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    "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&#46; The acute process is generally due to gram-positive cocci infections which produce purulent secretions that collect in the mediastinum&#46; Acute mediastinitis is a rare&#44; aggressive disease with a high mortality rate&#46; A clear&#44; complete description of diagnostic criteria for mediastinitis is provided by Estrera et al<span class="elsevierStyleSup">1</span>&#44; and in Archivos de Bronconeumolog&#237;a&#44; Gonz&#225;lez-Aragoneses et al<span class="elsevierStyleSup">2</span> reported 2 cases of descending necrotizing mediastinitis originating in the oropharynx&#44; recommending posterolateral thoracotomy for all mediastinitis cases&#46; The literature describes mortality rates ranging from 14&#37; to 42&#37;&#46;<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&#46;<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&#44; Spain&#44; from January 1994 to March 2002&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Clinical Observation</span></p><p class="elsevierStylePara">During the study period we treated 26 cases &#40;20 men and 6 women&#41; for acute mediastinitis&#46; The mean age of the patients was 55 years &#40;range 26&#173;85 years&#41;&#46; In 17 cases &#40;64&#37;&#41; mediastinitis originated in the esophagus&#58; 8 &#40;30&#37;&#41; occurred after resection of esophageal carcinoma and 9 &#40;34&#37;&#41; were secondary to esophageal perforation&#46; Four of the perforations were due to spontaneous rupture &#40;Boerhaave syndrome&#41;&#44; 4 were iatrogenic&#44; and 1 was caused by ingestion of a foreign body &#40;a lamb bone&#41;&#46; In 6 cases &#40;23&#37;&#41;&#44; the cause was oropharyngeal infection due to dental or peritonsillar abscess &#40;Figure&#41;&#44; and 3 cases &#40;12&#37;&#41; were secondary to median sternotomy wound infection&#46; Mediastinitis was associated with pleural empyema in 20 cases &#40;76&#46;9&#37;&#41; and with peritonitis in 1 case &#40;3&#46;5&#37;&#41;&#46; All diagnoses were confirmed by computed axial tomography&#46; In the cases with infection originating in the esophagus&#44; contrast-enhanced images were obtained to locate the perforation site&#46; Diagnosis was reached within 12 hours in 15 cases &#40;56&#46;7&#37;&#41; and within 24 hours in 8 &#40;30&#46;8&#37;&#41;&#46; Diagnosis and&#44; therefore&#44; treatment were delayed for the remaining three patients &#40;12&#46;5&#37;&#41;&#46; All the patients underwent thoracotomy except one who was treated by means of chest tube drainage&#46; In addition to mediastinal debridement and drainage&#44; 10 patients underwent esophagectomies or resection of the esophago-gastric reconstruction &#40;deferring a new reconstruction&#41;&#44; 5 received primary sutures of the esophagus covered with an intercostal muscle or pericardial fat flap&#44; 1 was reconstructed with a greater pectoral muscle flap&#44; and 1 underwent sternectomy plus intrathoracic omental transposition&#46; The patients required a mean 3&#46;33 &#40;range 2&#173;5&#41; surgical procedures in separate operations not counting deferred reconstructions&#46; Four patients &#40;15&#46;4&#37;&#41; died&#58; 2 in relation to esophageal disease and 2 with descending necrotizing mediastinitis&#46; Postoperative complications are summarized in Table 1&#46;</p><p class="elsevierStylePara"><img src="260v39n09-13051515tab01.gif"></img></p><p class="elsevierStylePara">Figure&#46; Mediastinitis due to oropharyngeal infection&#46; Cervical subcutaneous emphysema and purulent secretions in the right paratracheal region&#46;</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&#46;<span class="elsevierStyleSup">9-13</span> Such an increase&#44; if real&#44; 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&#46; Some have reported a relation between early diagnosis and treatment and lower mortality<span class="elsevierStyleSup">10&#44;13</span> and have also indicated that certain nonspecific problems&#44; such as an initial diagnosis of pneumothorax&#44; pneumoperitonea&#44; sepsis&#44; or shock&#44; could cause delay in reaching a full diagnosis and treatment&#46;<span class="elsevierStyleSup">10</span> Diagnosing acute mediastinitis through conventional x-rays alone may delay treatment&#44; and if mediastinitis is suspected based on clinical signs&#44; computed axial tomography should be performed&#46; Once diagnosis is confirmed&#44; aggressive treatment is recommended&#46;<span class="elsevierStyleSup">14</span> Aggressive treatment is defined as complete mediastinal debridement with excision of necrotic tissue&#44; and&#44; if necessary&#44; insertion of multiple mediastinal&#44; pleural&#44; and cervical drains&#46; Posterolateral thoracotomy is the approach of choice<span class="elsevierStyleSup">15&#44;16</span> because it allows good