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"etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Análisis descriptivo de una serie de casos diagnosticados de mediastinitis aguda" ] ] "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">Introduction</span></p><p class="elsevierStylePara">Mediastinitis is an acute or chronic inflammatory process of the connective tissues of the mediastinum. The acute process is generally due to gram-positive cocci infections which produce purulent secretions that collect in the mediastinum. Acute mediastinitis is a rare, aggressive disease with a high mortality rate. A clear, complete description of diagnostic criteria for mediastinitis is provided by Estrera et al<span class="elsevierStyleSup">1</span>, and in Archivos de Bronconeumología, González-Aragoneses et al<span class="elsevierStyleSup">2</span> reported 2 cases of descending necrotizing mediastinitis originating in the oropharynx, recommending posterolateral thoracotomy for all mediastinitis cases. The literature describes mortality rates ranging from 14% to 42%.<span class="elsevierStyleSup">1-6</span> High mortality correlates with delayed diagnosis or treatment<span class="elsevierStyleSup">7</span> whereas early treatment seems to reduce mortality.<span class="elsevierStyleSup">8</span> The present study is a retrospective review of patients who were initially diagnosed and treated for acute mediastinitis in the department of thoracic surgery of the Hospital Universitario de Salamanca, Spain, from January 1994 to March 2002.</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Clinical Observation</span></p><p class="elsevierStylePara">During the study period we treated 26 cases (20 men and 6 women) for acute mediastinitis. The mean age of the patients was 55 years (range 26­85 years). In 17 cases (64%) mediastinitis originated in the esophagus: 8 (30%) occurred after resection of esophageal carcinoma and 9 (34%) were secondary to esophageal perforation. Four of the perforations were due to spontaneous rupture (Boerhaave syndrome), 4 were iatrogenic, and 1 was caused by ingestion of a foreign body (a lamb bone). In 6 cases (23%), the cause was oropharyngeal infection due to dental or peritonsillar abscess (Figure), and 3 cases (12%) were secondary to median sternotomy wound infection. Mediastinitis was associated with pleural empyema in 20 cases (76.9%) and with peritonitis in 1 case (3.5%). All diagnoses were confirmed by computed axial tomography. In the cases with infection originating in the esophagus, contrast-enhanced images were obtained to locate the perforation site. Diagnosis was reached within 12 hours in 15 cases (56.7%) and within 24 hours in 8 (30.8%). Diagnosis and, therefore, treatment were delayed for the remaining three patients (12.5%). All the patients underwent thoracotomy except one who was treated by means of chest tube drainage. In addition to mediastinal debridement and drainage, 10 patients underwent esophagectomies or resection of the esophago-gastric reconstruction (deferring a new reconstruction), 5 received primary sutures of the esophagus covered with an intercostal muscle or pericardial fat flap, 1 was reconstructed with a greater pectoral muscle flap, and 1 underwent sternectomy plus intrathoracic omental transposition. The patients required a mean 3.33 (range 2­5) surgical procedures in separate operations not counting deferred reconstructions. Four patients (15.4%) died: 2 in relation to esophageal disease and 2 with descending necrotizing mediastinitis. Postoperative complications are summarized in Table 1.</p><p class="elsevierStylePara"><img src="260v39n09-13051515tab01.gif"></img></p><p class="elsevierStylePara">Figure. Mediastinitis due to oropharyngeal infection. Cervical subcutaneous emphysema and purulent secretions in the right paratracheal region.