Ris H B, Banic A, Furrer M, Caversaccio M, Cerny A, Zbären P
Department of Thoracic and Cardiovascular Surgery, University of Berne, Switzerland.
Ann Thorac Surg. 1996 Dec;62(6):1650-4. doi: 10.1016/s0003-4975(96)00683-2.
Descending necrotizing mediastinitis requires an early and aggressive surgical approach to reduce the high morbidity and mortality associated with this disease. The clamshell incision has provided excellent exposure of the entire mediastinum and both pleural cavities and was assessed in patients suffering from descending necrotizing mediastinitis.
Three patients with descending necrotizing mediastinitis and bilateral pleural empyema due to invasive streptococcal infections were operated on with this method. Radical debridement of the mediastinum and bilateral decortication was performed through a clamshell incision, including pericardiectomy in 2 patients. All patients received initially a high dose of antibiotic regimen, 2 had bilateral chest tube drainage, and 1 had mediastinal drainage and pleural debridement via cervical mediastinotomy and thoracoscopy, respectively. All these measures alone, however, failed to control the disease.
The clamshell incision offered an excellent exposure for bilateral decortication and debridement of the entire mediastinum including pericardiectomy. One patient, who was referred in critically ill condition, died of multiorgan failure in the postoperative period. The remaining 2 patients recovered without further interventions and without evidence of phrenic nerve palsy, sternum osteomyelitis, or sternal override.
The clamshell approach offers an excellent exposure for a complete one-stage surgical treatment with mediastinal debridement and bilateral decortication in patients suffering from descending necrotizing mediastinitis in the absence of profound septic shock.
下行性坏死性纵隔炎需要早期积极的手术治疗，以降低与该疾病相关的高发病率和死亡率。蛤壳形切口能很好地暴露整个纵隔和双侧胸腔，本研究对下行性坏死性纵隔炎患者采用该切口进行评估。
3例因侵袭性链球菌感染导致下行性坏死性纵隔炎和双侧胸腔积脓的患者接受了该手术方法。通过蛤壳形切口对纵隔进行彻底清创和双侧胸膜剥脱术，其中2例患者进行了心包切除术。所有患者最初均接受大剂量抗生素治疗，2例患者进行了双侧胸腔闭式引流，1例患者分别通过颈部纵隔切开术和胸腔镜进行了纵隔引流和胸膜清创术。然而，所有这些措施单独使用均未能控制病情。
蛤壳形切口为双侧胸膜剥脱术和包括心包切除术在内的整个纵隔清创术提供了良好的暴露。1例病情危重的患者术后死于多器官功能衰竭。其余2例患者无需进一步干预即康复，且未出现膈神经麻痹、胸骨骨髓炎或胸骨重叠的迹象。
对于没有严重感染性休克的下行性坏死性纵隔炎患者，蛤壳形手术入路可为纵隔清创术和双侧胸膜剥脱术的一期完整手术治疗提供良好的暴露。
