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Deszendierende nekrotisierende Mediastinitis

Therapiekonzept aus thoraxchirurgischer Sicht

Descending necrotizing mediastinitis

Treatment concept with focus on thoracic surgery

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Zusammenfassung

Hintergrund

Die deszendierende nekrotisierende Mediastinitis (DNM) stellt einen interdisziplinären Notfall dar, bei dem ein odontogener oder oropharyngealer Infektfokus entlang präformierter zervikothorakaler Spatien auf das Mediastinum übergreift.

Material und Methoden

Bei sieben Patienten wurde die Diagnose der DNM anhand pathognomonischer radiologischer Befunde in der Computertomographie gestellt und ein standardisiertes transzervikales und offenes transthorakales radikales Débridement durchgeführt.

Ergebnisse

Im primär nachgewiesenen polymikrobiellen Erregerspektrum dominierten Streptokokken gefolgt von Enterobakterien. Unter kalkulierter antibiotischer Therapie wurde eine Verschiebung des bakteriellen Erregerspektrums und insbesondere in 43 % der Fälle eine mykotische Superinfektion registriert. Über die anterolaterale Thorakotomie wurden nach mediastinalem Débridement mediastinothorakale Drainagen eingebracht. Diese wurden im Bedarfsfall auf zervikomediastinothorakale Spüldrainagen erweitert, welche im Rendevouz-Verfahren transmediastinal eingelegt und entweder prä- oder retroviszeral platziert wurden. Die Mortalität der DNM betrug trotz vornehmlich fortgeschrittener Mediastinitiden (Endo-Typ II B) in unserem Patientenkollektiv lediglich 14 %.

Schlussfolgerung

Elementarer Bestandteil einer erfolgreichen Therapie der DNM sind die rasche Diagnosestellung, die Kenntnis der Anatomie und der Ausbreitungswege der Infektion sowie die intensivmedizinische, antimikrobielle und radikale interdisziplinär-operative Therapie. Hierbei favorisieren wir die anterolaterale Thorakotomie als operativen Standardzugang zum Mediastinum. Die zervikomediastinothorakalen Spüldrainagen können zur Beherrschung der DNM beitragen.

Abstract

Background

Descending necrotizing mediastinitis (DNM) originates from odontogenic or oropharyngeal infections which spread along preformed cervicothoracic spaces into the mediastinum and requires emergency multidisciplinary treatment.

Material and methods

A total of seven patients were diagnosed with DNM based on typical radiological features in a cervicothoracic computed tomography (CT) scan and subsequently underwent standardized transcervical and open transthoracic radical debridement.

Results

The initially detected polymicrobial spectrum of pathogens was dominated by streptococci followed by enterobacteriae. After calculated antibiotic treatment a shift in the spectrum of pathogens was noted and in particular a mycotic superinfection occurred in 43 % of the cases. Anterolateral thoracotomy was performed for radical removal of tissue necrosis and mediastinothoracic drainage extending to the posterior mediastinum was placed. In selected cases, cervico-mediastino-thoracic tubes were transmediastinally placed by the rendevouz technique either in the previsceral or retrovisceral mediastinal space. Despite predominantly advanced mediastinitis (Endo classification type II B) in this patient cohort, the mortality only reached 14 %.

Conclusion

Rapid diagnosis, anatomical knowledge, understanding of the progression of infections as well as critical care, antimicrobial treatment and multidisciplinary radical surgical therapy are paramount for successful treatment of DNM. We favor anterolateral thoracotomy as the standard open transthoracic approach to the mediastinum. Placement of cervico-mediastino-thoracic irrigation drains can help to limit DNM.

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Danksagung

Die Autoren danken Maria Cecilia von Oertzen für die exzellente zeichnerische Arbeit.

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Authors and Affiliations

  1. Klinik und Poliklinik für Allgemein-, Viszeral-, Thorax- und Gefäßchirurgie, Universitätsklinikum Bonn, Sigmund-Freud-Str. 25, 53105, Bonn, Deutschland

    B. M. Buchholz, A. Kania & M. Kaminski

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  1. B. M. Buchholz
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  2. A. Kania
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Correspondence to B. M. Buchholz.

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B. M. Buchholz, A. Kania und M. Kaminski geben an, dass kein Interessenkonflikt besteht.

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B.M. Buchholz und A. Kania haben zu gleichen Teilen zur Erstellung des Manuskripts beigetragen.

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Buchholz, B.M., Kania, A. & Kaminski, M. Deszendierende nekrotisierende Mediastinitis. Chirurg 87, 585–592 (2016). https://doi.org/10.1007/s00104-015-0127-4

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