Mediastinal Sepsis Research Articles

ThP3.3 - Prophylactic Endoluminal Vacuum Therapy – towards an era of reducing leak related morbidity after elective oesophago-gastric resection

Abstract Aims Uncontrolled sepsis following leak from oesophago-gastric surgery is a devastating condition with increased morbidity & mortality affecting longer-term cancer-free survival in patients with cancer resections. We hypothesised that endoluminal vacuum therapy (EVT), previously used to treat leaks, could be used in prophylactic settings to provide source-control, prevent mediastinitis and minimise sepsis related morbidity from leaks. Methods An ad-hocEVT device was created using VACgranufoam (KCI)and a nasogastric-tube(16/18Fr), and placed intraluminally across the repair/anastomosis in select high-risk cases. Continuous negative pressure(75–125mmHg) was applied. Assessment of the repair-site/anastomosis was performed by radiology, endoscopy, clinical assessment or a combination following cessation of EVT. Results 27 patients had prophylactic EVT; M:F ratio was 3:1 and the median age was 68 years (range: 41-82years). 26surgeries were for cancer, while 1 was benign. The rationale for prophylactic EVT included patient related (10), technical factors (16) or both (1). The median duration of prophylactic EVT was 7 days (range: 4-14days). The median length-of-stay was 19.7 days (range: 6-96 days), the two longest admissions were unrelated to the anastomosis(prolonged chyle-leak, and long-term-sequelae of life-threatening bleed). One-patient developed a full-thickness microleak at endoscopic-evaluation, yet remained well with no systemic signs of sepsis, successfully managed with luminalEVT for a further 6days in a ward-based environment. Though prophylacticEVT did not prevent the leak, it significantly minimised the systemic hit that traditionally results from leak and associated mediastinal sepsis. Conclusions ProphylacticEVT is a useful adjunct for management of patients with a high risk for leak, though not a substitute for good surgical technique. There are no short-term complications, yet the additional morbidity, mortality and length-of-stay associated with a fully-fledged leak is avoided. Randomised-controlled-trials are required to further standardise selection criteria, assess potential patient benefit and longer-term impact on survivorship.

326. SPONTANEOUS OESOPHAGEAL PERFORATION TREATED WITH OESOPHAGEAL STENT

Abstract We present the case of a 66-year-old male with spontaneous oesophageal perforation treated with oesophageal stenting. This patient reports sudden onset severe anterior chest pain after coughing and haematemesis with a background medical history of Type II DM, ESRF on Haemodialysis, Hypertension, OSA and takes prophylactic Aspirin. Endoscopy reveals multiple areas of oesophageal perforation in the proximal, middle, and distal oesophagus as well as a haematoma extending the entire length of the oesophagus to the COJ. This was treated with insertion of a WallFlex™ Fully Covered Oesophageal Stent as the patient was unsuitable for surgery. The result was re-epithelialisation of the entire oesophagus and complete resolution of the perforation at the mid-oesophagus. Dutch physician Boerhaave first described spontaneous oesophageal perforation in 1724. Commonly, these were treated surgically with associated high morbidity and mortality. Advances in endoscopic and stent technology has given clinicians a greater armamentarium to treat patients especially in the frail end elderly population. These advances include choices such as stent covers, biodegradable and removable stents, and anti-reflux valves. Complications with oesophageal stents such as fistula formation, stent migration and retrosternal pain are often associated with the length of placement. The choice of a fully covered retrievable oesophageal stent in our case provided reconstitution of oesophageal lumen and minimisation of mediastinal sepsis. With the progress in stent technology, we believe there will be greater use of endoscopic oesophageal stenting for oesophageal perforations bridges the gap between operative and non-operative management.

Indigenous technique to develop sponge for endo vaccum therapy in post-operative anastomotic leak: A case report.

Oesophageal anastomotic leaks are serious complications with high mortality (20-50%)1 especially in the post-operative setting of malignant disease. They occur in 5-30% of cases,1 usually presenting with severe mediastinal sepsis. Revision surgery has been replaced by the use of endoscopic stents, clips, glue and vacuum therapy. The latter is the simplest and least liable to further complication. As an endo sponge was not commercially available, we introduced a self-made bed-side endo sponge, with evident success.

