Descending necrotizing mediastinitis: a 10-year surgical experience in a single institution.
OBJECTIVE
Early diagnosis and aggressive surgical drainage are very important for successful treatment of descending necrotizing mediastinitis. However, the surgical techniques used for this condition remain controversial. We report our 10-year experience of managing this devastating disease, focusing on the multidisciplinary, minimally invasive operative procedures and the unique bacteriologic factors in Taiwan.


METHODS
Between January 1997 and January 2007, we retrospectively reviewed 18 patients with descending necrotizing mediastinitis who were treated in the National Taiwan University Hospital. Diagnosis and Endo classification were confirmed by computed tomography of the neck and chest.


RESULTS
Eight women and 10 men were included in this study. The mean age was 57.8 +/- 15.2 years. Cervical drainage was performed in the involved area in all patients. The methods for mediastinal drainage included transcervical (n = 10), video-assisted thoracic surgical drainage (n = 6), subxiphoid drainage (n = 1), and mediastinoscopy-assisted drainage (n = 1). We could not rescue 3 patients because of uncontrolled sepsis before surgery, for a mortality rate of 16.7%. Klebsiella pneumoniae uniquely represents the most common pathogen in diabetic patients (P = .01), leading to more complicated courses in older patients (P =.04) and requiring more surgical interventions (P =.05) than other pathogens.


CONCLUSIONS
Transcervical mediastinal drainage is first justified in patients with limited disease in the upper mediastinum. For those with involvement of the lower anterior mediastinum, an additional subxiphoid approach is suggested. Cervicotomy with video-assisted mediastinal drainage is an excellent combination for involvement of the posterior mediastinum and pleural space. Klebsiella pneumoniae uniquely represents the most important and threatening causative pathogen for diabetic patients with descending necrotizing mediastinitis.
Chen
Ke-Cheng
KC
Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan.
Chen
Jin-Shing
JS
Kuo
Shuenn-Wen
SW
Huang
Pei-Ming
PM
Hsu
Hsao-Hsun
HH
Lee
Jang-Ming
JM
Lee
Yung-Chie
YC
D000038:Abscess / Q000453:epidemiology / Q000382:microbiology; D000328:Adult; D000368:Aged; D015984:Causality; D015897:Comorbidity; D003324:Coronary Artery Disease / Q000453:epidemiology; D003646:Debridement; D003920:Diabetes Mellitus / Q000453:epidemiology; D004322:Drainage; D005260:Female; D005547:Foreign Bodies / Q000453:epidemiology / Q000382:microbiology; D006801:Humans; D006973:Hypertension / Q000453:epidemiology; D008103:Liver Cirrhosis / Q000453:epidemiology; D008297:Male; D008480:Mediastinitis / Q000000981:diagnostic imaging / Q000382:microbiology / Q000401:mortality* / Q000601:surgery*; D008482:Mediastinum / Q000601:surgery; D008875:Middle Aged; D010994:Pleura / Q000601:surgery; D012189:Retrospective Studies; D013624:Taiwan / Q000453:epidemiology; D020775:Thoracic Surgery, Video-Assisted; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome