Ann Thorac Surg 2000;69:1573-1574
© 2000 The Society of Thoracic Surgeons
Case reports
Videothoracoscopic drainage of mediastinal abscess: an alternative to thoracotomy
Darryl A. Chung, FRCSa,
Andrew J. Ritchie, FRCSa
a Department of Cardiothoracic Surgery, Papworth Hospital, Cambridge, United Kingdom
Address reprint requests to Dr Ritchie, Department of Thoracic Surgery, Papworth Hospital, Papworth Everard, CB3 8RE Cambridge, UK
 |
Abstract
|
|---|
A late-presenting high esophageal perforation that resulted in a massive mediastinal abscess and bronchopleural fistula in an elderly moribund patient unfit for radical surgery was successfully drained using a videothoracoscopic technique.
|
Introduction
|
|---|
Perforation of the esophagus, unless treated early and aggressively, is associated with high mortality. In patients who are too ill to tolerate radical surgical debridement and drainage, thoracoscopy provides a lifesaving alternative.
A 70-year-old woman was admitted from home to the intensive care unit 9 days after a traumatic esophagoscopy with dysphagia, odynophagia, epigastric pain, fever, and productive cough. On examination she was moribund, tachycardic, tachypneic, and hypotensive, with a temperature of 38.5°C. She had bilateral, coarse basal respiratory crackles with reduced air entry, particularly on the right side.
Blood investigations showed a neutrophilia and hypoalbuminemia. A plain chest radiograph showed a prominent mediastinal air–fluid level, bronchopneumonic consolidation, and bilateral pleural effusions (Fig 1). After resuscitation and bilateral chest drain insertion, emergency contrast swallow revealed an esophageal leak at the level of the cricopharyngeus into a large mediastinal abscess, which a computed tomogram showed to be extending posteriorly to the diaphragm with a bronchomediastinal fistula into the lower lobe of the right lung (Fig 2).
View larger version (133K):
[in this window]
[in a new window]
|
Fig 1. Chest radiograph showing mediastinal fluid level, basal consolidation, and bilateral pleural effusions.
|
|
View larger version (118K):
[in this window]
[in a new window]
|
Fig 2. Computed tomogram showing massive mediastinal abscess cavity with right lower lobar bronchial fistulation.
|
|
With protection of the left lung by double lumen endotracheal intubation, the patient underwent emergency right-sided video-assisted thoracoscopy by means of two port holes. Direct needle aspiration through the mediastinal abscess wall confirmed the presence of pus. Two size 32F thoracostomy drains were then directed through the abscess wall superiorly and inferiorly and placed on suction, which allowed drainage of 350 mL of purulent fluid. Meticulous bronchial toilet was carried out and a nasogastric tube positioned. The patient was weaned from the ventilator 8 days later, supported by parenteral nutrition. Culture from the mediastinal drainage produced Proteus species and gram-negative Coliform bacilli; blood culture grew Acinetobacter species. She was treated with ciprofloxacin and metronidazole.
Serial contrast swallows and computed tomographic scans revealed healing of the perforation and marked reduction of the mediastinal cavity. With no further significant drainage, the mediastinal drains were removed and the patient was discharged to convalescent care, able to tolerate a soft diet, 59 days after her operation.
One month later, the patient was readmitted with dysphagia, weight loss, pyrexia, and neutrophilia. A contrast-enhanced computed tomographic scan revealed persistence of the pharyngeal pouch perforation leading into a small blind cavity. This was managed conservatively by intravenous antibiotics and nutritional support, but she subsequently developed fulminant pseudomembranous colitis for which she underwent emergency subtotal colectomy and ileostomy. She recovered uneventfully and remains well 3 years after initial presentation.
|
Comment
|
|---|
Descending cervical necrotizing mediastinitis is a relatively uncommon entity. It may be odontogenic, peritonsillar, or cervicofacial in origin, or it may follow high esophageal or pharyngeal perforation [1–3]. Aided by gravity and negative intrathoracic pressure, virulent organisms rapidly traverse the deep cervical and mediastinal fascial planes, accounting for the high mortality of 30% to 40% [1–3].
Dysphagia, odynophagia, retrosternal, midback or epigastric pain, and fever associated with cervical subcutaneous emphysema lead to the diagnosis of esophageal perforation. Investigations confirm the site and extent of the problem. The clinical presentation is usually fulminant, with signs of toxicity and shock, as in our case. Radiography may show a pneumomediastinum, mediastinal fluid level, or pleural effusions, easily mistaken for achalasic megaesophagus. Contrast swallow locates the site of the leak. A computed tomographic scan is valuable in defining the extent of the infective process and, performed serially, can monitor the progress of therapy [4]. Late presentation and the presence of bronchomediastinal fistula are usually associated with a fatal outcome [5].
The principal aim of management must be to drain the abscess, as it is the source of systemic infection. Aggressive surgical debridement and drainage are recommended but carry excessive risk in moribund patients. Transcervical debridement is the most common approach but access is only sufficient down to the tracheal carina [3]. Likewise, mediastinotomy affords a limited view. Although thoracotomy gives full exposure of the mediastinum, this was not an option in our patient. Video-assisted thoracoscopy presents a less radical approach to moribund elderly patients and provides good access to all mediastinal compartments without compromising adequate debridement and drainage [6]. In our patient, empyema was prevented by the visually directed insertion of thoracostomy tubes through the abscess wall, with no soiling of the thoracic cavity. The use of systemic antibiotics is directed by appropriate pus and blood culture sensitivity.
Although the principal aim of management in mediastinal abscess is complete drainage, thoracotomy places great stress on a moribund patient. Video-assisted thoracoscopy provides a less invasive, expeditious alternative. It allows directed chest tube placement for drainage and debridement with good clinical outcome.
|
References
|
|---|
-
Estrera A.S., Landay M.J., Grisham J., et al. Descending necrotizing mediastinitis. Surg Gynecol Obstet 1983;157:545-552.[Medline]
-
Corsten M.J., Shamji F.M., Odell P.F., et al. Optimal treatment of descending necrotising mediastinitis. Thorax 1997;52:702-708.[Abstract]
-
Kiernan P.D., Hernandez A., Byrne W.D., et al. Descending cervical mediastinitis. Ann Thorac Surg 1998;65:1483-1488.[Abstract/Free Full Text]
-
Becker M., Zbaren P., Hermans R., et al. Necrotizing fasciitis of the head and neck. Radiology 1997;202:471-476.[Abstract/Free Full Text]
-
Meysman M., Noppen M., Delvaux G., Peters O., Vincken W. Broncho-mediastinal fistula following perforation of the oesophagus. Respirology 1996;1:217-219.[Medline]
-
Roberts J.R., Smythe W.R., Weber R.W., Lanutti M., Rosengard B.R., Kaiser L.R. Thoracoscopic management of descending necrotizing mediastinitis. Chest 1997;112:850-854.[Abstract/Free Full Text]
Accepted for publication September 14, 1999.
This article has been cited by other articles:
|
|
|
|
 
T. Nagayasu, S. Akamine, T. Oka, and M. Muraoka
Thoracoscopic drainage with wound edge protector for descending necrotizing mediastinitis
Interactive CardioVascular and Thoracic Surgery,
March 1, 2003;
2(1):
58 - 60.
[Abstract]
[Full Text]
[PDF]
|
|
|
Top
Abstract
Introduction
