Search

Objectives: Descending necrotizing mediastinitis (DNM) developing after deep neck infection (DNI) is a potentially lethal disease of the mediastinum with a mortality rate as high as 40% prior to the 1990s. No standard treatment protocol is available. Here, we present the outcomes of our multidisciplinary approaches for treating DNM originating from a DNI., Methods: Between June 2016 and July 2021, there were 390 patients with DNIs admitting to our tertiary hospital. A total 21 patients with DNIs complicated with DNM were enrolled. The multidisciplinary approaches included establishment of airway security, appropriate surgery and antibiotics, extracorporeal membrane oxygenation, and intensive care unit management. The clinical variables were analyzed., Results: Two patients died and 19 survived (mortality 9.5%). The patients who died had a higher mean C-reactive protein (CRP) level than did those who survived (420.0 ± 110.3 vs 221.8 ± 100.6 mg/L) (P = .038). The most common pathogens were Streptococcus constellatus and Streptococcus anginosus. From 2001 to 2021, the average mortality rate of studies enrolling more than 10 patients was 16.1%., Conclusion: Multidisciplinary approaches, early comprehensive medical treatment, and co-ordination among departments significantly reduce mortality. Patients with severe inflammation and high CRP levels require intensive and aggressive interventions., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objectives: The aim of this study was to elaborate on and validate a score for the early diagnosis of mediastinitis after cardiothoracic surgery., Methods: Between 2007 and 2017, patients who experienced thoracic surgical-site infection after cardiothoracic surgery were enrolled. Laboratory, clinical, and chest CT findings were retrospectively analyzed. Patients were followed up until hospital discharge or intra-hospital death. Univariate and multivariate regression analyses were performed., Results: 950 surgical-site infections were found and analyzed (131 mediastinitis, 819 superficial/deep infections). Of the 131 mediastinitis episodes, 88% required surgical thoracic debridement,Staphylococcus aureus was identified in 43%, and overall mortality was 42%. The following variables were related to mediastinitis diagnosis: sternal diastasis (OR=2.5; 95% confidence interval [95%CI]: 1.2-5.3; P=0.012), bilateral pleural effusion (OR=1.9; 95%CI: 1.0-3.6; P=0.04), leukocyte count ≥14,000cells/mm 3 (OR=2.5; 95%CI: 1.3-4.7; P=0.006), male sex (OR=2; 95%CI: 1.11-4; P=0.022), and positive blood culture (OR=3.0; 95%CI: 1.6-5.6; P=0.001). The score predicted with reasonable accuracy mediastinitis in the derivation cohort (AUC-ROC, 0.7476) and the validation cohort (AUC-ROC, 0.7149). Groups with high (31%) and low (5%) risk of mediastinitis were identified., Conclusions: An early diagnostic score in patients with surgical-site infection after cardiothoracic surgery identified groups with a low and high risk for mediastinitis., (Copyright © 2019 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Mediastinitis is a rare but severe infection, defined as an inflammation of the connective tissues and structures within the mediastinum. Due to its proximity to vital structures, mediastinitis represents a highly morbid pathological process associated with a high risk of mortality. In most cases mediastinitis requires treatment in the intensive care unit., Objectives: To highlight to the reader the clinical features of mediastinitis, to attempt to define each clinical scenario, to describe the responsible pathogens and finally to depict both the medical and surgical treatments., Sources: We performed a literature search of the PubMed and Cochrane libraries, limited for articles published between January 2003 and December 2018, reporting on acute mediastinitis., Content: The term covers different entities of different aetiologies including deep sternal wound infection related to sternotomy; oesophageal perforation or anastomosis leakage; and finally descending necrotizing mediastinitis, often secondary to oropharyngeal abscess. The responsible pathogens and therefore subsequent management depends on the underlying aetiology. Empirical antimicrobial therapy should cover the suspected microorganisms while surgery and supportive measures should aim to reduce the inoculum of pathogens by providing adequate drainage and debridement., Implications: Literature concerning mediastinitis in the intensive care unit is relatively scarce. We have collated the evidence and reviewed the different causes and treatment options of acute mediastinitis with a particular focus on microbiological epidemiology. Future research in larger cohorts is needed to better understand the treatment of this difficult disease., (Copyright © 2019 European Society of Clinical Microbiology and Infectious Diseases. Published by Elsevier Ltd. All rights reserved.)

Objectives: Descending necrotizing mediastinitis (DNM) is a severe potentially fatal disease of the mediastinum which spreads downwards from oropharyngeal region. Mortality varies from 11 to 40%. There is agreement on the importance of early diagnosis, aggressive surgical treatment and the need for a multidisciplinary approach., Design: Retrospective study of series of patient treated for DNM regarding multidisciplinary approach and surgical treatment., Patients and Methods: Sixteen patients that were surgically treated for DNM from 2008 to 2017 at our hospital were consecutively enrolled in observational descriptive study., Results: Twelve patients had disease localised above tracheal bifurcation level. Nine of them underwent transcervical drainage, three patients underwent more extensive treatment. Four patients with disease spread below the treacheal bifurcation level were treated with transcervical drainage in combination with posterolateral thoracotomy or videothoracoscopy. Three patients underwent videothoracoscopy - two of them as primary surgical treatment with need of one reoperation - contralateral videothoracoscopy. The third patient was initially treated with a transcervical approach and videothoracoscopy was indicated as a reoperation because of the progression of the disease. One patient died (mortality 6.25%)., Conclusion: In management of descending necrotizing mediastinitis, early diagnosis, aggressive surgical treatment and use of broad-spectrum antibiotics and nowadays also multidisciplinary approach are crucial. Transcervical drainage combined with posterolateral thoracotomy or videothoracoscopy were used with good results.

Fibrosing mediastinitis is a rare, often debilitating and potentially lethal disease characterized by an exuberant fibroinflammatory response within the mediastinum. Patients typically present with insidious symptoms related to compression of adjacent structures including the esophagus, heart, airways, and cardiac vessels. Fibrosing mediastinitis is most often triggered by Histoplasmosis infection; however, antifungal and anti-inflammatory therapies are largely ineffective. While structural interventions aimed at alleviating obstruction can provide significant palliation, surgical interventions are challenging with high mortality and clinical experience with percutaneous interventions is limited. Here, we will review the presentation, natural history, and treatment of fibrosing mediastinitis, placing particular emphasis on catheter-based therapies., (© 2019 Wiley Periodicals, Inc.)

Background: Deep sternal wound infection (DSWI) represents a life-threatening complication following open-heart surgery and pectoralis major muscle flap reconstruction has led to a significant reduction in mortality and morbidity. Negative-pressure wound therapy represented a step forward in DSWI treatment, both as a single procedure or as a preparation for reconstructive surgery.In the present study, we report our 13 years' experience with sternal reconstruction in order to evaluate the impact of preoperative vacuum-assisted closure (VAC) therapy on reconstructive outcome., Methods: Seventy-three patients diagnosed with DSWI undergoing pectoralis major muscle flap reconstruction were divided into 2 subgroups: preoperative VAC treatment group (n = 37) and no preoperative VAC (NVAC n = 36). We collected patients' DSWI and reconstructive surgery clinical data, and we analyzed surgical outcome in terms of complication rate, reoperation rate, defects closure times, and intraoperative/30-day and 1-year mortality., Results: Eighty-three flaps were used, bilateral flaps were used more in the NVAC subgroup (P = 0.005), and operative time was significantly shorter in the VAC subgroup (P < 0.001). Complication rate was 9.6%, with no significant differences between the 2 subgroups (P = 0.723). There was no recurrence of mediastinitis, and all flaps survived. Sternal closure time was significantly lower in the VAC subgroup (P < 0.001). No intraoperative death occurred; 30-day and 1-year mortality were 2.7% and 19.2%, respectively, with no significant difference between the 2 groups (P = 0.596)., Conclusions: Preoperative VAC therapy makes reconstructive surgery easier and faster, even though it has no impact on complication rate and overall success of the reconstruction. Pectoralis major muscle flap represents a reliable solution even if not associated with preoperative VAC.