exposure of the mediastinal compartments&#46; Median sternotomy is inappropriate as it exposes the patient to the additional risk of sternal osteomyelitis&#46; Sternectomy plus omental muscle flap surgery should be reserved for cases of severe sternal osteomyelitis&#46;<span class="elsevierStyleSup">17</span> When mediastinitis originates in the oropharynx&#44; trans-cervical drainage is insufficient&#46; Drainage guided by computed tomography may be useful&#44; but only in initial stages and in some cases of post-sternotomy mediastinitis&#44; according to El Oakley and Wright<span class="elsevierStyleSup">19</span> and Berg et al&#46;<span class="elsevierStyleSup">20</span> For patients with spontaneous rupture or iatrogenic perforation of the esophagus&#44; the esophagus may be sutured directly if diagnosis is early and no serious underlying esophageal disease is present&#46;<span class="elsevierStyleSup">3</span> In the remaining cases with infection originating in the esophagus&#44; esophagectomy with gastrostomy and jejunostomy are indicated&#46; In cases of mediastinitis secondary to gastroplasty or coloplasty&#44; the reconstruction should be removed in order to proceed with a second reconstruction at a later time&#46; The literature describes an overall mortality rate ranging from 14&#37; to 42&#37;&#44; from which we have calculated a weighted mean of 16&#46;6&#37;&#44; which is similar to the mortality rate of 15&#46;4&#37; in our series &#40;Table 2&#41;&#46; In conclusion&#44; we strongly advise a high degree of suspicion&#44; early diagnosis&#44; and initiation of aggressive treatment&#46;</p><p class="elsevierStylePara"><img src="260v39n09-13051515tab03.gif"></img></p><hr></hr><p class="elsevierStylePara">Correspondence&#58; Dr&#46; P&#46; Macr&#237;&#46;<br></br> Secci&#243;n de Cirug&#237;a Tor&#225;cica&#46; Hospital Universitario de Salamanca&#46;<br></br> P&#46;&#186; San Vicente&#44; 58&#46; 37007 Salamanca&#46; Spain&#46;<br></br> E-mail&#58; <a href="mailto&#58;paolomacri&#64;katamail&#46;com" class="elsevierStyleCrossRefs"> paolomacri&#64;katamail&#46;com</a></p><p class="elsevierStylePara">Manuscript received February 18&#44; 2003&#46;<br></br> Accepted for publication April 18&#44; 2003&#46;</p>"
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A Descriptive Analysis of a Series of Patients Diagnosed With Acute Mediastinitis
Análisis descriptivo de una serie de casos diagnosticados de mediastinitis aguda
P. Macría, MF. Jiméneza, N. Novoaa, G. Varelaa
a Sección de Cirugía Torácica, Hospital Universitario de Salamanca, Salamanca, Spain.
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    "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&#46; The acute process is generally due to gram-positive cocci infections which produce purulent secretions that collect in the mediastinum&#46; Acute mediastinitis is a rare&#44; aggressive disease with a high mortality rate&#46; A clear&#44; complete description of diagnostic criteria for mediastinitis is provided by Estrera et al<span class="elsevierStyleSup">1</span>&#44; and in Archivos de Bronconeumolog&#237;a&#44; Gonz&#225;lez-Aragoneses et al<span class="elsevierStyleSup">2</span> reported 2 cases of descending necrotizing mediastinitis originating in the oropharynx&#44; recommending posterolateral thoracotomy for all mediastinitis cases&#46; The literature describes mortality rates ranging from 14&#37; to 42&#37;&#46;<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&#46;<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&#44; Spain&#44; from January 1994 to March 2002&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Clinical Observation</span></p><p class="elsevierStylePara">During the study period we treated 26 cases &#40;20 men and 6 women&#41; for acute mediastinitis&#46; The mean age of the patients was 55 years &#40;range 26&#173;85 years&#41;&#46; In 17 cases &#40;64&#37;&#41; mediastinitis originated in the esophagus&#58; 8 &#40;30&#37;&#41; occurred after resection of esophageal carcinoma and 9 &#40;34&#37;&#41; were secondary to esophageal perforation&#46; Four of the perforations were due to spontaneous rupture &#40;Boerhaave syndrome&#41;&#44; 4 were iatrogenic&#44; and 1 was caused by ingestion of a foreign body &#40;a lamb bone&#41;&#46; In 6 cases &#40;23&#37;&#41;&#44; the cause was oropharyngeal infection due to dental or peritonsillar abscess &#40;Figure&#41;&#44; and 3 cases &#40;12&#37;&#41; were secondary to median sternotomy wound infection&#46; Mediastinitis was associated with pleural empyema in 20 cases &#40;76&#46;9&#37;&#41; and with peritonitis in 1 case &#40;3&#46;5&#37;&#41;&#46; All diagnoses were confirmed by computed axial tomography&#46; In the cases with infection originating in the esophagus&#44; contrast-enhanced images were obtained to locate the perforation site&#46; Diagnosis was reached within 12 hours