Optimum drainage method in descending necrotizing mediastinitis

Descending necrotizing mediastinitis (DNM) is a rare but often fatal disease. Transcervical mediastinal drainage and transthoracic mediastinal drainage are the most commonly employed drainage methods for treating patients with DNM. It remains controversial as to whether transcervical mediastinal drainage alone would be adequate for the treatment of DNM, which is a life-threatening disease. Between 1996 and 2004, 13 patients with DNM were treated at our department. We performed transcervical mediastinal drainage in 6 patients with localized DNM, in whom the infection remained limited to above the level of the carina. A more aggressive approach, that is, transthoracic mediastinal drainage, was employed in the remaining 7 patients who had extensive DNM, with the infection extending below the carina. The overall mortality rate was 8%. All the 6 patients treated by transcervical drainage survived without major postoperative complications. Six out of the 7 patients treated by transthoracic drainage survived, while one died of pneumonia. Our results suggest that transcervical mediastinal drainage may be adequate for treating patients with localized DNM in whom the infection does not extend beyond the carina, while transthoracic mediastinal drainage must be adopted for patients with more extensive disease.     

Simplified treatment of postoperative mediastinitis

Background

Wound infection after median sternotomy for cardiac or thoracic surgery is a serious complication. A variety of treatment plans have been advocated, and there is lack of agreement regarding the best treatment method. We present our results in patients with mediastinitis who have been treated in a simple, consistent manner.

Methods

We reviewed our experience with 40 consecutive patients with mediastinitis who were treated between January 1995 and May 2003 with a single-stage treatment consisting of sternal and soft tissue debridement and wound closure over mediastinal tubes with continuous irrigation and drainage. Tubes were placed posterior to the sternum in all patients and were irrigated continuously for at least 7 days with antibiotic or antibacterial solution. Systemic antibiotics were selected based on culture and sensitivity data and were administered for 2 to 6 weeks.

Results

All patients with mediastinitis treated in this manner survived. Of the 40 patients, 38 achieved complete healing of the wound without further operative intervention or major complication. One patient had recurrent infection and required sternal resection and advancement of muscle flaps. One patient had a residual localized focus of chondritis and underwent limited resection of cartilage.

Conclusions

In this series of patients with postoperative mediastinitis, a simplified approach consisting of wound debridement, reclosure over drains, and anterior mediastinal irrigation has been an effective treatment. The results we have achieved suggest that this technique may be a suitable option for treating this condition.     

Descending necrotizing mediastinitis. Diagnosis and surgical treatment

AIM: Descending necrotizing mediastinitis (DNM) is an unusual and severe disease with a high mortality rate. Surgical management remains controversial. Our investigations reviews the most effective surgical treatment in the management of this rare pathology. METHODS: Seven patients with DNM and treated over a 20-year period are reported. All patients were evaluated according to the classification suggested by Endo et al. of the degree of mediastinal diffusion, based on CT scan findings. Five patients underwent combined cervical drainage and thoracotomy, 2 patients were treated with cervical drainage alone. RESULTS: The outcome was favorable in 5 patients, 4 treated with a combined cervical and thoracic approach and 1 with a cervical approach alone. Two patients that underwent a combinated cervical and thoracic approach alone, died of septic shock. Overall mortality rate was 28.5%. CONCLUSION: Early diagnosis and early, aggressive surgical treatment are required to improve the poor prognosis of DNM. Although a unique surgical management is still not completely accepted, we state, in agreement with other authors, a wide approach consisting of a cervical drainage and mediastinotomy in case of upper mediastinitis and a combined cervical and thoracic approach in case of lower mediastinitis. In the course of thoracotomy a wide excision of necrotic and particularly fat mediastinal tissue is needed, to avoid a recurrent infection. A continuous cervico-mediastinal irrigation system is suggested during the postoperative period.     

Ozone therapy as an adjunct to vancomycin enhances bacterial elimination in methicillin resistant Staphylococcus aureus mediastinitis

Background

We aimed to investigate the influence of intraperitoneal ozone therapy on bacterial elimination and mediastinal inflammation in experimental Staphylococcus aureus mediastinitis.

Materials and methods

Forty Wistar-Albino rats were randomized into five groups (eight per group) as follows: uncontaminated group, untreated contaminated group, ozone group, vancomycin group, and vancomycin + ozone group. Uncontaminated group underwent upper median sternotomy. The remaining four groups were inoculated with 0.5 mL 10⁸ colony-forming units/mL methicillin-resistant Staphylococcus aureus in the mediastinal and sternal layers. Untreated contaminated group had no treatment. Rats in the vancomycin group received intramuscular vancomycin (40 mg/kg/d), and ozone was administered intraperitoneally (70 μg/mL, 1 mg/kg/d) in the ozone group for the treatment of mediastinitis. Vancomycin + ozone group rats were treated by the combination of both methods. At the end of 10 d, quantitative bacterial cultures and sternal tissue samples were obtained for determination of bacterial counts and histologic degree of inflammation.

