今日の臨床サポート

縦隔洞炎

著者: 牛木淳人1) 信州大学 内科学第一教室

著者: 久保惠嗣2) 信州大学名誉教授・地方独立行政法人 長野県立病院機構理事長

監修: 久保惠嗣 信州大学名誉教授・地方独立行政法人 長野県立病院機構理事長

著者校正/監修レビュー済:2021/03/24
参考ガイドライン:
  1. 日本形成外科学会:形成外科診療ガイドライン第I編 3慢性創傷
患者向け説明資料

概要・推奨   

  1. 食道穿孔に続発した急性縦隔洞炎に対しては早期の食道修復術を行うことが強く推奨される(推奨度1)。
  1. 頭頚部領域の感染に続発した急性縦隔洞炎(降下性壊死性縦隔洞炎)に対しては、頚部のドレナージと縦隔のドレナージを併用することが強く推奨される(推奨度1)。
  1. 胸骨正中切開術後に発症した急性縦隔洞炎に対しては、外科的ドレナージとデブリードマンが強く推奨される(推奨度1)。
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薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
牛木淳人 : 特に申告事項無し[2021年]
久保惠嗣 : 特に申告事項無し[2021年]
監修:久保惠嗣 : 特に申告事項無し[2021年]

改訂のポイント:
  1. 定期レビューを行い、手術治療について加筆した。

病態・疫学・診察

疾患情報(疫学・病態)  
  1. 縦隔洞炎とは、縦隔に発生する炎症の総称であり、比較的まれな疾患である。
  1. 経過により急性縦隔洞炎と慢性縦隔洞炎に分けられる。
 
急性縦隔洞炎と慢性縦隔洞炎

急性縦隔洞炎は医療行為などを契機として急速に進行し予後不良である。一方、慢性縦隔洞炎は真菌や結核菌感染による緩徐進行性の疾患であり、予後良好である。

出典

img1:  著者提供
 
 
 
  1. 急性縦隔洞炎の原因としてかつては食道穿孔や、頭頚部領域の感染の波及(降下性壊死性縦隔洞炎と呼ばれる)が多かった。しかし近年は胸骨正中切開術後に発症することが多い。
  1. 急性縦隔洞炎は予後不良であり、早期診断・治療が重要である。
  1. 慢性縦隔洞炎は、ヒストプラズマなどの真菌や、結核菌などによる硬化性、線維性、肉芽腫性の炎症である。
  1. 慢性縦隔洞炎に対する治療は確立していないが、予後は比較的良好である。
問診、診察のポイント  
  1. 感染に伴う全身症状および局所症状を確認する。

これより先の閲覧には個人契約のトライアルまたはお申込みが必要です。

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文献 

著者: B Gårdlund, C Y Bitkover, J Vaage
雑誌名: Eur J Cardiothorac Surg. 2002 May;21(5):825-30.
Abstract/Text OBJECTIVE: During 1992-2000, postoperative mediastinitis developed after 126 (1.32%) of 9557 consecutive cardiac surgery procedures. The study was done to describe the variation in clinical characteristics and microbiological etiology in mediastinitis.
METHODS: The records of 126 cases of postoperative mediastinitis were reviewed.
RESULTS: The median time from operation to the development of mediastinitis was 7 days. Sternal dehiscence was seen in 86 patients (68%). Coagulase negative staphylococci (CNS) were isolated in 46% of the cases with a verified microbiological etiology, Staphylococcus aureus in 26% and gram-negative bacteria in 18%. CNS were more frequently isolated in patients with sternal dehiscence (44/80, 55%) than in patients with stable sternum (10/38, 26%) (P=0.003). However, S. aureus was more frequent in patients with stable sternum (18/38, 47%) than in patients with sternal dehiscence (13/80, 16%) (P<0.001). High body mass index was associated with coagulase negative staphylococci (P<0.001) and with sternal dehiscence (P=0.008). Chronic obstructive pulmonary disease was also associated with sternal dehiscence (P<0.001) and with coagulase negative staphylococci (P=0.04). Patients who had been reoperated before onset of mediastinitis tended to have an increased risk for a gram-negative etiology (32 vs. 15% in patients not reoperated, P=0.06). The overall 90-day all cause mortality in patients with mediastinitis was 19%. High age, need for reoperation before mediastinitis, and a long primary operation time was associated with increased mortality (P=0.02, P=0.007 and P=0.001, respectively). No specific bacterial etiology was associated with increased mortality nor was the presence of bacteriemia.
CONCLUSIONS: Three different types of postoperative mediastinitis can be distinguished: (1) mediastinitis associated with obesity, chronic obstructive pulmonary disease, and sternal dehiscence, typically caused by coagulase negative staphylococci; (2) mediastinitis following peroperative contamination of the mediastinal space, often caused by S. aureus, and (3) mediastinitis mainly caused by spread from concomitant infections in other sites during the postoperative period, often caused by gram negative rods. The proposed classification of mediastinitis into three groups with different pathogenic mechanisms may be useful in understanding which prophylactic counter measures have the potentials to be effective in a given situation.

PMID 12062270  Eur J Cardiothorac Surg. 2002 May;21(5):825-30.
著者: R San Juan, J M Aguado, M J López, C Lumbreras, F Enriquez, F Sanz, F Chaves, F López-Medrano, M Lizasoain, J J Rufilanchas
雑誌名: Eur J Clin Microbiol Infect Dis. 2005 Mar;24(3):182-9. doi: 10.1007/s10096-005-1302-1.
Abstract/Text Postsurgical mediastinitis (PSM) remains a major cause of morbidity and mortality in patients undergoing cardiac surgery procedures. Although prompt diagnosis is crucial in these patients, neither clinical data nor imaging techniques have shown enough sensitivity or specificity for early diagnosis of PSM. The aim of the present study was to assess the validity of blood cultures as a diagnostic test for the early detection of PSM in patients who become febrile after cardiac surgery procedures. During a 4-year period (1999-2002), patients who developed fever (>37.8 degrees C) in the first 60 days after a cardiac surgery procedure were evaluated. Blood cultures were drawn from these patients. PSM was defined as deep infection involving retrosternal tissue and/or the sternal bone directly observed by the surgeon and confirmed microbiologically. Three criteria for positivity of blood cultures were applied: bacteremia, staphylococcal bacteremia, or Staphylococcus aureus bacteremia. For purposes of the analysis, a positive blood culture in patients with PSM was considered a true-positive test and a negative blood culture a false-negative test. Otherwise, in febrile patients without PSM in the postsurgery period, a positive blood culture was considered a false-positive test and a negative blood culture a true-negative test. Blood cultures were drawn from 266 febrile patients in the postsurgery period. PSM occurred in 38 patients (26 cases due to S. aureus, 8 to Staphylococcus epidermidis, 3 to gram-negative enteric bacteria, and one to Pseudomonas aeruginosa). Within the 60-day postsurgical period, blood culture as a diagnostic test was most accurate in patients with S. aureus bacteremia, providing 68% sensitivity, 98% specificity, a positive predictive value of 87%, and a negative predictive value of 95%. If the analysis was limited to the period during which patients are at maximum risk for PSM (day 7-20), the values in patients with S. aureus bacteremia were as follows: 73% sensitivity, 98% specificity, 90% positive predictive value, and 93% negative predictive value. Blood culture is an accurate test for the early diagnosis of PSM in febrile patients after cardiac surgery, particularly in institutions where S. aureus is prevalent in this context. A negative blood culture practically excludes PSM and, during the period of maximum risk for PSM, the presence of S. aureus bacteremia should compel early surgical management.