in 15 cases &#40;56&#46;7&#37;&#41; and within 24 hours in 8 &#40;30&#46;8&#37;&#41;&#46; Diagnosis and&#44; therefore&#44; treatment were delayed for the remaining three patients &#40;12&#46;5&#37;&#41;&#46; All the patients underwent thoracotomy except one who was treated by means of chest tube drainage&#46; In addition to mediastinal debridement and drainage&#44; 10 patients underwent esophagectomies or resection of the esophago-gastric reconstruction &#40;deferring a new reconstruction&#41;&#44; 5 received primary sutures of the esophagus covered with an intercostal muscle or pericardial fat flap&#44; 1 was reconstructed with a greater pectoral muscle flap&#44; and 1 underwent sternectomy plus intrathoracic omental transposition&#46; The patients required a mean 3&#46;33 &#40;range 2&#173;5&#41; surgical procedures in separate operations not counting deferred reconstructions&#46; Four patients &#40;15&#46;4&#37;&#41; died&#58; 2 in relation to esophageal disease and 2 with descending necrotizing mediastinitis&#46; Postoperative complications are summarized in Table 1&#46;</p><p class="elsevierStylePara"><img src="260v39n09-13051515tab01.gif"></img></p><p class="elsevierStylePara">Figure&#46; Mediastinitis due to oropharyngeal infection&#46; Cervical subcutaneous emphysema and purulent secretions in the right paratracheal region&#46;</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&#46;<span class="elsevierStyleSup">9-13</span> Such an increase&#44; if real&#44; 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&#46; Some have reported a relation between early diagnosis and treatment and lower mortality<span class="elsevierStyleSup">10&#44;13</span> and have also indicated that certain nonspecific problems&#44; such as an initial diagnosis of pneumothorax&#44; pneumoperitonea&#44; sepsis&#44; or shock&#44; could cause delay in reaching a full diagnosis and treatment&#46;<span class="elsevierStyleSup">10</span> Diagnosing acute mediastinitis through conventional x-rays alone may delay treatment&#44; and if mediastinitis is suspected based on clinical signs&#44; computed axial tomography should be performed&#46; Once diagnosis is confirmed&#44; aggressive treatment is recommended&#46;<span class="elsevierStyleSup">14</span> Aggressive treatment is defined as complete mediastinal debridement with excision of necrotic tissue&#44; and&#44; if necessary&#44; insertion of multiple mediastinal&#44; pleural&#44; and cervical drains&#46; Posterolateral thoracotomy is the approach of choice<span class="elsevierStyleSup">15&#44;16</span> because it allows good exposure of the mediastinal compartments&#46; Median sternotomy is inappropriate as it exposes the patient to the additional risk of sternal osteomyelitis&#46; Sternectomy plus omental muscle flap surgery should be reserved for cases of severe sternal osteomyelitis&#46;<span class="elsevierStyleSup">17</span> When mediastinitis originates in the oropharynx&#44; trans-cervical drainage is insufficient&#46; Drainage guided by computed tomography may be useful&#44; but only in initial stages and in some cases of post-sternotomy mediastinitis&#44; according to El Oakley and Wright<span class="elsevierStyleSup">19</span> and Berg et al&#46;<span class="elsevierStyleSup">20</span> For patients with spontaneous rupture or iatrogenic perforation of the esophagus&#44; the esophagus may be sutured directly if diagnosis is early and no serious underlying esophageal disease is present&#46;<span class="elsevierStyleSup">3</span> In the remaining cases with infection originating in the esophagus&#44; esophagectomy with gastrostomy and jejunostomy are indicated&#46; In cases of mediastinitis secondary to gastroplasty or coloplasty&#44; the reconstruction should be removed in order to proceed with a second reconstruction at a later time&#46; The literature describes an overall mortality rate ranging from 14&#37; to 42&#37;&#44; from which we have calculated a weighted mean of 16&#46;6&#37;&#44; which is similar to the mortality rate of 15&#46;4&#37; in our series &#40;Table 2&#41;&#46; In conclusion&#44; we strongly advise a high degree of suspicion&#44; early diagnosis&#44; and initiation of aggressive treatment&#46;</p><p class="elsevierStylePara"><img src="260v39n09-13051515tab03.gif"></img></p><hr></hr><p class="elsevierStylePara">Correspondence&#58; Dr&#46; P&#46; Macr&#237;&#46;<br></br> Secci&#243;n de Cirug&#237;a Tor&#225;cica&#46; Hospital Universitario de Salamanca&#46;<br></br> P&#46;&#186; San Vicente&#44; 58&#46; 37007 Salamanca&#46; Spain&#46;<br></br> E-mail&#58; <a href="mailto&#58;paolomacri&#64;katamail&#46;com" class="elsevierStyleCrossRefs"> paolomacri&#64;katamail&#46;com</a></p><p class="elsevierStylePara">Manuscript received February 18&#44; 2003&#46;<br></br> Accepted for publication April 18&#44; 2003&#46;</p>"
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