Background: Surgical site infections after cardiac surgery are associated with severe outcomes, including reoperation and death. We aimed to describe the effect of a standardized clinical-care protocol for preventing mediastinitis in patients who underwent coronary artery bypass graft surgery (CABG)., Methods: In a hospital certified by Joint Commission International, all patients who underwent CABG from January 2011 to December 2016 were compared in two periods according to the moment of implementation of a standardized clinical-care protocol for prevention of mediastinitis (CCPPM): pre-protocol (January 2011-December 2012) and post-protocol (January 2013-December 2016). The CCPPM consisted of the patient using a kit containing chlorhexidine 2% for bathing, mupirocin 20 mg/g for nasal topical use and chlorhexidine 0.12% for oral hygiene for 5 days before surgery, in addition to prophylaxis with a glycopeptide antimicrobial and strict glucose control (110-140 mg/dL) during surgery and immediate postoperative., Results: We evaluated 1760 patients who underwent CABG in both periods. The occurrence of mediastinitis before protocol implementation was 1.44% (10 of 692 CABG). After the implementation of the protocol, there was an important reduction in the incidence of mediastinitis to 0.09% (1 of 1068 CABG) (P = 0.002). Although we did not observe a significant difference in mortality between the groups (2.3% vs 1%, P = 0.77), there was fewer in-hospital mortality due to mediastinitis after the CCPPM (0.2% vs 0%, P < 0.001)., Conclusion: Implementation of a standardized CCPPM was associated with a significant reduction in the incidence of mediastinitis after CABG and reduction of mortality in the group of patients with mediastinitis., (© 2019 Wiley Periodicals, Inc.)

Purpose: Timing and ideal reconstructive approach in deep sternal wound infection (DSWI) and mediastinitis still remain controversially debated. We present our own combined surgical strategy of bilateral pectoralis major muscle flap (BPMMF) or omental flap (OF) transposition., Methods: Between July 2010 and July 2016, poststernotomy patients with DSWI and mediastinitis underwent a secondary wound closure with modified BPMMF (Group A, center for disease control class (CDC)-II, n = 21; Group B, CDC-III, n = 20) or with OF (Group C, CDC-III, n = 19) following vacuum-assisted closure (VAC)., Results: Significant risk factors for mediastinitis (CDC-III) were chronic obstructive pulmonary disease (COPD; p = 0.001), peripheral arterial disease (PAD; p = 0.012), cardiopulmonary bypass (CPB) time (p = 0.027), total operation time (p = 0.039), total intensive care unit (ICU) stay (p = 0.011), and blood transfusion (p = 0.049). Mean antibiotic therapy (18.4 ± 8.8[B] vs. 36.2 ± 24.4[C] days, p = 0.026) and length of hospitalization (25.2 ± 12.1[B] vs 53.8 ± 18.5 days[C], p = 0.053) were significantly longer in group C. In-hospital death was 3/19 (15.8%) in group C versus 0 in group B (p = 0.026). Frequency of recurrent mediastinitis was equal (p = 0.92); however, complications occurred more often in group C (31.6% vs. 0%, p = 0.031). The mean follow-up time was 111 ± 62 days., Conclusion: In younger (<70 years) patients without sternal bone necrosis, the BPMMF is superior to the OF technique with relatively low recurrence and mortality risks.

Introduction: Descending Necrotizing Mediastinitis (DNM) is the fatal form of mediastinitis and mostly develops as a complication of peritonsillar abscesses or dental-odontogenic infections. The aim of this study is to evaluate clinical and surgical feature of the patients with DNM who were managed in our clinic., Methodology: We retrospectively evaluated 13 consecutive patients with the diagnosis of DNM between February 2005 and February 2018. All of them had the typical physical appearance, history and radiological findings., Results: Ten (77%) patients were male, 3 (23%) patients were female with a median age of 48.2 (18-76 years). All patients underwent Cervico-Mediastinal Drainage (CMD) with debridement of the necrotic and infected tissues. Other supplimantary surgical procedures were tube thoracostomy (n = 8), VATS mediastinal drainage (n = 4), tracheostomy (n = 2) and thoracatomy (n = 1). The median time to diagnosis of DNM, tube drainage (inserted after CMD) removal time, tube thoracostomy removal time, lenght of hospital stay were 1.8 (range 1-4) days, 13.6 (range 10-20), 12.6 days (range 10-27) and 21.5 days (range 15-30), respectively. Appropriate and potent antibiotics were used according to the fever-CRP response with the consultation on infectious disease specialist. Two patients were lost due to fulminant sepsis (n = 1) and massive cervical haemorrhage (n = 1). Overall mortality rate was 15%. Complications were recorded in 6 patients (46%)., Conclusions: The critical point in the management of DNM is the correct diagnosis, rapid surgical intervention with antibiotherapy and close follow-up for possible complications. We concluded that the combination of minimally invasive management as VATS-tube thoracostomy with CMD is the most appropriate surgical interventions., Competing Interests: No Conflict of Interest is declared, (Copyright (c) 2018 Fazlı Yanık, Yekta Altemur Karamustafaoğlu, Yener Yoruk.)

Purpose: Descending necrotizing mediastinitis (DNM) is a serious complication of head and neck infections and has an excessively high mortality rate owing to the lack of understanding of DNM. We assessed the clinical characteristics, diagnosis, treatment, and outcomes of odontogenic DNM and evaluated the risk factors affecting the prognosis of DNM to provide an up-to-date overview for clinical practice., Materials and Methods: We performed a retrospective cohort study, enrolling a sample of patients with DNM due to odontogenic infection who had been referred from January 2013 to December 2016. The patients were classified into surviving and deceased groups. The primary predictors in the present study were the presence of multiple comorbidities, complications, demographic data (age, gender), laboratory tests (white blood cell count, percentage of neutrophils), and time (duration before diagnosis, length of hospital stay). The primary outcome variable was the patient outcome (dead or alive). The continuous variables were evaluated using Student's t test or the t test, and the categorical and binary variables were compared using the χ 2 test or Fisher exact test., Results: A total of 81 patients (68 men, 13 women; median age of 57.2 ± 12.2 years) were included. The mortality was 4.9%. The most frequent cause of DNM was periapical periodontitis (66.7%). The lower posterior molars were involved in 39.5% of the cases. Treatment consisted of antibiotic therapy, aggressive transcervical mediastinal drainage (n = 74), and thoracotomy (n = 7). The associated risk factors for mortality were complications (P < .005) and severe sepsis or septic shock (P < .001) on bivariate analysis., Conclusions: Septic shock and complications were the risk factors that correlated with a poor prognosis. A timely diagnosis and use of aggressive mediastinal drainage are fundamental to reducing the incidence of complications and the development of septic shock in odontogenic DNM patients., (Copyright © 2018 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.)

A retrospective cohort study, were evaluated: polymyxin B plus aminoglycosides or polymyxin B plus other antibiotics. Any degree of acute kidney injury occurred in 26 (86.6%) patients. The median time to acute kidney injury was 6.0 (95% CI 3-14) days in the polymyxin-aminoglycoside containing regimen group, against 27.0 (95% CI 6-42) days in the polymyxin with other antimicrobial combinations group (p=0.03). Polymyxin B with aminoglycosides group progressed faster to any degree of renal dysfunction., (Copyright © 2017 Sociedade Brasileira de Infectologia. Published by Elsevier Editora Ltda. All rights reserved.)

Background: Post-sternotomy mediastinitis is associated with significant mortality and morbidity. Despite surgical advances in cardiac surgery and improvements in perioperative care, mediastinitis remains a devastating post-operative complication. This study provides a comprehension review of post-sternotomy mediastinitis in the modern era, and discusses the incidence, risk factors, microbiology, prevention, and management of this complication., Methods: This review was based on a PubMed/MEDLINE literature search up until 9th March 2017 for publications relevant to mediastinitis post-cardiac surgery., Results: The incidence of mediastinitis post-cardiac surgery varies between 0.3 and 3.4%, and is associated with an in-hospital mortality ranging from from 1.1 to 19%. The risk of developing post-operative mediastinitis is dependent on the patients' co-morbidities (diabetes, obesity, smoking, renal failure) and surgical techniques (bilateral pedicled internal mammary harvest, excessive cautery, long duration of surgery). Preventative measures including skin and nasal decontamination, antibiotic prophylaxis, strict glycemic control, and meticulous surgical techniques are crucial in reducing the risk. Treatment of post-operative mediastinitis include culture-directed antibiotic therapy, early wound exploration, and debridement followed by sternal reconstruction/closure. Vacuum-assisted therapy can be used as a single line therapy or as a bridge to eventual sternal reconstruction/closure., Conclusion: Post-sternotomy mediastinitis remains a potentially fatal complication of cardiac surgery despite the advancements in the perioperative care in the modern era. Management on preventative measures, prompt diagnosis, and managements are crucial in reducing associated mortality and morbidity., (© 2017 Wiley Periodicals, Inc.)

Results of treatment in 2000-2016 yrs of 183 patients for the neck phlegmon were analyzed. In 60 (32.8%) of them a descending purulent mediastinitis (DPM) was diagnosed. The main causes of the DPM occurrence were tonsilogenic and odontogenous factors. Postoperative lethality in DPM have constituted 25%.

