Division of General Thoracic Surgery, University Hospital Bern, Bern, Switzerland.
Eur J Cardiothorac Surg. 2012 Oct;42(4):e66-72. doi: 10.1093/ejcts/ezs385. Epub 2012 Jul 3.
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.
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.
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).
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.
下行性坏死性纵隔炎（DNM）是一种罕见但进展迅速的疾病，具有潜在的致命后果，源自牙源性或颈部感染。本文的目的是提供对这种仍被低估的疾病的最新概述，引起临床医生的注意，特别是强调需要快速诊断和适当的手术治疗。
我们对 1999 年至 2011 年间在三级转诊医疗中心诊断和治疗的 17 例晚期 DNM 患者进行回顾性分析。因此，这是近年来关于 DNM 弥漫性（即延伸至下纵隔）的最大单中心研究之一。随后，我们分析并比较了国际文献与我们的数据，重点是手术管理和结果。
在我们的 17 例成年患者系列中，16 例经正中胸骨切开术（n=8）或蛤壳式（n=8）入路手术治疗弥漫性 DNM。一名因感染性休克就诊的患者在手术后 2 天死亡。所有患者（除 1 例死亡患者外）均在颈椎和胸部计算机断层扫描诊断为 DNM 后 6 小时（1-24 小时）内行胸部手术，该患者的间隔时间为 48 小时。11 例（65%）患者同时行颈部切开术，9 例（53%）患者行气管切开术。中位住院时间为 16 天（4-50 天），包括重症监护病房住院时间 4 天（1-50 天）。
对于局限于纵隔上部的 DNM，即大多数病例，经颈入路和引流可能就足够了。在晚期疾病中，延伸至气管隆嵴以下时，需要立即采用更具侵袭性的手术方法，以降低该亚组患者的高发病率和死亡率。通过正中胸骨切开术或蛤壳式切口进行及时的情况处理，使我们能够保持非常低的发病率、死亡率和再次手术率，而不会因手术入路本身而产生重大并发症。
