Descending necrotizing mediastinitis: transcervical drainage is not enough

One of the most lethal forms of mediastinitis is descending necrotizing mediastinitis, in which infection arising from the oropharynx spreads to the mediastinum. Two recently treated patients are reported, and the English-language literature on this disease is reviewed from 1960 to the present. Despite the development of computed tomographic scanning to aid in the early diagnosis of mediastinitis, the mortality for descending necrotizing mediastinitis has not changed over the past 30 years, in large part because of continued dependence on transcervical mediastinal drainage. Although transcervical drainage is usually effective in the treatment of acute mediastinitis due to a cervical esophageal perforation, this approach in the patient with descending necrotizing mediastinitis fails to provide adequate drainage and predisposes to sepsis and a poor outcome. In addition to cervical drainage, aggressive, early mediastinal exploration--debridement and drainage through a subxiphoid incision or thoracotomy--is advocated to salvage the patient with descending necrotizing mediastinitis.     

胸段食管骨性异物穿孔的分类与外科治疗

目的 探讨骨性异物所致胸段食管破裂穿孔的分类及其治疗方法.方法 对57例胸段食管骨性异物破裂穿孔患者根据食管损伤性质和继发感染程度进行分类,分别采取不同手术方式并总结其疗效.结果 Ⅰ类为食管破裂、纵隔无脓肿形成,共计17例;其中直接食管破口连续缝合修补7例,直接缝合修补后,外穿孔部位用肋间肌加强6例,心包和带蒂大网膜加强各2例.Ⅱ类为纵膈脓肿期,共计13例;其中食管穿孔切除、胃代食管10例,纵隔脓肿清除胸腔引流3例.Ⅲ类为脓胸期,即骨性异物穿破食管后感染波及胸腔而形成脓胸,共计21例;其中食管穿孔切除、一期胃带食管12例,食管穿孔切除、二期胃或结肠带食管9例.Ⅳ类为脓肿侵犯周围器官并形成主动脉-食管瘘或气管食管瘘,共计6例;气管瘘修补、大网膜填塞、二期胃或结肠代食管术4例,病变段血管切除、人工血管置换、二期胃或结肠代食管2例.Ⅰ、Ⅱ、Ⅲ类的51例患者50例获治愈,1例死于脓毒症引起的多脏器功能衰竭综合征.Ⅳ类的6例患者术前准备时麻醉诱导过程死亡1例,手术死亡1例,死因皆为食管-主动脉瘘导致的大出血,其余4例治愈.结论 对骨性异物所致胸段食管损伤病变进行分类,并采取相应方法治疗有助于提高疗效;一旦确诊均应采取积极的手术方式.     

急性感染性纵隔炎的诊断和治疗（25例报告）

１９８０年１月～１９９１年１２月我们治疗２５例急性感染性纵隔炎，包括食管、气管穿孔后１１例，食管手术后８例，胸骨劈开心脏手术后５例，胸部外伤感染蔓延者１例。诊断要注重食管外伤和手术史。Ｘ线胸片和食管造影对诊断和治疗有重要意义。本组治愈率６０％，成功的关键是去除原发病因和进行有效的纵隔引流。     

Guideline of surgical management based on diffusion of descending necrotizing mediastinitis.