</p><p class="elsevierStylePara"><img src="260v39n09-13051515tab02.gif"></img></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Discussion</span></p><p class="elsevierStylePara">Most authors have described an increase in the incidence of acute mediastinitis in recent years.<span class="elsevierStyleSup">9-13</span> Such an increase, if real, might be the result of a rising number of procedures on the esophagus or a greater interest on the part of authors in the diagnosis and treatment of the problem. Some have reported a relation between early diagnosis and treatment and lower mortality<span class="elsevierStyleSup">10,13</span> and have also indicated that certain nonspecific problems, such as an initial diagnosis of pneumothorax, pneumoperitonea, sepsis, or shock, could cause delay in reaching a full diagnosis and treatment.<span class="elsevierStyleSup">10</span> Diagnosing acute mediastinitis through conventional x-rays alone may delay treatment, and if mediastinitis is suspected based on clinical signs, computed axial tomography should be performed. Once diagnosis is confirmed, aggressive treatment is recommended.<span class="elsevierStyleSup">14</span> Aggressive treatment is defined as complete mediastinal debridement with excision of necrotic tissue, and, if necessary, insertion of multiple mediastinal, pleural, and cervical drains. Posterolateral thoracotomy is the approach of choice<span class="elsevierStyleSup">15,16</span> because it allows good exposure of the mediastinal compartments. Median sternotomy is inappropriate as it exposes the patient to the additional risk of sternal osteomyelitis. Sternectomy plus omental muscle flap surgery should be reserved for cases of severe sternal osteomyelitis.<span class="elsevierStyleSup">17</span> When mediastinitis originates in the oropharynx, trans-cervical drainage is insufficient. Drainage guided by computed tomography may be useful, but only in initial stages and in some cases of post-sternotomy mediastinitis, according to El Oakley and Wright<span class="elsevierStyleSup">19</span> and Berg et al.<span class="elsevierStyleSup">20</span> For patients with spontaneous rupture or iatrogenic perforation of the esophagus, the esophagus may be sutured directly if diagnosis is early and no serious underlying esophageal disease is present.<span class="elsevierStyleSup">3</span> In the remaining cases with infection originating in the esophagus, esophagectomy with gastrostomy and jejunostomy are indicated. In cases of mediastinitis secondary to gastroplasty or coloplasty, the reconstruction should be removed in order to proceed with a second reconstruction at a later time. The literature describes an overall mortality rate ranging from 14% to 42%, from which we have calculated a weighted mean of 16.6%, which is similar to the mortality rate of 15.4% in our series (Table 2). In conclusion, we strongly advise a high degree of suspicion, early diagnosis, and initiation of aggressive treatment.</p><p class="elsevierStylePara"><img src="260v39n09-13051515tab03.gif"></img></p><hr></hr><p class="elsevierStylePara">Correspondence: Dr. P. Macrí.<br></br> Sección de Cirugía Torácica. Hospital Universitario de Salamanca.<br></br> P.º San Vicente, 58. 37007 Salamanca. Spain.<br></br> E-mail: <a href="mailto:paolomacri@katamail.com" class="elsevierStyleCrossRefs"> paolomacri@katamail.com</a></p><p class="elsevierStylePara">Manuscript received February 18, 2003.<br></br> Accepted for publication April 18, 2003.