3 patients who lost their vital signs while being transported from the scene, cardiopulmonary resuscitation was terminated on arrival to hospital. No further active resuscitative measures were taken. Seven patients lost their vital signs on arrival at the hospital or during resuscitation in our emergency department. These patients underwent emergency department thoracotomy. Six of the 7 patients died. The heart was the main source of bleeding in 2, the aorta in 3, and a combined injury of

Discussion

Transmediastinal gunshot injuries are becoming more common because of the increased spread of firearms and have not been frequently reported in the literature. During the last two decades, only a few studies have been published about this injury.2, 3, 4 Therefore several questions have to be answered regarding the correct management of the patients so there can be a decrease in its high mortality rate.

It would have been interesting to know what percentage of patients with transmediastinal

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    Nagy et al.4 reported a 16% incidence of significant occult injuries in their stable cohort of patients. Degiannis et al.3 reported 42% of occult injuries among initially stable patients. Richardson et al.6 observed an occult injury in 63% of their stable patients.

  • Triage and Outcome of Patients with Mediastinal Penetrating Trauma

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    The operative mortality was 25% for patients who survived long enough to transfer to the operating room. This is similar to the results in several small series of transmediastinal gunshot wounds, where the operative mortality for unstable patients was 20% to 36% [4–6]. Selective management of transmediastinal gunshot wounds was first proposed in 1981 by Richardson and colleagues [4] and has become the standard for the current management of stable patients.

  • Screening helical computed tomographic scanning in haemodynamic stable patients with transmediastinal gunshot wounds

    2007, Injury
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    Evaluation of patients with TMGSWs remains a challenge to the trauma surgeon. Haemodynamically unstable patients generally have potentially lethal cardiac or vascular injuries and require immediate surgery.1,2,6,8 Haemodynamic stable patients can be uninjured, or have occult vascular, oesophageal and cardiac injuries.

  • Penetrating vascular trauma in Johannesburg, South Africa

    2002, Surgical Clinics of North America
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*

Reprint requests: E. Degiannis, MD, FRCS, Department of Surgery, Medical School, 7 York Road, Parktown 2193, Johannesburg, Republic of South Africa.

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