OP-EUJC160095online 10..29

European Journal of Cardio-Thoracic Surgery 51 (2017) 10–29 POSITION STATEMENT
doi:10.1093/ejcts/ezw326 Advance Access publication 12 December 2016
Cite this article as: Abu-Omar Y, Kocher GJ, Bosco P, Barbero C, Waller D, Gudbjartsson T et al. European Association for Cardio-Thoracic Surgery expert consensus
statement on the prevention and management of mediastinitis. Eur J Cardiothorac Surg 2017;51:10–29.
European Association for Cardio-Thoracic Surgery expert consensus

statement on the prevention and management of mediastinitis
Yasir Abu-Omara,*,†, Gregor J. Kocherb,†, Paolo Boscoa, Cristina Barberoc, David Wallerd, Tomas Gudbjartssone,
Miguel Sousa-Uvaf,‡, Peter B. Lichtg,¶, Joel Dunningh, Ralph A. Schmida and Giuseppe Cardilloi,§
a
Department of Cardiothoracic Surgery, Papworth Hospital NHS Foundation Trust, Cambridge, UK
Downloaded from https://academic.oup.com/ejcts/article-abstract/51/1/10/2670570 by guest on 12 August 2019

b
Division of General Thoracic Surgery, Bern University Hospital / Inselspital, Switzerland
c
Department of Cardiovascular and Thoracic Surgery, University of Turin-Italy, Citta della Salute e della Scienza-San Giovanni Battista Hospital, Torino, Italy
d
Department of Thoracic Surgery, Glenfield Hospital, Leicester, UK
e
Department of Cardiothoracic Surgery, Landspitali University Hospital and Faculty of Medicine, University of Iceland, Reykjavık, Iceland
f
Unit of Cardiac Surgery, Hospital Cruz Vermelha, Lisbon, Portugal
g
Department of Cardiothoracic Surgery, Odense University Hospital, Odense, Denmark
h
Department of Cardiothoracic Surgery, James Cook University Hospital, Middlesbrough, UK
i
Unit of Thoracic Surgery, Azienda Ospedaliera S. Camillo Forlanini, Lazzaro Spallanzani Hospital, Rome, Italy
* Corresponding author. Department of Cardiothoracic Surgery, Papworth Hospital NHS Foundation Trust, Cambridge CB23 3RE, UK. Tel: +44-1480-364797; fax:
+44-1480-364744; e-mail: [email protected] (Y. Abu-Omar).
Received 23 February 2016; received in revised form 10 August 2016; accepted 11 August 2016
Abstract
Mediastinitis continues to be an important and life-threatening complication after median sternotomy despite advances in prevention
and treatment strategies, with an incidence of 0.25–5%. It can also occur as extension of infection from adjacent structures such as the
oesophagus, airways and lungs, or as descending necrotizing infection from the head and neck. In addition, there is a chronic form of ‘chronic
fibrosing mediastinitis’ usually caused by granulomatous infections. In this expert consensus, the evidence for strategies for treatment and
prevention of mediatinitis is reviewed in detail aiming at reducing the incidence and optimizing the management of this serious condition.
Keywords: Mediastinitis • Cardiac surgery • General thoracic surgery • Treatment • Prevention • Guideline
BACKGROUND detail, and in the second part other, less common, but important
types and pathologies of mediastinitis are discussed.
Mediastinitis and deep sternal wound infection (DSWI) are devastat-
ing and life-threatening complications after median sternotomy.
This involves the mediastinal–interpleural space within the chest. METHODOLOGY
Despite advances in prevention and treatment strategies, its
incidence remains significant and ranges between 0.25% and 5% [1– The European Association for Cardiothoracic Surgery (EACTS)
3, 58–61, 62, 63, 64]. Surgical wound infections may result from con- Thoracic and Adult Cardiac Domain established a team of sur-
tamination during surgery from both the patient and the surgeon geons to produce a statement on the surgical treatment of
[65]. Blood-borne infection could represent an alternative route to mediastinitis. Initially, a set of key clinical questions was formu-
the surgical wound [4], as well as extension of infection from adja- lated on the epidemiology, diagnosis and classification of media-
cent structures such as the oesophagus (i.e. due to oesophageal per- stinitis. Furthermore, two main groups of experts were formed in
foration), airways (e.g. due to tracheobronchial perforation) and order to concentrate on the two main forms of mediastinitis: (i)
lungs (e.g. pleural empyema), or a descending necrotizing infection mediastinitis after cardiac surgery and (ii) mediastinitis related to
from the head and neck [e.g. descending necrotizing mediastinitis non-cardiac surgery. To obtain a body of scientific evidence, a
(DNM)]. In addition to the aforementioned acute types of mediasti- systematic literature search was performed on medical databases
nitis, there is also a chronic form namely ‘chronic fibrosing mediasti- Medline/PUBMED (National Library of Medicine, USA), EMBASE
nitis’, which is very rare and usually caused by granulomatous (Elsevier, Netherlands) and Cochrane Library (UK). The initial
infections. In the first part of the document DSWI is reviewed in search was performed in January 2015. The search was limited to
reference material published since 1938 (Table 1).
† The first two authors contributed equally to this paper.‡ Chair of Clinical Levels of evidence are derived from published papers (Table 2)
Guidelines Committee.¶ Chair of the EACTS Thoracic Domain.§ Chair of EACTS and recommendations classed by the strength of evidence (Table 3).
Working Group for Pleural Diseases.
The preliminary document was circulated among all the involved
C The Author 2016. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
V
Y. Abu-Omar et al. / European Journal of Cardio-Thoracic Surgery 11
Table 1: Methodology checklist Table 3: Classes of recommendations
Yes No Classes of Definition

recommendations
Panel assembly
• Experts from chest medicine and thoracic surgery x Class I Evidence and/or general agreement that a
• Experts vetted for conflict of interest x given treatment or procedure is beneficial,
• Patient representative x useful, effective
• Expert methodologist x Class II Conflicting evidence and/or a divergence of
Literature review opinion about the usefulness/efficacy of the
• Performed in collaboration with librarian x given treatment or procedure
POSITION STATEMENT
• Searched in multiple electronic databases x Class IIa Weight of evidence/opinion is in favour of
• Reviewed reference list of retrieved articles x usefulness/efficacy
(Medline/PUBMED,EMBASE, Cochrane Library) Class IIb Usefulness/efficacy is less well established by

