Objective:To evaluate contemporary trends in etiology, diagnosis, management, and outcome of descending necrotizing mediastinitis (DNM) and to draw the clinician's attention on this probably underappreciated disease.Summary of Background Data:An uncommon but one of the most serious forms of mediasti

Descending necrotizing mediastinitis: contemporary trends in etiology, diagnosis, management, and outcome.

Management of descending necrotizing mediastinitis.

It is perhaps surprising that this quotation comes from a gentleman of tradition and conservatism. However, even one of the greatest prime ministers of Great Britain recognized that we live in a constantly evolving world and adaptation is the key to survival. In surgery for lung cancer, we are witnessing a significant revolutionary change in approach that has not been witnessed since the 1990’s when major lung resection became possible through minimally invasive “key-hole” surgery in the form of video-assisted thoracic surgery (VATS) instead of through a large open thoracotomy. In 2011, as we recognized the 20 th anniversary of VATS lobectomy (1), another promising major advance in lung surgery, uniportal (single port) VATS lobectomy, was developed that has subsequently been more rapidly adopted than its parent procedure (2,3).

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Uniportal VATS—a new era in lung cancer surgery

Pulmonary actinomycosis is a chronic pulmonary infection caused by Actinomyces. Both improving oral hygiene and early application of antibiotics to the case of suspicious pulmonary infections result in changes in incidences and presentations of pulmonary actinomycosis. However, there are little reports dealt with the recent clinical characteristics of pulmonary actinomycosis. This study aimed to review the characteristics of pulmonary actinomycosis occurred during the first decade of 21st century. This retrospective study was performed on 94 subjects with pulmonary actinomycosis diagnosed pathologically from January 2000 to December 2010 in 13 hospitals in Korea. The data of the study showed that pulmonary actinomycosis occurs frequently in middle to old-aged males (mean age; 57.7 years old) and that the most common symptoms are cough, hemoptysis, and sputum production. Various radiologic features such as the consolidation with central low attenuation (74.5%) and no regional predominance were also observed. Most of patients recovered completely with medical and/or surgical treatment, reaching approximately 98% cure rate. The results demonstrate that pulmonary actinomycosis is one of the cautious pulmonary diseases. More importantly, in cases of persistent hemoptysis or for differential diagnosis from lung malignancy, our data have revealed that surgical resection appears to be a useful intervention and that radiologic diagnosis may not provide decisive information. These findings indicate that it is important for the clinicians to include pulmonary actinomycosis as one of differential diagnoses for refractory pulmonary abnormal lesions to the current usual management.

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Pulmonary actinomycosis during the first decade of 21st century: cases of 94 patients

Treatment of Tracheobronchial Injuries: A Contemporary Review

Background: Descending necrotizing mediastinitis resulting from oropharyngeal abscess, is a serious, life-threatening infection. Exisiting strategies for surgical management, such as transcervical mediastinal drainage or aggressive thoracotomic drainage, remain controversial.Methods: Four patients, (three males and one female) were treated for descending necrotizing mediastinitis resulting from oropharyngeal infection. Two had peritonsillar abscesses, while the others experienced dental abscess and submaxillaritis. Descending necrotizing mediastinitis received its classification according to the degree of diffusion of infection diagnosed by computed tomography. Mediastinitis in two cases, (Localized descending necrotizing mediastinitis-Type I), was localized to the upper mediastinal space above the carina. In the others, infection extended to the lower anterior mediastinum (Diffuse descending necrotizing mediastinitis-Type IIA), and to both anterior and posterior lower mediastinum (Diffuse descending necrotizing mediastinitis-Type IIB). The spread of infection to the pleural cavity occurred in three cases.Results: The surgical outcome concerning each of the patients was successful. Radical cervicotomy (unilateral in three patients, bilateral in the other) in conjunction with mechanical ventilation with continuous postoperative positive airway pressure, was performed in all cases. Tracheostomy was established in three patients and pharyngostomy in two. The two descending necrotizing mediastinitis-Type I cases were successfully managed with transcervical mediastinal drainage. The descending necrotizing mediastinitis-Type IIA case received treatment through transcervicotomy and anterior mediastinal drainage through a subxiphoidal incision. The patient with descending necrotizing mediastinitis-Type IIB required posterior mediastinal drainage through a right standard thoracotomy followed by left minimal thoracotomy.Conclusions: The mediastinal infection, the extent of which has been accurately determined by computed tomograms, necessitates radical cervicotomy followed by pleuromediastinal drainage. Situations where infection has spread to posterior mediastinum, particularly when it reaches in the level of the carina (descending necrotizing mediastinitis-type I), may not always require aggressive mediastinal drainage. In comparison, diffuse descending necrotizing mediastinitis-Type IIB demands complete mediastinal drainage with debridement via thoracotomy. Subxiphoidal mediastinal drainage without sternotomy may provide adequate drainage in diffuse descending necrotizing mediastinitis-Type IIA.

