ORIGINAL ARTICLES  THORACIC SECTION 

The Journal of Cardiovascular Surgery 2003 October;44(5):655-60

Copyright © 2009 EDIZIONI MINERVA MEDICA

lingua: Inglese

Descending necrotizing mediastinitis. Diagnosis and surgical treatment

Lavini C. ¹, Natali P. ¹, Morandi U. ¹, Dallari S. ², Bergamini G. ²

¹ Department of Thoracic Surgery University of Modena and Reggio Emilia, Modena, Italy 2 Department of Otorhynolaryngology University of Modena and Reggio Emilia, Modena, Italy

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 1­with 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.