Anastomotic leakage following resection of the esophagus\u2014introduction of an endoscopic grading system

BackgroundMalignant tumors of the esophagus are the sixth leading cause of cancer-related deaths worldwide. Postoperative leakage of the esophago-gastrostomy leads to mediastinal sepsis, which is still associated with a high morbidity and mortality rate. The aim of this study was to describe the endoscopic view of the different severity grades of an anastomotic leakage.MethodsPatientsBetween June 2016 and September 2018, 144 patients were operated upon in the Department of Surgery, University of Munich, Germany.Among these patients, 34 (23.6%) presented with a leakage of the anastomosis.EndoscopyIn this retrospective analysis, the focus is to describe different patterns of leakage of the anastomosis.ResultsWe studied 34 patients in whom post-esophagectomy leakage of the anastomosis was detected and treated with an endoluminal vacuum sponge system. The leakage healed in 26 of 29 patients (success rate 89.7%).With the increasing severity of leakage, the treatment time and the in-hospital mortality correspondingly increased. Furthermore, the incidence of the development of a fistula to the tracheobronchial system increased with higher grades of leakage.ConclusionsExact descriptions of leakage are necessary to compare the cases and to prove post-treatment improvement. This is, to our knowledge, the first publication to present a leakage grading score in patients after esophagectomy including reconstruction with a gastric tube.This new grading system needs to be tested in further analyses, with a special focus on prospective analysis.

PS01.086: TRANSGASTRIC VACUUM DRAINAGE FOR OESOPHAGEAL PERFORATIONS: A SIMPLE TECHNIQUE FOR A COMPLEX PROBLEM

Abstract Background We present an updated case series of patients treated with a novel Transgastric (TG) drainage technique, previously published by the senior author in 2008 [Ref], which has now been used in 6 hospitals across United Kingdom and Ireland. The technique establishes vacuum drainage of the lumen of the injured oesophagus whilst maintaining its patency, effectively exteriorizing complex oesophageal perforations to allow healing. Methods Patients presenting with Boerhaave or iatrogenic rupture, undergo an initial decontamination of the chest with drainage as required. A 32–36 Fr Chest drain is inserted in a PEG guided technique, where the proximal end of the drain is positioned 5 cm above the perforation site within the oesophagus, whilst the distal end is pulled out through the stomach and abdominal wall. Continuous low-pressure suction at -10 cm water is applied. Patients continue to drink water. Further intervention is not required until the leak has healed and the drain removed. Results We have used this technique in 20 patients in our institution (3 iatrogenic perforations, 17 Boerhaave), with a median age of 72 (range; 55–85). Perforation length ranged from 1–15 cms. Three cases were performed after stenting failed to control the leak. Pleural decontamination required thoracotomy (n = 12), VATS (n = 2); in 6 cases, no pleural decontamination was required. There were four in-hospital deaths. Median duration from surgery to removal of TG drain was 31 days (range; 10 - 71). Two patients required post discharge dilatation for stricture and are currently asymptomatic. Conclusion TG drainage in effect exteriorizes the oesophageal lumen at the site of oesophageal perforation, encouraging the perforated edges to appose and allow healing by secondary intention. Mediastinal sepsis drains through the transgastric drain (on suction) and intercostal drains placed at decontamination (off suction). Patients tolerate it well, drinking while their perforation heals, avoiding nasogastric intubation. [Ref] Berrisford RG, Krishnadas R, Froeschle P, Wajed S. European Journal of Cardiothoracic Surgery 33(2008):742–744. Disclosure All authors have declared no conflicts of interest.