BACKGROUND: Descending necrotizing mediastinitis resulting from oropharyngeal abscess, is a serious, life-threatening infection. Exisiting strategies for surgical management, such as transcervical mediastinal drainage or aggressive thoracotomic drainage, remain controversial. METHODS: Four patients, (three males and one female) were treated for descending necrotizing mediastinitis resulting from oropharyngeal infection. Two had peritonsillar abscesses, while the others experienced dental abscess and submaxillaritis. Descending necrotizing mediastinitis received its classification according to the degree of diffusion of infection diagnosed by computed tomography. Mediastinitis in two cases, (Localized descending necrotizing mediastinitis-Type I), was localized to the upper mediastinal space above the carina. In the others, infection extended to the lower anterior mediastinum (Diffuse descending necrotizing mediastinitis-Type IIA), and to both anterior and posterior lower mediastinum (Diffuse descending necrotizing mediastinitis-Type IIB). The spread of infection to the pleural cavity occurred in three cases. RESULTS: The surgical outcome concerning each of the patients was successful. Radical cervicotomy (unilateral in three patients, bilateral in the other) in conjunction with mechanical ventilation with continuous postoperative positive airway pressure, was performed in all cases. Tracheostomy was established in three patients and pharyngostomy in two. The two descending necrotizing mediastinitis-Type I cases were successfully managed with transcervical mediastinal drainage. The descending necrotizing mediastinitis-Type IIA case received treatment through transcervicotomy and anterior mediastinal drainage through a subxiphoidal incision. The patient with descending necrotizing mediastinitis-Type IIB required posterior mediastinal drainage through a right standard thoracotomy followed by left minimal thoracotomy. CONCLUSIONS: The mediastinal infection, the extent of which has been accurately determined by computed tomograms, necessitates radical cervicotomy followed by pleuromediastinal drainage. Situations where infection has spread to posterior medisatinum, particularly when it reaches in the level of the carina (descending necrotizing mediastinitis-type I), may not always require aggressive mediastinal drainage. In comparison, diffuse descending necrotizing mediastinitis-Type IIB demands complete mediastinal drainage with debridement via thoracotomy. Subxiphoidal mediastinal drainage without sternotomy may provide adequate drainage in diffuse descending necrotizing mediastinitis-Type IIA.     

Transesophageal irrigation for the treatment of mediastinitis produced by esophageal rupture

Esophageal rupture in the thorax, unless small and contained, is followed by the early onset of fulminant mediastinitis. When the rupture occurs in the cervical esophagus, mediastinitis will also occur if cervical drainage is delayed and the infection is allowed to spread along the periesophageal planes towards the mediastinum. The purpose of this article is to report the good results obtained in the treatment of life-threatening sepsis from esophageal rupture with the combination of continuous per oral transesophageal irrigation of the mediastinum and drainage of the irrigating fluid by accurately positioned chest tubes connected to a wall-suctioning system. When the patient cannot swallow, mediastinal irrigation is accomplished via a nasogastric tube positioned by the upper esophagus proximal to the perforation. Irrigation by mouth was also used for the treatment of cervical perforations with the drainage tubes positioned in the neck. With this method in eight patients, sepsis has invariably been controlled, and in six cases, in which no irreversible damage to the esophagus existed, the perforations have healed spontaneously. There was no death resulting from mediastinitis, which is most often the lethal factor in esophageal rupture.     

Therapie der akuten Mediastinitis

Despite modern intensive care management, acute mediastinitis is still associated with a high morbidity and mortality (up to approximately 40?%). Effective antibiotic therapy, intensive care management, elimination of the causative sources of infection and drainage of the affected mediastinal compartments are the cornerstones of therapy in a multidisciplinary treatment concept. Early diagnosis, prompt and uncompromising initial therapy and planned computed tomography (CT) control after the first stages of therapy in order to decide on the necessity for surgical re-interventions are essential for achieving optimal results. Knowledge of the specific anatomical characteristics is crucial for the understanding of this disease and its treatment; therefore, the current knowledge on fascial layers and interstitial spaces from the neck to the mediastinum is described and discussed. A possible foudroyant spread of the infection, especially within the posterior mediastinum, has to be anticipated. The approach to the mediastinum depends on the mediastinal compartments affected, on the causative disease and on the patient’s clinical situation. The surgical approach should be adapted to the particular clinical situation of the individual patient and to the surgical experience of the surgeon. When in doubt, the more invasive approach to the mediastinum, such as bilateral thoracotomy, is recommended. An ascending mediastinitis due to pancreatitis is a very rare condition; however, as chest pains are often the main clinical sign surgeons should be aware of this differential diagnosis. An intraoperative brown-black serous fluid in the mediastinal tissue is virtually pathognomonic. The treatment results of esophageal perforation as the most frequent cause of mediastinitis have been improved by integration of various interventional procedures. Hyperbaric oxygen therapy or immunoglobulin treatment can play an auxiliary role in selected patients with acute mediastinitis.     