PMID 15776251  Eur J Clin Microbiol Infect Dis. 2005 Mar;24(3):182-9. ・・・
著者: T M Mole, J Glover, M N Sheppard
雑誌名: Thorax. 1995 Mar;50(3):280-3.
Abstract/Text BACKGROUND: Sclerosing mediastinitis is a rare condition which causes dense fibrosis of the mediastinum. Few large studies have been reported to date. The clinical and pathological features of cases have been studied in a specialist referral centre in the UK.
METHODS: The pathological files of the Royal Brompton Hospital were examined and 18 cases of sclerosing mediastinitis were identified between 1970 and 1993. The clinical notes were obtained and the pathological specimens analysed.
RESULTS: There were 12 men and six women of age range 9-64 years. Twelve patients presented with shortness of breath, six had haemoptysis, three had hoarseness, four had pleuritic chest pain, three general weakness, two had dysphagia, and one was asymptomatic. Nine patients had a previous history of pulmonary tuberculosis. Two had auto-immune disease--one rheumatoid arthritis and the other systemic lupus erythematosus. There were three cases of previous malignancy--two undifferentiated carcinoma of the lung and the other Hodgkin's disease. Serological tests revealed only one positive reaction to Histoplasma. The erythrocyte sedimentation rate and serum immunoglobulins were raised in nine patients. Diagnosis was usually by thoracotomy with biopsy. All cases had fibrosis and chronic inflammation with no active granulomas. No infective organisms or positive cultures were obtained in any case. Ten of the 18 cases are alive up to 15 years after diagnosis, with only two deaths and six lost to follow up.
CONCLUSIONS: Sclerosing mediastinitis is a slowly progressive condition associated with previous tuberculosis, mediastinal malignancy, and autoimmune disease. The outlook is excellent for those cases without underlying malignancy.

PMID 7660343  Thorax. 1995 Mar;50(3):280-3.
著者: D B Flieder, S Suster, C A Moran
雑誌名: Mod Pathol. 1999 Mar;12(3):257-64.
Abstract/Text The clinicopathologic and immunohistochemical findings in 30 cases of idiopathic fibroinflammatory lesions of the mediastinum are presented. There were 17 male and 13 female patients between 10 and 64 years of age; 19 were African-American, and 10 were Caucasian. Clinically, respiratory and/or systemic symptoms including cough, shortness of breath, and fever were present in 28 patients. Five patients also presented with evidence of superior vena cava syndrome. All of the lesions involved the anterior mediastinum with radiographic evidence of hilar and paratracheal involvement in nine and five patients, respectively. Histologically, the lesions were characterized by an inflammatory fibrosing process that showed three distinctive histologic patterns. On the basis of the histologic pattern, they were subdivided into three distinct groups (stages). Stage I demonstrated edematous fibromyxoid tissue with numerous spindle cells, eosinophils, mast cells, lymphocytes, plasma cells, and thin-walled blood vessels; Stage II showed thick glassy bands of haphazardly arranged collagen with focal interstitial spindle cells, lymphocytes, and plasma cells; and Stage III was characterized by dense acellular collagen with scattered lymphoid follicles and occasional dystrophic calcification. Immunohistochemical studies in 17 cases highlighted large numbers of vimentin- and actin-positive spindle cells and capillary-like vessels in Stage I lesions, with fewer numbers of vimentin-positive, actin-negative spindle cells and vessels in Stage II lesions. Our findings suggest that "sclerosing mediastinitis" represents the final stage of an evolving, dynamic process with different morphologic appearances akin to abnormal wound healing. Thus, we propose the term fibroinflammatory lesion of the mediastinum to convey the true nature of the process.

PMID 10102610  Mod Pathol. 1999 Mar;12(3):257-64.
著者: Sidney Benlolo, Joaquim Matéo, Laurent Raskine, Omar Tibourtine, Alain Bel, Didier Payen, Alexandre Mebazaa
雑誌名: J Thorac Cardiovasc Surg. 2003 Mar;125(3):611-7. doi: 10.1067/mtc.2003.164.
Abstract/Text OBJECTIVES: Poststernotomy mediastinitis after cardiac operations is a nosocomial infection involving the mediastinal space and the sternum, with a high mortality rate mostly related to a late diagnosis. We investigated whether sternal puncture might facilitate and shorten the delay in the diagnosis of mediastinitis.
METHODS: Of 1024 patients undergoing sternotomy for cardiac surgery, sternal puncture was performed in a subgroup of 49 patients in whom mediastinitis was suspected.
RESULTS: Sternal puncture culture results were positive for all patients with true mediastinitis (n = 23) and negative in 24 of 26 patients without mediastinitis. In addition, sternal puncture allowed diagnosis of mediastinitis with a shorter delay (9 +/- 5 days vs 13 +/- 8 days, P =.04) and caused a reduction in the length of mechanical ventilation (3 +/- 4 days vs 10 +/- 13 days, P =.02) and stay in the intensive care unit (9 +/- 7 days vs 18 +/- 15 days, P =.02) compared with that found in another group of patients (n = 20) operated on for true mediastinitis on the basis of the presence of classic, delayed, clinical signs.
CONCLUSIONS: Our study shows that sternal puncture is a rapid and safe method to ensure the diagnosis of poststernotomy mediastinitis.

PMID 12658203  J Thorac Cardiovasc Surg. 2003 Mar;125(3):611-7. doi: 1・・・
著者: Clayton J Brinster, Sunil Singhal, Lawrence Lee, M Blair Marshall, Larry R Kaiser, John C Kucharczuk
雑誌名: Ann Thorac Surg. 2004 Apr;77(4):1475-83. doi: 10.1016/j.athoracsur.2003.08.037.
Abstract/Text Esophageal perforation remains a devastating event that is difficult to diagnose and manage. The majority of injuries are iatrogenic and the increasing use of endoscopic procedures can be expected to lead to an even higher incidence of esophageal perforation in coming years. Accurate diagnosis and effective treatment depend on early recognition of clinical features and accurate interpretation of diagnostic imaging. Outcome is determined by the cause and location of the injury, the presence of concomitant esophageal disease, and the interval between perforation and initiation of therapy. The overall mortality associated with esophageal perforation can approach 20%, and delay in treatment of more than 24 hours after perforation can result in a doubling of mortality. Surgical primary repair, with or without reinforcement, is the most successful treatment option in the management of esophageal perforation and reduces mortality by 50% to 70% compared with other interventional therapies.

PMID 15063302  Ann Thorac Surg. 2004 Apr;77(4):1475-83. doi: 10.1016/j・・・
著者: E Gur, D Stern, J Weiss, O Herman, E Wertheym, M Cohen, R Shafir
雑誌名: Plast Reconstr Surg. 1998 Feb;101(2):348-55.
Abstract/Text The presumption that computed tomography is the "gold standard" imaging method for diagnosing poststernotomy sternal wound infection was never validated. This study was designed to evaluate the accuracy and role of computed tomography in diagnosing the extent of infectious complications following sternotomy. A high postoperative infection recurrence rate in our earliest cases (30 percent, 1984 to 1988) motivated us to assess whether this modality enables the surgeon to choose the optimal surgical approach, which will make it possible to reduce morbidity and mortality rates. Two-hundred three patients with poststernotomy sternal wound infections were operated upon between 1984 and 1993. All pertinent clinical and radiological data of these patients were collected retrospectively and reinterpreted by an unbiased radiologist; the radiological data were correlated both to the intraoperative clinical findings and to histological interpretation of the surgical specimens. The study group available for statistical analysis included 160 patients. Predictive statistical analysis confirmed that computed tomography is a highly reliable imaging method for identifying the different pathologies as soft tissue, sternum mediastinal infections, in sternal wound infection with overall sensitivity of 93.5 percent and specificity of 81.7 percent. New radiographic findings were identified for the distinction of costochondral infection. This complication was, and still is, a major deceptive clinical problem in these patients and the major contributor to recurrences. We propose a sternal wound infection classification system that outlines the recommended approach for each clinical-radiological condition. Since computerized tomography was found to be a highly accurate modality, we strongly believe that the surgeon should take its pathological-radiographic findings into serious consideration, even if there are no "clear-cut" clinical signs for an existing or recurring infection.