PTU-130 Endoscopic transluminal vacuum therapy: an alternative method of treating oesophago-gastric defects

Introduction Oesophago-gastric defects which occur as a result of anastomotic leak or spontaneous/iatrogenic perforation often result in severe sepsis. Traditionally, surgery is the mainstay of treatment. However this is associated with high rates of morbidity and mortality and may not always be feasible. We describe our experience of using a minimally invasive method of using an endoscopic transluminal vacuum system to treat these oesophago-gastric defects and deal with the associated mediastinal and abdominal sepsis. Method An endoscopic vacuum system is created by using an open-pore polyurethane sponge fixed by 0 Silk suture to the distal end of a 12–16 F naso-gastric tube. The sponge tip is trimmed to the desired shape and placed under endoscopic visualisation through the oesophageal defect into the cavity. The vacuum assisted system is kept in position by applying a continuous negative pressure of 125 mmHg allowing the defect cavity to collapse around the sponge. The system is changed every 48–72 h until the cavity shrinks and stable granulation tissue forms a barrier. Results Between April 2011 and December 2014, 12 patients were treated with an endoscopic transluminal vacuum system for various causes of oesophago-gastric defects after established therapeutic measures had failed or as a primary procedure. Three patients had a spontaneous defect; two patients had an iatrogenic defect; and seven patients had a postoperative oesophageal defect. In 10 of 12 cases, the endoscopic vacuum transluminal system treatment was successful. The therapy was well tolerated with minimal discomfort. Two patients died due to intractable sepsis from the original insult. The rest of the patients are alive and well with a median follow up of nine months. Conclusion The endoscopic transluminal vacuum system can be used for a wide range of oesophago-gastric defects and, in our experience, successful treatment and healing can be achieved. It provides a new and useful treatment option in the management of these challenging patients. Disclosure of interest None Declared.

Safety implications of oesophageal stents used for the palliation of dysphagia in patients undergoing neoadjuvant therapy for oesophageal malignancy.

In their recent systematic review and meta-analysis, Nagaraja and colleagues support the use of self-expanding metal stents (SEMS) in patients with oesophageal malignancy undergoing neoadjuvant therapy prior to potentially curative oesophagectomy as ‘safe and effective’ (1). Summarising the results of nine studies comprising 180 patients, the authors identify both a significant reduction in dysphagia and matched increases in weight and serum albumin in patients treated with SEMS insertion. There is, however, a substantial body of evidence to demonstrate a myriad of adverse events resulting directly from the use of oesophageal stents which we believe should preclude their use for the relief of dysphagia in patients awaiting curative resection. Nagaraja and colleagues report the incidence of stent migration in their study to equal 32%, attributed to tumour response from neoadjuvant therapy. This figure masks significant rates of unplanned reintervention for stent revision, exchange or removal noted within series published by Adler et al., Lopes et al., Langer et al., Martin et al. and Siddiqui et al. (2-6). At best, this may inconvenience patients and delay neoadjuvant therapy whilst, at worst, emergency laparotomy is required to prevent or treat small bowel perforation. There are additional reports of severe adverse effects directly related to the presence of an oesophageal stent in an otherwise potentially curable patient. Within a series of 16 patients undergoing stent insertion, Christie and colleagues reported one case of stent erosion in to a vertebral body, which made surgery more difficult, and death resulting from mediastinal sepsis secondary to a mediastinal abscess formed following occult perforation caused by a stent (7). The risk of local anatomical disruption is supported by Langer and colleagues’ 2010 series of 38 patients which notes five serious complications resulting from stent use, including two oesophago-tracheobronchial fistulae, one acute oesophageal perforation, one small bowel perforation and one erosion of the aortic wall (4). Lopes et al. additionally makes note of a case of tracheoesophageal fistulation occurring within a series of ten patients (3). Even in patients who are unaffected by these life threatening complications other authors have noted difficult tissue planes during oesophagectomy in patients who have been treated with stents. A more common complication of stent insertion noted by the authors is one of chest discomfort, which occurred in 51% of their cohort. Although commonly reported to be self-limiting and readily relieved with oral analgesia, there are within the literature cited by Nagaraja a number of reports of significant chest pain which has followed stent insertion and subsequently necessitated emergency removal (1). Even in those who do not develop an adverse effect associated with stent insertion, their use appears marred by the potential for compromising survival and overall progression to surgery. Randomised analyses have revealed worse survival in patients with palliative oesophageal malignancy who receive metal stents, rather than alternative approaches for the relief of dysphagia (8). No similar analysis of survival or rates of progression to surgery is afforded by Nagaraja et al.’s analysis, yet progression to surgical resection is reported within series they cite to be as low as 15%. This may be due to the advanced nature of the tumours stented, however a direct effect of the stent cannot be discounted. There is interesting data from patients with colorectal cancer which highlights an increase in the number of free tumour cells within the circulation following stent insertion, a phenomenon considered secondary to mechanical stress imposed on the tumour body (9). Whilst the improvement in dysphagia, weight and serum albumin reported by Nagaraja et al. appears to afford promise in the management of patients with dysphagia undergoing neoadjuvant therapy, clinicians must apply caution to its interpretation in light of the above comments. There is a clear need for randomised controlled trial to compare oesophageal stents of all materials to alternative strategies (such as nasogastric tube or feeding jejunostomy) to relieve dysphagia in potentially curative patients undergoing neoadjuvant therapy.