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.     

Guideline of surgical management based on diffusion of descending necrotizing mediastinitis

Background: Descending necrotizing mediastinitis resulting from oropharyngeal abscess, is a serious, life-threatening infection. Exisiting strategies for surgical management, such as transcervical mediastinal drainage or aggressive thoracotomic drainage, remain controversial.Methods: Four patients, (three males and one female) were treated for descending necrotizing mediastinitis resulting from oropharyngeal infection. Two had peritonsillar abscesses, while the others experienced dental abscess and submaxillaritis. Descending necrotizing mediastinitis received its classification according to the degree of diffusion of infection diagnosed by computed tomography. Mediastinitis in two cases, (Localized descending necrotizing mediastinitis-Type I), was localized to the upper mediastinal space above the carina. In the others, infection extended to the lower anterior mediastinum (Diffuse descending necrotizing mediastinitis-Type IIA), and to both anterior and posterior lower mediastinum (Diffuse descending necrotizing mediastinitis-Type IIB). The spread of infection to the pleural cavity occurred in three cases.Results: The surgical outcome concerning each of the patients was successful. Radical cervicotomy (unilateral in three patients, bilateral in the other) in conjunction with mechanical ventilation with continuous postoperative positive airway pressure, was performed in all cases. Tracheostomy was established in three patients and pharyngostomy in two. The two descending necrotizing mediastinitis-Type I cases were successfully managed with transcervical mediastinal drainage. The descending necrotizing mediastinitis-Type IIA case received treatment through transcervicotomy and anterior mediastinal drainage through a subxiphoidal incision. The patient with descending necrotizing mediastinitis-Type IIB required posterior mediastinal drainage through a right standard thoracotomy followed by left minimal thoracotomy.Conclusions: The mediastinal infection, the extent of which has been accurately determined by computed tomograms, necessitates radical cervicotomy followed by pleuromediastinal drainage. Situations where infection has spread to posterior mediastinum, particularly when it reaches in the level of the carina (descending necrotizing mediastinitis-type I), may not always require aggressive mediastinal drainage. In comparison, diffuse descending necrotizing mediastinitis-Type IIB demands complete mediastinal drainage with debridement via thoracotomy. Subxiphoidal mediastinal drainage without sternotomy may provide adequate drainage in diffuse descending necrotizing mediastinitis-Type IIA.     

Acute mediastinitis: clinical features and review of a case load

The term acute mediastinitis describes a number of clinical conditions, usually secondary to diseases of other aetiology with which they tend to share the severity of the clinical picture. In these situations even a timely diagnosis and adequate therapeutic management are not always enough to ensure healing. Over the period 1987-2002 15 patients with acute mediastinitis were observed (8 male, 7 female), aged from 22 to 90 years (mean age: 57.9), distributed as follows: descending necrotising mediastinitis, 4 cases; iatrogenic oesophageal rupture, 2 cases; iatrogenic tracheal rupture, 3 cases; oesophageal perforation (foreign body), 4 cases; Boerhaave's syndrome, 1 case; oesophageal perforation (lye ingestion), 1 case. All patients except one--managed medically--were submitted to mediastinal drainage (surgical or by mediastinoscopy), combined with cervical debridement and drainage in cases of descending necrotising mediastinitis, alimentary tract diversion (cervical oesophagostomy + feeding jejunostomy + gastric decompression) in cases of large oesophageal lesions or if the lesion occurred more than 24 hours before observation, and uni- or bilateral tube thoracostomy. Furthermore, antibiotic therapy was always administered, initially choosing broad-spectrum medications, and subsequently adjusting according to bacterial cultures. Four patients died. In 4 cases (2 descending necrotising mediastinitis, 2 acute mediastinitis secondary to oesophageal perforation) repeated interventions were necessary in order to drain pleural or mediastinal effusions. Acute mediastinitis remains a serious clinical entity, the outlook of which is often poor. Factors influencing outcome are the patient's age and general condition (adequate immune response), a timely diagnosis, preoperative localisation of effusions, an aggressive therapeutic approach including drainage of infection sites in the mediastinum, neck and/or pleural cavities, alimentary tract diversion in cases of oesophageal lesions observed late, adequate antibiotic therapy, and nutritional support (total parenteral/enteral nutrition).     