</p>" "pdfFichero" => "260v39n09a13051515pdf001.pdf" "tienePdf" => true "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec191421" "palabras" => array:5 [ 0 => "Acute mediastinitis" 1 => "Surgery" 2 => "Complications" 3 => "Morbidity" 4 => "Mortality" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec191422" "palabras" => array:4 [ 0 => "Mediastinitis aguda" 1 => "Cirugía" 2 => "Complicaciones" 3 => "Morbimortalidad" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:1 [ "resumen" => "Acute mediastinitis is one of the most aggressive chest diseases. The mortality rate ranges between 14% and 42%. We present a retrospective analysis of a series of 26 cases (20 men and 6 women) treated between January 1994 and March 2002 and review the literature. Mediastinitis originated in the esophagus in 17 patients (8 postoperative, 4 due to iatrogenic perforation, 4 due to noniatrogenic perforation, and 1 due to a foreign body) and in the oropharynx in 6 patients; mediastinitis was secondary to median sternotomy in 3. Twenty-five patients were treated surgically. In addition to radical debridement and drainage, which were carried out on all the patients, 10 also underwent esophagectomy or resection of the esophago-gastric reconstruction, 5 received primary sutures of the esophagus, 1 received reconstructive surgery with a pectoral muscle flap, and 1 underwent sternectomy plus intrathoracic omental transposition. Four patients died within 30 days of surgery (15.4%). The mortality rate in our practice is similar to that described in the literature. The results argue for early, aggressive treatment." ] "es" => array:1 [ "resumen" => "La mediastinitis aguda es una de las enfermedades torácicas más agresivas. La mortalidad varía entre el 14 y el 42%. Nuestro objetivo es presentar un análisis retrospectivo de una serie de 26 casos (20 varones y 6 mujeres) tratados entre enero de 1994 y marzo de 2002 y una revisión de la bibliografía. La mediastinitis fue de origen esofágico en 17 pacientes (8 posquirúrgicas, 4 por rotura iatrogénica, 4 por rotura no iatrogénica y una por cuerpo extraño), de origen bucofaríngeo en 6 pacientes y secundarias a esternotomía media en 3. Se trató quirúrgicamente a 25 pacientes; además del desbridamiento radical y los drenajes, que se hicieron en todos los pacientes, en 10 se practicó una esofaguectomía o resección de plastia gástrica; en 5, suturas primarias de esófago; en uno, plastia de pectoral mayor, y en otro, esternectomía más omentoplastia. Cuatro pacientes fallecieron en los 30 días después de la intervención (15,4%). La mortalidad en nuestro entorno es similar a la descrita en la bibliografía. Los resultados justifican el tratamiento agresivo y temprano." ] ] "multimedia" => array:6 [ 0 => array:8 [ "identificador" => "tbl1" "etiqueta" => "Figure" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tablaImagen" => array:1 [ 0 => array:4 [ "imagenFichero" => "260v39n09-13051515tab01.gif" "imagenAlto" => 272 "imagenAncho" => 380 "imagenTamanyo" => 33438 ] ] ] ] ] "descripcion" => array:1 [ "en" => "Mediastinitis due to oropharyngeal infection. Cervical subcutaneous emphysema and purulent secretions in the right paratracheal region." ] ] 1 => array:8 [ "identificador" => "tbl2" "etiqueta" => "TABLE 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tablaImagen" => array:1 [ 0 => array:4 [ "imagenFichero" => "260v39n09-13051515tab02.gif" "imagenAlto" => 184 "imagenAncho" => 386 "imagenTamanyo" => 5846 ] ] ] ] ] "descripcion" => array:1 [ "en" => "Postoperative Complications" ] ] 2 => array:8 [ "identificador" => "tbl3" "etiqueta" => "TABLE 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tablaImagen" => array:1 [ 0 => array:4 [ "imagenFichero" => "260v39n09-13051515tab03.gif" "imagenAlto" => 206 "imagenAncho" => 384 "imagenTamanyo" => 8756 ] ] ] ] ] "descripcion" => array:1 [ "en" => "Review and Comparison of the Literature" ] ] 3 => array:5 [ "identificador" => "tbl4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" ] 4 => array:5 [ "identificador" => "tbl5" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" ] 5 => array:5 [ "identificador" => "tbl6" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" ] ] "bibliografia" => array:2 [ "titulo" => "Bibliography" "seccion" => array:1 [ 0 => array:1 [ "bibliografiaReferencia" => array:20 [ 0 => array:3 [ "identificador" => "bib1" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Descending cervical mediastinitis." 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Original language: English