Objectives: To review the management and outcomes of pediatric patients treated for descending mediastinitis at a single institution and contribute to an updated mortality rate., Study Design: Case series with chart review., Setting: Tertiary care pediatric hospital., Subjects and Methods: This study is a 19-patient case series of all patients treated for descending mediastinitis at a tertiary pediatric hospital from 1997 to 2015, and it serves as an update to the case series published from this institution in 2008. Review of management included time to diagnosis, time to surgery, surgical procedures performed, and antibiotics administered. The primary outcomes measured were length of hospitalization and mortality., Results: In addition to 8 previously reported patients, we identified 11 pediatric patients treated for descending mediastinitis in the period of review. All 19 patients were <18 months old, and all survived their hospitalization. Fourteen patients underwent surgical drainage at least twice. The median length of hospital stay was 15 days. Retropharyngeal abscess was the source of infection in 16 of 19 patients, and methicillin-resistant Staphylococcus aureus (MRSA) was the isolated organism in 14 of 15 positive cultures., Conclusion: This review represents the largest reported series of pediatric patients with descending mediastinitis. With 100% survival, our results suggest that pediatric descending mediastinitis can be safely managed by prompt surgical drainage. Broad-spectrum antibiotics covering MRSA and a low threshold for repeat surgical intervention have been an important part of our successful approach and may decrease length of stay., (© American Academy of Otolaryngology—Head and Neck Surgery Foundation 2016.)

Background: A systematic approach to the etiology and possible course of acute mediastinitis is a prerequisite for adequate diagnostics and therapy. Chronic mediastinitis represents a rarity in the clinical practice., Material and Method: A selective literature search was carried out., Results: An acute infection of the mediastinum occurs after perforation of mediastinal structures, such as the esophagus and trachea mostly of iatrogenic origin and as descending necrotizing mediastinitis (DNM) from oropharyngeal foci. The mortality rate of esophageal injuries, irrespective of the cause is currently given as 12 %. A DNM results from an unobstructed spread along the cervicothoracic spaces and is a severe infection which manifests as a clinical picture of sepsis. The mortality rate given in the currently available literature is 14 %. Chronic mediastinitis is a very rare condition which is characterized by the proliferation of fibrous and collagenous tissue in the mediastinum. Whereas the pathogenesis remains unclear, there are indications for a Histoplasma capsulatum infection as the causal link. The prognosis is good., Conclusion: After perforation of the esophagus or trachea there is always the risk of an infection of the mediastinum; therefore, the diagnosis is followed by further evaluation and early therapy. The DNM can cause unspecific symptoms of sepsis without an obvious focal point. It is important to be aware of a possible correlation between an oropharyngeal center of infection and mediastinitis in order to initiate appropriate diagnostic imaging in cases with the slightest suspicion. Chronic mediastinitis is a rare condition with varying courses and can be difficult to diagnose. An histological clarification for distinction from malignant diseases appears to be a sensible approach.

Despite modern intensive care management, acute mediastinitis is still associated with a high morbidity and mortality (up to approximately 40 %). Effective antibiotic therapy, intensive care management, elimination of the causative sources of infection and drainage of the affected mediastinal compartments are the cornerstones of therapy in a multidisciplinary treatment concept. Early diagnosis, prompt and uncompromising initial therapy and planned computed tomography (CT) control after the first stages of therapy in order to decide on the necessity for surgical re-interventions are essential for achieving optimal results. Knowledge of the specific anatomical characteristics is crucial for the understanding of this disease and its treatment; therefore, the current knowledge on fascial layers and interstitial spaces from the neck to the mediastinum is described and discussed. A possible foudroyant spread of the infection, especially within the posterior mediastinum, has to be anticipated. The approach to the mediastinum depends on the mediastinal compartments affected, on the causative disease and on the patient's clinical situation. The surgical approach should be adapted to the particular clinical situation of the individual patient and to the surgical experience of the surgeon. When in doubt, the more invasive approach to the mediastinum, such as bilateral thoracotomy, is recommended. An ascending mediastinitis due to pancreatitis is a very rare condition; however, as chest pains are often the main clinical sign surgeons should be aware of this differential diagnosis. An intraoperative brown-black serous fluid in the mediastinal tissue is virtually pathognomonic. The treatment results of esophageal perforation as the most frequent cause of mediastinitis have been improved by integration of various interventional procedures. Hyperbaric oxygen therapy or immunoglobulin treatment can play an auxiliary role in selected patients with acute mediastinitis.

Mediastinitis occurs as a severe complication of thoracic and cardiac surgical interventions and is the result of traumatic esophageal perforation, conducted infections or as a result of lymphogenic and hematogenic spread of specific infective pathogens. Treatment must as a rule be accompanied by antibiotics, whereby knowledge of the spectrum of pathogens depending on the pathogenesis is indispensable for successful antibiotic therapy. Polymicrobial infections with a high proportion of anaerobes are found in conducted infections of the mediastinum and after esophageal perforation. After cardiac surgery Staphylococci are the dominant pathogens and a nasal colonization with Staphylococcus aureus seems to be a predisposing risk factor. Fungi are the predominant pathogens in immunocompromised patients with consumptive underlying illnesses and can cause acute or chronic forms with granulomatous inflammation. Resistant pathogens are increasingly being found in high-risk patient cohorts, which must be considered for a calculated therapy. For calculated antibiotic therapy the administration of broad spectrum antibiotics, mostly beta-lactams alone or combined with metronidazole is the therapy of choice for both Gram-positive and Gram-negative bacteria inclusive of anaerobes. For patients at risk, additional antibiotic classes with a spectrum against methicillin-resistant Staphylococcus aureus (MRSA) or vancomycin-resistant Enterococcus (VRE) can be administered. Increasing rates of multidrug-resistant Gram-negative bacteria (e.g. Enterobacteriaceae) and non-fermenting bacteria (e.g. Pseudomonas and Acinetobacter) in individual cases necessitates the use of polymyxins (e.g. colistin), new tetracyclines (e.g. glycylglycines) and newly developed combinations of beta-lactams and beta-lactam inhibitors. For treatment of fungal infections (e.g. Candida, Aspergillus and Histoplasma) established and novel azoles, amphotericin B and echinocandins seem to be successful; however, detection of Candida, particularly in mixed infections does not always necessitate treatment. Mediastinitis is still a severe infectious disease with a high mortality, which necessitates an early and broad spectrum antibiotic therapy; however, with respect to optimal duration of therapy and selection of antibiotics, data from good quality comparative studies are lacking.

Invasive infections due to carbapenem-resistant Enterobacteriaceae (CRE), including polymyxin-resistant (PR-CRE) strains, are being increasingly reported. However, there is a lack of clinical data for several life-threatening infections. Here we describe a cohort of patients with post-surgical mediastinitis due to CRE, including PR-CRE. This study was a retrospective cohort design at a single cardiology centre. Patients with mediastinitis due to CRE were identified and were investigated for clinically relevant variables. Infecting isolates were studied using molecular techniques. Patients infected with polymyxin-susceptible CRE (PS-CRE) strains were compared with those infected with PR-CRE strains. In total, 33 patients with CRE mediastinitis were studied, including 15 patients (45%) with PR-CRE. The majority (61%) were previously colonised. All infecting isolates carried blaKPC genes. Baseline characteristics of patients with PR-CRE mediastinitis were comparable with those with PS-CRE mediastinitis. Of the patients studied, 70% received at least one agent considered active in vitro and most patients received at least three concomitant antibiotics. Carbapenem plus polymyxin B was the most common antibiotic combination (73%). Over 90% of patients underwent surgical debridement. Overall, in-hospital mortality was 33% and tended to be higher in patients infected with PR-CRE (17% vs. 53%; P=0.06). In conclusion, mediastinitis due to CRE, including PR-CRE, can become a significant challenge in centres with CRE and a high cardiac surgery volume. Despite complex antibiotic treatments and aggressive surgical procedures, these patients have a high mortality, particularly those infected with PR-CRE., (Copyright © 2016. Published by Elsevier B.V.)

Purpose: We aimed to investigate clinical features of patients with descending necrotizing mediastinitis (DNM) in order to improve management and outcome., Methods: We prospectively examined all patients with DNM admitted to the Intensive Care Unit (ICU) during the period from April 2007 to December 2013. Demographics, clinical features, microbiology, medical and surgical treatment data were recorded. Survivor and nonsurvivor groups were analyzed to identify factors associated with mortality., Results: Overall, 34 patients with DNM have been included. The mean age was 46.8 ± 11.2 years (range 24-70). The male/female ratio was 3.25. DNM arose from odontogenic infection in 22 (65%) patients; from peritonsillar abscess in 9 (26%) patients and from paranasal sinus in 3 (9%) patients. Microbiological cultures revealed a high percentage of aerobic/anaerobic coinfection. Nonsurvivors were statistically more likely to have higher SAPS II score (mean difference 19.1, 95% CI 12.3-25.9 P < 0.01) and more severe disease (P < 0.01) than survivors. Positive correlation was found between time to ICU admission after head or neck infection diagnosis and SAPS II score (ρ = 0.5, P = 0.03). The same was true for ICU length of stay and time to ICU admission (ρ = 0.6, P < 0.01) and time to surgery (ρ = 0.5, P = 0.03). Surgical treatments consisted in: transcervical drainage in 14 cases, (42%); irrigation through subxiphoid and cervical incisions of the anterior mediastinum with additional percutaneous thoracic drainage when necessary in ten cases, (29 %); thoracotomy with radical mediastinal surgical debridement, excision of necrotic tissue and decortication in ten cases, (29%). We have found a mortality rate of 12%. Patients with DNM type IIB were admitted to the ICU later than patients with DNM type I and type IIA (mean difference 3.2 days, 95% CI 1.2-5.1, P 0.02)., Conclusions: Prompt ICU admission in order to manage severe sepsis and/or septic shock, along with early and aggressive surgery and adequate antimicrobial therapy, could be key factors in reducing DNM mortality.