Evidence synthesis evidence/opinion
• Prespecified inclusion and exclusion criteria applied x Class III Evidence or general agreement that the given
• Evaluation of included studies for source of bias x treatment or procedure is not useful/
• Explicitly summarized benefits and harms x effective, and in some cases may be harmful
• Grading system used x
Included studies evaluated
• Recommendations for clinical practice x
• Summary/opinions x vessels; the trachea and main bronchi; lymph nodes; and the
phrenic, vagus and left recurrent laryngeal nerves.
The posterior mediastinum is bounded anteriorly by the pos-
terior trachea and pericardium, posteriorly by the vertebral col-
umn and the chest wall, respectively. It contains the oesophagus,
Table 2: Levels of evidence
descending aorta, azygos and hemiazygos veins, thoracic duct,
vagus and splanchnic nerves, lymph nodes and fat.
Level of Evidence A Data derived from multiple randomized clinical
trials or meta-analyses
Level of Evidence B Data derived from a single randomized clinical Presentation
trial or large non-randomized studies
Level of Evidence C Consensus of opinion of the experts and/or
small studies, retrospective studies, registries Mediastinitis manifests within a spectrum that ranges from the
subacute, stable patient to the fulminant critically ill patient who
requires immediate intervention in order to prevent death. Vital
members for further input and comments. A final version was then signs may generally show tachycardia and fever. In more
revised to incorporate all the pertinent comments suggested and advanced cases of sepsis, hypotension may be present and the
submitted to the EACTS Thoracic domain for further input and patient may require intensive care support. Systemic signs of sep-
implementation. sis strongly suggest mediastinal involvement. Detailed diagnostic
The manuscript has been approved by the Chair of the Clinical criteria are described later in detail.
Guidelines Committee and by the Chair of the Pleural Diseases
Working Group.
Imaging studies
This statement describes the current evidence and practices
for the management and prevention of mediastinitis.
Delays in the diagnosis of mediastinitis greatly influence morbidity,
mortality and overall outcome. The condition is typically recog-
GENERAL CONSIDERATIONS nized because of high clinical awareness in susceptible popula-
tions, including those with obesity, chronic obstructive pulmonary
Relevant anatomy disease (COPD), diabetes, smoking, osteoporosis, re-exploration
for bleeding, bilateral internal mammary artery (BIMA) use, redo
The mediastinum is limited bilaterally by the mediastinal parietal surgery, prolonged intensive care stay and use of mechanical ven-
pleura and extends from the thoracic inlet superiorly to the dia- tricular assist devices [5, 58, 64]. Contrast-enhanced computed
phragm inferiorly. It is further artificially divided into three parts: tomography (CT)-scan (with additional oral contrast if an oesopha-
the anterior, middle and posterior mediastinum. geal lesion is suspected) is the diagnostic tool of choice in the diag-
The anterior mediastinum is bounded anteriorly by the ster- nosis of mediastinitis. This does not only show the extent of
num; posteriorly by the pericardium, aorta and brachiocephalic infection but also helps in defining the underlying cause. Other
vessels; superiorly by the thoracic inlet; and inferiorly by the dia- imaging modalities can also be utilized that include magnetic res-
phragm. It includes the thymus, lymph nodes, adipose tissue and onance imaging (Fig. 1) and labelled white blood cell scan.
internal mammary vessels. The thyroid gland may also extend
into the anterior mediastinum. Treatment
The middle mediastinum lies in between anterior and posterior
mediastinum and is basically bounded anteriorly and posteriorly by Once a clinical diagnosis of mediastinitis is suspected or established,
the pericardium. Its contents include the heart and pericardium; the aggressive antibiotic therapy should be started after blood culture
ascending aorta and aortic arch; the superior vena cava (SVC) and and consideration can be given to the surgical techniques available.
inferior vena cava; the brachiocephalic vessels; the pulmonary In principle, control of the source of infection and surgical
12 Y. Abu-Omar et al. / European Journal of Cardio-Thoracic Surgery
• Patient has at least one of the following signs or symptoms:

fever (>38 C), chest pain or sternal instability.
And at least one of the following:
• Purulent drainage from mediastinal area;

• Mediastinal widening on imaging.
The definition of post-sternotomy mediastinitis by van

Wingerden et al. [10] is:
Infection occurring within 1 year following surgery, regardless
of whether an implant is in place or not,
AND infection appears related to the operative procedure,
AND, at least one of the following criteria:

1. Patient has organisms cultured from mediastinal tissue or fluid
obtained during a surgical operation or needle aspiration.
2. Patient has evidence of mediastinitis seen during a surgical
operation or histopathological examination.
3. Patient has at least one of the following signs or symptoms
with no other recognized cause: fever (>38 C), chest pain or
sternal instability.
AND at least one of the following:
Figure 1: Magnetic resonance imaging of the mediastinum demonstrating infil- a. Purulent discharge from the mediastinal area;
tration and enhancement of the soft tissues indicative of mediastinitis. b. Organisms cultured from blood or spontaneous discharge
debridement of affected tissue are the cornerstones of treatment [6, from the mediastinal area;
7, 66, 67]. c. Radiological evidence of an infective process in the
mediastinum.
Sternal wound infections can also be divided into ‘superficial’
Outcome
infections and ‘deep’ infections, based on the depth of the infec-
tion. Early infections include both ‘superficial’ infections, reaching
The outcome strongly depends on rapid diagnosis and adequate
the dermis and subcutaneous tissue, and DSWIs that reach under
treatment. It also depends on the underlying cause of the disease
the sternum and the anterior mediastinum. Thus, a DSWI can
and the patients’ comorbidities. Patients with DSWI have a worse
present either ‘early’—more common—or as a ‘late’ infection.
short- and long-term outcomes, with an associated mortality rate
‘Late’ infections often comprise a combination of superficial and
reported between 10% and 47% [4, 8, 59, 63, 64, 68–70]. The im-
deep infection and they include osteomyelitis, subcutaneous ab-
pact of this complication on both healthcare and hospital budg-
scess and sternocutaneous fistulas.
ets is significant [4, 8, 69].
Risk factors
Prevention
The pathogenesis of mediastinitis is complex and multifactorial.
Many preventative measures are suggested as effective for reduc-
Several risk factors have been identified and of those, diabetes
ing the incidence of surgical site infections (SSIs), such as pre-
and obesity remain most important [62]. Preoperative, intraoper-
operative screening for carriage of multiresistant organisms [e.g.
ative and postoperative variables have been described.
methicillin-resistant Staphylococcus aureus (MRSA)], antimicrobial
Preoperative risk factors include diabetes mellitus [1, 11–13,
prophylaxis, preoperative skin preparation, accurate surgical
59, 64, 71–85], obesity [1, 11, 59, 64, 71, 72, 74–77, 80–82, 84,
technique and wound management.
86–94], advanced age [75–77, 82, 90, 95, 96], COPD [59, 81, 84,
91, 97–99], heart failure and left ventricular dysfunction [1, 77, 81,
MEDIASTINITIS AND DEEP STERNAL WOUND 86, 95, 100], smoking [1, 12, 82, 89], female sex [75, 79, 95, 96,
INFECTION AFTER MEDIAN STERNOTOMY 101], elevated serum creatinine level or patients undergoing hae-
modialysis [77, 81, 95, 100], peripheral vascular disease [1, 13, 80],
Definition prolonged preoperative stay in hospital [59, 78, 101], emergent
or urgent surgery [82, 99, 102].
According to Centers for Disease Control and Prevention (CDC) Intraoperative risk factors include use of BIMA grafts [1, 11, 64,
guidelines [9], the definition of mediastinitis requires at least one 72, 81, 86, 91, 92], prolonged duration of surgery, perfusion time
of the following criteria: and aortic cross clamp time [11, 13, 72, 77, 79–81, 86, 95–97], redo
cardiac surgery and reoperation [12, 58, 59, 64, 87, 90, 101–105].
• Patient has organisms cultured from mediastinal tissue or fluid. Postoperative risk factors include postoperative respiratory
• Patient has evidence of mediastinitis on gross anatomical or failure [1, 12, 59, 71, 85, 90, 92, 97] and prolonged intensive care
histopathological examination. stay [64, 73, 80, 85, 106].
Diagnosis organism to others. Topical mupirocin is the most commonly

used method for MRSA eradication. It is safe, well tolerated and
Signs and symptoms of mediastinitis typically present within 30 not systemically absorbed, which makes it an ideal agent for de-
days of cardiac surgery. Local signs include purulent drainage colonization. However, there is growing evidence of increasing
from the sternal wound and sternal instability. Often patients pre- mupirocin resistance and treatment failure, especially in those in-
sent with fever, raised inflammatory markers and reporting slow dividuals colonized with MRSA in multiple sites. In a large inter-
or no recovery. One of the most reliable signs of DSWI is sternal national cohort of patients undergoing cardiac surgery, which
instability, which can be easily appreciated on physical examin- were observed prospectively, invasive postoperative S. aureus in-
ation and is often reported by the patients themselves [107]. It fections occurred in 1% of adult patients despite modern peri-
may be difficult to distinguish on physical examination between operative management. The corresponding mortality rates were
DSWI and superficial infection. When a high index of suspicion is 3% for MSSA and 13% for MRSA infections. Preoperative nasal
POSITION STATEMENT
present, early wound opening and inspection with appropriate colonization with S. aureus increased the risk of postoperative in-
sampling of tissue for bacteriologic assessment are strongly fection 3-fold [113].