Year/Month | Html | Total | |
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2024 November | 13 | 0 | 13 |
2024 October | 61 | 21 | 82 |
2024 September | 49 | 17 | 66 |
2024 August | 94 | 38 | 132 |
2024 July | 73 | 27 | 100 |
2024 June | 74 | 25 | 99 |
2024 May | 49 | 31 | 80 |
2024 April | 48 | 30 | 78 |
2024 March | 42 | 28 | 70 |
2024 February | 36 | 39 | 75 |
2023 June | 1 | 0 | 1 |
2023 April | 1 | 2 | 3 |
2023 March | 14 | 7 | 21 |
2023 February | 78 | 17 | 95 |
2023 January | 46 | 42 | 88 |
2022 December | 56 | 39 | 95 |
2022 November | 61 | 35 | 96 |
2022 October | 44 | 45 | 89 |
2022 September | 30 | 31 | 61 |
2022 August | 48 | 46 | 94 |
2022 July | 50 | 49 | 99 |
2022 June | 51 | 35 | 86 |
2022 May | 58 | 39 | 97 |
2022 April | 51 | 32 | 83 |
2022 March | 71 | 46 | 117 |
2022 February | 69 | 41 | 110 |
2022 January | 71 | 40 | 111 |
2021 December | 84 | 47 | 131 |
2021 November | 83 | 53 | 136 |
2021 October | 104 | 42 | 146 |
2021 September | 110 | 53 | 163 |
2021 August | 50 | 32 | 82 |
2021 July | 48 | 32 | 80 |
2021 June | 68 | 40 | 108 |
2021 May | 86 | 37 | 123 |
2021 April | 158 | 87 | 245 |
2021 March | 85 | 15 | 100 |
2021 February | 60 | 17 | 77 |
2021 January | 53 | 11 | 64 |
2020 December | 56 | 22 | 78 |
2020 November | 82 | 15 | 97 |
2020 October | 49 | 15 | 64 |
2020 September | 72 | 14 | 86 |
2020 August | 50 | 20 | 70 |
2020 July | 70 | 24 | 94 |
2020 June | 259 | 20 | 279 |
2020 May | 83 | 27 | 110 |
2020 April | 110 | 20 | 130 |
2020 March | 87 | 75 | 162 |
2020 February | 102 | 19 | 121 |
2020 January | 65 | 7 | 72 |
2019 December | 86 | 22 | 108 |
2019 November | 57 | 15 | 72 |
2019 October | 62 | 8 | 70 |
2019 September | 103 | 22 | 125 |
2019 August | 97 | 21 | 118 |
2019 July | 50 | 20 | 70 |
2019 June | 57 | 20 | 77 |
2019 May | 81 | 22 | 103 |
2019 April | 73 | 25 | 98 |
2019 March | 78 | 22 | 100 |
2019 February | 54 | 15 | 69 |
2019 January | 57 | 16 | 73 |
2018 December | 60 | 19 | 79 |
2018 November | 70 | 14 | 84 |
2018 October | 88 | 30 | 118 |
2018 September | 72 | 9 | 81 |
2018 May | 20 | 0 | 20 |
2018 April | 41 | 13 | 54 |
2018 March | 54 | 6 | 60 |
2018 February | 34 | 10 | 44 |
2018 January | 46 | 7 | 53 |
2017 December | 54 | 11 | 65 |
2017 November | 54 | 7 | 61 |
2017 October | 43 | 8 | 51 |
2017 September | 76 | 13 | 89 |
2017 August | 72 | 13 | 85 |
2017 July | 57 | 7 | 64 |
2017 June | 96 | 27 | 123 |
2017 May | 74 | 10 | 84 |
2017 April | 84 | 16 | 100 |
2017 March | 72 | 14 | 86 |
2017 February | 53 | 7 | 60 |
2017 January | 35 | 7 | 42 |
2016 December | 42 | 5 | 47 |
2016 November | 89 | 9 | 98 |
2016 October | 69 | 16 | 85 |
2016 September | 80 | 13 | 93 |
2016 August | 82 | 10 | 92 |
2016 July | 40 | 11 | 51 |
2016 March | 1 | 0 | 1 |
2016 February | 2 | 0 | 2 |
2015 December | 1 | 0 | 1 |
2015 November | 2 | 0 | 2 |
2015 October | 46 | 3 | 49 |
2015 September | 51 | 6 | 57 |
2015 August | 49 | 14 | 63 |
2015 July | 58 | 11 | 69 |
2015 June | 43 | 7 | 50 |
2015 May | 55 | 5 | 60 |
2015 April | 44 | 4 | 48 |
2015 March | 41 | 10 | 51 |
2015 February | 43 | 10 | 53 |
2015 January | 42 | 8 | 50 |
2014 December | 48 | 9 | 57 |
2014 November | 49 | 8 | 57 |
2014 October | 53 | 5 | 58 |
2014 September | 40 | 10 | 50 |
2014 August | 47 | 7 | 54 |
2014 July | 63 | 10 | 73 |
2014 June | 70 | 8 | 78 |
2014 May | 84 | 8 | 92 |
2014 April | 72 | 6 | 78 |
2014 March | 72 | 11 | 83 |
2014 February | 60 | 6 | 66 |
2014 January | 58 | 7 | 65 |
2013 December | 56 | 11 | 67 |
2013 November | 40 | 11 | 51 |
2013 October | 48 | 9 | 57 |
2013 September | 60 | 9 | 69 |
2013 August | 62 | 19 | 81 |
2013 July | 61 | 32 | 93 |
2013 June | 51 | 9 | 60 |
2013 May | 58 | 8 | 66 |
2013 April | 29 | 6 | 35 |
2013 March | 12 | 3 | 15 |