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.     

Pedicled full‐thickness abdominal flap combined with skin grafting for the reconstruction of anterior chest wall defect following major electrical burn

Successful reconstruction of extensive anterior chest wall defect following major electrical burn represents a very challenging surgery. Herein we report the first case using pedicled full‐thickness abdominal flap combined with skin grafting to treat this injury with severe infection and exposure of pericardium and ribs in a Chinese patient. Following the performance of chest debridement to remove necrotic and infected tissues and the injection of broad‐spectrum antibiotics to reduce infection, a pedicled full‐thickness abdominal flap was used to cover the exposed pericardium and ribs, and skin grafting from the right leg of the patient was done to cover the exposed vital tissues. The patient was followed up for a total of 3·5 years, and satisfactory cosmetic and functional outcomes were obtained without complications. This report provides an effective method for the surgeons who encounter similar cases where reconstruction of extensive anterior chest wall is required.     

Successful treatment of descending necrotizing mediastinitis

Descending necrotizing mediastinitis (DNM) is a fatal disease that is caused by a cervical or odontogenical infection spreading downward to the mediastinum through anatomical cervical spaces. The mortality rate of DNM is still high. We have experience of 2 cases of DNM. In case 1 patient, a cervical abscess expanded to the esophageal hiatus through the superior and posterior mediastinum. A right minithoracotomy on the triangle of auscultation was performed with a thoracoscope in order to dissect the necrotic materials and drain the abscess. In case 2 patient, a left second costal cartilage resection was performed to approach the anterior mediastinal abscess. Both patients recovered well.     

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.     

Early open thoracotomy and mediastinopleural irrigation for severe descending necrotizing mediastinitis.

OBJECTIVE: Descending necrotizing mediastinitis (DNM) is a severe infection spreading from the cervical region to the mediastinal connective tissue. The mortality rate was reported as 40% until the 1980s. Since DNM is uncommon, few reports of large series of patients with DNM (i.e. more than 10 cases) have been published. The present aim was to evaluate our treatment strategy for DNM by retrospective chart review. METHODS: Retrospective chart review was performed in 10 patients with DNM between 1991 and 2003. The mean age was 53.8+/-23.3 years (median 58, range 16-82). The causes of DNM were primary peritonsillar or parapharyngeal abscess in 5 patients, post-extraction odontogenic abscess in 3, cervical abscess of post-tracheostomy in 1, and unknown in 1 patient. In nine cases, the abscess extended from the cervical region to the lower mediastinum. Immediately after the diagnosis of DNM, broad-spectrum antibiotics were administered empirically, and surgical treatments consisting of cervical drainage, thoracotomy with radical surgical debridement of the mediastinum and excision of necrotic tissue, decortication, and irrigation were performed in all cases. Post-operatively, mediastinopleural irrigation with saline was performed once or twice a day until a culture of pleural effusion became negative. RESULTS: The mean duration of chest tube retention was 26.7+/-17.0 days, and the mean hospital stay was 62.3+/-33.9 days. Five patients suffered from severe complications including septic shock, acute respiratory distress syndrome, disseminated intravascular coagulation, and pan-peritonitis due to duodenal perforation. The outcome was favorable in 8 patients. Of those with severe complications, two patients, who were older than 75 and had diabetes, died of multiple organ failure due to septic shock. Therefore, the mortality rate was 20%. CONCLUSION: Our treatment strategy for severe DNM was efficacious for early treatment and reduced the mortality rate. Early detection of DNM, and immediate thoracotomy and irrigation of the mediastinum and thoracic cavity, are recommended.     

Successful video-thoracoscopic drainage for descending necrotizing mediastinitis

Descending necrotizing mediastinitis (DNM) is a rare but severe disease with a high mortality rate. We report a case of a 77-year-old woman with DNM who was treated using video-thoracoscopic drainage and a Blake drain. She was admitted to our hospital with a 3-day history of a sore throat. Computed tomography (CT) revealed a peritonsillar abscess descending into the anterior and posterior mediastinum below the carina. She was diagnosed with DNM, and emergency surgery was performed. The mediastinal abscess was drained via video-thoracoscopy, and a 24F Blake drain was inserted into the mediastinum. Following mediastinal drainage, cervical drainage was performed for treatment of the retropharyngeal abscess. The outcome of videothoracoscopic mediastinal drainage was satisfactory, and no further invasive treatment was required. We believe that video-thoracoscopic mediastinal drainage is an effective, minimally invasive treatment for DNM with subcarinal spread. Blake drains are useful for mediastinal drainage.     