advised. San Juan et al. [114] showed that endogenous nasal coloniza-
Radiographic imaging can support the clinical diagnosis and is tion often precedes methicillin-susceptible S. aureus post-sternot-
included as part of the CDC guidelines for defining mediastinitis omy mediastinitis, which suggests that preoperative
[14]. A simple postero-anterior chest radiograph can show the decontamination is adequate for preventing methicillin-
presence of air between the sternal edges. Furthermore, lateral susceptible S. aureus post-sternotomy mediastinitis, whereas hos-
displacement of one or more sternal wire could represent an in- pital infection control measures seem to be the major factor for
direct sign of fractured or separated sternum [108]. CT-scanning preventing MRSA post-sternotomy mediastinitis.
provides excellent detail and is the investigation of choice when A meta-analysis by van Rijen et al. [18] included four random-
a diagnosis cannot be easily established by clinical examination ized controlled studies to assess the use of mupirocin preopera-
alone [15, 109]. It is also valuable in guiding surgical planning. tively in patients who were S. aureus nasal carriers. In the largest
The typical CT findings in cases of mediastinitis are sternal dis- of these studies, Perl et al. [19] reported a significant effect of
ruption, free gas bubbles underneath the sternal plate and medi- mupirocin on the S. aureus rate. In the studies of Garcia et al.
astinal fluid collection [110]. [20], Kalmeijer et al. [115] and Konvalinka et al. [116], no signifi-
cant effect was found. Meta-analysis of these four studies dem-
onstrated a significant effect of mupirocin on the S. aureus
Perioperative prevention measures infection rate after surgery in carriers [relative risk (RR) 0.55, 95%
confidence interval (CI): 0.34–0.89]. In surgical patients who were
The principles of prevention are to (i) minimize the intraoperative not carrying S. aureus, the treatment had no significant beneficial
wound contamination with skin bacteria, (ii) avoid contamination effect (RR 1.09, 95% CI: 0.52–2.28). Using molecular typing tech-
with more virulent pathogens (S. aureus, Gram-negative bacteria), niques, Perl et al. reported that 85% of the S. aureus infections
(iii) reduce preconditions for secondary haematogenous contam- were endogenous. The study by Kalmeijer et al. concurs with a
ination of bacteria, (iv) optimize the local conditions for wound percentage of 86%. The authors concluded that the effectiveness
healing and optimize the general host defence and (v) prevent of mupirocin is related to carriers only, because in proven nasal
development of infection by contaminating bacteria (antibiotic carriers a significant and effective reduction in the rate of S. aur-
prophylaxis). Different measures can be applied during the pre- eus infection was found.
operative phase for reducing DSWI rate. These include preopera- The review by Trautmann et al. [21] analysed four randomized
tive screening for carriage of multiresistant organisms (e.g. and seven sequential open cohort studies. Three of the five stud-
MRSA), antimicrobial prophylaxis, preoperative skin preparation ies carried out in cardiac surgery patients showed a significant re-
and accurate surgical technique. duction in sternotomy site infections. However, all three studies
were open sequential cohort studies. In contrast, a prospective,
Staphylococcus aureus nasal carriage. The anterior nares randomized, double-blind study in cardiac surgical patients
are the commonest area for S. aureus colonization. showed no benefit of mupirocin.
Approximately 20% of the general population are persistently A meta-analysis by Kallen et al. [22] included seven studies:
colonized, whereas 30% represent an intermittent carrier and the three randomized controlled trials (RCTs) and four before-and-
remaining 50% appear not to be susceptible to S. aureus carriage after studies. When cardiothoracic surgery studies were analysed,
for unclear reasons [16]. Methicillin-sensitive S. aureus (MSSA) mupirocin was found to reduce infection compared with controls
lives on the skin of humans as a commensal. Nasal colonization in both the RCTs and non-randomized studies although the dif-
with strains of methicillin-resistant S. aureus (MRSA) is estimated ference was not statistically significant in the former. The authors
at around 1% of the total population [111] and is more frequent concluded that perioperative intranasal mupirocin appeared to
in certain sub-groups such as elderly people, immunosuppressed reduce the incidence of SSI in non-general surgery patients, but
patients, diabetics and those who are frequently hospitalized. had no apparent effect in general surgery.
Staphylococcus aureus is the most common causal microorganism The Society of Thoracic Surgeons (STS) practice guidelines
for wound infections in general, causing up to 80% of post-surgi- [23] recommend routine mupirocin nasal administration for all
cal mediastinitis [17, 112]. patients undergoing cardiac surgical procedures in the absence
Compared with MSSA mediastinitis, MRSA mediastinitis has up of a documented negative testing for staphylococcal coloniza-
to 11-fold increase in mortality rate [61, 75]. As a result of the as- tion; the duration of mupirocin therapy for suppressing S. aur-
sociation between colonization and subsequent infection, nu- eus nasal carriage is 5 days (Class I, Level of Evidence A). In
merous studies have focused on decolonization strategies in general, cardiothoracic patients are considered at high risk for
order to reduce the risk of infection and transmission of the serious MRSA infection and therefore should be routinely
screened at the time of admission or preferably prior to admis- Level of Evidence A). For patients who are considered beta-
sion. It is recommended that carriers of MRSA, who are receiv- lactam or penicillin allergic, vancomycin is recommended as the
ing prophylaxis for an operation, should undergo nasal primary prophylactic antibiotic (Class I, Level of Evidence A) with
decolonization with mupirocin [24]. additional Gram-negative coverage (Class IIB recommendation,
Level of Evidence C).
In order to reach adequate antibiotic serum concentration and
Skin antiseptic preparation. Skin antiseptic preparation is
effective tissue level, the time of administration is proven to be
aimed at reducing bacterial colonization of the skin and the risk
an important aspect of antibiotic prophylaxis. In patients for
of wound contamination during the surgical procedure.
whom cefazolin is the appropriate prophylactic antibiotic for car-
Iodophor [such as povidone-iodine (PI)] and chlorhexidine gluco-
diac surgery, administration within 60 min of the skin incision is
nate (CHG) are the main types of antiseptics and can be mixed
indicated (Class I, Level of Evidence A). In patients for whom
with either alcohol or water. Chlorhexidine reduces skin bacterial
vancomycin is the prophylactic agent of choice, a dose of 1–1.5 g
colony counts to a greater extent than PI does or other agents
or a weight-adjusted dose of 15 mg/kg administered intraven-
that have been studied [117, 118]. Adjunctive means to reduce

