Direct Endoscopic Mediastinal Necrosectomy

Abstract

Figure: No Caption available.Purpose: The patient is a 68-year-old male with stage IV non-small cell lung cancer who presented with a 3-month history of progressive solid food dysphagia. Initial evaluation included a chest CT that showed an increase in subcarinal lymphadenopathy, a decrease in the left lower lobe adenocarcinoma and an EGD that showed a 5-cm midesophageal stricture secondary to extrinsic compression. Palliative radiation therapy was administered to the subcarinal area. Two months later, the patient presented with productive cough and fevers. Chest CT revealed progression of disease and a 7.5-cm walled-off necrotic mass with air and fluid levels in the posterior mediastinum. Per the patient's and his family's wishes, the patient was hospitalized for the abscess management with IV antibiotics and endoscopic therapy. Methods: A diagnostic upper endoscope was inserted into the esophagus and a completely obstructing mass was encountered in the proximal esophagus. Mechanical debridement with a spiral snare was initiated and repeated multiple times. The continued debridement allowed for visualization of the second obstructing mass located at the gastroesophageal junction and a fistulous tract from the esophagus into the mediastinum. The endoscope was driven into the necrotic cavity through the fistulous tract. The same maneuvers used for debridement of the esophageal mass were again used for the debridement of infected walled-off mediastinal necrosis. A partially covered self-expandable stent was then deployed under direct fluoroscopic visualization across the first obstructing mass and fistula; contrast injected showed no leak. A second, bridging, partially covered self-expandable stent was then deployed to traverse a second tumor obstruction. Results: An esophogram on post-procedure day one showed good position of the overlapping stents without contrast extravasation. Conclusion: Direct endoscopic necrosectomy is most commonly used for debridement of walled-off pancreatic necrosis with good results. When possible, and in the right clinical setting, mediastinal direct endoscopic necrosectomy can be safely performed. This treatment modality is potentially a feasible therapeutic alternative to thoracoscopic or open surgical therapy in a right clinical setting. However, experience and published data are limited.