Background: Endosonography is being implemented rapidly in pulmonary medicine for the diagnosis and staging of lung cancer, the assessment of sarcoidosis, and the assessment of mediastinal lesions. Although serious adverse events (SAEs) have been described, safety data outside cohort studies are scarce., Objective: To assess the SAE and mortality rate of EUS-guided FNA (EUS-FNA) and endobronchial ultrasound guided transbronchial needle aspiration (EBUS-TBNA) for mediastinal and/or hilar analysis., Design: Nationwide, retrospective survey by using questionnaires., Setting: All hospitals in the Netherlands., Patients: All patients undergoing EUS-FNA and EBUS-TBNA for intrathoracic analysis in the period 1999 to 2011., Interventions: EUS-FNA and EBUS-TBNA., Main Outcome Measurements: Occurrence of fatal outcomes and SAEs. Detailed information was obtained for each reported case, and all cases were reviewed independently by 2 investigators, including identification of risk factors., Results: All 89 hospitals (100%) responded. An estimated 14,075 EUS-FNA and 2675 EBUS procedures were performed. Seven patients died after endosonography (5 EUS-FNA, 2 EBUS [mortality rate 0.04%]). All fatalities occurred in patients of poor performance status (American Society of Anesthesiologists Physical Status Classification System score of III/IV). Twenty-five SAEs were reported (22 EUS-FNA, 3 EBUS [SAE rate of 0.15%; EUS-FNA 0.16%, EBUS 0.11%]). SAEs were mostly (64%) of infectious origin. No specific risk factors for infectious adverse events could be identified., Limitations: Retrospective study, possible recall bias, overrepresentation of EUS-FNA cases., Conclusion: Endosonography appears to be a safe technique for the analysis of mediastinal and/or hilar lesions. Poor performance status is a risk factor for fatal outcomes. Mediastinitis and/or mediastinal abscess formation is rare but is a potential and dangerous adverse event of endosonography., (Copyright © 2015 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)

Acute infection of the mediastinum remains a condition with high morbidity and lethality rates. The manifestation and course of the illness vary widely depending on the cause of infection. Lack of knowledge or awareness of the illness and mostly unspecific clinical symptoms often delay diagnosis and thereby the start of adequate therapy. Computed tomography (CT) of the neck and thorax is the method of choice for diagnostics and control of therapeutic success. An early diagnosis with immediate surgical debridement and drainage of all infected tissue compartments, as well as strict sepsis therapy, are decisive for the prognosis., (Georg Thieme Verlag KG Stuttgart · New York.)

Objectives: Sternal wound infections are serious postoperative complications that increase the length of hospital stay and healthcare costs. The benefit of implantable gentamicin-collagen sponges in reducing sternal wound infections has been questioned in a recent multicenter trial. We aimed to perform a comprehensive meta-analysis of studies assessing the efficacy of implantable gentamicin-collagen sponges in sternal wound infection prevention., Methods: Multiple databases were screened for studies assessing the efficacy of implantable gentamicin-collagen sponges after heart surgery. The primary end point was sternal wound infection, and secondary end points were the occurrence of deep sternal wound infection, superficial sternal wound infection, mediastinitis, and mortality. Randomized controlled trials and observational studies were analyzed separately. By means of meta-regression, we examined the correlation between sternal wound infection and extent to which the bilateral internal thoracic artery was harvested., Results: A total of 14 studies (N = 22,135, among them 4 randomized controlled trials [N = 4672]) were included in the analysis. Implantable gentamicin-collagen sponges significantly reduced the risk of sternal wound infection by approximately 40% when compared with control (risk ratio [RR], 0.61; 95% confidence interval [CI], 0.39-0.98; P = .04 for randomized controlled trials and RR, 0.61; 95% CI, 0.42-0.89; P = .01 for observational studies). A similar, significant benefit was demonstrated for deep sternal wound infection (RR, 0.60; 95% CI, 0.42-0.88; P = .008) and superficial sternal wound infection (RR, 0.60; 95% CI, 0.43-0.83; P = .002). The overall analysis revealed a reduced risk of mediastinitis (RR, 0.64; 95% CI, 0.45-0.91; P = .01). The risk of death was unchanged. A significant positive linear correlation (P = .05) was found between the log RR of sternal wound infection and the percentage of patients receiving bilateral internal thoracic artery grafts., Conclusions: Implantable gentamicin-collagen sponges significantly reduce the risk of sternal wound infection after cardiac surgery, with evidence consistent in randomized and observational-level data. However, the extent of this benefit might be attenuated in patients receiving bilateral internal thoracic artery grafts., (Copyright © 2015 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objectives: Optimal management of poststernotomy mediastinitis is controversial. Negative pressure wound treatment improves wound environment and sternal stability with low surgical invasiveness. Our protocol was based on negative pressure followed by delayed surgical closure. The aim of this study was to provide the results at early follow-up and to identify the risk factors for adverse outcome., Methods: In 5400 cardiac procedures, 44 consecutive patients with mediastinitis were enrolled in the study. Mediastinitis treatment was based on urgent debridement and negative pressure as the first-line approach. After wound sterilization, chest closure was achieved by elective pectoralis muscle advancement flap. Each patient's hospital data were collected prospectively. Variables included patient demographics and clinical and biological data. Acute Physiology and Chronic Health Evaluation (APACHE) II score was calculated at the time of diagnosis and 48 hours after debridement. Focus outcome measures were mediastinitis-related death and need for reintervention after pectoralis muscle closure., Results: El Oakley type I and type IIIA mediastinitis were the most frequent types (63.6%). Methicillin-resistant Staphylococcus aureus was present in 25 patients (56.8%). Mean APACHE II score was 19.4±4 at the time of diagnosis, and 30 patients (68.2%) required intensive care unit transfer before surgical debridement. APACHE II score improved 48 hours after wound debridement and negative pressure application (mean value, 19.4±4 vs 7.2±2; P=.005) independently of any other variables included in the study. One patient in septic shock at the time of diagnosis died (2.2%)., Conclusions: Negative pressure promotes a significant improvement in clinical status according to APACHE II score and allows a successful elective surgical closure., (Copyright © 2014 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: The authors examined the relationship between débridement delay and mortality for mediastinitis patients. The authors also assessed mortality trends for mediastinitis patients between 1998 and 2010., Methods: The authors conducted a retrospective cross-sectional study with data from the Nationwide Inpatient Sample, 1998 to 2010. They studied adult patients, 18 years of age or older, who were surgically treated for mediastinitis. They used a logistic regression model adjusted for patient demographic and clinical characteristics to evaluate the association between timing of first operative débridement and in-hospital mortality. Using their logistic model, they calculated the adjusted probability of in-hospital mortality for each year of the study., Results: Results showed that initial débridement after the fourth day of admission increased the odds of in-hospital mortality by 50 percent (odds ratio, 1.5; 95 percent confidence interval, 1.0 to 2.1). In addition, the adjusted probability of in-hospital mortality for an average patient treated for mediastinitis decreased from 10.6 percent in 1998 to 3.1 percent in 2010., Conclusion: There is a survival advantage from timely initial débridement in mediastinitis patients., Clinical Question/level of Evidence: Risk, II.