ously slowly over 1 h, with completion within 1 h of the skin inci-
contamination include measures to reduce airborne contamin-
sion, is recommended (Class I, Level of Evidence A). For patients
ation in the operating room by use of tight scrub-suits and lam-
who receive an aminoglycoside (usually gentamicin, 4 mg/kg) in
inar airflow. The use of plastic adhesive drapes on the skin is
addition to vancomycin before cardiac surgery, the initial dose
commonly practiced but should be questioned, as it has in fact
should be administered within 1 h of the skin incision (Class I,
not been shown to reduce SSIs and might even increase the re-
Level of Evidence C).
colonization of the skin.
The 2011 American College of Cardiology/American Heart
The role of preoperative shower or bath with antiseptic agents
Association (ACC/AHA) guideline for CABG surgery [2] recom-
in reducing bacterial colonization is largely debated. A recent sys-
mends a first- or second-generation cephalosporin for prophy-
tematic review supports the idea that presurgical showering with
laxis in patients without MRSA colonization (Class I, Level of
CHG is effective in reducing bacterial burden, but the effect on
Evidence A) and vancomycin alone or in combination with other
SSIs was inconclusive [119].
antibiotics to achieve broader coverage is recommended for
Two previous systematic reviews [25, 26] reported mixed find-
prophylaxis in patients with proven or suspected MRSA coloniza-
ings for the reduction of skin flora and SSIs with presurgical
tion (Class I, Level of Evidence B).
showering. Jakobsson et al. examined 10 studies and, while they
Duration of antibiotic prophylaxis is another point of debate.
were unable to produce definitive recommendations due to the
Ideally, short courses of antibiotic prophylaxis are preferred to
different study designs, they concluded that preoperative disin-
longer courses to reduce risks of drug toxicity, infection with
fection showers with CHG are effective from a microbiological
Clostridium difficile, the emergence of resistant pathogens and
point of view as eight of the reviewed studies demonstrated a
cost [28, 93, 94, 123, 124]. On the other hand the rationale given
sharp reduction in skin flora. On the other hand, Webster et al.
for prolonging the duration of antibiotic prophylaxis in cardiac
reviewed seven trials, which provided no clear evidence of bene-
surgery includes the pharmacokinetic/pharmacodynamic
fit for preoperative showering or bathing with chlorhexidine over
changes caused by the use of cardiopulmonary bypass, hypo-
other wash products in reducing the rate of SSI.
thermia and blood loss. The STS Practice Guidelines on antibiotic
The CDC guidelines recommend that patients shower or bath
prophylaxis recommend that the duration of a prophylactic anti-
with an antiseptic solution the night before surgery and that the
biotic regimen is limited to the shortest amount of time required
skin is prepared with ‘an appropriate antiseptic agent’ [16].
to effectively minimize the probability of postoperative infection.
Clinical practice guidelines from the National Institute for Health
They recommend postoperative prophylactic antibiotics to be
and Clinical Excellence recommend that patients shower or have
given for 48 h or less (Class IIa, Level B).
a bath using soap, either the day before or on the day of surgery.
Lador et al. [29] in a recent systematic review and meta-
There is no evidence of a difference of effect on SSI rate between
analysis of RCTs comparing one antibiotic regimen versus an-
chlorhexidine as a cleansing agent and plain detergent or soap.
other in cardiac surgery found that shorter duration of prophy-
In addition, chlorhexidine has been found not to be cost-
laxis was associated with a higher rate of DSWI. The difference
effective. They also recommend preparing the skin at the surgical
originated from studies in which the short-duration arm was <_24
site with antiseptic immediately before incision, but they do not
h postoperation. There were no significant differences between
indicate a preference for CHG or PI [120].
short versus longer prophylaxis when the short-duration arm
provided more than 24 h postoperative coverage. In this group
Prophylactic antibiotic therapy. Perioperative antimicrobial of studies, the mean postoperative prophylaxis duration in the
prophylaxis is the cornerstone of SSI prevention. The benefits of short-duration arm was 48 h (range: 30–60). The same trends
appropriately administered prophylactic antibiotic therapy in pa- were observed for all other SSI categories, with a statistically sig-
tients undergoing cardiac surgery have been clearly demon- nificant benefit for longer versus <_24 h postoperative prophylaxis
strated and preoperative antibiotics should be administered to all for any sternal wound infection.
patients to reduce the risk of postoperative infection (Class I, In a recent systematic review and meta-analysis, Mertz et al.
Level of Evidence A) [27, 121, 122]. [30] compared the relative effectiveness of short-term (<24 h) and
However, the choice of antibiotic, optimal dose, duration and long-term (24 h or more) antibiotic prophylaxis in cardiac sur-
timing of antimicrobial prophylaxis protocol remains controver- gery. In this review, longer term prophylaxis reduced the risk of
sial. The STS Practice Guidelines on antibiotic prophylaxis in car- sternal SSIs by 38% with a greater reduction in risk when analysis
diac surgery [23] indicate a beta-lactam antibiotic as a single was restricted to four trials comparing the same drug regimens (a
antibiotic of choice for standard cardiac surgical prophylaxis in total of 12 trials were eligible). The study concluded that long-
populations that do not have a high incidence of MRSA (Class I term antibiotic prophylaxis may be more effective than short-
term regimens in preventing sternal SSIs in patients undergoing mechanically rigid fixation of the sternal halves reduces infection
cardiac surgery, but no definite conclusion could be drawn be- rate. Several new techniques with wires, plates or other devices
cause of heterogeneity in antibiotic regimen and risk of bias in have been published although more evidence from adequately
the published studies. powered, prospective, controlled studies is needed. The tech-
Local antibiotic prophylaxis with collagen–gentamicin has nique with lateral reinforcement (Robicsek), however, did not re-
been evaluated since 2005 in several studies including four large duce the incidence of sternal wound complications in high risk
RCTs, retrospective studies and in meta-analyses [31]. In brief, all patients in a large randomized controlled multicentre trial [36].
RCTs but one [32] showed a reduction in SWI. The divergent re- The risks of mediastinitis and sternal osteomyelitis from the lib-
sult in this multicentre RCT has later been questioned for the eral application of bone wax have been a source of concern.
technique of soaking the sponges in saline prior to implant. Recently, a prospectively randomized study on 400 patients
Recent meta-analyses support the technique concluding that undergoing isolated coronary bypass surgery has shown no detri-
POSITION STATEMENT
implantable gentamicin–collagen sponges significantly reduce mental effect of the use of bone wax on wound healing and in-
the risk of sternal wound infection after cardiac surgery [31]. fection rate [37].