Successfully treated descending necrotizing mediastinitis through mediansternotomy using a pedicled omental flap.

A 21-year-old man with an oropharyngeal abscess admitted to our institution was initially treated with systemic antibiotics but was referred to our department when his condition rapidly deteriorated. His respiratory insufficiency required circulatory support. A computed tomographic scan showed a parapharyngeal abscess descending into the mediastinum with multiple right-side capsulized empyema and pericardial effusion. We conducted emergency surgery through a mediansternotomy using a pedicled omental flap. Postoperative clinical and radiologic assessment showed a normal chest X-ray and primary wound healing without sternal dehiscence. Mediansternotomy using a pedicled omental flap offers excellent exposure for a complete one-stage operation with debridement of all affected tissues of the subauricular region, the mediastinum, and both pleural cavities. We conclude that this method yields good results for patients with acute widespread descending necrotizing mediastinitis.     

Descending necrotizing mediastinitis: a retrospective surgical experience.

OBJECTIVE: Descending necrotizing mediastinitis (DNM) is a primary complication of cervical or odontogenical infections that can spread to the mediastinum through the anatomic cervical spaces. We reviewed the last 10 years of our surgical experience in DNM and commented on early diagnosis and aggressive surgical treatment in these patients. METHODS: Five males (71%) and two females (29%), mean age 34 years, with DNM, were surgically treated. Primary oropharyngeal infection occurred in three (43%) and odontogenic abscess in four (57%) patients. All had serious cervical and mediastinal infections with severe respiratory and hemodynamic repercussions, i.e. bacteremia, systemic arterial hypotension and obnubilation. Diagnosis was confirmed by computerized chest tomography. RESULTS: All patients underwent surgical drainage of the cervical region by bilateral transverse cervicotomy with debridement of the necrotic and infected tissues, associating ample mediastinal drainage with or without thoracotomy. Six patients (86%) evolved well and were discharged after a mean of 35 days. Two patients (29%) required reoperation due to local surgical complications: empyema and dehiscence of the sternum. One patient (14%) died on the second postoperative (p.o.) day due to renal and respiratory insufficiency. Cultures of DNM showed the development of associated aerobic and anaerobic flora in 71% of the operated patients and only aerobic in 29%. CONCLUSION: Early diagnosis by CAT scan of the neck and thorax aids in rapid indication of a surgical approach of DNM. Performing ample cervicotomy with mediastinal drainage generally associated with thoracotomy can significantly reduce the mortality rate for this condition to 14%.     

A case of Fournier's gangrene reconstructed using a rectus abdominis muscle flap

We encountered a case of Fournier's gangrene complicated with vesicorectocutaneous fistula that was treated with a pedicled rectus abdominis muscle flap (pedicled RA m-c flap). A 75-year-old man was admitted with consciousness disorder and swelling of the scrotum. The patient had noticed swelling of the scrotum 4 days before admission, but he had ignored this condition. The scrotum and the penis appeared necrotic. On the basis of clinical and radiological findings, we diagnosed this condition as Fournier's gangrene. Surgical debridement was performed in conjunction with the use of broad-spectrum antibiotics. After the patient's general condition was improved, the broad defect in the perineal tissue was covered with a pedicled rectus abdominis muscle flap. The flap was successful. In Japan, this is the first case of Fournier's gangrene complicated with vesicorectocutaneous fistula that was treated with a pedicled RA m-c flap. In order to determine whether plastic surgery after debridement shortens the duration of hospitalization, we reviewed the cases of 120 patients with Fournier's gangrene in Japan. We conclude that plastic surgery after debridement does not shorten the duration of hospitalization, however, this procedures is very useful to deep and broad defects by Fournier's gangrene.     

The pedicled extended serratus anterior myocutaneous flap for head and neck reconstruction

A new "extended" myocutaneous flap has been designed by fasciocutaneous extension anteriorly and inferiorly from the 6th to 8th slips of the serratus anterior muscle. This flap has been used as a pedicled flap for various types of head and neck reconstructions and satisfactory results obtained. This article describes the anatomy of the flap, surgical technique and typical cases.     