Aim: To investigate possible predictors for failed self-expandable metallic stent (SEMS) therapy in consecutive patients with benign esophageal perforation-rupture (EPR)., Methods: All patients between 2003-2013 treated for EPR at the Karolinska University Hospital, a tertiary referral center, were studied with regard to initial management with SEMS. Patients with malignancy as an underlying cause and those with anastomotic leakages were excluded. Sealing of the perforation with a covered SEMS was the primary strategy whenever feasible. Stent therapy failure was defined as a radical change of treatment strategy due to uncontrolled mediastinitis, which in this setting consisted of emergency esophagectomy with end-esophagostomy or death as a consequence of the perforation and subsequent uncontrolled sepsis. Patient and lesion characteristics were analyzed and are presented as median and interquartile range. Possible predictors for failed stent therapy were analyzed with uni-variate logistic regression, while variables with P < 0.2 were further analyzed with multi-variate logistic regression., Results: Of the total number of 48 patients presenting with EPR, 40 patients (83.3%) were treated with SEMS at the time of admission, with an intention to heal the perforation. Twenty-three patients had Boerhaave's syndrome (58%), 16 had an iatrogenic perforation (40%) and 1 had external trauma to the esophagus (3%). The total in-hospital mortality, including the cases that had other initial treatments (n = 8), was 10.4% and 7.5% among those who were subjected to the SEMS-based strategy. In 33 of the 40 patients (82.5%) who were treated with stent, the EPR healed without further change in treatment strategy. Patients classified as treatment success received a SEMS at a median time of 1 (1-1) d after the actual EPR, compared to 3 (1-10) d among those where the initial treatment failed, P = 0.039 in uni-variate analysis and P = 0.052 in multi-variate analysis. No other significant factors emerged, indicating an increased risk for failure. Six of 7 patients, where stent treatment of the defect failed, underwent an emergency esophagectomy with end esophagostomy and one patient died., Conclusion: SEMS as an upfront therapeutic strategy seems to be a successful concept, when applied to an unselected group of patients with EPR.

Mediastinitis is a devastating sternal wound complication. The aim of this study was to identify the incidence, risk factors, mortality, and different treatment modalities of mediastinitis after isolated coronary artery bypass grafting. From January 2007 to May 2010, 1424 patients who underwent isolated coronary artery bypass grafting were studied retrospectively; 1398 (group 1) had no mediastinitis, and 26 (group 2) developed mediastinitis. The diagnosis and classification of mediastinitis were based on the criteria of the Center for Disease Control and Prevention and the Emory classification, respectively. Multivariate analysis showed only 4 risk factors: diabetes mellitus, obesity, prolonged postoperative intensive care unit stay, and prolonged intubation time. On univariate analysis, female sex, renal failure, and reexploration for bleeding were also significant risk factors. The incidence of mediastinitis (1.83%) and the subsequent mortality rate (7.69%) were comparable to those of previous reports. Early detection and aggressive management of mediastinitis play major roles in decreasing the related mortality and morbidity. The Emory classification with some modification is very helpful in choosing the proper treatment modality., (© The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav.)

Mediastinitis is treated with either vacuum-assisted closure (VAC) or traditional closed drainage (TCD) with irrigation. The aim of the study was to determine the effect of the two treatments on mortality and re-infection rate in a source population, using 21 314 consecutive patients undergoing isolated coronary artery bypass grafting (CABG) from January 1997 to October 2010. Median observation time was 2·9 years in the VAC group and 8·0 years in the TCD group. The epidemiological design was of an exposed (VAC, n = 64) versus non-exposed (TCD, n = 66) cohort with two endpoints: (1) mortality and (2) failure of sternal wound healing or re-infection. The crude effect of treatment technique versus endpoint was estimated by univariate analysis. Stratification analysis by the Mantel-Haenszel method was performed to quantify confounders and to pinpoint effect modifiers. Adjustment for confounders was performed using Cox regression analysis. Mediastinitis was diagnosed 6-105 (median 14) days after primary operation in the VAC group and 13 (5-29) days in the TCD group. There was no difference between groups in long-term survival. Failure of sternal wound healing or re-infection occurred less frequently in the VAC group (6%) than in the TCD group (21%; relative risk = 0·29, 95% CI = 0·06-0·88, P = 0·01). There are concerns for increase in right ventricle rupture in VAC compared with TCD. There was no difference in survival after VAC therapy and TCD therapy of post-CABG mediastinitis. Failure of sternal wound healing or re-infection was more common after TCD therapy., (© 2012 The Authors. International Wound Journal © 2012 Medicalhelplines.com Inc and John Wiley & Sons Ltd.)

The aim of this study was to describe the features of a large cohort of patients with postoperative mediastinitis, with particular regard to Gram-negative bacteria (GNB), and assess their outcome. This bicentric retrospective cohort included all patients who were hospitalized in the Intensive Care Unit with mediastinitis after cardiac surgery during a 9-year period. Three hundred and nine patients developed a mediastinitis with a mean age of 65 years and a mean standard Euroscore of six points. Ninety-one patients (29.4%) developed a GNB mediastinitis (GNBm). Of the 364 pathogens involved, 103 GNB were identified. GNBm were more frequently polymicrobial (44% versus 3.2%; p <0.001). Being female was the sole independent risk factor of GNBm in multivariate analysis. Initial antimicrobial therapy was significantly more frequently inappropriate with GNBm compared with other microorganisms (24.6% versus 1.9%; p <0.001). Independent risk factors for inappropriateness of initial antimicrobial treatment were GNBm (OR = 8.58, 95%CI 2.53-29.02, p 0.0006), and polymicrobial mediastinitis (OR = 4.52, 95%CI 1.68-12.12, p 0.0028). GNBm were associated with more drainage failure, secondary infection, need for prolonged mechanical ventilation and/or use of vasopressors. Thirty-day hospital mortality was significantly higher with GNBm (31.9 % versus 17.0%; p 0.004). GNBm was identified as an independent risk factor of hospital mortality (OR = 2.31, 95%CI 1.16-4.61, p 0.0179)., (© 2013 The Authors Clinical Microbiology and Infection © 2013 European Society of Clinical Microbiology and Infectious Diseases.)

Background: Descending necrotizing mediastinitis is a dreadful disease with a high mortality rate, particularly when below the tracheal carina. This study describes the epidemiologic, clinical, and paraclinical features of patients treated for this condition., Methods: We performed a single-center retrospective descriptive review of 60 patients with descending necrotizing mediastinitis below the tracheal carina, who were treated during a 7-year period, the largest study in the last 50 years. Demographic, clinical, paraclinical, and therapeutic variables were analyzed., Results: 43 (71.7%) patients were male. The mean age was 41.2 ± 14.7 years. Mean hospital length of stay was 25.0 ± 19.8 days. Comorbidities were present in 46.7% of patients, diabetes mellitus being the most common. Odontogenic infections (45%) were the most frequent source of descending necrotizing mediastinitis. Cultures showed Gram-negative bacilli in 68.3%, Gram-positive cocci in 38.3%, and fungi in 6.7%. Mortality was 35% (21 patients); risk factors for mortality were age (>35 years), diabetes mellitus among other comorbidities, and associated complications., Conclusions: In this low socioeconomic status patient population, descending necrotizing mediastinitis below the carina causes high morbidity and mortality, the latter particularly associated with age, complications, diabetes mellitus and other comorbidities.

Background: Mediastinitis following pediatric cardiac surgery is associated with significantly high morbidity and mortality., Method: In our review, 21 studies from 1986 to 2011 (12 retrospective studies, eight prospective studies, and a multi-institutional study) including 44,693 pediatric cardiac patients were analyzed., Results and Conclusion: Younger age, malnutrition, preoperative respiratory tract infection, high American anesthesiology score, longer duration of surgery, prolonged ventilation, and ICU stay were definite risk factors for mediastinitis. Early primary closure over drains, vacuum-assisted closure, muscle flap, and omental flap remain the most frequently performed treatments for post-sternotomy mediastinitis. Vacuum-assisted closure has emerged as the technique of choice in recent years., (© 2013 Wiley Periodicals, Inc.)

Objectives: Post-sternotomy mediastinitis is a severe complication of open heart surgery resulting in prolonged hospital stay and increased mortality. Vacuum-assisted closure is commonly used as treatment for post-sternotomy mediastinitis, but has some disadvantages. Primary closure over high vacuum suction Redon drains previously has shown to be an alternative approach with promising results. We report our short- and long-term results of Redon therapy-treated mediastinitis., Methods: We performed a retrospective analysis of 124 patients who underwent primary closure of the sternum over Redon drains as treatment for post-sternotomy mediastinitis in Amphia Hospital (Breda, Netherlands) and St. Antonius Hospital (Nieuwegein, Netherlands). Patient characteristics, preoperative risk factors and procedure-related variables were analysed. Duration of therapy, hospital stay, treatment failure and mortality as well as C-reactive protein and blood leucocyte counts on admission and at various time intervals during hospital stay were determined., Results: Mean age of patients was 68.7 ± 11.0 years. In 77.4%, the primary surgery was coronary artery bypass grafting. Presentation of mediastinitis was 15.2 ± 9.8 days after surgery. Duration of Redon therapy was 25.9 ± 18.4 days. Hospital stay was 32.8 ± 20.7 days. Treatment failure occurred in 8.1% of patients. In-hospital mortality was 8.9%. No risk factors were found for mortality or treatment failure. The median follow-up time was 6.6 years. One- and 5-year survivals were 86 and 70%, respectively., Conclusions: Primary closure using Redon drains is a feasible, simple and efficient treatment modality for post-sternotomy mediastinitis.

