Descending necrotizing mediastinitis: Management and controversies

Background: Descending necrotizing mediastinitis has been known to be a life-threatening condition. It is most likely to be lethal without a prompt diagnosis and aggressive surgical management. In the surgical management of this subset of mediastinitis, a debate remains as to whether a transthoracic incision should be mandatory in addition to cervical approach.Methods: This is a single-center retrospective study performed at Cipto Mangunkusumo Hospital from January 2012 to June 2014. Patients with descending necrotizing mediastinitis were treated with broad-spectrum antibiotics and with cervical and transthoracic approach (via sternotomy) surgical debridement.Results: There were 16 consecutive cases of descending necrotizing mediastinitis. One patient did not undergo sternotomy and was ruled out from the study. The mean intensive care unit stay was 26.4 days, with a mean hospital stay of 46.7 days. There were three mortality cases reported and a total of three cases that needed reoperation. There was neither post-operative sternal dehiscence nor osteomyelitis found.Conclusion: Considering there are no post-operative sternal-related infection reported in this study, sternotomy should be considered as an access in descending necrotizing mediastinitis management. In the three mortality cases reported, two patients came with preoperative sepsis and one had iatrogenic subclavian artery injury.