PMID 9462765  Plast Reconstr Surg. 1998 Feb;101(2):348-55.
著者: Fabio Roccia, Gian Carlo Pecorari, Alberto Oliaro, Ettore Passet, Paolo Rossi, Juri Nadalin, Paolo Garzino-Demo, Sid Berrone
雑誌名: J Oral Maxillofac Surg. 2007 Sep;65(9):1716-24. doi: 10.1016/j.joms.2006.10.060.
Abstract/Text PURPOSE: Through a 10-year retrospective study, we report our experience in the management of descending necrotizing mediastinitis (DNM), a rare and often lethal complication of odontogenic and oropharyngeal infections.
PATIENTS AND METHODS: We reassessed 23 patients between the ages of 16 and 69 years (mean, 49 years) seen between 1996 and 2005, with DNM secondary to odontogenic abscess or phlegmon in 9 cases or secondary to peritonsillar abscess in 14 cases. In this study, 48% of the patients had immune system disorders, mainly diabetes mellitus (6 patients). The diagnosis of DNM was confirmed by cervicothoracic computed tomography.
RESULTS: Eight patients underwent a bilateral collar cervicotomy, and 15 underwent a combined cervicothoracic approach. Five, 2, 1, and 1 patients underwent surgery 2, 3, 4, and 5 times, respectively. Seven patients died as a result of septic shock and multiorgan failure, for a mortality rate of 30.4%. Four of those who died had a compromised immune system.
CONCLUSION: The relatively high mortality rate seen in this study shows that, in addition to early diagnosis and aggressive treatment, it is important to give greater attention to and be more medically and surgically aggressive in the management of patients whose immune system is compromised in any way.

PMID 17719388  J Oral Maxillofac Surg. 2007 Sep;65(9):1716-24. doi: 10・・・
著者: Armand Mekontso-Dessap, Stéphanie Honoré, Matthias Kirsch, Rémi Houël, Daniel Loisance, Christian Brun-Buisson
雑誌名: J Clin Microbiol. 2004 Nov;42(11):5245-8. doi: 10.1128/JCM.42.11.5245-5248.2004.
Abstract/Text Poststernotomy mediastinitis (PSM) is one of the most serious complications of cardiac surgery, and its associated morbidity and mortality demand early recognition for emergency therapy. In this study, we investigated the usefulness of epicardial pacing wire (EPW) cultures for the prediction of PSM. Among 2,200 patients who underwent a cardiac surgical procedure at our hospital between 1 January 1999 and 31 December 2001, 82 (3.7%) had PSM; Staphylococcus aureus was the organism (45.1%) most frequently isolated at the time of surgical debridement. EPWs from 1,607 (73.0%) patients, 73 (4.5%) of whom developed PSM, were cultured. EPW cultures from 466 (29.0%) were positive, most often (74.9%) for coagulase-negative Staphylococci. EPW cultures were truly positive in 26 cases, truly negative in 1,106 cases, falsely positive in 428 cases, and falsely negative in 47 cases (with sterile cultures in 35 cases and a culture positive for an organism different from that isolated at the time of debridement in 12 cases). EPW culture had a positive predictive value of only 5.7% and a high negative predictive value (95.9%) for the diagnosis of PSM, with an accuracy of 70.4%. However, the likelihood ratio of positive (1.27) and negative (0.89) tests indicated only small changes in pretest-to-posttest probability. Therefore, a strategy of routine culture of EPWs to predict PSM seems questionable.

PMID 15528721  J Clin Microbiol. 2004 Nov;42(11):5245-8. doi: 10.1128/・・・
著者: L C Maroto, J M Aguado, Y Carrascal, A Pérez, E Pérez-de-la-Sota, J M Cortina, R Delgado, E Rodriguez, L Molina, J J Rufilanchas
雑誌名: Clin Infect Dis. 1997 Mar;24(3):419-21.
Abstract/Text Mediastinitis after cardiac surgery is difficult to diagnose in many cases. The transitory epicardial pacing wires used after surgery are placed in the mediastinum, so the culture of these wires could be useful for the diagnosis of this disease. To test this hypothesis, we routinely cultured the epicardial pacing wires of 565 patients undergoing extracorporeal circulation. Wires were removed on the 7th to 9th postoperative day under sterile conditions and were cultured with routine techniques used for the culture of venous catheters. Mediastinitis developed in 16 patients, and Staphylococcus aureus was the most common pathogen (81.25%). We had 103 positive and 462 negative cultures. There were 458 true-negative, 12 true-positive, 91 false-positive and 4 false-negative results. For mediastinitis in general, epicardial pacing wire culture has a sensitivity of 75%, specificity of 83.4%, positive predictive value of 11.6%, and negative predictive value of 99.1%. For Staphylococcus aureus mediastinitis, epicardial pacing wire culture has a sensitivity of 84.6%, specificity of 95.8%, positive predictive value of 32.3%, and negative predictive value of 99.6%. We conclude that a sterile culture of the epicardial pacing wires strongly contradicts a diagnosis of postsurgical mediastinitis.

PMID 9114193  Clin Infect Dis. 1997 Mar;24(3):419-21.
著者: Panagiotis Misthos, Stylianos Katsaragakis, Stamatis Kakaris, Dimitrios Theodorou, Ioannis Skottis
雑誌名: J Oral Maxillofac Surg. 2007 Apr;65(4):635-9. doi: 10.1016/j.joms.2006.06.287.
Abstract/Text PURPOSE: Descending necrotizing anterior mediastinitis (DNAM) is a severe infectious disease with a very high mortality rate. The aim of this study was to define the impact of several clinical factors on survival.
PATIENTS AND METHODS: Between 1985 and 2002, 27 patients were managed for DNAM, 11 with combined transthoracic mediastinal and cervical drainage (group A) and 16 with a less aggressive surgical approach, such as cervical drainage and transcervical mediastinal drainage (group B). The records of all patients were statistically analyzed for the impact of several clinical factors on survival.
RESULTS: Although patients in group A were admitted to the hospital faster, treated with antibiotics as outpatients earlier, and operated on much sooner after hospital admission compared with the patients in group B, multivariate analysis revealed that early combined transthoracic mediastinal and cervical debridement and drainage was the only favorable factor for survival in patients DNAM patients (odds ratio = 9.99; 95% confidence interval = 1.02 to 97.49).
CONCLUSIONS: Less extensive surgical approaches (ie, thoracic drainage without cervical drainage or combined cervical and subxiphoid thoracic drainage) led to unsatisfactory results and high reoperation rates. In contrast, early, aggressive combined cervical and thoracic drainage proved to be an effective method for managing DNAM.

PMID 17368356  J Oral Maxillofac Surg. 2007 Apr;65(4):635-9. doi: 10.1・・・
著者: A S Estrera, M J Landay, J M Grisham, D P Sinn, M R Platt
雑誌名: Surg Gynecol Obstet. 1983 Dec;157(6):545-52.
Abstract/Text From January 1975 through July 1981, ten patients with mediastinitis complicating an oropharyngeal infection, that is, a form of mediastinitis best termed as DNM, were encountered at our institution. Based upon rather relatively stringent diagnostic criteria, 21 other instances were found in the literature from 1960 to 1980, a time period well into the antibiotic era. The predominant underlying oropharyngeal infection was of odontogenic origin, specifically, infection involving the mandibular molars. Bacteriologically, DNM is most frequently a polymicrobial process, with anaerobes playing a major role. Although there has been a decline in the over-all incidence of DNM since the introduction of antibiotics, its morbid and lethal nature persists, as evidenced by the present prohibitive mortality of approximately 42 per cent. Delayed diagnosis and inadequate drainage procedures are the primary underlying factors contributing to this high mortality. At present, CT scan is the single most important tool for the early diagnosis of DNM. This noninvasive procedure also helps determine the adequacy of the surgical drainage procedure performed. However, with all the presently available diagnostic tools, it is still the high index of suspicion by physicians toward patients with unrelenting oropharyngeal or deep neck infection that is of utmost importance for making an early diagnosis of DNM. In view of our experience and that of others, we believe that only through aggressive combined medical and surgical management can the highly morbid, if not lethal, course of DNM be reversed. It should be emphasized that, to accomplish successful operative intervention, a thorough knowledge of the complex anatomy of the region is crucial.