One-stage operation for esophageal perforation of a thoracic aortic aneurysm

The patient was a 65-year-old man. Preoperative computed tomography showed a ruptured thoracic aortic aneurysm that formed a submucosal hematoma in the thoracic esophagus with perforation near the esophageal-cardiac junction. A one-stage operation was performed. The aortic arch and proximal descending aorta were replaced with rifampicin-soaked synthetic grafts, followed by subtotal esophagectomy with primary reconstruction using a gastric tube. His early postoperative course was uneventful, and he started oral intake on postoperative day (POD) 15; however, dysphagia occurred on POD 20, and an esophageal fistula and mediastinitis developed more than 1 month after the operation. The patient recovered from mediastinitis after 4 months of mediastinal drainage and administration of antibiotics. Thus, a one-stage operation for esophageal perforation of a ruptured thoracic aortic aneurysm with primary esophageal reconstruction is possible in selected patients. Care must be taken to avoid postoperative compression of the reconstructed esophagus by a mediastinal hematoma.     

Primary esophageal repair for Boerhaave's syndrome

BACKGROUND: Boerhaave's syndrome is the most sinister cause of esophageal perforation. The mediastinal contamination with microorganisms, gastric acid, and digestive enzymes results in a mediastinitis that is often fatal if untreated. METHODS: We present a series of 21 patients seen in our unit in the 10 years 1987 to 1996. Esophageal repair was performed in 17 (81%) of them. After the resuscitation of the patient in the intensive care unit, our strategy is primary esophageal repair with a single layer of interrupted absorbable sutures combined with mediastinal toilet, mediastinal drainage, and drainage gastrostomy. The majority of patients (12/21) were referred more than 24 hours after perforation. RESULTS: The mean age of the patients was 60+/-17 years. The mean stay in the intensive care unit was 1.6+/-1.8 days and the median hospital stay, 14 days. There were three deaths, an overall mortality rate of 14.3%. CONCLUSIONS: When combined with mediastinal toilet, mediastinal drainage, and drainage gastrostomy, primary esophageal repair for Boerhaave's syndrome gives an acceptable mortality and should not be reserved for patients seen within 24 hours after spontaneous rupture.     

胸食管异物损伤病变的分级和外科治疗

目的探讨异物性胸食管损伤病变的分级及其治疗方法。方法对84例异物性胸食管损伤患者根据其病变程度进行分级,其中食管非穿透性损伤（Ⅰ级）18例;食管穿透性损伤伴食管周围炎或纵隔炎（Ⅱ级）39例;食管穿透性损伤并发严重纵隔和（或）胸内感染（Ⅲ级）17例;食管穿孔炎症累及邻近大血管（Ⅳ级）10例。根据食管损伤程度和炎症累及范围分别采取经胸食管切开异物摘取（Ⅰ级患者）,食管修补、食管部分切除、纵隔引流、瘘口修补（Ⅱ、Ⅲ级患者）或大动脉置换（Ⅳ级患者）等手术。结果Ⅰ级和Ⅱ级异物性胸食管损伤57例均治愈,Ⅲ级患者中死亡1例（1／17）,Ⅳ级患者中死亡9例（9／10）。结论对异物性胸食管损伤病变进行分级有助于制定科学、合理的治疗方案,降低病死率的关键是预防食管-主动脉瘘的发生。     

