Medical treatment in acute mediastinitis by perforation of the esophagus: clinical case

Abstract

Background. Mediastinitis is the inflammation of the soft tissues of mediastinum. The main causes of mediastinitis are infections caused by heart surgery. Within the iatrogenic etiology the perforation of the esophagus predominates - 85% of cases. The incidence of esophageal perforation is most often due to the inflammatory response of mediators from the stomach, pleura and adjacent tissues. Mortality is due to acute mediastinitis, pneumonia, empyema, polymicrobial sepsis and MODS (Multiple Organ Dysfunction Syndrome). The treatment ofacute mediastinitis by perforation of the esophagus imposes the diagnostic problem and still arouses numerous discussions regarding the treatment. Case report. Case report: The patient, aged 1.5 months, with no pathological history, presents within the framework of the National Scientific-Practical Center Pediatric Surgery 'Natalia Gheorgiu' with accusations of dysphagia, with temperature 39 °C. Objectively observed symptoms: dyspnea, pallor, tachycardia, slight bulging in the cervical, suprasternal and supraclavicular pits. The presence of subcutaneous emphysema was a determining factor for the chest radiograph, in which there was an enlargement of the shadow of the upper mediastinum. Based on the clinical examination, the etiological factor was not confirmed, but ingestion of a foreign body was not excluded, and based on the imaging examination the suspicion of acute mediastinitis by esophageal perforation was determined. Esophagoscopy indicated the presence in the upper third of the esophagus of an ulceration surrounded by edema and hyperemia. The first therapeutic gesture was the introduction of a naso-gastric feeding probe, the introduction of broad-spectrum antibiotic therapy, hydro-electrolyte rebalancing, and analgesic therapy. Computer tomography with angiography confirmed the presence of esophageal perforation and mediastinal infiltration. The second medical gesture was the opening and the suprasternal drainage of the anterior mediastinum, the drainage with sleeve blade. Therapeutic attitude was conservative and antibiotic therapy was continued. Patient monitoring during treatment was favorable with the relapse of fever, pain, dyspnea and improvement of the general condition. After 1 month of conservative treatment was performed the esogastric transit control with radiopaque substance (Gastrofarm). This procedure does not highlight the contrast substance outside the esophagus. In this clinical case, we combined a conservative treatment and a surgical treatment with the opening of the previous mediastinum. There was no major surgery despite the fact that the mediastinal syndrome was manifest. The patient presented good results as well as at a distance. Conclusions. Conclusions. Suspicion of perforation of the esophagus requires emergency hospitalization and complete investigation of the esophagus and mediastinum under strict supervision. Indication for drug or surgical therapy will be required on a case-by-case basis, depending on the size of the efficacy, the short time from perforation, the association of neighborhood lesions and the presence of sepsis.