PMID 6648776  Surg Gynecol Obstet. 1983 Dec;157(6):545-52.
著者: D H Bor, R M Rose, J F Modlin, R Weintraub, G H Friedland
雑誌名: Rev Infect Dis. 1983 Sep-Oct;5(5):885-97.
Abstract/Text Postoperative mediastinitis complicated 21 (3.4%) of 616 median sternotomy procedures at Beth Israel Hospital (Boston, Mass.) between 1975 and 1979. These cases were analyzed by means of a case control study to identify host and operative risk factors and to characterize the clinical features of mediastinitis. Eighteen patients with mediastinitis (86%) had serious underlying noncardiac diseases, as compared with 14 (33%) of 42 noninfected controls (P = .001). Reoperation was positively associated with infection (P = .03). All patients had abnormal sternal wounds and fever; sternal instability and mediastinal widening were unusual. Twelve patients (57%) were bacteremic. Twenty-four organisms were recovered from the 21 patients with mediastinitis; 13 of the isolates were gram-positive, and 11 were gram-negative. Infections due to gram-negative bacteria appeared earlier and were more likely to be bacteremic (70%). All gram-negative isolates and five of six isolates of Staphylococcus epidermidis were resistant to the antimicrobial agent used perioperatively. Patients were treated with extensive debridement and appropriate antibiotics. The mortality rate was 24% (five of 21). Long-term complications in survivors were not seen.

PMID 6635427  Rev Infect Dis. 1983 Sep-Oct;5(5):885-97.
著者: K Moghissi, D Pender
雑誌名: Thorax. 1988 Aug;43(8):642-6.
Abstract/Text The records of 39 patients who had developed a perforation of the oesophagus after instrumentation were reviewed. Ten (group A) had cervical and 29 (group B) thoracic oesophageal perforation. Twenty three perforations occurred during dilatation of an oesophageal stricture, 10 during oesophagoscopic removal of a foreign body, and six during diagnostic oesophagoscopy. Of the 21 patients treated within 36 hours (early treatment group), four (19%) died; of the 18 treated more than 36 hours after the perforation (late treatment group), nine (50%) died. None of the 10 patients in group A had strictures and only two presented late. After drainage of the neck and mediastinum the outcome was successful in all patients. Thirteen of the 29 in group B were treated early and four of these died; nine of the 16 treated late died, the total mortality for thoracic perforation being 48%. An oesophageal stricture was present in 23 patients. Twelve of these underwent various forms of conservative surgery and there were 10 deaths. This contrasts with the 11 who received radical treatment with resection and reconstruction, only two of whom died. The six patients with no pre-existing stricture were treated with conservative forms of surgery, with one death.

PMID 3175977  Thorax. 1988 Aug;43(8):642-6.
著者: Johan Sjögren, Malin Malmsjö, Ronny Gustafsson, Richard Ingemansson
雑誌名: Eur J Cardiothorac Surg. 2006 Dec;30(6):898-905. doi: 10.1016/j.ejcts.2006.09.020. Epub 2006 Oct 23.
Abstract/Text Poststernotomy mediastinitis, also commonly called deep sternal wound infection, is one of the most feared complications in patients undergoing cardiac surgery. The overall incidence of poststernotomy mediastinitis is relatively low, between 1% and 3%, however, this complication is associated with a significant mortality, usually reported to vary between 10% and 25%. At the present time, there is no general consensus regarding the appropriate surgical approach to mediastinitis following open-heart surgery and a wide range of wound-healing strategies have been established for the treatment of poststernotomy mediastinitis during the era of modern cardiac surgery. Conventional forms of treatment usually involve surgical revision with open dressings or closed irrigation, or reconstruction with vascularized soft tissue flaps such as omentum or pectoral muscle. Unfortunately, procedure-related morbidity is relatively frequent when using conventional treatments and the long-term clinical outcome has been unsatisfying. Vacuum-assisted closure is a novel treatment with an ingenious mechanism. This wound-healing technique is based on the application of local negative pressure to a wound. During the application of negative pressure to a sternal wound several advantageous features from conventional surgical treatment are combined. Recent publications have demonstrated encouraging clinical results, however, observations are still rather limited and the underlying mechanisms are largely unknown. This review provides an overview of the etiology and common risk factors for deep sternal wound infections and presents the historical development of conventional therapies. We also discuss the current experiences with VAC therapy in poststernotomy mediastinitis and summarize the current knowledge on the mechanisms by which VAC therapy promotes wound healing. Finally, we suggest a structured algorithm for using VAC therapy for treatment of poststernotomy mediastinitis in clinical practice.

PMID 17056269  Eur J Cardiothorac Surg. 2006 Dec;30(6):898-905. doi: 1・・・
著者: P M Murray, S M Finegold
雑誌名: Rev Infect Dis. 1984 Mar-Apr;6 Suppl 1:S123-7.
Abstract/Text Anaerobic bacteria often are neglected in discussions of the bacteriology of mediastinitis. Two cases of anaerobic mediastinitis are reported and the literature in this field is reviewed. Anaerobes are important pathogens in the etiology of mediastinitis secondary to perforation of the esophagus, extension of a retropharyngeal abscess, or extension of cellulitis or abscess of dental origin from the neck. Although anaerobes indigenous to the oral cavity predominate in these cases, there are also a few cases reported involving Bacteroides fragilis. The source of the mediastinitis should be considered when antimicrobial therapy is initiated so that appropriate anaerobic coverage can be included when indicated.

PMID 6372020  Rev Infect Dis. 1984 Mar-Apr;6 Suppl 1:S123-7.
著者: Ann Tammelin, Anna Hambraeus, Elisabeth Ståhle
雑誌名: J Clin Microbiol. 2002 Aug;40(8):2936-41.
Abstract/Text The diagnosis of postsurgical mediastinitis (PSM) among patients with sternal wound complication (SWC) after cardiac surgery is sometimes difficult, as fever, elevated C-reactive protein levels, and chest pain can be caused by a general inflammatory reaction to the operative trauma and/or sternal dehiscence without infection. The definitions of PSM usually used emphasize clinical signs and symptoms easily observed by the surgeon. The aim of the study was to investigate whether the use of standardized multiple tissue sampling, optimal culturing methods, and strain typing, together with a microbiological criterion for infection, could identify more infected patients than clinical assessment alone. Patients reexplored due to SWC after cardiac artery bypass grafting (CABG) or heart valve replacement (HVR) with or without CABG performed at the Department for Cardio-Thoracic Surgery at the Uppsala University Hospital between 10 March 1998 and 9 September 2000 were investigated prospectively. Tissue samples were taken from the sternum or adjacent mediastinal tissue, preferably before the administration of antibiotics. Culturing was performed both directly (on agar plates) and using enrichment broth. Species identification was performed by standard methods, and strain typing was performed by pulsed-field gel electrophoresis. A total of 41 cases with at least five tissue samples each were included in the study group. Of these patients, 32 were infected according to the microbiological criterion (i.e., the same strain was found in >/=50% of the samples). Staphylococcus epidermidis was the primary pathogen in 38% of the cases (12/32), S. aureus was the primary pathogen in 31% (10/32), P. acnes was the primary pathogen in 25% (8/32), and S. simulans and S. haemolyticus were the primary pathogens in 3% (1/32) each. All cases of S. aureus infection and 86% (12/14) of coagulase-negative staphylococcus (CoNS) infections were identified from primary cultures. All cases fulfilling the microbiological criterion for S. aureus infection were clinically diagnosed as cases of infection, but among the 14 cases fulfilling the criterion for microbiological diagnosis of CoNS infection, only 10 appeared to qualify clinically as cases of infection. Among the patients with sternal dehiscence in whom a microbiological diagnosis was established, 67% (12/18) had a CoNS infection, compared to 14% (2/14) of those without sternal dehiscence. The difference was statistically significant. PSM caused by S. aureus is readily identified by the surgeon, whereas 30% of cases with CoNS infections may be misinterpreted as noninfected. Multiple sampling before administration of antibiotics, primary culturing on agar plates, species identification, strain typing, and susceptibility testing should be used to ensure a fast and microbiologically correct diagnosis which identifies the primary pathogen and infected patients among those with minor infective symptoms. The role of P. acnes as a possible cause of PSM needs further investigation. PSM caused by CoNS is significantly related to sternal dehiscence.