Aorto-oesophageal fistula and aortic pseudoaneurysm caused by a swallowed fish bone

We describe a rare case of aorto-oesophageal fistula and aortic pseudoaneurysm in a middle-aged man, who presented with chest pain and haematemesis 1 week after swallowing a fish bone. Oesophagogastroduodenoscopy and computed tomographic angiography findings were consistent with oesophageal perforation, proximal descending aortic pseudoaneurysm, and aorto-oesophageal fistula. Thoracic endovascular aortic repair was performed. The patient died from severe mediastinal sepsis. Early surgical intervention and broad-spectrum antibiotic therapy are crucial in preventing life-threatening mediastinal infection.

Managing esophageal leaks by endoscopic transluminal drainage in esophageal cancer patients with superior mediastinal sepsis after esophagectomy

The management of postoperative leaks into the mediastinum after esophagectomy remains a challenge. We describe our clinical management of this complication through endoscopic transluminal drainage. Between 2008 and 2011, 4 patients with esophageal squamous cell carcinoma (ESCC) who underwent McKeown-type esophagectomy with two-field lymphadenectomy experienced complicated anastomotic fistulae in the presence of superior mediastinal sepsis. All 4 patients underwent endoscopic transluminal drainage, and all survived. The mean healing period was 50 days (range, 31 to 58 days), the mean stay in the intensive care unit was 7.3 days (range, 1 to 18 days), and the mean hospital stay was 64.5 days (range, 49 to 70 days). Endoscopically guided transluminal drainage should be considered for ESCC patients with superior mediastinal fistulae after esophagectomy.

Transesophageal endoscopic myotomy for achalasia: recognizing potential pitfalls before clinical application

Laparoscopic Heller esophagomyotomy is the standard of care for achalasia treatment. This procedure, although effective, must be performed with the patient under general anesthesia and is associated with several serious potential complications. The authors aimed to develop a method of performing transesophageal endoscopic esophagomyotomy (TEEM) that would obviate the need for both general anesthesia and external incisions while offering lower intra- and postoperative complications. The TEEM procedure was performed on eight pigs. For six of the pigs, the procedure aimed at survival. A mid-esophageal mucosal incision was performed using an endoscope, and a submucosal plane was developed. The lower esophageal sphincter (LES) muscle fibers were clearly visualized and divided. The mucosal incision was closed using fibrin sealant. After 2 weeks of survival, a gastrografin swallow study and necropsy were performed. The TEEM procedure was performed successfully in all eight porcine models. The myotomy included the LES fibers and extended 4 to 6 cm proximally to the esophagus. The proximal gastric muscle was divided up to 1 to 2 cm. No injuries to the abdominal or mediastinal structures occurred. One pig died on postoperative day 1 due to an unrecognized pneumothorax. Two pigs had ischemic ulcers at the myotomy site. The last three pigs had an uneventful recovery. The mucosal incision site healed completely in all the survived pigs, and except for the pig with mediastinal sepsis, all ate heartily and gained weight as expected. The TEEM procedure is technically feasible. Due to the morbidity encountered in the first three pigs, the reported technique was modified to include a slimmer endoscope, a shorter tunnel, and a partial-thickness myotomy. These changes together with an understanding of the pitfalls involved in this procedure led to successful results for the next three pigs. Nevertheless, the authors believe that TEEM is not yet ready for prime time. Perfection of the technique and development of dedicated instruments are mandatory before safe translation of this method to human patients.