Results

Both the vancomycin and the ozone treatments caused significant reduction of bacterial counts in quantitative bacterial cultures. Combination of vancomycin and ozone treatments resulted in further reduction of bacterial counts in mediastinum and sternum. Histologic examination of tissue samples revealed significant reduction in severity of mediastinitis related inflammation in vancomycin and vancomycin + ozone groups compared with untreated contaminated group.

Conclusions

Ozone therapy as an adjunct to vancomycin leads to enhanced bacterial elimination in infected sternal and mediastinal tissues in experimental methicillin-resistant Staphylococcus aureus mediastinitis. The benefit of adjuvant ozone therapy is suggested to be related to its bactericidal effect.     

Surgical treatment of virulent descending necrotizing mediastinitis.

We report a 58-year-old male treated with surgical drainage by mediansternotomy using a pedicled omental flap for descending necrotizing mediastinitis (DNM). The patient recovered from DNM after five months of mechanical respiratory support. In deciding upon the most appropriate surgical approach for mediastinal drainage, the level of infection is a good landmark and should be investigated by CT scan. We also review the 43 cases of successful surgical treatment of DNM reported since 1989 in Japan, including our own patient, who were diagnosed with DNM by CT scan according to the classification proposed by Endo et al., and discuss the most appropriate surgical approach for mediastinitis based on the literature. In the treatment of DNM localized to the upper mediastinal space above the carina, a transcervical approach may be appropriate. In diffuse DNM extending into the lower anterior mediastinum, a mediansternotomy or a thoracotomy may be useful, and in diffuse DNM extending into both the anterior and posterior lower mediastinum, a thoracotomy may be the best approach for debridement of the lower posterior mediastinum, in addition to early complete debridement of the entire cervical area.     

Evaluation of the surgical fat-filling procedure in the treatment of refractory cough after systematic mediastinal lymphadenectomy in patients with right lung cancer

Background

To evaluate the efficacy of the surgical fat-filling procedure (SFFP) in the treatment of refractory cough and quality of life (QOL) after systematic mediastinal lymphadenectomy in patients with right lung cancer.

Methods

This is a blinded, randomized, controlled clinical trial to evaluate refractory cough and QOL in patients after mediastinal lymphadenectomy for lung cancer. One hundred eligible lung cancer patients were randomly divided into two groups: the fat-filling group and non-filling group. In the fat-filling group, post-lymphadenectomy residual cavities (PLRCs) were filled with fatty tissue autografts after lymph node dissection. In the non-filling group, the PLRCs remained unfilled. Clinical endpoints were postoperative cough score and QOL.

Results

The SFFP did not increase intraoperative bleeding, extend operation time, or hospital stay. Further, night cough was significantly improved after 4 wk in the fat-filling group after the removal of a chest drainage tube. QOL issues, such as emotional condition, functional status, and additional concerns, demonstrated a remarkable improvement in the fat-filling group at postoperative 1 mo compared with the non-filling (control) group.

Conclusions

This study demonstrates that filling PLRCs with fatty tissue autografts is a safe and partially effective treatment for refractory cough after major pulmonary resection and mediastinal lymphadenectomy. This novel procedure significantly improved patient QOL and may prove useful as a relatively safe preventive surgical adjunct operation for refractory cough.     

Descending necrotizing mediastinitis: a case report and review of the literature

Descending necrotizing mediastinitis (DNM) is a highly fatal disease and as infection spreads along deep cervical planes into the mediastinum, widespread cellulitis, necrosis, abscess formation, and sepsis may occur. Early diagnosis is crucial for starting aggressive treatment without delay. Cervicothoracic computed tomography (CT) scanning may be useful for early diagnosis and preoperative evaluation of the surgical approach. Optimal treatment includes broad-spectrum antimicrobial therapy and extensive cervicomediastinal and transthoracic drainage. Clamshell incision provides an excellent exposure of both thoracic cavities and all mediastinal structures with minimal morbidity. We report here a fatal case of DNM with bilateral empyema and purulent pericarditis due to an odontogenic abscess with a brief review of the literature.     