In summary, antibiotic prophylaxis reduces the SSI rate to ap- Although the use of bilateral mammary artery (BIMA) may im-
proximately 1/5 compared with placebo and is recommended prove long-term survival in CABG patients, its use has long been
for all cardiac surgery [27]. Antibiotics need to be present in the considered a risk factor for DSWI when compared with the use
tissues before contamination occurs and the first dose should be of a single left internal mammary artery (LIMA) [133]. This is
given immediately preoperatively. There is no additional effect of thought to be related to decreased vascularization of the sternum
extending the prophylaxis to more than 48 h and a duration of following BIMA harvesting [134]. The perceived risk of infection is
24 h may be sufficient and is generally practiced in many centres. considered the main reason for the low use of BIMA despite its
Local application of vancomycin, in addition to intravenous survival benefit, probably one of the reasons why in the USA it is
(IV) prophylactic antibiotics and tight glycaemic control, has used in <5% of isolated CABG operations [135]. In a large meta-
been shown to be very effective to substantially decrease the in- analysis by Dai et al. [136], the use of BIMA was shown to in-
cidence of sternal wound infection after cardiac surgery [125] crease the relative risk of DSWI by 62% when compared with
and may become recommended part of multifaceted prophylac- LIMA. This increased risk was most prominent in patients with
tic strategy to prevent sternal wound infections. There are how- diabetes and in the elderly. The risk for all levels of sternal wound
ever concerns regarding potentially high serum levels and the infections (superficial and deep infections including mediastinitis)
risk of selection of resistant strains to this important antibiotic. was similarly increased in the BIMA group. Importantly, however,
the use of skeletonized BIMA was not associated with increased
risk of DSWI [136–140].
Control of hyperglycaemia. The maintenance of physiologic
Furthermore, the association of the use of BIMA and DSWI
blood glucose levels is an important strategy to decrease DSWI
was recently challenged in a large study using US national out-
rate. Diabetes mellitus has been established as an independent risk
come data from the Nationwide Inpatient Sample. In over 1.5
factor for postoperative surgical wound infection, with infection
million CABG cases from 2002 to 2008, the use of BIMA was not
rates two to five times more prevalent than in non-diabetic popu-
an independent risk factor for DSWI except in patients with
lation [1, 11–13, 59, 64, 71–85, 126]
chronic complications of diabetes mellitus [135, 141].
Diabetic patients undergoing cardiac surgical procedures, be-
fore use of IV insulin, were more likely to have worse short- and
long-term survival and higher rates of DSWI [33, 71, 72, 93, 127– Management principles
131]. Furthermore, post-sternotomy mediastinitis in diabetic
patients after cardiac surgery increases operative mortality 2- to Antibiotics. Microbial identification and antibiotic susceptibility
3-fold [34]. should be established as soon as possible after the diagnosis of
Furnary et al. [127] found the average blood glucose level over sternal wound infection. Expeditious treatment with broad-
the first two postoperative days to be the strongest predictor of spectrum antibiotics should be started [6]. The dosing of anti-
any DSWI in diabetic patients who have undergone cardiac microbial agents should be adjusted in obese patients to ensure
surgery. adequate tissue levels [142]. Zeitlinger et al. showed that in pa-
There is therefore convincing evidence that the presence of tients undergoing surgical revascularization, IMA harvesting sig-
perioperative hyperglycaemia adversely affects the DSWI rate nificantly diminishes antimicrobial penetration into the
and continuous insulin infusions should represent the standard peristernal tissue suggesting the need for dosing adjustment fol-
of care for glycometabolic control in all patients undergoing car- lowing IMA harvesting [143].
diac surgery (Class I, Level of Evidence B). Sternal SSI is therefore initially treated with IV antibiotics. As
Coagulase-negative Staphyloccocus (CoNS) is often multiresistant
and MRSA is common in some centres, first-line antibiotic treat-
Surgical technique. Adherence to basic surgical principles is in-
ment is commonly IV vancomycin, until results from antimicro-
tuitive. These include careful median sternotomy, control of
bial susceptibility tests become available. Cloxacillin and other
bleeding, parsimonious use of diathermy, gentle and limited tis-
b-lactamase-resistant staphylococcal antibiotics are commonly
sue handling and dissection. Meticulous haemostasis is particu-
used when infection with either S. aureus or CoNS has been
larly important, as postoperative bleeding represents a major risk
established.
for mediastinitis [62]. Moreover, paramedian sternotomy is
strongly associated with postoperative chest instability [132]
causing deep wound dehiscence favouring mediastinitis [35]. Surgical strategies. Many approaches have been described for
Sternal instability or dehiscence may be a consequence of an SSI the surgical treatment of post-sternotomy mediastinitis. These in-
but also by itself promotes bacterial growth. In cardiac surgery, a clude: revision with open dressings, primary closure, closed
irrigation, negative pressure wound therapy (NPWT) and recon- reports have been published providing stronger empirical evi-
struction with vascularized soft tissue flaps (e.g. omentum, pec- dence of the use of NPWT in the treatment of sternal SSI.
toral muscle). Negative-pressure wound therapy promotes healing in differ-
Surgical treatment is generally necessary for DSWI. Although ent types of wounds through removal of excess fluids and other
the most appropriate surgical approach for the treatment of ster- debris by creating negative pressure, often referred to as vacuum,
nal SSI is still debated, there is a consensus that at least wound in a well-sealed wound. The proposed mechanisms by which
debridement is necessary. Two approaches are most common to NPWT aids wound healing are numerous; increased perfusion of
close the wound: (i) primary intention, i.e. the wound is closed the wound, facilitated granulation tissue formation, and removal
by drawing the wound edges together, or (ii) tertiary intention or of fluid. A recent review by Glass et al. suggests that promotion
delayed primary closure, i.e. the wound is debrided and left open of wound healing occurs by modulation of cytokines to an anti-
for treatment and observation, and is then closed a few days inflammatory profile, and mechanoreceptor- and
later. A secondary intention approach, i.e. there is no direct clos- chemoreceptor-mediated cell signalling, culminating in angio-
ure and the wound granulates and heals, however, is rarely used genesis, extracellular matrix remodelling and deposition of