Invited commentary

Primary and secondary aortoesophageal and aortobronchial fistulas are uniformly fatal if untreated, remain a formidable surgical problem, and carry high operative mortality in older, high-risk patients with hemorrhagic shock or sepsis, and in those with secondary communications between the aorta and/or graft and the aerodigestive tract. This article represents one of the larger series, which define the role for thoracic endovascular aortic repair (TEVAR) for these problems. Clearly, TEVAR is becoming the initial primary treatment, but the importance of this article is the analysis of patient outcomes in the group treated with TEVAR alone compared with the group who had TEVAR followed later by aortic reconstruction and treatment of the esophageal and bronchial defects. The authors question the utility of TEVAR as the only mode of therapy because of a higher 30-day and midterm mortality in this group compared with patients treated with a combined approach. Based on their data, TEVAR as sole definitive treatment should be reserved for patients with small aortobronchial communications and no CT evidence of mediastinal infection at initial presentation or during follow up. Since patients in shock with primary or secondary aortoesophageal fistulas had a much higher early and late mortality, the authors appropriately recommend a combined approach to treat them. The choice of conduit and route for aortic reconstruction, and the specific treatment of the fistula are dependent on patient age and comorbid conditions, the severity of infection, the location and type of fistula, and whether a thoracic graft is already in place. Definitive treatment should follow the precepts used to treat aortic graft-enteric erosions or fistulas in the abdomen. Choices for aortic reconstruction include ascending aorta to upper abdominal prosthetic bypass; or in situ replacement with antibiotic-soaked prosthetic or homografts. The authors suggest early resection of the involved segment of esophagus or lung in patients with mediastinal sepsis. Vascularized pericardial or pleural flaps, serratus muscle, or omentum can be used to cover the graft or the aortic stumps. What seems crucial to improve patient outcomes, not addressed in detail in this report, is identification of specific factors that influence timing of the definitive open surgical repair, and the role for suppressive antibiotics. Similar to the treatment of abdominal aortic graft infection, one could argue for a 6 to 8- week course of broad spectrum IV antibiotics in the interval between TEVAR and definitive repair, followed by lifelong oral antibiotic suppression for those with aortoesophageal fistulas, extensive mediastinal contamination, and in situ prosthetic aortic grafts. Endovascular treatment of aortoesophageal and aortobronchial fistulaeJournal of Vascular SurgeryVol. 51Issue 5PreviewEven when promptly recognized and treated, aortoesophageal (AEF) and aortobronchial (ABF) fistulae are highly lethal conditions. Open surgical repair also carries a high risk of mortality and morbidity. Several alternative strategies have been recently reported in the literature including thoracic endovascular aortic repair (TEVAR). However, relatively little is known about results of TEVAR for AEF and ABF due to their rarity and the lack of large surveys. Full-Text PDF Open Archive

Boerhaave′s syndrome: Thoracolaparoscopic approach

We present a case of Boerhaave’s syndrome managed thoracolaparoscopically. A 45-year- old man presented with hydropneumothorax following severe retching. He was treated with Intercostal drainage insertion as the primary management and referred to a tertiary care centre. There endoscopic stapling was attempted, following which he developed a leak. He presented to us with severe sepsis and mediastinal collection on the ninth day following the perforation. We treated him with thoracoscopic mediastinal toilet, laparoscopic-assisted feeding jejunostomy and cervical oesophagostomy. The patient was managed conservatively. A computed tomography (CT) scan was repeated at intervals of 15 days. He was continued on full jejunostomy feeds. Regular assessment of the oesophagus injury was conducted via the CT scan. The patient had complete healing of the perforation at end of two months. His oesophagostomy was closed and he remained symptom-free at follow-up. We conclude that thoracoscopy has an important role to play in the management of patients with mediastinal sepsis and late presentation of Boerhaave’s perforation.

