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, associat ed with drainage of the mediastinum through a thoracic approach in 11 patie nts. Thoracic procedures included radical surgical debridement of the media stinum with complete excision of the tissue necrosis, decortication, and pl eural drainage with adequate placement of chest tubes for mediastino-pleura l irrigation. Transcervical mediastinal drainage was performed in only 1 pa tient. Results. The outcome was favorable in 10 patients, 9 of whom had mediastina l drainage through thoracotomy. Two patients were initially drained through a minor thoracic approach; the first died of tracheal fistula and the seco nd required new drainage through a thoracotomy. The patient who had transce rvical mediastinal drainage without a thoracic approach presented an absces s 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 mediasti num. However, ongoing mediastinal sepsis requires new drainage, through a m ajor thoracic approach, without delay. Extensive mediastinitis can not be a dequately treated without mediastinal drainage including a thoracotomy. Thi s aggressive surgical policy has allowed us to maintain a low mortality rat e (16.5%) in a series of 12 patients with this highly lethal disease. (C) 1 999 by The Society of Thoracic Surgeons.