Objective: The mortality rate of patients with poststernotomy mediastinitis remains very high. The aim of this study was to identify the risk factors associated with mortality in these patients., Subjects and Methods: Surveillance of sternal surgical-site infections including mediastinitis was carried out for adult patients undergoing a sternotomy between 2004 and 2012. Criteria from the US Centers for Disease Control and Prevention were used to make the diagnosis. All data on patients with a diagnosis of mediastinitis who were included in the study and on mortality risk factors were obtained from the hospital database and then analyzed using SPPS 16.0 for Windows., Results: Of the 19,767 patients undergoing open heart surgery, 117 (0.39%) had poststernotomy mediastinitis; 32% of these 117 died. The independent risk factors for mortality were methicillin-resistant Staphylococcus aureus (MRSA) [odds ratio (OR) 12.11 and 95% confidence interval (CI) 3.15-46.47], intensive-care unit stays >48 h after the first operation (OR 11.21 and 95% CI 3.24-38.84) and surgery that included valve replacement (OR 6.2 and 95% CI 1.44-27.13). The mortality rate decreased significantly, dropping from 38% (34/89) between 2004 and 2008 to 14% (4/28) between 2009 and 2012 (p = 0.018)., Conclusion: In this study, elimination of MRSA from the hospital setting decreased the rate of mortality in patients with poststernotomy mediastinitis., (© 2014 S. Karger AG, Basel.)

Background: Descending necrotizing mediastinitis (DNM) is a highly morbid infectious process. This uncommon disease process has carried historically a substantial burden of morbidity and mortality. In this study we hypothesized that application of a prospective modified management algorithm would decrease the morbidity and mortality from this highly destructive process., Methods: We developed a systematic approach for managing DNM, focusing on serial debridement guided by imaging, in conjunction with the use of broad-spectrum antibiotics and modern principles of critical care. We reviewed all patients admitted with this disease process from 2007-2012. Data collected included demographic information, co-morbidities, laboratory data including culture results, operative details, imaging frequency and findings, complications, and survival. Continuous variables were reported as median values and ranges., Results: From 2007-2010, we treated eight patients with DNM. The median age of the patients was 33 y (range 28-63 y), and 63% were male. In accordance with our algorithm, the patients underwent serial imaging at regular intervals following operative debridement. The median number of imaging studies was 11 (range 4-19). The patients required a median of five operative debridements (range 1-15). In five patients, drainage was necessary through a cervical exploration. A thoracic approach was required in six patients (two thoracoscopic, four via thoracotomy). Additional procedures included thymectomy (n=2), anterior mediastinotomy, carotid sheath exploration and resections of the clavicle, first rib, manubrium, pectoralis major muscle, and sternocleidomastoid muscle. The most common etiologic agents were Peptostreptococcus spp. and Streptococcus anginosus. Study patients received a median of six different antibiotics (range 2-10) for a total of 42 d (range 34-55 d). These patients were hospitalized for a median of 29 days (range 16-56 d), with 15 d (range 7-48 d) spent in the intensive care unit. Remarkably, the rate of survival was 100% (median follow-up of 33 mo). The patients developed no major complications, required no re-admissions, and had no re-infections., Conclusions: We applied an algorithmic approach to the treatment of DNM, consisting of aggressive operative debridement and enhanced by equally aggressive imaging. Our patients had excellent outcomes despite the widely known lethality of DNM. An aggressive approach may decrease complications and improve survival in this devastating disease process. Furthermore, our prospective experience with DNM suggests that this algorithm used in the present study should be the standard for managing patients with this challenging condition.

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether vacuum-assisted closure therapy (VAC) is superior to conventional therapy for treating post-sternotomy mediastinitis. Altogether >261 papers were found using the reported search, of which 9 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Several studies indicate that VAC therapy is associated with shorter lengths of intensive care and in-hospital stay as well as faster rates of wound healing and fewer dressing changes. It has also been shown that VAC therapy is correlated with a statistically significant reduction in reinfection rates, particularly those that occur in the early postoperative period (at the 1-week follow-up). Patients can be discharged with the dressing in situ and managed in the community with a view to delayed closure or reconstruction. However, the studies comparing VAC with conventional therapy are all retrospective in nature and reinforce the need for randomized controlled trials in order to more accurately establish differences in outcomes between VAC and conventional therapy. Additionally, owing tło the variability of treatment protocols within the non-VAC arm, it is more challenging to draw definitive conclusions regarding the superiority of VAC therapy to every modality that is considered conventional treatment. We conclude that VAC therapy is a portable and an increasingly economical option for the treatment of post sternotomy mediastinitis. Although reductions in mortality rates were not reproduced in all studies, evidence suggests that VAC should still be considered as a first-line therapy for post-sternotomy mediastinitis and as a bridge therapy to musculocutaneous reconstruction or primary closure.

This study attempts to find a prediction method of death risk in patients with acute mediastinitis (AM). There is no such tool described in available literature for this serious disease. The study comprised 37 consecutive cases of iatrogenic AM. General anamnesis and biochemical data were included. Factor analysis was used to extract the risk characteristic for the patients. The most valuable results were obtained for eight parameters, which were selected for further statistical analysis (all collected during a few hours after admission). Three factors reached eigenvalue > 1. Clinical explanations for these combined statistical factors are as follows: Factor 1--proteinic status (serum total protein, albumin, and hemoglobin level), Factor 2--inflammatory status (white blood cells, C-reactive protein, and procalcitonin), and Factor 3--general risk (age and number of coexisting diseases). Threshold values of prediction factors were estimated using statistical analysis (factor analysis, Statgraphics Centurion XVI). The final prediction result for the patients is constructed as simultaneous evaluation of all factor scores. High probability of death should be predicted if factor 1 value decreases with simultaneous increase of factors 2 and 3. The diagnostic power of the proposed method was revealed to be high [sensitivity = 100 %, specificity = 69.2 %]: Factor 1 [SNC = 95.8 %, SPC = 76.9 %]; Factor 2 [SNC = 100 %, SPC = 53.8 %]; and Factor 3 [SNC = 75 %, SPC = 76.9 %]. The described method may turn out to be a valuable prognostic tool for patients with AM.

Background: Acute mediastinitis (AM) is the most lethal form of infection within the thorax. The authors of this study, using statistical tools, made an attempt to determine the most important clinical risk factors in retrospective material of patients treated surgically due to AM., Methods: A total of 44 consecutive patients with AM were subjected to surgery. The aetiology was differentiated: iatrogenic (19), traumatic (11), descending mediastinitis (9) and neoplastic (5). A statistical analysis was performed using chi-square test with Yates correction and analysis of variance test to investigate the correlation between mortality and selected risk factors such as age, gender, aetiology, microbiology, delay between the diagnosis and surgery, coexisting diseases and the kind and number of post-operative complications., Results: The general death rate was 31.82%. Aetiology was associated with mortality: neoplastic (100%), descending (33.3%), iatrogenic (26.3%) and post-traumatic (9.1%). The following types of bacteria were isolated: aerobes (65.9%), anaerobes (25%) and mixed flora (9.1%). The prognosis was not related to age, gender or the kind of the pathogen. The risk of death increased depending on the number of preoperative co-morbidities (P = 0.0446), particularly on the occurrence of a neoplasm (P = 0.0104). Early qualification for surgery (<24 h) resulted in lower death rate (P = 0.085). Manifestation of more than two post-operative complications (P = 0.0007) should be listed as one of the most negative risk factors., Conclusions: The knowledge of negative prognostic factors can appear to be a crucial tool enabling one to work out a better therapeutic strategy for high-risk patients with AM., (© 2012 The Authors. ANZ Journal of Surgery © 2012 Royal Australasian College of Surgeons.)

Objective: This study aims to compare hospital mortality rate of surgical debridement followed by primary wound closure versus surgical debridement with closure after preconditioning of the wound., Methods: A historical cohort of 43 patients with postoperative mediastinitis type III and IV between 2000 and 2008. The diagnosis of mediastinitis was based on physical examination and laboratory tests. Patients were divided into two groups: patients who received the protocol of preconditioning of the wound (Group 2) and those who did not (Group 1)., Results: Of the 43 patients, 15 received the protocol and were assigned to Group 2, and 28 patients to Group 1. Myocardial revascularisation was the surgical intervention most affected by infection, accounting for 69.8% of patients in Group 1 and 64.3% in Group 2.Staphylococcus aureus was the predominant pathogen, accounting for 58.1% of all cases, 50% in Group 1 and 73.3% in Group 2. Hospital mortality rate was 42.9% in Group 1 and 20% in Group 2 (P=1.86), with relative risk of 2.14 and CI [0.714-6.043]. Among the 28 (65.1%) patients who underwent single-stage surgical approach, 12 (27.9%) underwent primary wound closure with irrigation, seven (16.3%) only primary closure, six (14%) omental flap, and three (7%) pectoralis muscle flap., Conclusion: Due to the lack of established guidelines, the choice of the surgical approach is based largely on low-level evidence references. Preconditioning of the wound appears to lead to a reduction in mortality in these patients, being a good surgical option.

