BACKGROUND: Despite early diagnosis, prompt antibiotic administration and aggressive surgical debridement, descending necrotizing mediastinitis (DNM) has a high morbidity and mortality rate. The optimal surgical access for infectious control is controversial and no surgical guideline has been issued. We present our results from surgical treatment of DNM by a minimally invasive thoracoscopic uniportal approach (uVATS).
METHODS: A retrospective analysis of patients submitted in our department to uVATS treatment for DNM in the period between 01/12/2020-01/12/2023 (3 years) was made. Data was collected from clinical records, to present pre, peri and pos-operative information, to evaluate the efficacy of this minimally invasive approach in this aggressive infectious disease.
RESULTS: A total of 17 patients were treated. Most were male (11; 64,7%) with a median age of 55 (28-86) years. The majority of patients had multiple organ dysfunctions at presentation associated with late diagnosis, with DNM mostly (86,2%) originating from a cervical infection. All patients were submitted to thoracic uVATS infection control focus, with a unilateral right approach in 88,2%. A majority of patients had concomitant cervical surgery (88,2%) and 17,6% needed a second uVATS drainage. Our institutional Uniportal approach, with a 3-4 cm portal access, allowed good visualization and effective infectious control. The median duration of the procedure was 45 min. The median number of drains was 3. (2-4). The majority needed prolonged inotropic (76,5%) and mechanical ventilatory support (17 days) (94,1%). 7 patients (41,2%) needed tracheostomy. The median in-hospital stay was 38 days (18-137). The overall mortality was 17,6% (3), in previously sicker and with more comorbidity patients, in which even with effective drainage, systemic disease remained uncontrolled.
CONCLUSIONS:We believe that minimally invasive drainage of DNM, is a safe and effective choice for the treatment of patients with comparable results to more aggressive surgical approaches.