食管穿孔83例分析

８３例不同原因引起的食管穿孔，保守治疗５７例；手术２６例，行单纯食管修补术２０例、开胸行纵隔和／或胸腔引流２例、切除贲门肿物行胃食管吻合１例、颈部食管外置２例（其中１例并行二期结肠代食管手术）、１例开胸取异物形成食管瘘后，行二期修补瘘术。全组死亡８例，其中死于纵隔胸腔感染和主动脉破裂出血各４例。总治愈率８５％。并指出异物假牙造成食管穿孔的重要性，对严重的腐蚀性食管灼伤应早期行食管镜检，并针对食管穿孔部位、种类、间隔期、纵隔与胸腔的感染程度及病人具体情况采取相应的治疗措施。     

Treatment of mediastinitis using video-assisted thoracoscopic surgery

Background: Mediastinitis remains a life-threatening disease that is difficult to manage and has a poor prognosis. This is especially true of descending necrotizing mediastinitis, which before the 1990s era had a mortality of approximately 40% despite the use of antibiotics, surgical techniques, and intensive care monitoring. Several authors have recommended that aggressive surgical approaches for mediastinitis are more effective than simple surgical approaches; however the best surgical option for mediastinitis remains controversial. Materials and methods: In a retrospective analysis between January 2000 and June 2006, 17 patients who underwent surgical debridement and drainage using video-assisted thoracoscopic surgery are included in this report. Data extracted from medical records included sex, age, origin of infection, surgical intervention, progress, and outcome including cause of death. There were eight men and nine women. The mean age was 52 years old (range, 20-72). Results: The origins of infection included esophageal perforation in nine patients and odontogenic or peritonsillar abscesses in the remaining eight patients. Among them, two patients required conversion to thoracotomy during operation in cases of mediastinitis due to esophageal perforation, so excluding the two patients, we calculated next five data for 15 patients. The mean duration from onset of symptoms to surgery was 12.4+/-13.1 days (range, 0-43) and the mean duration from the initial operation to discharge was 43.6+/-24.4 days (range, 8-113). There was serial operation in one case. There were three cases of postoperative mortality. Conclusion: Mediastinal drainage using video-assisted thoracoscopic surgery with or without cervical drainage can be a feasible and effective surgical option. This less invasive technique seems to have an outcome similar to more aggressive open surgical approaches for patients with mediastinitis previously reported in the literature, although it has not been directly compared.     

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.     

Primary esophageal repair for Boerhaave's syndrome whatever the free interval between perforation and treatment.

OBJECTIVES: Boerhaave's syndrome is the most sinister cause of esophageal perforation responsible with mortality rate ranging from 20 to 30%. Combination of mediastinal contamination with microorganisms, gastric acid and digestives enzymes, long free interval between injury and initiation of treatment causes severe mediastinitis which is fatal in most untreated cases. The aim of this paper is to emphasize primary esophageal repair and resuscitation whatever the free interval from rupture and repair. METHODS: A retrospective review of patients treated for Boerhaave's syndrome in our department from January 1980 to February 2003 was performed. The principle of treatment was surgical treatment and avoidance of esophageal exclusion or esophagectomy whichever was possible. RESULTS: There were 25 patients (17 males and 8 females). All patients were operated on by primary esophageal repair, except for three who underwent immediate exclusion of the esophagus and one patient who deceased on arrival before being operated. Patients were classified according to free interval between perforation and treatment: group 1 (n=9; 36%) within the 24 h (range from 12 to 24 h) and group 2 (n=16; 64%) more than 24 h (range from 2 to 17 days). Altogether 6 patients deceased (24%). In hospital mortality rate for groups 1 and 2 was, respectively, 44% (four patients) and 13% (two patients), not significantly different. Mean hospital stay was 63 days. Two patients developed anastomotic leakage needing esophagectomy and retrosternal coloplasty in one or more steps. One patient developed pleural abscess treated by percutaneous drainage. Three patients presented temporary symptomatic esophageal stenosis, of whom one underwent dilation. CONCLUSIONS: Long free interval before treatment does not preclude primary esophageal repair in Boerhaave's syndrome. Esophageal exclusion may be more often than not avoided in most cases.     