PMID 12149355  J Clin Microbiol. 2002 Aug;40(8):2936-41.
著者: S E Rossi, H P McAdams, M L Rosado-de-Christenson, T J Franks, J R Galvin
雑誌名: Radiographics. 2001 May-Jun;21(3):737-57. doi: 10.1148/radiographics.21.3.g01ma17737.
Abstract/Text Fibrosing mediastinitis is a rare benign disorder caused by proliferation of acellular collagen and fibrous tissue within the mediastinum. Although many cases are idiopathic, many (and perhaps most) cases in the United States are thought to be caused by an abnormal immunologic response to Histoplasma capsulatum infection. Affected patients are typically young and present with signs and symptoms of obstruction or compression of the superior vena cava, pulmonary veins or arteries, central airways, or esophagus. There may be two types of fibrosing mediastinitis: focal and diffuse. The focal type usually manifests on computed tomographic (CT) or magnetic resonance (MR) images as a localized, calcified mass in the paratracheal or subcarinal regions of the mediastinum or in the pulmonary hila. The diffuse type manifests on CT or MR images as a diffusely infiltrating, often noncalcified mass that affects multiple mediastinal compartments. CT and MR imaging play a vital role in the diagnosis and management of fibrosing mediastinitis.

PMID 11353121  Radiographics. 2001 May-Jun;21(3):737-57. doi: 10.1148/・・・
著者: C V Strimlan, D E Dines, W S Payne
雑誌名: Mayo Clin Proc. 1975 Dec;50(12):702-5.
Abstract/Text In a group of 47 patients with mediastinal granulomas, the most common clinical symptoms were cough, chest pain, dysphagia, hemoptysis, and dyspnea. The main laboratory findings were right paratracheal or hilar mass on chest roentgenogram, positive histoplasmin skin test, and caseating granuloma on histopathologic examination. Complications included fibrosing mediastinitis with superior vena cava obstruction, esophageal compression, and major upper airway compression. Treatment was usually surgical resection or evacuation of caseous contents. The prognosis in most patients with mediastinal granulomas appears to be good--long-term survival with minimal or no disability.

PMID 1195780  Mayo Clin Proc. 1975 Dec;50(12):702-5.
著者: E J Dunn, K S Ulicny, C B Wright, L Gottesman
雑誌名: Chest. 1990 Feb;97(2):338-46.
Abstract/Text Sclerosing mediastinitis is an uncommon disease associated with a multiplicity of clinical syndromes. The cause of this disorder is probably an abnormal fibroproliferative response to an inflammatory stimulus, most commonly a granulomatous infection secondary to Histoplasma capsulatum. The pathophysiology of this disease is predicated on the encasement of mediastinal vital organ structures within a dense fibrotic mass. This mass appears to emanate from an invasive chronic inflammatory process causing erosion as well as external compression of these structures. The following case reports illustrate the diversity of this disease entity, representing a patient population from the Ohio River Valley, endemic for histoplasmosis. The purpose of this report is to elucidate the various clinical manifestations of sclerosing mediastinitis and to correlate the pathologic process with a rational approach to treatment.

PMID 2404701  Chest. 1990 Feb;97(2):338-46.
著者: H C Urschel, M A Razzuk, G J Netto, J Disiere, S Y Chung
雑誌名: Ann Thorac Surg. 1990 Aug;50(2):215-21.
Abstract/Text Recognition that many patients with benign sclerosing mediastinitis have smoldering disease responsible for failure of surgical procedures or for development of collateral circulation in patients with superior vena caval obstruction has markedly improved management of these difficult patients. Histoplasmosis complement fixation titers have been used to detect unsuspected subacute disease and to follow the therapeutic adjunctive management with ketoconazole, an oral antifungal agent. Twenty-two patients with benign sclerosing mediastinitis demonstrated a variety of symptoms relating to the area of compression: superior vena cava, 13; esophagus, 3; pulmonary artery and pericardium, 3; and trachea, 3. Histoplasmosis was documented in 12 patients. Operation is used initially for diagnosis, to rule out carcinoma, and to treat the complications: superior vena caval reconstruction, 6; tracheal decompression, 2; right middle lobectomy, 1; esophageal decompression, 2; division of tracheoesophageal fistula, 1; and release of pericardial effusion and cardiac tamponade, 1. Postcardiotomy syndrome occurred in 1 patient and wound infection in another. No deaths resulted. In 6 cases of histoplasmosis, symptoms recurred in 100% of patients and were successfully managed with ketoconazole treatment, and then clinical progress was monitored with serial histoplasmosis complement fixation studies. One patient had four superior vena caval reconstructions at an outside hospital, each 1 year apart, with symptoms recurring each time. With ketoconazole therapy alone, she has been asymptomatic for more than 2 years. Vigorous search for a fungal cause may even obviate the necessity for surgical intervention. If an operation is necessary, preoperative and postoperative use of ketoconazole has assured success.

PMID 2383106  Ann Thorac Surg. 1990 Aug;50(2):215-21.
著者: Koei Ikeda, Hiroaki Nomori, Takeshi Mori, Hironori Kobayashi, Kazunori Iwatani, Kentaro Yoshimoto, Masakazu Yoshioka
雑誌名: Ann Thorac Surg. 2007 Mar;83(3):1199-201. doi: 10.1016/j.athoracsur.2006.09.034.
Abstract/Text The use of steroids to successfully treat a 75-year-old woman with fibrosing mediastinitis and sclerosing cervicitis causing a stricture of the left common carotid artery is reported. Biopsy specimens showed collagenous fibers and fibroblasts with moderate infiltration of lymphocytes. The mediastinal and neck lesions were significantly reduced, with almost complete resolution of arterial stricture, 3 months after initiating administration of prednisolone at 20 mg/d.

PMID 17307498  Ann Thorac Surg. 2007 Mar;83(3):1199-201. doi: 10.1016/・・・
著者: E M Cordasco, M Ahmad, A Mehta, F Rubio
雑誌名: Cleve Clin J Med. 1990 Oct;57(7):647-52.
Abstract/Text Mediastinal fibrosis, a rare cause of pulmonary hypertension, may produce cough, dyspnea, and hemoptysis. Steroid therapy has been suggested for individuals with progressive symptoms, but data demonstrating the efficacy of such therapy are lacking. We present a case of pulmonary hypertension secondary to fibrosing mediastinitis. Hemodynamic and scintigraphic studies performed before and after a trial of corticosteroid therapy were unable to demonstrate any therapeutic benefit from the corticosteroids. In order to achieve better use of steroids for the treatment of this disease, we suggest that similar determinations be made on other patients with mediastinal fibrosis who receive such treatment.

PMID 2225451  Cleve Clin J Med. 1990 Oct;57(7):647-52.
著者: Simon Bays, Chanaka Rajakaruna, Ed Sheffield, Anthony Morgan
雑誌名: Eur J Cardiothorac Surg. 2004 Aug;26(2):453-5. doi: 10.1016/j.ejcts.2004.03.025.
Abstract/Text Fibrosing mediastinitis is a rare, chronic inflammatory process that can cause superior vena cava syndrome, and can mimic malignancy. We present two cases of this disease where surgical resection was not possible and review the treatment options.

PMID 15296918  Eur J Cardiothorac Surg. 2004 Aug;26(2):453-5. doi: 10.・・・
著者: B A Savelli, M Parshley, M L Morganroth
雑誌名: Chest. 1997 Apr;111(4):1137-40.
Abstract/Text Fibrosing mediastinitis and sclerosing cervicitis are fibrosclerotic disorders akin to retroperitoneal fibrosis, with presenting symptoms related to local pain or viscus obstruction or both. No definitive treatment is known. This is the first report of these disorders dramatically responding to tamoxifen citrate and prednisone.

PMID 9106605  Chest. 1997 Apr;111(4):1137-40.
著者: G A Dodds, J K Harrison, M P O'Laughlin, J S Wilson, K B Kisslo, T M Bashore
雑誌名: Chest. 1994 Jul;106(1):315-8.
Abstract/Text Relief of superior vena cava (SVC) syndrome due to non-neoplastic mediastinal disease presents a formidable challenge. Long-term patency of surgically created bypass grafts has been poor, and the morbidity associated with these procedures is substantial. We report a case of SVC syndrome, caused by fibrosing mediastinitis, treated with Palmaz balloon expandable intravascular stents. Intravascular stents are a promising alternative for relief of non-neoplastic SVC obstruction.

