Ann Thorac Surg 2005;79:751
© 2005 The Society of Thoracic Surgeons
Correspondence
Is Video-Assisted Thoracoscopic Surgery an Optimal Approach for Descending Necrotizing Mediastinitis?
Shunsuke Endo, MD,
Tsuyoshi Hasegawa, MD,
Yukio Sato, MD,
Yasunori Sohara, MD
Division of General Thoracic Surgery Department of Surgery, Jichi Medical School, Minamikawachi-machi, Kawachi-gun, Tochigi 329-0498, Japan
tcvshun{at}jichi.ac.jp
To the Editor:
We read with interest the article by Dr Min and associates [1] regarding descending necrotizing mediastinitis (DNM) managed using minimally invasive thoracoscopic procedures. In 1999, we [2] proposed guidelines for surgical management based on the spread of DNM diagnosed by computed tomography. When applied early, video-assisted thoracic surgery (VATS) is effective as a less invasive method for treating patients with DNM We agree that VATS is an excellent option for managing DNM if infection involves the lower and posterior mediastinum, which we [2] classified as type IIB. However, it is unclear whether VATS is the optimal choice for DNM localized to the upper or anterior mediastinum or both. Some authors [3] have reported that the transcervical approach may be adequate if infection involves the superior mediastinum above the level of the carina. In our report, patients with type I and IIA DNM can be treated by transcervical drainage, or subxiphoid mediastinal drainage, or both. Video-assisted thoracic surgery can provide effective drainage for DNM, but after the mediastinal pleura has been opened, because residual empyema can occur cervical pus readily descends into the pleural cavity through the mediastinum [3]. Gravity and negative inspiratory pressure also play a part in that process [3].
Descending necrotizing mediastinitis localized to the upper or anterior mediastinum or both should be managed by transcervical drainage with or without anterior mediastinal drainage through a subxiphoid incision or mediastinoscopy, not thoracoscopy. We suggest that VATS is not always minimally invasive in the these patients. Thoracoscopic irrigation should be the optimal treatment when DNM involves the posterior and lower mediastinum.
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References
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- Min H-K, Choi YS, Shim YM, Sohn YI, Kim J. Descending necrotizing mediastinitis: a minimally invasive approach using video-assisted thoracoscopic surgery. Ann Thorac Surg. 2004;77:306–310[Abstract/Free Full Text]
- Endo S, Murayama F, Hasegawa T, et al. Guideline of surgical management based on diffusion of descending necrotizing mediastinitis. Jpn J Thorac Cardiovasc Surg. 1999;47:14–19[Medline]
- Marty-Ane CH, Alauzen M, Alric P, Serres-Cousine O, Mary H. Descending necrotizing mediastinitis. Advantage of mediastinal drainage with thoracotomy. J Thorac Cardiovasc Surg. 1994;107:55–61[Abstract/Free Full Text]
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