Interactive Cardiovascular and Thoracic Surgery 2:58-60(2003)
© 2003 European Association of Cardio-Thoracic Surgery
Case report - Thoracic general |
Thoracoscopic drainage with wound edge protector for descending necrotizing mediastinitis
Takeshi Nagayasu*,
Shinji Akamine,
Tadayuki Oka and
Masashi Muraoka
First Department of Surgery, Nagasaki University School of Medicine, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan
* Corresponding author. Tel.: +81-95-849-7304; fax: +81-95-849-7306
nagayasu{at}net.nagasaki-u.ac.jp
Received July 20, 2002;
received in revised form October 14, 2002;
accepted October 21, 2002
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Abstract
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It has recently been found that wide recognition of descending necrotizing mediastinitis (DNM) and its resultant early diagnosis can reduce the high mortality rate associated with this disease by allowing for rapid surgical intervention. Nevertheless, thoracotomy remains controversial as a treatment for DNM. We report a successful case of DNM in which the mediastinitis had spread below the carina and which was treated by drainage through cervicotomy and by thoracoscopic drainage with mini-thoracotomy using the newly available wound edge protector called a Lap-protector.
Key Words: Descending necrotizing mediastinitis; Thoracoscopic drainage; Wound edge protector; Mini-thoracotomy
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1. Introduction
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Descending necrotizing mediastinitis (DNM), the most lethal form of mediastinitis, is a life-threatening disease commonly caused by odontogenic infection, peritonsillar abscess, or retropharyngeal abscess. The high mortality rate of DNM is attributed to its rapid spread through the deep cervical fascial planes into the mediastinum.
In surgical management, it remains controversial whether mediastinal drainage with systematic use of thoracotomy is an appropriate treatment for DNM. Estrera et al. [1] recommend transthoracotomy only if the mediastinitis has spread below and anterior to the tracheal bifurcation or below and posterior to the fourth thoracic vertebra. In contrast, Marty-Ane et al. [2] suggest an aggressive surgical approach including thoracotomy regardless of the level of mediastinitis.
We report here on a successful case of DNM in which the mediastinitis had spread below the carina and which was treated by drainage through cervicotomy and by video-assisted thoracoscopic drainage with mini-thoracotomy using the newly available ‘Lap-protector’ for wound edge protection [3].
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2. Case report
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A 56-year-old woman with a 2-month history of dental repair of the right lower molar presented to her general practitioner with a sore throat and a high-grade fever. She was treated with penicillin over the next 3 days, but was then admitted to a district hospital with additional symptoms, including leukocytosis of 14 100/µl and a C-reactive protein (CRP) level of 33.7 mg/dl. A right peritonsillar abscess was found and treated with per oral drainage and broad-spectrum antibiotics (ceftazidime (CAZ) and clindamycin (CLDM)) for 2 days. In spite of this treatment, the patient's condition deteriorated, she suffered swallowing disturbance and her high-grade fever continued. A computed tomography (CT) scan revealed a parapharyngeal abscess descending into the mediastinum in the paratracheal area and in the posterior mediastinum (Fig. 1) and extending below the carina. There were no pleural effusions on either thorax. The patient was transferred to our institution and emergency surgery was performed that day.
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Fig. 1 A computed tomography (CT) scan revealed a parapharyngeal abscess descending into the mediastinum in the paratracheal area and in the posterior mediastinum.
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During surgery, a spiral tracheal tube was inserted perorally under general anesthesia. Cervico-mediastinal drainage was performed via a V-shaped neck skin incision along the bilateral sternocleidomastoid muscle. Purulent discharge was evacuated from the parapharyngeal and paratracheal areas. Debridement of necrotic tissue and drainage of both the upper anterior and posterior mediastinum via cervical incision were carried out.
Once the cervical procedure was finished, the spiral tracheal tube was replaced with a double lumen tracheal tube. Mini-thoracotomy was performed through the fifth intercostal space with a skin incision of 6 cm in length, and a Lap-protector (Hakko Co., Nagano, Japan) was attached without a retractor (Fig. 2). We used long-handled scissors and forceps through the mini-thoracotomy by looking at the video monitor to open a mediastinal pleura, which was made prominent by pus in the pleural space. Debridement and drainage of the right paratracheal and paraesophageal spaces were performed in video-assisted thoracoscopic surgery (VATS). The thoracic cavity was washed with 10 000 cc of saline and two chest drains were placed in the right pleural cavity. Postoperative CT scan confirmed achievement of efficient surgical drainage. The chest drains were removed at 5 postoperative days and all neck drains were removed at 8 postoperative days. The patient was discharged from hospital without complications at 15 postoperative days.
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Fig. 2 Mini-thoracotomy was performed through the fifth intercostal space with a skin incision of 6 cm in length, and a Lap-protector (Hakko Co., Nagano, Japan) was attached without a retractor.
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3. Discussion
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DNM is now widely recognized as a severe form of acute mediastinal infection resulting from oropharyngeal abscesses. Delay in diagnosis and delayed or inappropriate drainage of the mediastinum are the primary causes of the high mortality rate, which, according to several reports published in the 1980s, can reach levels as high as 30–40% [1,4]. However, in recent cases, early diagnosis by neck and chest CT together with wide recognition of disease lead to rapid surgical intervention and thus reduce the mortality rate approximately 14–23% [2,5,6].
In order to understand the pathways of propagation of DNM, it is essential to recognize that the deep cervical fascia is divided into three layers: the pretracheal, perivascular and retrovisceral spaces [2]. The retrovisceral space, which is divided into the retropharyngeal and danger spaces by the alar fascia, is particularly important as a main route for the spread of oropharyngeal infections to the mediastinum. Gravity, respiration, and negative intrathoracic pressure increase the spread of infection downward into the retrovisceral space [2].
The use of thoracotomy is the most controversial aspect of the management of DNM. In addition to the opposing points of view presented by Estrera et al. [1] and Marty-Ane et al. [2] (see above), Ris et al. [7] also report the successful treatment of DNM patients with bilateral empyema who underwent mediastinal drainage via the clamshell approach. Although median sternotomy is another option for aggressive surgical debridement and drainage, it affords a limited view and may cause subsequent osteomyelitis and dehiscence of the sternum [8]. Thoracotomy provides better access to all mediastinal compartments, thus allowing radical surgical debridement and drainage.
It is important to recognize, however, that such an aggressive surgery may be too invasive for DNM patients whose condition has deteriorated and who are therefore too ill to tolerate it. To lessen the invasiveness of the drainage procedure for our patient, we performed video-assisted thoracoscopic drainage with mini-thoracotomy. Instead of using a standard retractor for the mini-thoracotomy space, we attached a Lap-protector, a device consisting of two flexible rings made of superelasticity alloys and covered with polyurethane-polyamide; a thin silicone rubber membrane is attached to the outer rim of each of the two rings. We believe that this procedure is more effective than thoracoscopy alone [9,10] because it provides flexible use of long-handled instruments without stress and with greater accuracy to open the entire mediastinum and thereby avoid insufficient drainage. If the infection involves the contralateral thoracic cavity, thoracotomic approach on both sides can begin with thoracoscopy. The Lap-protector reduces neuropathy caused by compression of the intercostals as opposed to a rib spreader and also prevents wound infection from pus or necrotic tissue during drainage.
In conclusion, preoperative cervicothoracic CT scanning provides accurate information about the extension of DNM, and video-assisted thoracoscopic drainage with mini-thoracotomy using a Lap-protector was determined to be a highly effective and less invasive procedure for mediastinal drainage and debridement.
doi:10.1016/S1569-9293(02)00090-7
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References
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Abstract
1. Introduction