Expanding mesh stent in the emergency treatment of Boerhaave's syndrome.

Boerhaave's syndrome, or spontaneous esophageal perforation, is a life threatening condition demanding early diagnosis and rapid aggressive management to prevent fulminant mediastinitis and death. We describe a patient treated in an emergency situation with an expanding esophageal mesh stent to bridge the esophageal rent together with chest and mediastinal drainage, resulting in complete recovery and return to the community. We also describe the partial recovery of the stent in the convalescent period.     

Mediastinal teratoma complicated with acute mediastinitis

We report a case of a mediastinal teratoma associated with acute mediastinitis that required an emergency operation. These tumors cause a variety of complications, but reports of acute mediastinitis are rare. A 24-year-old woman was admitted to our hospital for complaints of chest pain and fever and was subsequently diagnosed as having an anterior mediastinal tumor. Follow-up computed tomography showed rapidly progressing acute mediastinitis, which was diagnosed as a perforation of the teratoma. We performed emergency surgical extirpation of the tumor and mediastinal drainage. The histopathologic diagnosis was a mature teratoma that included pancreatic tissue. Although the apparent site of the rupture was not obvious, there was a wide area of acute inflammation in the mediastinal adipose tissue. The patient did well and was discharged from the hospital without major complications.     

Personal management of 57 consecutive patients with esophageal perforation

BACKGROUND: Esophageal perforation is a surgical emergency associated with high morbidity and mortality. There is no consensus regarding the appropriate management of this life-threatening condition. METHODS: A retrospective review was made of 57 patients with esophageal perforations treated at the Department of Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India, between September 1986 and December 2001. RESULTS: Forty-four (77%) perforations were due to iatrogenic causes, spontaneous perforations occurred in 6 patients (11%). Foreign body ingestion caused perforation in 4 (7%), followed by blunt trauma in 2 (4%) and caustic injury in 1 patient. A total of 6 (11%) patients had cervical injury, 49 (86%) patients had thoracic, and 1 patient had abdominal esophageal injury. Thirty-three (58%) patients underwent emergency esophagectomy, 4 (7%) patients underwent primary repair, and 4 patients (7%) underwent drainage alone, whereas 16 (28%) patients were managed by nonoperative treatment. Using these treatment principles, we achieved 86% survival rate for all patients. Eight (14%) patients died. Spontaneous perforation had the highest mortality (67%). CONCLUSIONS: Esophageal perforation needs aggressive treatment. The treatment depends mainly on two factors: perforation in a healthy esophagus, and perforation with a preexisting underlying intrinsic esophageal disease causing distal obstruction. Esophageal perforation associated with stenotic lesions (benign or malignant) needs esophageal extirpation. Perforation in a healthy esophagus should be treated by primary closure if encountered early. Nonoperative conservative treatment is appropriate when esophageal perforation is encountered late.     

Esophageal perforations. The need for an individualized approach

Since 1971 we have treated 33 patients with esophageal perforation caused by instrumentation in 21 patients, trauma in six, and spontaneous perforation in six. Chest pain, fever, mediastinal air, and an abnormal esophagogram were frequent but not invariable findings. Surgical therapy, consisting of primary repair and drainage in 12 patients, drainage alone in five, esophageal diversion in two, and esophagogastrectomy in one, was initiated within 24 hours in 14 patients, all of whom survived. A delay of more than 24 hours in six patients resulted in 33% mortality. Nine patients with small instrumental perforations were treated successfully with antibiotics alone, while three other patients with late traumatic (n = 2) and spontaneous (n = 1) perforations were treated nonoperatively; all three died. Overall mortality for the series was 15.5%. Except for small contained instrumental injuries, esophageal perforations demand prompt exploration, with primary repair and drainage as the procedure of choice.