for DSWI. When either primary intention or delayed primary granulation tissue [40].
closure is used, the sternal halves can often be rewired in a fash- When NPWT is used for DSWI, multiple layers of paraffin
ion similar to that in a primary operation—or more securely, if gauze are placed at the bottom of the sternal wound after de-
there is risk of fracture, using the Robicsek technique [144]. bridement in order to prevent damage to the right ventricle of
The earliest treatment for DSWI was revision of the wound, fol- the heart. Following placement of the paraffin gauzes, polyureth-
lowed by either open wound dressings or closed irrigation. Open ane foam is cut to fit the wound and a sterile wound drape cov-
wound dressing changes involve frequent changes of paraffin ers it; a tube for transmission of pressure is attached through a
gauzes and close observation of the wound. The first adjunct hole in the drape. The negative pressure applied to the wound
therapy to debridement and open wound dressing was the use has been shown to increase microvascular blood flow a few cen-
of antibiotic irrigation of the wound, or closed irrigation [145]. timetres from the wound, whereas hypoperfusion has been seen
Stability of the sternum before delayed primary closure is of close to the edge of the wound [153]. Recent studies have shown
great importance regardless of the treatment method. Cases of that gauze may be used, with similar results as for polyurethane
right ventricle perforation during conventional treatment have foam [154].
been described that are often believed to be related to rupture The negative pressure in a sternal wound is most often applied
due to the sternal halves tearing the ventricular wall [146]. at a continuous pressure of -125 mmHg. However, in a rat model,
Furthermore, pulmonary function of patients with an open continuous pressures of -50, -75 or -125 mmHg were shown to
wound is impaired, often requiring them to remain intubated for be similarly effective at reducing the wound area [155].
prolonged periods of time. For delayed closure of the wound, a Furthermore, in a porcine model the stability of the sternum was
steel plate can be used for fixation of an unstable sternum after found to be similar at pressures of -75, -125 and -175 mmHg but
extensive debridement for DSWI [147]. diastasis of the foam was more pronounced at pressures less
Soft tissue flap transposition is often required to fill a sternal than -100 mmHg [156]. The finding that -75 mmHg leads to opti-
defect resulting from repeated treatment interventions, or to dir- mal contraction of the wound has been confirmed, but it was
ectly fill a sternal wound after debridement. Use of the omentum observed that if the wound fluid volume was high, an initial pres-
as a soft tissue flap was first described in 1976 [148]. After sub- sure of -125 mmHg could be regarded as optimal [157]. Instead
total sternectomy, followed by transposition of highly vascular- of continuous pressure, cyclical (or intermittent) application of
ized greater omentum to the sternal defect, the wound is then negative pressure may sometimes be more convenient and it
closed by delayed primary intention. Instead of an omental flap, may even have advantages for wound healing [154]. However,
a muscle flap is more commonly used today, most often the pec- this has limited use in DSWI due to the lack of added stability to
toralis muscle. This was first described in 1980 by Jurkiewicz et al. the wound.
[149] in patients who had not responded to either open wound The wound is usually reopened after 2–4 days after treatment
dressing or closed irrigation. The pectoralis major, and in some with negative pressure. Based on both clinical observations and
cases the rectus abdominis muscle, is transposed to fill up the parameters of inflammation (such as neutrophil count and C-
sternal defect with good results. reactive protein), the clinician can determine whether the
Recurrent sternal SSI is not uncommon and can be challenging wound is sterile and the proliferative stage of wound healing
to manage. This is seen more frequently following open wound has begun [158]. If the wound is not healed, new foam is placed
dressing treatment, irrigation and other forms of older treatment with negative pressure. Patients with DSWI most often require a
methods compared with the newer treatment using negative- total of two to four dressing changes as part of the NPWT treat-
pressure [38, 150, 151]. ment. This includes the initial debridement where the foam is
A particularly difficult problem following sternal reconstruction first placed, and wound closure [159]. After the wound is
using muscle flaps is chronic pain and/or sternal instability, which healed and all signs of infection are gone the sternum is rewired
has been reported in over 40% of cases as well as commonly re- and the skin closed. In this way, a delayed primary closure can
ported long-term muscle weakness [152]. Abdominal hernias fol- be achieved in most cases [160]. A few reports have described
lowing omental transfer can occur, and may require surgical the use of NPWT for secondary intention as method of
intervention. closure of the wound, but this has generally led to a worse
Negative-pressure wound therapy, introduced in the late outcome [41].
1990s, is a newer treatment modality that can stabilize the ster- Complications related to NPWT when used for sternal SSIs are
num and promote granulation of the wound. In 1999, Obdeijn most often minor, and they most often involve pain at the edges
et al. [39] were the first to describe successful use of NPWT in of the wound, which usually subsides shortly after initiation of
three patients with deep sternal SSI. Since then, numerous the negative pressure. In-growth of granulation tissue into the
foam can also cause light bleeding upon removal. Other, mostly when compared with closure and suction–irrigation drainage
preventable, minor wound complications include pressure sores [177]. The use of pectoral muscle flaps or omentum following
caused by mislaid evacuation tubes and erosion of the wound sternal stabilization could be recommended although in some
edges caused by the foam being laid out over the wound edge cases removal of the plates due to infection is necessary [179].
onto healthy skin [161]. Major bleeding has been reported and is In Type 4 the sternum is necrotic; therefore, debridement of
a potentially fatal complication of NPWT in the sternal wound; it necrotic tissue followed by flap reconstruction provides vascular-
can be seen when negative suction is introduced to the sponge ized tissue cover, some sternal stability and obliteration of dead
or when the sponge dressings are changed. There is concern that space (Class IIb Level B). Muscle flap (pectoralis and rectus
rupture of the right ventricle is more likely when using NPWT abdominis) and omentum flap have been described and recom-
than with other methods [146] due to displacement of the heart mended for this type of reconstruction [179–183].
towards the thoracic wall and possible contact of the right ven- There is no consensus regarding the timing for surgical recon-
POSITION STATEMENT
tricle with the edge of the sternum. Other causes of major bleed- struction. Concerns still remain about the necessity for obtaining
ing during NPWT have also been reported such as infectious negative cultures at the time of closure. Two recent studies found

erosion of the ascending aorta and mobile sternal wires. that the presence of positive tissue cultures does not influence
In a recent and comprehensive review, van Wingerden et al. the rate of readmissions with recurrent infection [43].
[10] classified post-sternotomy mediastinitis into four groups,
suggesting surgical approaches based on the available evidence
(see Table 4). Outcomes of treatment
The authors divided post-sternotomy mediastinitis according to
sternum stability viability, and available bone stock. Types 1 and 2 Historically, mortality due to deep sternal SSIs was 20–45% be-
are characterized by a reasonably stable sternum, whereas Types 3 fore more advanced surgical techniques were developed [184]. In
and 4 by an unstable sternum. In Type 1 (relatively stable sternum contemporary reports, the mortality is reported to range be-
and minimal bone loss) the use of NPWT is advised. Clear evi- tween 1% and 14% [159, 185, 186]. Patients treated surgically for
dence for the use of NPWT therapy is provided by two systematic sternal SSIs most often require lengthy hospitalizations, with nu-
reviews and two meta-analyses (Class I, Level B) [7, 42, 66, 67, merous procedures required for resolution of the infection. They
162–167]. do not have improved quality of life after surgery to the same de-
In Type 2 (relatively stable sternum with sufficient and viable gree as patients without sternal SSI.
bone stock), direct closure is proposed. This can be done with or Long-term outcome is negatively associated with DSWI. In a
without a bridge of conservative management with NPWT. The re- long-term study, the adjusted hazard ratio for all-cause mortality 10
cent reports are in favour of delayed closure, as the use of NPWT years after the primary operation in patients with deep sternal SSIs
allows better definition of the extent of the infection and better as- who survived the first 6 months was almost doubled. Furthermore,
sessment of sternal viability. Furthermore, antibiotic therapy can early sternal SSI increases the risk of late chronic infections [184].
be administered in the conservative phase of the treatment and Already established advantages of NPWT are both improved
surgical risks related to the debridement and closure can be miti- sternal stabilization and earlier mobilization of patients.
gated by a delayed approach [168–170] (Class I, Level B). However, it has been debated whether NPWT is indeed superior
In Types 3 and 4 there is sternal instability. The viability of to older techniques for the treatment of DSWI. A systematic re-
the sternum differentiates these two entities. In Type 3 (viable view of NPWT for various acute or chronic wounds concluded
sternum), sternal stabilization can be achieved with plates or that there was no evidence to support that NPWT was superior
clips [171–176]. Complete reconstruction can be achieved with to conventional treatment, and the authors called for more RCTs
or without the use of pectoral flaps or omentum (Class IIb, [44]. Randomized trials comparing NPWT and conventional treat-
Level B). ment are few and concerns about publication bias have been
For the above-mentioned reasons, delayed closure with bridge raised. Despite this lack of evidence, currently many institutions
therapy with topical negative pressure (TNP) seems a sensible ap- prefer NPWT for the treatment of sternal SSIs.
proach. Even when rewiring only is compared with rewiring and The overall cost of sternal SSI treatment is generally no higher
suction irrigation system, the outcome seems to be better with when NPWT is used than when conventional treatment is used.
the latter; a recent study showed the superiority of TNP system Mokhtari et al. [186] showed that the total cost of treatment was
Table 4: AMSTERDAM classification (Assiduous Mediastinal Sternal Debridement & Aimed Management) [10] Reproduced with per-
mission from Biomed Central
Type Sternal stability Bone viability and stock Reconstruction Staging of reconstruction
1 Stable Reasonable TNP Class I, Level B