PMID 8020305  Chest. 1994 Jul;106(1):315-8.
著者: M G Sarr, J H Pemberton, W S Payne
雑誌名: J Thorac Cardiovasc Surg. 1982 Aug;84(2):211-8.
Abstract/Text Experience with 47 consecutive instrumental perforations of the esophagus is described. Perforation occurred in the cervical esophagus in 18 patients, mid-thoracic esophagus in 12, and distal esophagus in 17. The majority of patients (87%) harbored a primary esophageal disorder necessitating esophageal instrumentation. Eight select patients were treated nonoperatively with one death; however, some form of morbidity with prolonged hospital stay occurred in half of these patients. In contrast, 39 patients underwent emergency surgical intervention. Only one death occurred in the 31 patients treated by local drainage and attempted closure of the perforation. However, three of six patients with distal perforations treated by esophageal resection with primary esophagogastrostomy died in the early postoperative period. Our results suggest that most instrumental perforations of the esophagus should be managed surgically. Drainage and closure of cervical perforations yields goods results. Esophageal resection with primary reconstitution of esophagogastric continuity should be reserved for select situations. Nonoperative management might be entertained in minimally symptomatic patients harboring a late, locally contained perforation without signs of ongoing sepsis.

PMID 7098508  J Thorac Cardiovasc Surg. 1982 Aug;84(2):211-8.
著者: Jacques Jougon, Tarun Mc Bride, Frédéric Delcambre, Antonio Minniti, Jean-François Velly
雑誌名: Eur J Cardiothorac Surg. 2004 Apr;25(4):475-9. doi: 10.1016/j.ejcts.2003.12.029.
Abstract/Text OBJECTIVES: Boerhaave's syndrome is the most sinister cause of esophageal perforation responsible with mortality rate ranging from 20 to 30%. Combination of mediastinal contamination with microorganisms, gastric acid and digestives enzymes, long free interval between injury and initiation of treatment causes severe mediastinitis which is fatal in most untreated cases. The aim of this paper is to emphasize primary esophageal repair and resuscitation whatever the free interval from rupture and repair.
METHODS: A retrospective review of patients treated for Boerhaave's syndrome in our department from January 1980 to February 2003 was performed. The principle of treatment was surgical treatment and avoidance of esophageal exclusion or esophagectomy whichever was possible.
RESULTS: There were 25 patients (17 males and 8 females). All patients were operated on by primary esophageal repair, except for three who underwent immediate exclusion of the esophagus and one patient who deceased on arrival before being operated. Patients were classified according to free interval between perforation and treatment: group 1 (n=9; 36%) within the 24 h (range from 12 to 24 h) and group 2 (n=16; 64%) more than 24 h (range from 2 to 17 days). Altogether 6 patients deceased (24%). In hospital mortality rate for groups 1 and 2 was, respectively, 44% (four patients) and 13% (two patients), not significantly different. Mean hospital stay was 63 days. Two patients developed anastomotic leakage needing esophagectomy and retrosternal coloplasty in one or more steps. One patient developed pleural abscess treated by percutaneous drainage. Three patients presented temporary symptomatic esophageal stenosis, of whom one underwent dilation.
CONCLUSIONS: Long free interval before treatment does not preclude primary esophageal repair in Boerhaave's syndrome. Esophageal exclusion may be more often than not avoided in most cases.

PMID 15037257  Eur J Cardiothorac Surg. 2004 Apr;25(4):475-9. doi: 10.・・・
著者: J L Cameron, R F Kieffer, T R Hendrix, D G Mehigan, R R Baker
雑誌名: Ann Thorac Surg. 1979 May;27(5):404-8.
Abstract/Text Eight patients with intrathoracic esophageal disruptions were managed nonoperatively and without pleural drainage. Criteria for nonoperative treatment included the following: disruption contained in the mediastinum or between the mediastinum and visceral lung pleura; drainage of the cavity back into the esophagus; minimal symptoms; and minimal signs of clinical sepsis. Cause of the esophageal perforation was pneumostatic dilatation (1 patient), vomiting (2), and a leak following esophageal operation (5). Antibiotics were administered intravenously to all patients; hyperalimentation was accomplished intravenously in 5, and nasogastric suction was used in only 1. The cavities contracted and the esophageal leaks sealed in all instances. Time before oral intake was resumed ranged from 7 to 38 days (average, 18 days). Days until discharge ranged from 15 to 52 days (average, 28 days).

PMID 110275  Ann Thorac Surg. 1979 May;27(5):404-8.
著者: H A Shaffer, G Valenzuela, R K Mittal
雑誌名: Arch Intern Med. 1992 Apr;152(4):757-61.
Abstract/Text Treatment for esophageal perforation has traditionally been surgery, but development of more effective antibiotics and parenteral nutrition has led to a cautious trend toward nonoperative management. The goal of this investigation was to identify relevant presenting features that would guide a physician in making the therapeutic choice between medical and surgical therapy. Twenty-five consecutive patients with esophageal perforation--20 iatrogenic and five spontaneous--were reviewed. Treatment was medical in 12 cases and surgical in 13. The findings indicate that many patients with esophageal perforation can be treated medically. The following guidelines are suggested for selecting nonoperative treatment: (1) clinically stable patients; (2) instrumental perforations detected before major mediastinal contamination has occurred or perforations with such a long delay in diagnosis that the patient has already demonstrated tolerance for the perforation without the need for surgery; and (3) esophageal disruptions well contained within the mediastinum or a pleural loculus.

PMID 1558433  Arch Intern Med. 1992 Apr;152(4):757-61.
著者: M J Corsten, F M Shamji, P F Odell, J A Frederico, G G Laframboise, K R Reid, E Vallieres, F Matzinger
雑誌名: Thorax. 1997 Aug;52(8):702-8.
Abstract/Text BACKGROUND: Descending necrotising mediastinitis is caused by downward spread of neck infection and has a high fatality rate of 31%. The seriousness of this infection is caused by the absence of barriers in the contiguous fascial planes of neck and mediastinum.
METHODS: The recent successful treatment of seven adult patients with descending necrotising mediastinitis emphasises the importance of optimal early drainage of both neck and mediastinum and prolonged antibiotic therapy. The case is also presented of a child with descending necrotising mediastinitis, demonstrating the rapidity with which the infection can develop and lead to death. Twenty four case reports and 12 series of adult patients with descending necrotising mediastinitis published since 1970 were reviewed with meta-analysis. In each case of confirmed descending necrotising mediastinitis the method of surgical drainage (cervical, mediastinal, or none) and the survival outcome (discharge home or death) were noted. The chi 2 test of statistical significance was used to detect a difference between cases treated with cervical drainage alone and cases where mediastinal drainage was added.
RESULTS: Cervical drainage alone was often insufficient to control the infection with a fatality rate of 47% compared with 19% when mediastinal drainage was added (p < 0.05).
CONCLUSIONS: Early combined drainage with neck and chest incisions, together with broad spectrum intravenous antibiotics, should be considered standard care for this disease.

PMID 9337829  Thorax. 1997 Aug;52(8):702-8.
著者: M J Wheatley, M C Stirling, M M Kirsh, O Gago, M B Orringer
雑誌名: Ann Thorac Surg. 1990 May;49(5):780-4.
Abstract/Text One of the most lethal forms of mediastinitis is descending necrotizing mediastinitis, in which infection arising from the oropharynx spreads to the mediastinum. Two recently treated patients are reported, and the English-language literature on this disease is reviewed from 1960 to the present. Despite the development of computed tomographic scanning to aid in the early diagnosis of mediastinitis, the mortality for descending necrotizing mediastinitis has not changed over the past 30 years, in large part because of continued dependence on transcervical mediastinal drainage. Although transcervical drainage is usually effective in the treatment of acute mediastinitis due to a cervical esophageal perforation, this approach in the patient with descending necrotizing mediastinitis fails to provide adequate drainage and predisposes to sepsis and a poor outcome. In addition to cervical drainage, aggressive, early mediastinal exploration--debridement and drainage through a subxiphoid incision or thoracotomy--is advocated to salvage the patient with descending necrotizing mediastinitis.