Guideline of surgical management based on diffusion of descending necrotizing mediastinitis

https://www.annalsthoracicsurgery.org/article/S0003-4975(02)03616-0/pdf

Surgical considerations for pulmonary actinomycosis.

Surgical outcome of pulmonary resection in chronic necrotizing pulmonary aspergillosis

Objectives: The indications for video-assisted thoracoscopic surgery (VATS) for advanced-stage lung cancer are expanding, but the criteria vary among institutions. This study compared the minimal invasiveness and oncologic validity of VATS lobectomy and thoracotomy lobectomy for the treatment of large-diameter primary lung cancer.

Methods: We retrospectively reviewed clinical features and surgical outcomes of 68 patients who underwent anatomical pulmonary resection for primary lung cancer of >5-cm diameter from July 2006 to March 2013. The patients were divided into a VATS group (Group V, n = 35) and a thoracotomy group (Group T, n = 33).

Results: Group V exhibited less intraoperative bleeding (p = 0.012) and had a shorter length of postoperative hospital stay (p = 0.024). The 1- and 5-year overall survival rates were 91.3% and 39.3% in Group V and 84.8% and 56.9% in Group T, respectively (p = 0.48). Multivariate analysis showed that limited lymph node dissection contributed to local recurrence. The extraction bag lavage cytology in Group V revealed that the positivity rate was 35.7%.

Conclusions: VATS for primary lung cancer of >5-cm diameter is similar to thoracotomy in terms of surgical outcomes. Large tumors must be carefully maneuvered during VATS to prevent cancer cell spillage.

Surgical Outcome of Video-Assisted Thoracoscopic Surgery vs. Thoracotomy for Primary Lung Cancer >5 cm in Diameter

Objectives Graft occlusion is a problem after superior vena cava (SVC) reconstruction for thoracic malignancy. Expanded polytetrafluoroethylene (ePTFE) is considered to be an optimal material for venous reconstruction. Methods We reviewed the hospital records of 13 patients who underwent complete resection of thoracic malignancy invading the SVC, including SVC reconstruction with ePTFE grafts. Single bypass grafting was performed in two patients (one right-sided, one left-sided) and double bypasses grafting was performed in the other patients. All patients received antithrombotic therapy after surgery. Eight patients died of recurrence or other disease during the follow-up period (range 5-41 months). Results Of the 24 grafts in 13 patients, graft patency was confirmed in 20 grafts in 9 patients at a mean time follow-up time of 47.8 ± 50.0 months after surgery. In the remaining four grafts in four patients, occlusion was diagnosed at a mean time of 1.25 ± 0.50 months after surgery. All obstructed grafts were left-sided bypass grafts in patients who underwent double bypass grafting, and did not result in SVC syndrome. Conclusions SVC reconstruction with ringed ePTFE grafts was safe and had good outcomes. In patients who underwent double bypasses grafting, the left-sided bypass grafts were susceptible to occlusion.

Shinichi Yamamoto

Papers

Guideline of surgical management based on diffusion of descending necrotizing mediastinitis

Surgical considerations for pulmonary actinomycosis.

Surgical outcome of pulmonary resection in chronic necrotizing pulmonary aspergillosis

Surgical Outcome of Video-Assisted Thoracoscopic Surgery vs. Thoracotomy for Primary Lung Cancer >5 cm in Diameter

Surgical Outcomes after Superior Vena Cava Reconstruction with Expanded Polytetrafluoroethylene Grafts