Esophageal Leaks Repaired by a Muscle Onlay Approach in the Presence of Mediastinal Sepsis

Nineteen patients were evaluated after closure of intrathoracic esophageal leaks by a pediculated muscle flap onlay repair in the presence of mediastinal and systemic sepsis. Intrathoracic esophageal leaks with mediastinitis and systemic sepsis occurred after delayed spontaneous perforations (n = 7) or surgical and endoscopic interventions (n = 12). Six patients presented with fulminant anastomotic leaks. Seven patients had previous attempts to close the leak by surgery (n = 4) or stenting (2) or both (n = 1). The debrided defects measured up to 2 x 12 cm or involved three quarters of the anastomotic circumference and were closed either by a full thickness diaphragmatic flap (n = 13) or a pediculated intrathoracically transposed extrathoracic muscle flap (n = 6). All patients had postoperative contrast esophagography between days 7 and 10 and an endoscopic evaluation 4 to 6 months after surgery. There was no 30-day mortality. During follow-up (4 to 42 months), 16 patients (84%) revealed functional and morphological restoration of the esophagointestinal integrity without further interventions. One patient required serial dilatations for a stricture, and 1 underwent temporary stenting for a persistent fistula; both patients had normal control endoscopy during follow-up. A third patient requiring permanent stenting for stenosis died from gastrointestinal bleeding due to stent erosion during follow-up. Intrathoracic esophageal leaks may be closed efficiently by a muscle flap onlay approach in the presence of mediastinitis and where a primary repair seems risky. The same holds true for fulminant intrathoracic anastomotic leaks after esophagectomy or other surgical interventions at the gastroesophageal junction.

Boerhaave Syndrome Presenting as Massive Hemothorax

Boerhaave syndrome is a rare entity which classically presents with perforation and mediastinal sepsis. The patients' outcome is directly related to the length of time required to diagnose and surgically address the syndrome. Atypical presentations can contribute to a delay in recognizing the phenomenon, which portends poorly. The case of a man with postemetic esophageal perforation presenting with a massive left hemothorax is presented. To the authors' knowledge, this is the only case of this type to be described in the literature.

Endovascular Stenting of Peripheral Infected Aneurysms: A Temporary Measure or a Definitive Solution in High-Risk Patients

The purpose of this study was to demonstrate the use of endovascular technology in the management of peripheral infected aneurysms in high-risk patients as a temporary measure or definitive solution. Five cases underwent successful endovascular stenting of infected aneurysms of the subclavian, femoral, and carotid arteries. All these patients were at high risk for open surgery. Covered stents were placed by percutaneous approach under local anesthesia in all patients. Postoperatively, antibiotics were continued for 3 months. A literature review using the Medline database was also undertaken, and all the relevant papers on endovascular management of peripheral infected aneurysms were taken into account. Stent deployment was successful in all patients. One patient died of mediastinal sepsis and another from type A aortic dissection 5 weeks later. Two patients required drainage of the infected hematoma. Three patients did well at a median follow-up of 1 year, with no evidence of sepsis. A review of the literature shows promising early and midterm results. Most early reports were of single cases, reflecting the low incidence of peripheral infected aneurysms. We conclude that further development of endoluminal techniques and long-term follow-up to establish the durability of stenting could potentially lead to a decrease in the high morbidity and mortality rates associated with infected aneurysmal disease in this high-risk group of patients.

Honoring the Admiral: Boerhaave-van Wassenaer's syndrome

Dr. Herman Boerhaave (1668-1738) first described esophageal rupture and the subsequent mediastinal sepsis based upon his careful clinical and autopsy findings and hundreds of references have since been written about Boerhaave's syndrome. Several fine historical accounts of this brilliant scientist have been published over the years and he has received appropriate credit for his valuable contributions. But what about that unfortunate propositus that Dr. Boerhaave attended to, performed necropsy upon, and subsequently received acclaim with? Medical history pays inadequate regard to the Baron Jan Gerrit van Wassenaer heer van Rosenberg, Prefect of Rhineland and Grand Admiral of the Dutch Fleet. This figure was a nobleman and war hero at the peak of the Dutch Golden Age who played his role in steering the course of European history. Without this nobleman's heroic contemporaneous account, Boerhaave's celebrated impact on medical science would never have been realized. Therefore, we offer an overdue recitation of Admiral van Wassenaer's biography. Based on found precedent we propose that spontaneous rupture of the esophagus be henceforth referred to as the 'Boerhaave-van Wassenaer's syndrome'.