PMID 2288561  Ann Thorac Surg. 1990 May;49(5):780-4.
著者: Renzo Mora, Barbara Jankowska, Ugo Catrambone, Giulio Cesare Passali, Francesco Mora, Giacomo Leoncini, Francesco Maria Passali, Marco Barbieri
雑誌名: Ear Nose Throat J. 2004 Nov;83(11):774, 776-80.
Abstract/Text Descending necrotizing mediastinitis is a rare disease that is usually caused by a spreading, diffuse inflammatory reaction (phlegmon) to an odontogenic infection or peritonsillar abscess. Reported mortality rates range from 25 to 40%. The use of antibiotics and advances in resuscitation procedures and critical care techniques have not essentially improved survival, and an effective treatment has not been clearly established. We report the findings of our 10-year study of 21 patients affected by phlegmon and/or fasciitis of the neck. The aim of our contribution is to help define the clinical criteria and diagnostic procedures that will improve the early diagnosis of mediastinal sepsis secondary to neck fasciitis and to suggest optimal treatment approaches. Our experience indicates that (1) cervical drainage alone is sufficient for cases of cervical phlegmon or mediastinal involvement that are limited to a single superior mediastinal space and (2) thoracotomy and drainage of mediastinal collections is necessary when mediastinal sepsis is more extensive.

PMID 15628636  Ear Nose Throat J. 2004 Nov;83(11):774, 776-80.
著者: Walter H Merrill, Shahab A Akhter, Randall K Wolf, E William Schneeberger, John B Flege
雑誌名: Ann Thorac Surg. 2004 Aug;78(2):608-12; discussion 608-12. doi: 10.1016/j.athoracsur.2004.02.089.
Abstract/Text BACKGROUND: Wound infection after median sternotomy for cardiac or thoracic surgery is a serious complication. A variety of treatment plans have been advocated, and there is lack of agreement regarding the best treatment method. We present our results in patients with mediastinitis who have been treated in a simple, consistent manner.
METHODS: We reviewed our experience with 40 consecutive patients with mediastinitis who were treated between January 1995 and May 2003 with a single-stage treatment consisting of sternal and soft tissue debridement and wound closure over mediastinal tubes with continuous irrigation and drainage. Tubes were placed posterior to the sternum in all patients and were irrigated continuously for at least 7 days with antibiotic or antibacterial solution. Systemic antibiotics were selected based on culture and sensitivity data and were administered for 2 to 6 weeks.
RESULTS: All patients with mediastinitis treated in this manner survived. Of the 40 patients, 38 achieved complete healing of the wound without further operative intervention or major complication. One patient had recurrent infection and required sternal resection and advancement of muscle flaps. One patient had a residual localized focus of chondritis and underwent limited resection of cartilage.
CONCLUSIONS: In this series of patients with postoperative mediastinitis, a simplified approach consisting of wound debridement, reclosure over drains, and anterior mediastinal irrigation has been an effective treatment. The results we have achieved suggest that this technique may be a suitable option for treating this condition.

PMID 15276531  Ann Thorac Surg. 2004 Aug;78(2):608-12; discussion 608-・・・
著者: M Kirsch, A Mekontso-Dessap, R Houël, E Giroud, M L Hillion, D Y Loisance
雑誌名: Ann Thorac Surg. 2001 May;71(5):1580-6.
Abstract/Text BACKGROUND: Several different surgical techniques have been described for the treatment of poststernotomy mediastinitis. The present study was undertaken to evaluate the midterm results of primary closed drainage using Redon catheters and to identify risk factors for adverse outcome.
METHODS: Hospital records of 72 patients in whom poststernotomy mediastinitis developed and who underwent closed drainage with Redon catheters between April 1, 1996, and December 31, 1999, were reviewed. Follow-up was complete and averaged 11.8 +/- 11.5 months.
RESULTS: Of the 25 deaths (34.7%) recorded, 15 were directly attributable to mediastinitis. Actuarial estimates for freedom from mediastinitis-related death were 80.1% at 1 month and 77.4% at 1 year, 2 years, and 3 years. Logistic regression identified older age (odds ratio, 1.1; 95% confidence interval, 1.02 to 1.18), incubation time of 14 days or less (6.5; 1.33 to 31.4), and methicillin-resistant Staphylococcus aureus (5.8; 1.2 to 27.2) as independent risk factors for mediastinitis-related death. Reintervention for recurrent mediastinitis was necessary in 9 patients (12.5%) and occurred at a mean interval of 18.7 +/- 13.5 days from the first debridement. Actuarial estimates for freedom from reintervention were 87.1% at 1 month and 85.2% at 1 year, 2 years, and 3 years. The combined end point of treatment failure (mediastinitis-related death or reintervention) was recorded in 9 patients (26.4%). Actuarial estimates for freedom from treatment failure were 74.3% at 1 month and 72.7% at 1 year, 2 years, and 3 years. Logistic regression identified older age (1.01; 1.02 to 1.18), preoperative renal insufficiency (6.8; 1.04 to 44.5), and methicillin-resistant S aureus infection (4.8; 1.04 to 22.33) as independent risk factors for treatment failure (includes mediastinitis-related death and reintervention [with or without death]).
CONCLUSIONS: Primary closed drainage using Redon catheters is an effective and simple treatment for most patients in whom poststernotomy mediastinitis develops. However, patients with methicillin-resistant S aureus infection or recurrent mediastinitis may benefit from a more aggressive approach.

PMID 11383803  Ann Thorac Surg. 2001 May;71(5):1580-6.
著者: E H Cheung, J M Craver, E L Jones, D A Murphy, C R Hatcher, R A Guyton
雑誌名: J Thorac Cardiovasc Surg. 1985 Oct;90(4):517-22.
Abstract/Text Mediastinitis after cardiac valve replacement is a dreaded complication with consequent mortality estimated as high as 70%. We have reviewed 2,491 patients with cardiac valve operations to assess the impact of mediastinitis upon mortality in our institution in the past 10 years. Mediastinitis developed after valve replacement in 36 patients (1.4%). All patients required operative intervention for mediastinal infection with positive bacterial cultures. Twelve of these patients had other perioperative problems associated with a high mortality independent of mediastinitis: bacterial endocarditis not cured by valve replacement (three), recent preoperative myocardial infarction (four), triple valve disease with biventricular failure (one), and severe perioperative cerebral damage (four). Ten of these high-risk patients died (83.3%). The impact of mediastinitis upon survival is best evaluated in the remaining 24 patients without high-risk perioperative problems. Eight of these patients were managed before 1980 with débridement and irrigation as the primary treatment, with two hospital deaths (25%). Pectoral or rectus muscle flaps were frequently used after 1980 (flaps in 11 of 16 patients), leading to a significantly shorter time between diagnosis of infection and hospital discharge free of infection (62 versus 385 days, p less than 0.05). Only one of these 16 patients died. Valve re-replacement for endocarditis was performed in three of these 24 patients although 13 of 24 had positive blood cultures. Mediastinitis after valve operations in the absence of other high-risk perioperative problems can be successfully managed. Early débridement and muscle flap closure has led to a 94% survival rate in 16 patients during the past 4 years.

PMID 4046620  J Thorac Cardiovasc Surg. 1985 Oct;90(4):517-22.
著者: Rainer Petzina, Julia Hoffmann, Artashes Navasardyan, Malin Malmsjö, Christof Stamm, Axel Unbehaun, Roland Hetzer
雑誌名: Eur J Cardiothorac Surg. 2010 Jul;38(1):110-3. doi: 10.1016/j.ejcts.2010.01.028. Epub 2010 Feb 19.
Abstract/Text OBJECTIVE: Negative pressure wound therapy (NPWT) is a recently introduced treatment modality for post-sternotomy mediastinitis. The aim of this study was to compare the mortality rate, the sternal re-infection rate and the length of hospital stay in patients with post-sternotomy mediastinitis after NPWT and conventional treatment.
METHODS: We retrospectively analysed 118 patients with post-sternotomy mediastinitis after cardiac surgery. One group of 69 patients was treated with NPWT and the other group of 49 patients with conventional therapy.
RESULTS: There were no major differences between the two groups concerning preoperative data (EuroScore) or primary cardiac surgery (mainly coronary artery bypass grafting). NPWT therapy was found to reduce mortality rate (P=0.005) and sternal re-infection rate (P=0.008) compared with conventional treatment and tended to lead to a shorter length of hospital stay (P=0.08).
CONCLUSIONS: NPWT for post-sternotomy mediastinitis demonstrates encouraging clinical results with a reduction of the mortality rate and the sternal re-infection rate compared with conventional treatment. The results support NPWT as the first-line treatment for deep sternal wound infections.