2a Local muscle flap Primary (Class II, Level B)
2b Muscle or omentum flap Delayed (Class I, Level B)
3a Unstable Viable & sufficient Rewiring/osteosynthesis Primary delayed (Class IIb, Level B)
3b Rewiring/osteosynthesis and Muscle or omentum flap
4a Necrotic and insufficient Muscle flap Primary/delayed (Class IIb, Level B)
4b Omental flap
4c Muscle and omental flap
2.5 times higher for deep sternal SSI cases treated with NPWT (ii) demonstration of characteristic roentgenographic features;
than for non-SSI patients, which was similar to conventional treat- (iii) documentation of the necrotizing mediastinal infection at op-
ment. Although the material cost is often greater using NPWT, it is eration or post-mortem examination, or both; (iv) establishment
less laborious, as the wound is only changed two or three times a of the relationship of oropharyngeal or cervical infection, with
week, resulting in similar or even reduced total cost [187]. the development of the necrotizing mediastinal process.
The extent of infection directly affects the mortality rate, which
is around 10% in localized (above the tracheal carina) and 30% in
Summary of recommendation for prevention and diffuse disease (extending below the tracheal carina) [45].
management of post-sternotomy mediastinitis Descending necrotizing mediastinitis results from infections of
polymicrobial origin (most commonly Streptococcus and
In the absence of documented negative testing for staphylococ- Bacteroides species [188]), reflecting the process of oral bacteria
cal colonization, routine prophylactic topical mupirocin is rec- entering through disruptions of mucosal and tissue barriers and
ommended for 5 days spreading along the deep fascial planes, from the neck down-

(Class I, Level of Evidence A) ward into the mediastinum. The different anatomical neck spaces
A shower or bath using soap, either the day before or on the from which infection spreads to the mediastinum are the pretra-
day of surgery should be considered cheal and the retropharyngeal space, respectively.
(Class IIa, Level of Evidence B) The pretracheal space ends inferiorly at the pericardium and
A beta-lactam antibiotic as a single antibiotic of choice in pa- parietal pleura at carinal height. In about 8% of DNM cases this
tients without MRSA colonization is recommended space is a possible pathway for infections of the airways, i.e. epi-
(Class I, Level of Evidence A) glottitis/laryngitis and the thyroidea to the anterior and middle
For patients who are considered beta-lactam or penicillin aller- mediastinum. Odontogenic infections tend to spread posteriorly
gic or with proven or suspected MRSA colonization, vancomycin towards the vascular space and from there, in 12% of cases of
is recommended as the primary prophylactic antibiotic with add- DNM, further to the anterior mediastinum. The retropharyngeal
itional Gram-negative coverage space drains directly into the posterior mediastinum and is, with
(Class I, Level of Evidence B) an estimated incidence of 70%, one of the main spreading routes
It is recommended that administration of antibiotic prophy- especially for oropharyngeal infections in DNM [60]. However, as
laxis should be completed within 1 h of the skin incision and start each of these potential spaces contains loose areolar tissue that
of surgery lacks defence cells and is poorly vascularized, and therefore allows
(Class I, Level of Evidence A) the unopposed spread of any cervical infection along and across
Use of continuous IV insulin to achieve and maintain an early them, any cervical infection can potentially involve the entire
postoperative glycometabolic control is indicated to reduce the mediastinum. Downward spread is additionally facilitated by grav-
incidence of DSWI ity, breathing and negative intrathoracic pressure [46, 47, 190].
(Class I, Level of Evidence B) Other potential causes of DNM, besides dental infections and
Skeletonized IMA dissection is recommended in patients with common oropharyngeal infections such as tonsillitis and epiglot-
diabetes or when bilateral IMAs are harvested titis, include pharyngitis, primary neck infections (including post-
(Class I, Level of Evidence B) traumatic), cervical lymphadenitis, suppurative thyroiditis,
Negative pressure wound therapy is recommended either as a parotitis [191], traumatic endotracheal intubation (with DNM
destination or as a bridge prior to final surgical closure in cases usually occurring in the early postoperative period) and jugular
of post-sternotomy mediastinitis IV drug use/abuse [192].
(Class I, Level of Evidence B) Descending necrotizing mediastinitis appears to affect men as
The use of muscle or omental flap in case of sternal instability well as women with a mean age of around 50 years, but the dis-
or insufficient bone stock may be considered ease can affect patients from an age of a few months up to the
(Class IIb, Level of Evidence B) eighth decade [193].
History
OTHER TYPES OF MEDIASTINITIS Patients usually have experienced and present with symptoms
and signs of an oropharyngeal/odontogenic infection and fever.
Descending necrotizing mediastinitis Neck and chest pain together with dyspnoea are other potential
findings. Further course of the disease can be rather dramatic,
Background. Descending necrotizing mediastinitis describes an
rapidly evolving into systemic sepsis.
infection with its origin from a head and neck source, most com-
monly an oropharyngeal or odontogenic focus, which then
spreads in the fascial spaces of the head and neck and descends Diagnosis
downward into the mediastinum. The most common origins of Besides oropharyngeal examination, liberal use of contrast-
DNM infection include peritonsillar, dental or odontogenic enhanced cervicothoracic CT-scan [184] is essential for the early
abscesses. In general, the mortality rate is high, with reports rang- detection of DNM.
ing from 11% to 40% [45, 46] as mediastinal infection rapidly Typical CT features of DNM are increased density of the adi-
leads to sepsis and multiorgan failure if not treated early and pose tissues (>25 Hounsfield units), cervical lymphadenopathy,
appropriately. mediastinal fluid collections and pleural and/or pericardial fluid
The criteria for diagnosis of DNM established by Estrera et al. collections (Fig. 2). Furthermore, myositis and vascular throm-
[46] include: (i) clinical manifestations of severe infection; bosis can be seen [194].
decortications and debridement of the entire mediastinum.

Nevertheless, a clamshell incision is associated with significant
morbidity in these already compromised patients.
Sternotomy has the problem of limited access to the postero-
basal mediastinum, especially on the left side, which can be over-
come by single-lung ventilation (double lumen tube, bronchial
blocker), as well as using short-term apnoea or ventilation with
small tidal volumes if single-lung ventilation is not tolerated.
Possible reported adverse events after median sternotomy or
clamshell incision include phrenic nerve palsy, sternal dehiscence
or even sternal osteomyelitis. Although in the series reported by
POSITION STATEMENT
Kocher et al. [202] none of the 16 patients treated by median
sternotomy (n = 8) or clamshell (n = 8) suffered from any of these