Background: Infection of thoracic aortic grafts occurs infrequently; however, once present, it is associated with high patient morbidity and mortality. We report our successful experience in the treatment of 11 patients who developed infection of their thoracic aortic graft., Methods: This is an institutional review board-approved retrospective review of 11 patients who had documented thoracic aortic graft infections with associated mediastinitis or empyema. After diagnosis, plastic surgery consultation was obtained, and the patients underwent formal operative debridement with cardiovascular service. Intraoperative cultures were obtained, and the patients were placed on specific antibiotic regimens. After the wound bed was adequately prepared, the omentum was harvested and was based on the right gastroepiploic vessels. The flap was circumferentially wrapped around the aortic graft and simultaneously used to fill the mediastinal dead space. In a certain subset of patients, a cryopreserved homograft replaced the synthetic graft before omental flap reconstruction., Results: The infections were eventually controlled in all surviving patients. Ten of 11 patients were discharged either to a rehab or to a nursing facility. There was 1 perioperative death secondary to multisystem organ failure. Mean follow-up period was 36 months and revealed a greater than 90% survival rate. Serial imaging reported no suture-line complications., Conclusions: We report our series on the treatment of patients with infection of thoracic aortic grafts. Debridement and tissue coverage with an omental flap provided these patients with successful recovery and survival.

Introduction: Surgery is essential to any curative plan for lung cancer, but is associated with a high complication rate. We sought to determine the impact of complications on long-term survival after a curative surgery for lung cancer, independent of the effect on early postoperative mortality., Methods: We studied a population-based cohort of patients with lung cancer who underwent curative-intent surgery in the province of Quebec, Canada, from 2000 to 2005. Kaplan-Meier survival analysis was used to compare unadjusted overall survival (OS) beyond postoperative day 90 for patients with and without complications. Cox regression was used to determine the prognostic impact of 30-day postoperative complications on the OS after adjusting for several confounders., Results: The overall 30-day postoperative complication rate was 58.2% among 4033 eligible patients. A major infectious complication (pneumonia, empyema, or mediastinitis) occurred in 378 patients. The 5-year OS was lower for those with any postoperative complication (62.8%) than those without (73.8%; p < 0.001). Those with major infectious complications had the lowest OS (56.3%; p < 0.001). Postoperative complication was an independent prognostic factor after adjusting for several patient and treatment factors (hazard ratio = 1.37; 95% confidence interval, 1.21-1.54). Adjusted hazard ratio for major infectious complications was 1.67 (95% confidence interval, 1.39-2.01)., Conclusions: Postoperative complications, particularly of a major infectious type, are strong negative predictors of long-term survival in lung cancer patients. The strong association between major infectious complications and survival may also open the door to investigational therapies targeting bacterial antigens in the perioperative period in patients who undergo lung cancer surgery.

This study aims to identify predisposing characteristics of descending necrotizing mediastinitis (DNM) arising from deep neck infection (DNI) and to determine appropriate therapeutic intervention strategies. We retrospectively reviewed 54 patients (male, n = 34; female, n = 20; mean age, 64.5 years) who had been treated at Mie University Hospital for DNI between April 2001 and October 2011. Eight of nine patients who developed DNM confirmed by computed tomography of the neck and chest, underwent mediastinal drainage (video-assisted thoracic surgical drainage, n = 6; mediastinoscopy-assisted drainage, n = 2). A patient developed uncontrolled acute respiratory distress syndrome after aggressive surgery, resulting in a mortality rate of 12 %. High blood CRP values, and the pharynx and tonsils as origins of infection were factors involved in the development of DNM arising from DNI. In conclusion, DNM remains a destructive and fatal disease that requires aggressive treatment including mediastinal exploration.

Objectives: Vacuum-assisted closure (VAC) is a commonly used therapy for the treatment of post-sternotomy mediastinitis. Primary closure of the sternum with high vacuum suction using Redon drains is an alternative that may reduce hospital stay. The aim of this study was to describe for the first time, the results of VAC compared with Redon drainage., Methods: We performed a retrospective analysis of 132 patients undergoing VAC (n = 89) or primary closure of the sternum with Redon drains (n = 43) as treatment for post-sternotomy mediastinitis between January 2000 and January 2011. Patient characteristics, risk factors and procedure-related variables were analysed. Duration of therapy, treatment failure, hospital stay and mortality as well as C-reactive protein and blood leucocyte counts on admission and at various time intervals during hospital stay were determined., Results: In-hospital mortality was 12.5% in the VAC group compared with 14% in the Redon group (P = 0.96). Treatment failure in the VAC and Redon groups occurred in 28 and 23% of the patients, respectively (P = 0.68). Intensive-care stay in the VAC group was 6.8 ± 14.4 days, and 4.8 ± 10.1 days in the Redon group (P = 0.99). Hospitalization in the VAC group was 74 ± 61 days and in the Redon group, 45 ± 38 days (P = 0.0001)., Conclusions: Primary closure using high vacuum suction drains is a safe and feasible treatment modality for post-sternotomy mediastinitis. It reduces hospital stay when compared with VAC therapy, without compromising mortality.

Background: Delayed sternal closure (DSC) is employed after conventional cardiac surgery without a significantly increased risk of late mediastinitis or sternal wound infection. There are no data specifically examining its late effects on patients undergoing implantation with a ventricular assist device (VAD)., Methods: Between October 1996 and October 2010, 364 patients underwent primary VAD implant and DSC was utilized in 184 (51%) patients for coagulopathy (n = 155; 84%), hemodynamic instability (n = 103; 56%), isolated right ventricular dysfunction (n = 15; 8%) or unspecified reasons (n = 17; 9%)., Results: Median duration of DSC was 1 day (range 1 to 7 days). Patients with DSC were older (54.5 vs. 50.3 years, p = 0.002), had a higher incidence of previous sternotomy (42% vs. 28%, p = 0.005), pre-operative intra-aortic balloon pump (50% vs. 30%, p < 0.001), pre-operative temporary extracorporeal mechanical circulatory support (23% vs 10%, p < 0.001), lower platelet counts (171,000 vs. 209,000, p < 0.001) and lower hematocrit levels (32% vs. 36%, p < 0.001). Operative (11% vs. 9%, p = 0.65) or late (2 years; 66 ± 7% vs 66 ± 7%, p = 0.720) mortality; composite incidence of mediastinitis, percutaneous drive-line infection, pocket infection and VAD-related endocarditis (15% vs. 16%, p = 0.79); re-exploration for bleeding (18% vs. 18%, p = 0.99); urgent transplantation for infection (4% vs. 3%, p = 0.99); or need for device exchange (9% vs. 10%, p = 0.16) was not increased after DSC when compared with immediate sternal closure. DSC increased ICU stay (10 vs. 5 days, p = 0.001)., Conclusions: DSC was performed most commonly for coagulopathy and/or hemodynamic instability, and patients were older with a greater severity of illness as shown by the higher incidence of right-sided circulatory failure and history of prior sternotomy. Although DSC was associated with longer ICU stay, DSC was not associated with a significantly increased risk of death or infection., (Copyright © 2012 International Society for Heart and Lung Transplantation. Published by Elsevier Inc. All rights reserved.)

Objectives: Descending necrotizing mediastinitis (DNM) is a rare but rapidly progressing disease with a potentially fatal outcome, originating from odontogenical or cervical infections. The aim of this article was to give an up-to-date overview on this still underestimated disease, to draw the clinician's attention and particularly to highlight the need for rapid diagnosis and adequate surgical treatment., Methods: We present a retrospective analysis of 17 patients diagnosed and treated for advanced DNM between 1999 and 2011 in a tertiary referral medical centre. Hence, this is one of the largest single-centre studies in recent years concerning the diffuse form (i.e. extending into the lower mediastinum) of DNM. Subsequently, we analysed and compared the international literature with our data, with the focus on surgical management and outcome., Results: In our series of 17 adult patients, 16 were surgically treated by median sternotomy (n = 8) or the clamshell (n = 8) approach for diffuse DNM. One patient, referred with septic shock, died 2 days after surgery. The median interval from diagnosis of DNM by cervicothoracic computed tomography scan and thoracic surgery was 6 h (range 1-24 h) in all but the one patient with fatal outcome (48 h). Concomitant cervicotomy was performed in 11 patients (65%) and tracheotomy in 9 (53%). The median duration of hospitalization was 16 days (range 4-50 days), including an intensive care unit stay of 4 days (range 1-50 days)., Conclusions: For DNM limited to the upper part of the mediastinum, which applies to the majority of cases, a transcervical approach and drainage may be sufficient. In advanced disease, extending below the tracheal carina, an immediate and more aggressive surgical approach is required to combat a much higher morbidity and mortality in this subset of patients. A timely situational approach via median sternotomy or a clamshell incision allowed us to maintain a very low morbidity, mortality and rate of reoperations, without major complications due to the surgical approach itself.