Copyright 2010 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.
PMID 20171898  Eur J Cardiothorac Surg. 2010 Jul;38(1):110-3. doi: 10.・・・
著者: Uwe Fuchs, Armin Zittermann, Benjamin Stuettgen, Arndt Groening, Kazutomo Minami, Reiner Koerfer
雑誌名: Ann Thorac Surg. 2005 Feb;79(2):526-31. doi: 10.1016/j.athoracsur.2004.08.032.
Abstract/Text BACKGROUND: It is suggested that the vacuum technique is a promising new method for the therapy of mediastinitis, but reliable investigations are currently almost completely lacking. We therefore compared clinical outcome of patients whose sternal infection was managed with the vacuum-assisted closure system or with the conventional procedure of open packing.
METHODS: We performed a retrospective analysis in 68 cases of sternal wound infection that were identified at our Heart Center between September 1998 and September 2003. Thirty-five patients could be allocated to the vacuum group and 33 patients to the conventional group. We compared the time interval from sternal infection until freedom of microbiological cultures, in-hospital stay, the status at discharge (rewired or open sternum), the time interval until wound healing was achieved, and survival rates. Moreover, we compared serum levels of C-reactive protein and blood leukocyte counts on admission, at diagnosis of sternal infection, and at different points of time until discharge.
RESULTS: Baseline characteristics and blood factors did not differ between the two study groups at diagnosis of sternal infection. Moreover, the number of prescribed antibiotics was similar, and the C-reactive protein level and blood leukocyte counts at discharge were comparable in both groups. However, freedom from mediastinal microbiological cultures was achieved earlier (p < 0.01), C-reactive protein levels declined more rapidly (p < 0.025), in-hospital stay was shorter (p < 0.01), rewiring was earlier (p < 0.01), and survival tended to be higher (p < 0.15) in the vacuum group compared to the conventional group.
CONCLUSIONS: This retrospective analysis could demonstrate that the vacuum technique improves the medical outcome of patients with mediastinitis compared with the conventional technique of open packing.

PMID 15680828  Ann Thorac Surg. 2005 Feb;79(2):526-31. doi: 10.1016/j.・・・
著者: Johan Sjögren, Ronny Gustafsson, Johan Nilsson, Malin Malmsjö, Richard Ingemansson
雑誌名: Ann Thorac Surg. 2005 Jun;79(6):2049-55. doi: 10.1016/j.athoracsur.2004.12.048.
Abstract/Text BACKGROUND: The conventional treatment for poststernotomy mediastinitis usually involves surgical revision, closed irrigation, or reconstruction with omentum or pectoral muscle flaps. Recently, vacuum-assisted closure has been successfully used in poststernotomy mediastinitis. The aim of the present study was to compare the clinical outcome and survival in 101 patients undergoing vacuum-assisted closure therapy or conventional treatment for poststernotomy mediastinitis.
METHODS: One hundred one consecutive patients underwent treatment for poststernotomy mediastinitis: vacuum-assisted closure therapy (January 1999 through December 2003, n = 61) or conventional treatment (July 1994 through December 1998, n = 40). Follow-up was made in April 2004 and was 100% complete. Actuarial statistics were used to calculate the survival rates.
RESULTS: The 90-days mortality was 0% in the vacuum-assisted closure group and 15% in the conventional treatment group (p < 0.01). The failure rate to first-line treatment with vacuum-assisted closure and conventional treatment were 0% and 37.5%, respectively (p < 0.001). There was no statistically significant difference in the recurrence of sternal fistulas after vacuum-assisted closure therapy or conventional treatment: 6.6% versus 5.0%, respectively. Overall survival in the vacuum-assisted closure group was significantly better (p < 0.05) than in the conventional treatment group: 97% versus 84% (6 months), 93% versus 82% (1 year), and 83% versus 59% (5 years).
CONCLUSIONS: Our findings support that vacuum-assisted closure therapy is a safe and reliable option in poststernotomy mediastinitis with excellent survival and a very low failure rate compared with conventional treatment.

PMID 15919308  Ann Thorac Surg. 2005 Jun;79(6):2049-55. doi: 10.1016/j・・・
著者: H F Berg, W G Brands, T R van Geldorp, F Q Kluytmans-VandenBergh, J A Kluytmans
雑誌名: Ann Thorac Surg. 2000 Sep;70(3):924-9. doi: 10.1016/s0003-4975(00)01524-1.
Abstract/Text BACKGROUND: It is not clear which closed drainage technique is preferred as initial therapy for mediastinitis as soon as it is detected after cardiac surgery. A comparison is made between a continuous irrigation system and vacuum drainage using redon catheters.
METHODS: A retrospective cohort study of patients undergoing cardiac surgery between January 1, 1989 and January 1, 1997 was made. Patients who developed a deep surgical site infection at the sternotomy site and who were treated with one of the two closed drainage techniques were included. Patient characteristics and procedure-related variables were analyzed. Also, variables related to the drainage procedure were included. Outcome parameters were treatment failure, total hospital stay, postoperative hospital stay and in-hospital mortality.
RESULTS: The study population consisted of 11,488 patients, of whom 102 developed a deep surgical site infection (0.89%). The final study population consisted of 60 patients who fulfilled the inclusion criteria. From those, 29 were treated with continuous irrigation and 31 were treated with vacuum drainage. Both groups were comparable for patient characteristics and procedure-related variables. Treatment failure was more than three times as likely in the continuous irrigation group (relative risk: 3.2, 95% confidence interval: 1.3 to 7.7). Also, postoperative (p = 0.03) and total hospital stay (p = 0.03) were significantly longer in the group treated with continuous irrigation (mean prolongation of 14 and 13 days, respectively). After correcting for confounding, using multivariate analysis, the treatment method employed was found to be an independent and statistically significant variable associated with treatment failure (p = 0.04).
CONCLUSIONS: Closed drainage using vacuum-drainage system is the initial therapy of choice for patients with mediastinitis after cardiac surgery, because it is associated with significantly less treatment failure and a shorter stay in hospital.

PMID 11016335  Ann Thorac Surg. 2000 Sep;70(3):924-9. doi: 10.1016/s00・・・
著者: David H Song, Liza C Wu, Robert F Lohman, Lawrence J Gottlieb, Mieczyslawa Franczyk
雑誌名: Plast Reconstr Surg. 2003 Jan;111(1):92-7. doi: 10.1097/01.PRS.0000037686.14278.6A.
Abstract/Text A method to refine the treatment of sternal wounds using Vacuum Assisted Closure (V.A.C.) therapy as the bridge between débridement and delayed definitive closure is described. A retrospective review of 35 consecutive patients with sternal wound complications over a 2-year period (March of 1999 to March of 2001) was performed. The treatment of sternal wounds with traditional twice-a-day dressing changes was compared with the treatment with the wound V.A.C. device. An analysis of the number of days between initial débridement and closure, number of dressing changes, number and types of flaps needed for reconstruction, and complications was performed. Eighteen patients were treated with traditional twice-a-day dressing changes and 17 patients were treated with V.A.C. therapy alone. The two groups were similar regarding age, sex, type of cardiac procedure, and type of sternal wound. The V.A.C. therapy group had a trend toward a shorter interval between débridement and closure, with a mean of 6.2 days, whereas the dressing change group had mean of 8.5 days. The V.A.C. therapy group had a significantly lower number of dressing changes, with a mean of three, whereas the twice-a-day dressing change group had a mean of 17 (p < 0.05). Reconstruction required an average of 1.5 soft-tissue flaps per patient treated with traditional dressing changes versus 0.9 soft-tissue flaps per patient for those treated with V.A.C. therapy (p < 0.05). Before closure, there was one death among patients undergoing dressing changes and three in the V.A.C. therapy group, all of which were unrelated to the management of the sternal wound. Patients with sternal wounds who have benefited from V.A.C. therapy alone have a significant decrease in the number of dressing changes and number of soft-tissue flaps needed for closure. Finally, the V.A.C. therapy group had a trend toward a decreased number of days between débridement and closure.

PMID 12496568  Plast Reconstr Surg. 2003 Jan;111(1):92-7. doi: 10.1097・・・

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