Ascending necrotizing mediastinitis

Abstract

Rupture of sub-diaphragmatic abdominal or retroperitoneal abscesses that result in thoracic infections have been reported by several investigators. Stomach or colonic lesions have been found to be more common in the postoperative period, also duodenal and caecal ruptures have been described. When an abscess opens to the peritoneal cavity, surgical treatment by drainage and lavage of viscous, purulent exudate is in most instances enough to control the infectious process. However, quite often this complication could be fatal. If an early diagnosis is not made, severe sepsis develops in such patients. Sometimes it persists as seen in many bizarre examples, which are difficult to detect and diagnose, leading to further complications by opening into the thoracic cavity, mediastinum and pericardium. Extension or propagation of the infectious process could begin from the kidneys, suprarenal glands, urinary tract, pancreas, retroperitoneal muscles or pelvis, disseminating by means of the lymphatic vessels, in the blood stream, or by direct invasion of retroperitoneal compartments and their fascia through adjacent tissues. When an infection with these characteristics affects the mediastinum, it causes sepsis, tissue destruction, an acute inflammatory response, or death due to multi-organic failure if not treated in a timely and appropriate manner. This is why treatment protocols should be conformed and executed by a multidisciplinary team of physicians involved in the management of the metabolic aspects of disease (electrolyte imbalances, septic shock and acute inflammatory response) at the intensive care unit and during anesthesia. The abdominal septic origin has to be attended by a general surgeon in conjunction with the cardiothoracic surgery team. In the chapter, a thorough review of the scarce literature available on the subject is presented to understand where the specialist stands when confronting this rare situation.