Off-Pump Repair of a Giant Pseudoaneurysm of a Distal Saphenous Vein Bypass Graft

Pseudoaneurysm of a saphenous vein bypass graft is a rare occurrence after coronary artery bypass grafting but may have lethal consequences. We treated a giant pseudoaneurysm of a saphenous vein graft to the right coronary artery in an 80-year-old male Jehovah's Witness who had undergone coronary artery bypass grafting 4 and a half years earlier. His history revealed a recurrent sternal wound infection. By using a venous patch to close the damaged graft, we were able to perform a successful surgical repair without the need for extracorporeal circulation.

Descending Necrotizing Mediastinitis: Ten Years’ Experience

Descending necrotizing mediastinitis is a rare disease that is usually caused by a spreading, diffuse inflammatory reaction (phlegmon) to an odontogenic infection or peritonsillar abscess. Reported mortality rates range from 25 to 40%. The use of antibiotics and advances in resuscitation procedures and critical care techniques have not essentially improved survival, and an effective treatment has not been clearly established. We report the findings of our 10-year study of 21 patients affected by phlegmon and/or fasciitis of the neck. The aim of our contribution is to help define the clinical criteria and diagnostic procedures that will improve the early diagnosis of mediastinal sepsis secondary to neck fasciitis and to suggest optimal treatment approaches. Our experience indicates that (1) cervical drainage alone is sufficient for cases of cervical phlegmon or mediastinal involvement that are limited to a single superior mediastinal space and (2) thoracotomy and drainage of mediastinal collections is necessary when mediastinal sepsis is more extensive.

Emergency Oesophagectomy and Proximal Deviating Oesophagostomy for Fulminent Mediastinal Sepsis

To evaluate an aggressive surgical strategy in patients with mediastinal sepsis as a result of oesophageal leakage. A prospective clinical study. University hospital, Sweden. 11 consecutive patients who presented with mediastinal sepsis as a result of a damaged oesophagus caused by instrumental perforation in 4 cases and spontaneous rupture in 6 cases during a 6-year period. Ten patients were treated with oesophagectomy with a diverting proximal oesophagostomy and in one case a primary cervical oesophagogastrostomy was done after emergency resection. Mortality and morbidity. The median delay from onset of symptoms to admission to the unit was 3 days (range 0-6). All patients required artificial ventilation postoperatively and the stay in the ICU amounted to 12.5 days but only 1 patient died during the postoperative course. All patients have subsequently undergone substernal oesophageal replacement with either a gastric tube or a colonic graft. Emergency oesophagectomy and proximal deviating oesophagostomy is a salvage procedure for patients with severe fulminant mediastinal sepsis, and it can be done in selected cases with good results.

Management of descending necrotizing mediastinitis: an aggressive treatment for an aggressive disease

Background. Descending necrotizing mediastinitis represent a virulent form of mediastinal infection requiring prompt diagnosis and treatment to reduce the high mortality associated with this disease. Surgical management and a particularly optimal form of mediastinal drainage remain controversial.Methods. Over a 10-year period, 12 patients were treated at our institution. Surgical treatment consisted of 1 or several cervical drainages, associated with drainage of the mediastinum through a thoracic approach in 11 patients. Thoracic procedures included radical surgical debridement of the mediastinum with complete excision of the tissue necrosis, decortication, and pleural drainage with adequate placement of chest tubes for mediastino-pleural irrigation. Transcervical mediastinal drainage was performed in only 1 patient.Results. The outcome was favorable in 10 patients, 9 of whom had mediastinal drainage through thoracotomy. Two patients were initially drained through a minor thoracic approach; the first died of tracheal fistula and the second required new drainage through a thoracotomy. The patient who had transcervical mediastinal drainage without a thoracic approach presented an abscess limited to the anterior and superior mediastinum. In 3 patients, ongoing mediastinal sepsis required a second thoracotomy.Conclusion. A stepwise approach with transcervical mediastinal drainage is first justified in patients with very limited disease to the upper mediastinum. However, ongoing mediastinal sepsis requires new drainage, through a major thoracic approach, without delay. Extensive mediastinitis can not be adequately treated without mediastinal drainage including a thoracotomy. This aggressive surgical policy has allowed us to maintain a low mortality rate (16.5%) in a series of 12 patients with this highly lethal disease.