PURPOSE: Descending necrotising mediastinitis (DNM) is an uncommon complication of oropharyngeal infections with a mortality rate of 25%. Most authors advocate thoracotomy for thoracic drainage. We report our experience managing DNM using VATS.
METHODS: A retrospective study between 2000 and 2005 showed 8 patients (mean age 49.3) had DNM. Primary infection include peritonsillar abscess (7) and odontogenic abscess (1). 2 had septic shock. Contrast CT demonstrated the following distribution of DNM: Upper mediastinum (1), Lower anterior mediastinum (2), Lower Posterior mediastinum (5). All patients underwent cervical and VATS debridement: 4 patients during the same anaesthetic and 4 patients in stages. 5 patients underwent one cervical debridement, one patient underwent 2, one patient had 5. There was one bilateral cervical procedure. All patients underwent Right VATS debridement of mediastinum; one had bilateral VATS. 5 patients underwent one VATS and 3 patients required two right VATS debridement.
RESULTS: Mean time from symptom onset to hospitalization= 3.1 days, and to VATS drainage= 8.6 days. 4 patients required percutaneous drainage of residual mediastinal collection. 7 patients required ICU stay. 2 required inotropic support. Mean number of days on ventilator= 11.7 days. Mean length of ICU stay= 13.1 days. Mean length of hospital stay= 35.2 days. There were no deaths. Morbidity include: reoperation for bleeding (1), acute renal failure (2), rhabdomyolysis (1), prolonged dysphagia (1). At mean followup 30.5 months, all patients were alive and well.
CONCLUSION: VATS debridement combined with cervical drainage is feasible, effective and safe for the management of DNM regardless of the distribution of the mediastinal disease, with acceptable morbidity and zero mortality in our experience. A significant number of patients may require repeat VATS debridement and percutaneous drainage as guided by postoperative CT and the clinical picture.
CLINICAL IMPLICATIONS: In this group of sick patients, repeated drainage is often required even following open thoracotomy. VATS debridement can reduce the access trauma whilst allowing adequate drainage. In experienced hands, VATS approach should be considered in the initial management of DNM.
DISCLOSURE: Michael Hsin, None.