title: Descending necrotizing mediastinitis: a 10-year surgical experience in a single institution.
abstract: 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.
authors.affiliation: Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan.
authors.forename: Ke-Cheng
authors.initials: KC
authors.lastname: Chen
authors.forename: Jin-Shing
authors.initials: JS
authors.lastname: Chen
authors.forename: Shuenn-Wen
authors.initials: SW
authors.lastname: Kuo
authors.forename: Pei-Ming
authors.initials: PM
authors.lastname: Huang
authors.forename: Hsao-Hsun
authors.initials: HH
authors.lastname: Hsu
authors.forename: Jang-Ming
authors.initials: JM
authors.lastname: Lee
authors.forename: Yung-Chie
authors.initials: YC
authors.lastname: Lee
mesh_terms: 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