Descending necrotizing mediastinitis with sternocostoclavicular osteomyelitis and partial thoracic empyema: Report of a case

We present herein the case of a 50-year-old woman in whom descending necrotizing mediastinitis originating from an anterior neck abscess spread to the left upper bony thorax, resulting in osteomyelitis of the left sternocostoclavicular articulation and left partial thoracic empyema. Transcervical mediastinal irrigation and drainage was performed with aggressive antibiotic therapy, followed by resection of the left sternocostoclavicular joint and debridement of the anterior mediastinum. The patient had an uneventful postoperative course, and her left arm and shoulder mobility was well preserved.     

Management of descending necrotizing mediastinitis using minimally invasive video-assisted thoracoscopic surgery

Early diagnosis and aggressive surgical drainage are very important for successful treatment of descending necrotizing mediastinitis (DNM). However, the surgical techniques used for DNM treatment remain controversial. The purpose of this study was to evaluate the effectiveness of video-assisted thoracoscopic surgery (VATS) and cervical drainage for the management of DNM. Nine patients diagnosed with DNM were treated from May 2001 to April 2004. The mean age of the patients was 51.1+/-15.0 years. VATS and cervical drainage, including debridement and drainage of the mediastinum and pleura, were performed simultaneously. The mean postoperative hospital stay was 20.6+/-6.6 days. One patient (11%) died of sepsis and renal failure on the 15th postoperative day. Minimal mastication difficulty developed in 2 patients (22%). The mean postoperative follow-up period was 28.7+/-14.7(5 to 52) months. All the survivors are in good health with no recurrences. VATS was safe, effective, and a less invasive surgical option for the management of DNM and should be considered as a good alternative therapeutic modality.     

Surgical treatment for patients with descending necrotizing mediastinitis

Descending necrotizing mediastinitis (DNM) originating from deep cervical infection is a rare and serious clinical condition with a high mortality rate. Clinical feature of 5 patients undergone surgical drainage for DNM, between 2006 and 2009 were assessed. There were 3 male and 2 female patients whose age ranged from 57 to 83 years old (mean 69.8). All 5 patients had no underlying disease except for 1 patient with severe dental caries. The primary infections of these patients were tonsillitis and pharyngitis. The mean duration from onset of symptom to the referral to our hospital was 14 days (ranged 2 to approximately 41). Two patients underwent cervical drainage for upper mediastinum, and 3 patients were required mediastinal drainage by thoracotomy. There was no post-operative death. Early and aggressive surgical drainage of the neck and mediastinum by a multidisciplinary team of surgeons is very important in the treatment of DNM.     

A case of post-upper lobectomy empyema treated by serratus anterior muscle and pedicled latissimus dorsi musculocutaneous flaps plombage via open-window thoracostomy.

A 62-year-old male was admitted to our hospital for operation for Aspergillus empyema with a fungus ball in the right upper lobe. We performed a right upper lobectomy and decortication of the middle and lower lobes through a standard posterolateral thoracotomy with dissection of the latissimus dorsi and serratus anterior muscles, in October 2000. Twenty-one days postoperatively (POD), he developed an empyema and a bronchopleural fistula. We performed open-window thoracostomy through the axilla with removal of the third and fourth ribs at 41 POD, and sterilized the open drainage cavity in the out-patient clinic 11 months after discharge. Although the condition of the bronchopleural fistulas was not improved, and methicillin-resistant Staphylococcus aureus (MRSA) was found in the purulent discharge, the discharge decreased. Finally, a pedicled latissimus dorsi musculocutaneous and serratus anterior muscle flap plombage was performed 11 months after initial operation. The patient is now well and works as a driver 21 months after discharge. We conclude that muscle flaps of the pedicled latissimus dorsi and serratus anterior muscles can be useful for plombage of the cavity in cases of post-standard thoracotomy.     

Devastating massive knee defect reconstruction using the cornucopian chimera flap from the subscapular axis: two case reports

Two cases of successful reconstruction of massive defects around the knee with multiple-island combined flaps based on the subscapular axis are reported. Both defects resulted from aggressive debridement for acute osteomyelitis after open fixation of high-energy fractures around the knee. In Case 1, a four-island combined flap consisting of the scapular flap, the lattissimus dorsi muscle flap, the serratus anterior muscle flap, and the scapular osseous flap, based on the same subscapular axis, was used. Partial bone transport using the Ilizarov apparatus was added as reinforcement of arthrodesis. In Case 2, a five-island combined flap, consisting of the scapular, parascapular flap, the lattissimus dorsi muscle flap, the serratus anterior fascial flap, and the scapular osseous flap, was used. Consequent ankylosis of the knee joint afforded the patient painless full weight bearing without secondary arthrodesis. Multiple-island combined flaps based on the subscapular axis can provide three-dimensional reconstruction of destructive knee defects.     