Successful treatment for descending necrotizing mediastinitis with severe thoracic emphysema using video-assisted thoracoscopic surgery

Descending necrotizing mediastinitis (DNM) is a rare, highly fatal disease that occurs as a complication of a cervical or odontogenic infection spreading into the mediastinum. We herein report of a 50-year-old man with DNM and severe thoracic emphysema who was successfully treated using surgical drainage by videoassisted thoracoscopic surgery (VATS) and a transcervical approach. Chest enhanced computed tomography on admission revealed massive left pleural effusion, pneumothorax, absolute collapse of the left lung, and a mediastinal shift to the right side with emphysema. We urgently performed left thoracic and mediastinal drainage using VATS. Retropharyngeal and upper mediastinal drainage was performed transcervically on the third hospital day. He recovered and was discharged on hospital day 57. Surgical drainage is the most important therapy in the treatment of DNM, but there is no standard surgical approach. We believe that VATS is a less invasive, effective modality for draining the posterior mediastinum.     

Outcome of patients after single-stage repair of perineal fistula without colostomy according to the Krickenbeck classification

Purpose

The aim of the study is to assess the characteristics and outcome of anorectal malformation (ARM) patients who underwent single-stage repair of perineal fistula without colostomy according to the Krickenbeck classification.

Methods

From 2002 to 2013, twenty-eight males and four females with perineal fistula who underwent single-stage repair without colostomy in our institute were included in this study. Patients with perineal fistula who underwent staged repair were excluded. Demographics, associated anomalies, and operative complications were recorded. The type of surgical procedures and functional outcome were assessed using the Krickenbeck classification.

Results

Six patients had associated anomalies, including two patients with renal, two with cardiac, one with vertebral, and one with limb abnormalities. Thirteen patients underwent perineal operation, and fourteen patients underwent anterior sagittal approach in the neonatal period. One patient underwent anterior sagittal approach, and four patients underwent PSARP beyond the neonatal period. One patient had an intra-operative urethral injury and one a vaginal injury. Complications were not associated with the type of surgical procedure (p = 0.345). All perineal wounds healed without infection. By using the Krickenbeck assessment score, all sixteen children older than five years of age had voluntary control. One patient had grade 1 soiling, and no patient had constipation.

Conclusions

Single-stage operation without colostomy was safe with good outcomes in patients with perineal fistula. The use of Krickenbeck classification allows standardization in assessment on the surgical approach and on functional outcome in ARM patients.     

The use of spinal angiography in the management of posterior mediastinal tumors: Case series and review of the literature

Introduction

Resection of inferiorly located posterior mediastinal tumors can be complicated by their proximity to the artery of Adamkiewicz (AKA). Although uncommon, intraoperative injury to the AKA may result in paraparesis or paralysis secondary to spinal cord ischemia. The use of preoperative spinal angiography may serve as a useful adjunct to the surgeon in guiding extent of resection of the tumor to avoid injury to this critical artery.

Methods

After IRB approval (H-31712), three patients, from 2008 to 2011, with lower posterior mediastinal tumors were identified. Their charts were reviewed for information concerning preoperative imaging, operative details, and postoperative neurologic complications. The literature regarding imaging of the AKA, cases of injury in pediatric patients, and recommendations for treatment after its injury were reviewed.

Results

One patient, who did not have preoperative spinal angiography, developed transient paresis lasting 6 weeks after posterior mediastinal tumor resection. Two patients underwent preoperative spinal angiography with successful localization of the AKA. In both cases, the patients subsequently underwent posterior mediastinal tumor resection without injury to the artery and without postoperative neurologic sequelae.

Conclusions

Preoperative spinal angiography may serve as a useful adjunct in the evaluation of children with inferior posterior mediastinal tumors in order to delineate the relationship of the artery of Adamkiewicz to the tumor for the purpose of guiding surgical resection.     

Pilonidal disease in a military population: how far have we really come?

Background

Pilonidal disease (PD) has a long connection with military personnel, even nicknamed “jeep disease” during World War II. The aim of this study was to identify factors associated with recurrence and complications after surgery in a military population.

Methods

A retrospective cohort analysis of operative therapy for PD at a single institution from 2005 to 2011 was conducted. Patient demographics, disease characteristics, and surgical methods were assessed for the primary outcomes of recurrence and morbidity.

Results

A total of 151 patients with PD were identified, who underwent excision (45.7%), excision with primary closure (29.8%), and incision and drainage (9.9%). Overall recurrence and morbidity rates were 27.2% and 34.4%, respectively. Black race, chronic disease, wound infection, and infection and drainage were associated with recurrence (P < .05), and excision with primary closure was associated with increased complications (P < .001).

Conclusions

PD remains a significant source of morbidity and recurrence among military personnel. Certain patient-related and disease-related factors portend a worse prognosis, with black race and operative method the strongest predictors of outcomes.     

