Descending necrotizing mediastinitis: surgical tactics in the progression of mediastinal infection

Abstract

Determination of optimal surgical approach for descending necrotizing mediastinitis (DNM) treatment still remains a challenging issue due to absence of guidelines or well-designed prospected multicenter studies. The aim of the study was to evaluate the results of patients with DNM treatment depending on spread of mediastinum lesions, characteristics of clinical course and surgical tactics. 27 patients were included in the study. The patients were assigned to groups according to Endo S. et al. and Sugio K. et al. mediastinitis classification. We investigated the cause of infection and its causative agents, time interval from symptoms onset to hospitalization, time of antibiotics administration, presence of comorbidities including diabetes mellitus, SIRS or sepsis arise during treatment, clinical course of the disease and peculiarities of surgical management. Development of types I, IIA, IIB DNM is associated with odontogenic or pharyngeal source of infection including pharyngeo-esophageal perforations. Types I, IIB, IIC — with pharyngeal infection. Patients with type I DNM have high risk of infection dissemination to inferior mediastinum in early postoperative period and requires CT monitoring during first 48-72 hours in case of certain positive clinical dynamic presence. Combined mediastinotomy in patients with type IIA DNM can require either right-sided or left-sided incision. Thoracoscopic mediastinotomy is expedient and perspective approach for treatment of patients with type IIC DNM. Fulminant clinical course with early DNM verification (2nd-4th day) suggest for high causative agents virulence and host inability to limit infection spreading. Potential predictors of unfavorable DNM course could be odontogenic etiology, presence of decompensated comorbidities and severe patient condition at the time of hospitalization.