Introduction: Acute descending necrotizing mediastinitis (DNM) is a severe septic inflammation of the mediastinum with necrosis, which progrediates rapidly and leads to death without adequate surgical treatment in 80% of cases., Patients and Method: 17 patients were treated with acute DNM between 1999 and 2012 at the Thoracic Surgical Department of Koranyi National Institute and Semmelweis University of Hungary. The infection source was primarily in the head-neck region with dental infections in eight cases, retro/parapharyngeal abscess in four patients, primary collar phlegmone and abscess in one case and two retrotonsillar abscesses. Further, in one case there was a previous operation (mediastinoscopy) in the history and in another case there was "difficult intubation process" (not recognized trachea-laesion) mentioned during abdominal operation. Primary exploration was performed from the neck in nine cases, thoracotomies plus collar incisions were carried out in four cases, athoracotomy only was done in one and orofacial exploration in further three patients. Disease progression could be evaluated by computer tomography which had to be followed by immediate surgery., Results: Four patients needed two operations, five patients underwent exploration three times, while three patients needed 4 interventions four times. More than one anatomical region was explored in 70% of the cases. Based on our experience prognosis is affected by the time elapsed between detection and surgical intervention, age of the patient and comorbidites such as diabetes mellitus. We lost nine patients (53%), eight patients recovered and symptom free (47%)., Conclusions: Successful treatment is based on early diagnosis, urgent elimination of the primary source, adequate exploration of the cervico-facial region, debridement, collar and upper mediastinal drainage. If the inflammation spreads below the azygos vein or the aortic arch, a right thoracotomy should be performed with wide mediastinal exploration, debridement, and thoracic suction-lavage drainage. Treatment should be completed with broad spectrum and targeted antibiotics as well as organ support. Mortality and morbidity can be reduced with prompt and aggressive therapy.

Background: Deep sternal wound infection and mediastinitis determine high in-hospital mortality. International studies show that these patients are also at increased cardiovascular mortality risk in long-term follow-up. However, data are scarce and there is no national data., Objectives: The aim of this study is to evaluate the mortality and incidence of cardiovascular events in long-term follow-up of patients suffering from deep sternal wound infection and mediastinitis., Methods: Case-control study, matched by propensity score in a 1:1 proportion, in patients submitted to coronary artery bypass grafting between 2005 and 2008 at the Institute Dante Pazzanese of Cardiology (São Paulo, SP, Brazil). The primary outcome was death. As a secondary outcome, we analyzed the composite event of myocardial infarction, new revascularization, stroke or death., Results: Of 1975 patients, 114 developed one of the infections. During the mean follow up of 3.6 years, deep sternal wound infection and mediastinitis increased the risk of death by 8.26 (95% CI 1.88-36.29, P = 0.005) and the incidence of combined end point by 2.61 (95% CI 1.2-5.69, P = 0.015). The Kaplan-Meier curves for both outcomes demonstrated that the greatest risk occurs in the first six months, followed by a period of stabilization and further increase in the incidence of events after 4 years of hospital discharge. The similarity between the curves of primary and secondary outcomes may be consequent to the predominance of death on the combined cardiovascular events., Conclusion: The presence of deep sternal wound infection or mediastinitis increased mortality in long-term follow-up in this sample of the Brazilian population according to the same pattern displayed by the developed countries.

Background: Monitoring of biochemical markers of inflammation in acute mediastinitis (AM) can be useful in the modification of treatment. This study was a retrospective evaluation of selected biochemical parameters with negative impact on the prognosis in surgically treated patients., Material/methods: There were 44 consecutive patients treated surgically due to AM of differentiated etiology. Selected biochemical markers (WBC, RBC, HGB, HCT, PLT, CRP, PCT, ionogram, protein and albumins) were assessed before surgery and on the 3rd day after surgery. ANOVA was applied to find factors influencing observations. Numerical data [laboratory parameters] were compared by means of medians., Results: The overall hospital mortality rate was 31.82%. In the group of dead patients, there were observed statistically significant lower mean preoperative values of RBC [p=0.0090], HGB [p=0.0286], HCT [p=0.0354], protein [p= 0.0037], albumins [p=0.0003] and sodium [p<0.0001] and elevated values of CRP [P=0.0107] and PCT p<0.0001]. High level of inflammatory markers on day 3 after surgery was found to increase the risk of death - for WBC (by 67%), for CRP (by 88%) and for PCT (by 100%)., Conclusions: Poor prognosis was more frequent in patients with preoperative high levels of CRP, PCT, anemia, hypoproteinemia and hyponatremia. The risk of death increases significantly if in the immediate postoperative period no distinct decrease in WBC count and of the CRP and PCT level is observed. In such a situation the patients should be qualified earlier for broadened diagnostic workup and for reoperation.

Background: Post-sternotomy mediastinitis reduces survival after cardiac surgery, potentially further affected by details of mediastinal vascularized flap reconstruction. The aim of this study was to evaluate survival after different methods for sternal reconstruction in mediastinitis., Methods: Two hundred twenty-two adult cardiac surgery patients with post-sternotomy mediastinitis were reviewed. After controlling infection, often augmented by negative pressure therapy, muscle flap, omental flap, or secondary closure was performed. Outcomes were reviewed and survival analysis was performed., Results: Baseline characteristics were similar. In-hospital mortality (15.7%) did not differ between groups. Secondary closure was correlated with negative pressure therapy and reduced length hospital of stay. Recurrent wound complications were more common with muscle flap repair. Survival was unaffected by sternal repair technique. By multivariate analysis, heart failure, sepsis, age, and vascular disease independently predicted mortality, while negative pressure therapy was associated with survival., Conclusions: Choice of sternal repair was unrelated to survival, but mediastinal treatment with negative pressure therapy promotes favorable early and late outcomes., (Copyright © 2011. Published by Elsevier Inc.)

Objective: Descending necrotizing mediastinitis (DNM) is a serious form of mediastinitis with a high mortality rate. It is caused by the downward spread of an oropharyngeal or cervicofascial infection. The optimal surgical approach for this often fatal disease is controversial. This article describes the authors' experience and characterizes the surgical strategies and treatment outcomes of patients with DNM., Study Design: Case series with chart review., Setting: A tertiary referral medical center., Subjects and Methods: This study conducted a retrospective chart review of patients with deep neck infections treated at a medical center from 1994 to 2007 and identified 29 patients with DNM. The clinical characteristics and outcomes were compared between patients treated with transcervical drainage alone (group I) and those with both cervical and thoracic drainage (group II)., Results: There were 20 patients in group I and 9 patients in group II. The overall mortality rate was 10.3%. The mean duration of the hospital stay was 29.3 ± 15.5 days. There was no statistically significant difference in age, sex distribution, or duration from the appearance of symptoms to hospital admission between the 2 groups. The duration of hospital stay, tracheotomy rate, and mortality rate also did not differ significantly between the 2 groups. However, the numbers of surgeries were significantly higher in group II than in group I., Conclusion: Transthoracic mediastinal drainage is not a compulsory therapy, but timely, aggressive, transcervical mediastinal drainage with extensive debridement is very important for a good outcome when treating DNM patients.

Background: To report our experience, with Deep mediastinal wound infections (DMWI). Emphasis was given to the management of deep infections with omental flaps, Methods: From February 2000 to October 2007, out of 3896 cardiac surgery patients (prospective data collection) 120 pts (3.02%) developed sternal wound infections. There were 104 males & 16 females; (73.7%) CABG, (13.5%) Valves & (9.32%) CABG and Valve., Results: Superficial sternal wound infection detected in 68 patients (1.75%) and fifty-two patients (1.34%) developed DMWI. The incremental risk factors for development of DMWI were: Diabetes (OR = 3.62, CI = 1.2-10.98), Pre Op Creatinine > 200 μmol/l (OR = 3.33, CI = 1.14-9.7) and Prolong ventilation (OR = 4.16, CI = 1.73-9.98). Overall mortality for the DMWI was 9.3% and the specific mortality of the omental flap group was 8.3%. 19% of the "DMWI group", developed complications: hematoma 6%, partial flap loss 3.0%, wound dehiscence 5.3%. Mean Hospital Stay: 59 ± 21.5 days., Conclusion: Post cardiac surgery sternal wound complications remain challenging. The role of multidisciplinary approach is fundamental, as is the importance of an aggressive early wound exploration especially for deep sternal infections.