Depressive burden is associated with a poorer surgical outcome among lumbar spinal stenosis patients: a 5-year follow-up study

Background context

In lumbar spinal stenosis (LSS), conservative treatment is usually the first choice of treatment. If conservative treatment fails, surgery is indicated. Psychological factors such as depression and anxiety are known to affect the outcome of surgery. Previous studies on depression and surgery outcome using long follow-up times are scarce.

Purpose

The purpose of this study was to investigate the effect of depressive symptoms on the surgical outcome during a 5-year follow-up among patients with LSS.

Study design

A prospective observational study.

Patient sample

Patient sample included 102 LSS patients who needed surgical treatment.

Outcome measures

The outcome of surgery was evaluated with the Oswestry Disability Index (ODI), visual analog scale pain assessment, and self-reported walking capacity.

Methods

The patients completed a set of questionnaires preoperatively and 3 and 6 months, as well as 1, 2, and 5 years after the surgery. Depressive symptoms were assessed with the Beck Depression Inventory. The depressive burden was estimated by summing all individual Beck Depression Inventory scores. Statistical analyses included cross-sectional group comparisons and linear regression analyses. No conflicts of interest.

Results

On 5-year follow-up, a high depressive burden associated with a poorer outcome of surgery when assessed with the ODI. In linear regression analysis, a high depressive burden associated with higher ODI score.

Conclusions

Even slightly elevated long-term depressive symptoms in LSS patients are associated with an increased risk of a poorer functional ability after decompressive surgery.     

Does the type of skin replacement surgery influence the rate of infection in acute burn injured patients?

Introduction

Infection is a major cause of morbidity and mortality following burn. Early debridement and wound closure minimize the risk of infection. This study aimed to examine the association of surgical modalities with burn wound infection (BWI) rate, graft loss and length of stay (LOS) outcome.

Method

This study is a retrospective analysis of all patients undergoing surgical intervention at the Royal Perth Hospital between 2004 and 2011. Multivariable regression analyses were used to predict the impact of burn and patient factors on the outcomes.

Results

Seven hundred seventy patients were eligible for inclusion with 74.8% males and a mean total body surface area (TBSA) burnt of 7.9% (range 1.0–75). Sixty-seven patients (8.7%) had positive post-operative swabs indicating potential wound infection. Age and TBSA significantly increased the risk of BWI (confirmed by quantitative swab). Positive microbiology was not associated with surgery type. Age, TBSA, diabetes and surgical modalities had significant influence on LOS in hospital. Only TBSA was an independent predictor of graft loss.

Conclusion

Age, TBSA and diabetes were associated with poorer outcomes after burn. Surgery type was not associated independently with the risk of infection.     

Predictive factors for failure of percutaneous drainage of postoperative abscess after abdominal surgery

Background

The aims of this study were to assess the efficacy of percutaneous drainage of postoperative abscess after abdominal surgery and to identify factors predictive of failed drainage.

Methods

Data from 81 patients with postoperative abdominopelvic abscesses treated with percutaneous drainage were reviewed. Percutaneous drainage failure was considered when surgery was needed to control the sepsis. Predictive variables were sought using univariate and multivariate analyses with logistic regression models.

Results

Successful drainage requiring 1 (n = 46) or 2 (n = 17) procedures was observed in 63 patients (78%; 95% confidence interval, 67%–86%). Surgery was needed in 18 patients (22%; 95% confidence interval, 14%–38%). Residual collection after a first percutaneous drainage was the single predictive factor for failed drainage on univariate and multivariate analyses (P = .0275).

Conclusions

Percutaneous imaging-guided drainage is a feasible and effective method for the treatment of abdominopelvic abscess, with a success rate of 78%. Residual collection is an independent predictor of unfavorable outcome after percutaneous drainage.     

ACS national surgical quality improvement program: Targeting quality improvement in Canadian pediatric surgery

Purpose

The pediatric NSQIP program is in the early stages of facilitated surgical quality improvement for children. The objective of this study is to describe the initial experience of the first Canadian Children’s Hospital participant in this program.

Method

Randomly sampled surgical cases from the “included” case list were abstracted into the ACS-NSQIP database. These surgical procedure-specific data incorporate patient risk factors, intraoperative details, and 30 day outcomes to generate annual reports which provide hierarchical ranking of participant hospitals according to their risk-adjusted outcomes.

Results

Our first risk-adjusted report identified local improvement opportunities based on our rates of surgical site infection (SSI) and urinary tract infection (UTI). We developed and implemented an engagement strategy for our stakeholders, performed literature reviews to identify practice variation, and conducted case control studies to understand local risk factors for our SSI/UTI occurrences. We have begun quality improvement activities targeting reduction in rates of SSI and UTI with our general surgery division and ward nurses, respectively.

