Management of major hemorrhage during mediastinoscopy

Objective: The management of major hemorrhage complicating mediastinoscopy is not well described. We reviewed our experience to determine the frequency, optimal management strategy, and outcome of these injuries. Methods: A retrospective review of all mediastinoscopies performed at a single institution during a 12-year period (January 1990-January 2002) was performed. Major hemorrhage was defined as that requiring exploration for definitive control. Results: During the study period, 3391 mediastinoscopies were performed. Fourteen patients (0.4%) experienced major hemorrhage. Most patients (12/14) had non-small cell lung cancer, and only 1 patient each underwent preoperative radiation, repeat mediastinoscopy, or extended mediastinoscopy. The most common biopsy site (4/14 cases) resulting in major hemorrhage was the lower right paratracheal region (level 4R), and the most frequently injured vessels were the azygos vein and the innominate and pulmonary arteries. Initial control of hemorrhage was achieved through packing in 93% (13/14), and the most common initial approach for exploration was sternotomy (8/14). Four patients underwent a planned pulmonary resection after definitive control of bleeding. The median amount of blood transfused was 2 units (range 0-18 units). Postoperative complications occurred in 2 of 14 patients (14%). There were no intraoperative deaths, but 1 patient died postoperatively (1/14, 7% mortality). The median postoperative length of stay was 6 days (range 1-19 days). Conclusions: Major hemorrhage during mediastinoscopy is an uncommon but potentially morbid event. Initial control can usually be achieved through packing. Subsequent management presents a technical challenge but can result in minimal morbidity and mortality.