带蒂下部前锯肌肌皮瓣及筋膜皮瓣的临床应用

目的：探讨带蒂下部前锯肌肌皮瓣及筋膜皮瓣修复皮肤软组织缺损的可行性。方法：采用5例肌皮瓣、4例筋膜皮瓣修复皮肤软组织缺损患者共9例，其中腋窝3例，颈部2例，胸部2例，上臂1例，背部1例。结果：9例皮瓣完全存活，无供血不足及静脉回流障碍，供区瘢痕隐蔽，无“翼状”肩胛出现。结论：下部前锯肌肌皮瓣或筋膜皮瓣血管蒂长，血管管径粗，便于操作，皮瓣不臃肿，易于塑形，供区并发症少，是一种值得推广应用的皮瓣。     

下行性坏死性纵隔炎的诊断与治疗

下行性坏死性纵隔炎是由牙源性或颈部感染沿颈筋膜扩散侵及纵隔所致的急性纵隔炎,其临床特点为发病罕见、病情危重、进展迅速和病死率高,发病过程与颈、纵隔的解剖生理特点有密切的关系。早期诊断和有效的治疗可降低病死率,胸部CT检查是早期诊断该病的有效方法;早期、足量应用广谱抗生素,根据胸部CT分型采取个体化的及时切开引流、冲洗,彻底清除坏死组织是降低病死率的有效手段,必要时应会同各有关科室,如口腔、头颈外科、胸外科、重症监护、感染科等协同处理治疗;同时对易导致下行性坏死性纵隔炎发生和恶化的原有全身系统性疾病,如糖尿病以及体质不良者,应加以关注和治疗,以降低致死并发症的发生率,提高治疗效果。     

The free serratus anterior artery perforator flap—A case report and anatomic study

We report a reconstructive case using a free serratus anterior artery perforator flap and an anatomic study. A 50‐year‐old man with upper esophageal sphincter stricture underwent segmental cervical esophageal resection. The size of the defect was approximately 5.5 cm. We then performed esophageal reconstruction using the free serratus anterior artery perforator flap. Esophagography performed on postoperative day 7 revealed no definite leakage and a viable anastomosis site with wide patency. No complications developed during the long‐term follow‐up period of 3 years. We reviewed the literature and performed an anatomic study using four fresh cadavers. We performed an angiographic study using two specimens and dissection of this perforator using other two specimens. We found that a direct connection existed between the serratus anterior artery and intercostal perforator to the skin in two of eight chests. The connection was located at the 4th intercostal space in the left chest of one cadaver and at the 6th/7th intercostal space in the left chest of the other cadaver. The free serratus anterior artery perforator flap is a new flap that could be considered for use during the elevation of a perforator flap in the lateral chest area, and especially in the area overlying the serratus anterior muscle. © 2016 Wiley Periodicals, Inc. Microsurgery 36:339–344, 2016.     

Microvascular transfers of serratus anterior muscles in rats

Summary The serratus anterior muscle in the rat is supplied by the serratus division of thoracodorsal vessels, in a pattern similar to man [2]. The serratus anterior muscles were transferred to the groin area as a free muscle flap in 17 rats and as a free muscle graft in 13 rats. In the free muscle flap group, the serratus anterior muscles of 8 of 10 rats survived; histological examination showed them to be viable and the vascular anastomoses were patent at the 30th day. In the free muscle graft group, all of the muscle grafts became necrotic. As a result, it is concluded that the microvascular transfer of serratus anterior muscles in rats is a useful small animal model for microsurgical laboratory training of clinical free flap transfers and also for performing pharmacological and biochemical studies in transplanted muscle.     

An approach to the management of necrotising fasciitis in neonates

Necrotising fasciitis is a severe, life-threatening soft tissue infection. It produces an extensive cellulitis with severe involvement of subcutaneous tissue, fascia, muscle or both, resulting in necrosis of the tissue. All age groups, including neonates, can be affected. Patients with necrotising fasciitis present with more severe constitutional symptoms and have a poor outcome, unless aggressive antibiotic therapy and surgical debridement are instituted promptly. The debridement of necrotic tissue is imperative to control the infection, but results in deep wounds that require further treatment. In this study, the neonate was treated with alginate dressings and negative pressure therapy after resolution of cellulitis, with excellent results and no untoward events.