Conclusions

The NSQIP pediatric program provides high quality outcome data that can be used in support of quality improvement. This process requires multidisciplinary teamwork, systematic stakeholder engagement, clinical research methods and process improvement through engagement and culture change.     

Outcomes of primary fascial closure after open abdomen for nontrauma emergency general surgery patients

Background

Emergency general surgery patients are increasingly being managed with an open abdomen (OA). Factors associated with complications after primary fascial closure (PFC) are unknown.

Methods

Demographic and operative variables for all emergency general surgery patients managed with OA at an academic medical center were prospectively examined from June to December 2013. Primary outcome was complication requiring reoperation.

Results

Of 58 patients, 37 managed with OA achieved PFC. Of these, 14 needed re-exploration for dehiscence, compartment syndrome, infection, or other. Complications after PFC were not associated with age, type of operative intervention, time to closure, re-explorations, comorbidities, or mortality. Complications correlated with higher body mass index (P = .02), skin closure (P = .04), plasma infusion (P = .01), and less intraoperative bleeding (P = .05). Deep surgical site infection correlated with fascial dehiscence (P = .02).

Conclusions

Reoperation after PFC was more likely in obese and nonhemorrhagic patients. Recognition of these factors and strategies to reduce surgical site infection may improve outcomes.     

Videothoracoscopic drainage for esophageal perforation with mediastinitis in children

Background

Esophageal perforation remains a devastating event that is difficult to diagnose and manage. The overall mortality associated with esophageal perforation can approach 20%, and delay in treatment of more than 24 hours after perforation can result in a doubling of mortality. The treatment option for esophageal perforation with mediastinitis is not very clear and still controversial.

Methods

Between April 2000 and March 2004, 6 males and 2 females, with ages ranging from 2 to 6 years (mean, 3.8 years), underwent videothoracoscopic drainage for esophageal perforation with mediastinitis.

Results

The mean hospital length of stay for patients in our series was 34.1 days (range, 14-47 days). There was no perioperative mortality. All patients were discharged from hospital without major sequelae.

Conclusions

Minimally invasive videothoracoscopic drainage is a feasible and effective method for esophageal perforation with mediastinitis in children.     

Comparison of outcomes after triceps split versus sparing surgery for extra-articular distal humerus fractures

Objectives

To compare elbow range of motion (ROM), triceps extension strength, and functional outcome of AO/OTA type A distal humerus fractures treated with a triceps-split or -sparing approach.

Design

Retrospective review.

Setting

Two level one trauma centres.

Patients

Sixty adult distal humerus fractures (AO/OTA 13A2, 13A3) presenting between 2008 and 2012 were reviewed. Exclusion criteria removed 18 total patients from analysis and three patients died before final follow-up.

Intervention

Patients were divided into two surgical approach groups chosen by the treating surgeon: triceps split (16 patients) or triceps sparing (23 patients).

Main outcome measurements

Elbow ROM and triceps extension strength testing were completed in patients after fractures had healed. All patients were also given the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire.

Results

Compared to the triceps-split cohort, the triceps-sparing cohort had greater elbow flexion (sparing 143 ± 7° compared to split 130 ± 12°, p = 0.03) and less extension contracture (sparing 6 ± 8° compared to split 23 ± 4°, p < 0.0001). Triceps strength compared to the uninjured arm also favoured the triceps-sparing cohort (sparing 88.9 ± 28.3% compared to split 49.4 ± 17.0%, p = 0.007). DASH scores were not statistically significant between the two cohorts (sparing 14.5 ± 12.2 compared to split 23.6 ± 22.3, p = 0.333).

Conclusions

A triceps-sparing approach for surgical treatment of extra-articular distal humerus fractures can result in better elbow ROM and triceps strength than a triceps-splitting approach. Both approaches, however, result in reliable union and similar functional outcome.

Level of evidence

Level III.     

Two cases of descending necrotizing mediastinitis

Descending necrotizing mediastinitis (DNM) is relatively rare inflammatory lesion with high mortality unless an appropriate surgical treatment is undertaken. Recently we successfully treated two surgical cases of DNM. In both cases, the disease started with pharyngeal abscess, and the mediastinal swelling followed. The surgery consisted with neck drainage and the mediastinal drainage through thoracotomy at the same time. A continuous mediastinal irrigation was performed postoperatively, and both patients recovered well. Immediate drainage of the primary lesion and the mediastinum is important once the diagnosis of DNM is established.