Ann Thorac Surg 2005;79:1878
© 2005 The Society of Thoracic Surgeons
Original article: General thoracic
Invited commentary
John Calhoon, MD,
Luis F. Angel, MD,
Daniel Martinez, MD,
Scott B. Johnson, MD
Department of Surgery, The University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr, MSC 7841, San Antonio, TX 78229-3900
(Email: calhoon{at}uthscsa.edu; angel{at}uthscsa.edu; martinezd4{at}uthscsa.edu; johnsons{at}uthscsa.edu).
The authors have described a compelling management approach to 18 patients treated over a 10-year period in their institution with iatrogenic tracheobronchial injury. It is important to stress that these are not trauma patients. This approach has been mentioned in the past mainly for those patients with compelling morbities such as age, cardiac disease, and other organ system dysfunction. This is one of, if not the largest, series of this particular injury and its management. The authors make a solid case for this type of management. They are to be congratulated for this series and for describing only one case of bronchial stenosis in good follow-up of this cohort. In our experience, a rate of stenosis after open repair this low is very satisfactory, especially when it was without symptoms. The deaths they saw seem to not be related to the treatment algorithm, but rather the disease leading to their need for intubation. We believe that they correctly outlined the reasons for a more traditional surgical approach. These remain massive air leak, associated esophageal injury, inability to ventilate adequately, and increasing subcutaneous emphysema. Likely size of the lesion over 4 cm in length will also prove to be an indication, although patients with this size lesion may well have one or more of the previously described signs or symptoms compelling urgent surgical attention. The main purpose of our commentary is to remind us all that this is a highly select group of patients who were not diagnosed with this problem on average more than 1 day after the likely injury occurred. We would be very reluctant to apply this management method to non-iatrogenic trauma patients. Having stressed this point, we congratulate the authors on this series and intend to consider this therapy from time to time in highly selected patients as they have. In the many other patients who present with large air leaks, ventilatory issues, esophageal injuries, and any sign of mediastinal sepsis, an immediate surgical approach will remain our standard.
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Ann. Thorac. Surg. 2005 79: 1872-1878.
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