Figure 2: CT-scan showing mediastinal air (arrows) and bilateral pleural effu- complications.
sions as a sign of anterior and posterior descending mediastinitis in a 33-year- As posterolateral thoracotomy is described as a standard ap-
old male patient with peritonsillar abscess. E: oesophagus; T: trachea. proach by some authors [49, 195, 204], others reported their ex-
perience with less-invasive approaches such as subxiphoidal
drainage or VATS drainage [205–207] similarly to the manage-
CT-scan can also be a helpful tool in identifying any clinically
ment of oesophageal perforations.
suspected progression or persistence of infection in the postop-
However, as addressed before, systematic debridement and
erative period [195–197].
broad opening of involved fascial spaces are essential in prevent-
ing persistent or even progressive disease, and with that, the
Management principles. Administration of IV broad-spectrum need for reoperation and the risk of severe complications [47–49,
antibiotics with coverage for aerobic and anaerobic bacteria as 190, 192, 197, 200, 208, 209]. Most studies that report less inva-
soon as possible is mandatory considering the high mortality sive approaches such as simple drainage [192] or VATS drainage
rates of up to 85% in the preantibiotic era [189]. In case of severe [205], or unilateral thoracotomy [186] show reoperation rates be-
sepsis and/or septic shock, early ICU admission for optimal man- tween 20% and 30%. Also unilateral thoracotomy and continuous
agement is strongly advisable. After treatment of the pharyngeal postoperative irrigation have been described, again with a reop-
or dental focus and airway management, prompt and adequate eration rate of 10% and an early mortality rate of 20% [196].
drainage of the neck and the mediastinum should be performed Obviously, each of the abovementioned techniques offers po-
[198, 199]. Airway compromise due to inflammatory oedema is a tential advantages and disadvantages, and presumably, the surgi-
common finding in DNM that should be anticipated and treated cal approach has to be carefully chosen according to the
with early tracheotomy, which can serve a dual role of opening patients’ condition, the extent of disease and the surgeons’ ex-
fascial planes and securing the airway. The surgical strategy is perience in order to maintain a low rate of complications, reop-
usually determined according to the expected extent of disease: erations and mortality.
For localized infection of the upper mediastinum above the tra- Comorbidities, especially of immunosuppressive character, i.e.
cheal carina, cervicotomy and transcervical drainage may be suf- diabetes, alcoholism, malnutrition, corticosteroid therapy and
ficient, whereas further downward spread should be treated by prior chemotherapy, might not only predispose to development
additional subxiphoidal drainage (in localized disease and stable of DNM but also lead to more complicated courses of the dis-
patients only) or even more aggressively by median sternotomy ease [45, 188, 190, 192–194].
and proper debridement of necrotic tissue [198]. The posterior
mediastinum can be accessed either by a clamshell approach,
Summary of recommendations for prevention and
uni-/bilateral thoracotomy and/or uni-/bilateral video-assisted
thoracoscopic surgery (VATS) in selected cases. As a general prin-
management of descending necrotizing mediastinitis.
ciple on which most authors agree [47–49, 190, 192, 200], opti- • Diagnosis is made by oropharyngeal examination and
mal treatment should include radical surgical debridement of contrast-enhanced cervicothoracic CT-scan (Class I, Level of
affected tissue, i.e. pericardial fat and thymic tissue, through an Evidence C).
open thoracic approach. Corsten et al. [190] were the first to • Immediate treatment with IV broad-spectrum antibiotics with
identify a statistically significant difference in survival in a meta- coverage for aerobic and anaerobic bacteria (Class I, Level of
analysis, between patients undergoing only transcervical medias- Evidence C).
tinal drainage (53%) and those receiving transthoracic medias- • Prompt surgical management is indicated including system-
tinal debridement (81%). Ten years later, Misthos et al. [48] atic debridement of affected tissue and broad opening of
showed that early combined transthoracic mediastinal and cer- involved fascial spaces:
vical debridement and drainage was the only favourable factor
1. Treatment of the pharyngeal or dental focus (Class I, Level
for survival compared with cervical drainage and/or transcervical
of Evidence C);
mediastinal drainage alone, in 27 patients with DNM extending
into the lower anterior mediastinum. 2. Airway management—tracheotomy maybe considered
Median sternotomy [48, 201, 202] is a fast and simple ap- (Class IIb, Level of Evidence C);
proach to the anterior mediastinum, whereas a clamshell ap- 3. Uni- or bilateral cervicotomy should be performed de-
proach [203] allows good exposure of the whole mediastinum, pending on the origin and extent of infection (Class IIa,
and both pleural cavities with the possibility of early bilateral Level of Evidence C);
4. Mediastinal management may include one or several of tachypnoea and dyspnoea) symptoms/signs of sepsis develop in
the following steps (Class IIb, Level of Evidence C): the later course of the disease.
• Transcervical drainage for confined disease of the upper Patients with spontaneous rupture (i.e. Boerhaave’s syndrome)
mediastinum; often have a history of alcoholism and/or gastric or duodenal
ulcer.
• Median sternotomy for main involvement of the anter-
Regardless of the aetiology, an oesophageal perforation is a
ior mediastinum;
surgical emergency, because leakage of oesophageal or gastric
• Uni-/bilateral thoracotomy or VATS in selected cases for contents into the mediastinum usually rapidly leads to sepsis,
involvement of the posterior mediastinum; multiorgan failure and death. Delay in diagnosis has a high im-
• Contained abscess formations in stable patients maybe pact on overall mortality, especially when the diagnostic delay is
only drained (e.g. transcervical and/or subxiphoidal for >24 h after perforation [51]. The rarity of the diagnosis and the
retrosternal abscess, VATS or CT-guided for pleural variability in clinical presentation are the main reasons for diag-
abscess). nostic–therapeutic delays. This is especially true for spontaneous

perforations where the clinical suspicion is low. In patients with
oesophageal perforation, the cornerstones of treatment are rapid
Mediastinitis after oesophageal perforation diagnosis, appropriate haemodynamic monitoring and support,
antibiotic therapy, restoration of luminal integrity and control of
Background. Depending on the aetiology and the course of dis-
extraluminal contamination.
ease, oesophageal perforations can be a diagnostic and thera-
peutic challenge. Mediastinitis can result from cervical as well as
from thoracic oesophageal perforations and is associated with Diagnosis
high mortality rates. Cervicothoracicabdominal contrast-enhanced CT-scan with add-
It has to be noted that this document mainly focuses on the itional oral contrast (water-soluble) is the diagnostic tool of
diagnosis and treatment of oesophageal perforation and not on choice—showing not only the extent of the oesophageal injury
oesophageal anastomotic leakage after oesophageal surgery. but also the extent of infection, including any mediastinal in-
The majority of perforations occurs at areas of physiologic nar- volvement. Additional oesophagoscopy might be necessary to as-
rowing, for example at the cricopharyngeus muscle or at the sess the exact extent of the perforation as well as to help with the
oesophagogastric junction. Approximately half of all oesophageal decision-making for the optimal treatment. When performing
perforations are iatrogenic and most of them occur during endo- oesophagoscopy in a patient with suspected oesophageal perfor-
scopic procedures [50, 213]. The incidence of perforation from ation, air insufflation should be strictly avoided because this may
simple endoscopy is <0.5%, but with additional pneumatic dilata- cause further dissection of the perforation.
tion for achalasia the incidence increases to rates of approxi-
mately 6% [214]. Especially interventions that involve the use of
rigid oesophagoscopy seem to be associated with an increased Management principles. The patient is made nil by mouth
risk of iatrogenic perforation [215]. A common location of perfor- and should undergo aggressive fluid resuscitation along with IV
ation from endoscopy as well as from foreign body ingestion, broad-spectrum antibiotics covering aerobic and anaerobic bac-
which is the reason for perforation in approximately 12% of pa- teria. Antifungal coverage is only advisable in selected cases (e.g.
tients, is at the first narrowing at the cricopharyngeus muscle patients in an immunosuppressive state or patients who already
[216]. When oesophageal dilatation is performed, the location is were under broad-spectrum antibiotics prior to perforation).
often proximal to or at the stricture [50]. Furthermore treatment with a proton pump inhibitor should be
Spontaneous perforation (Boerhaave’s syndrome) accounts for initiated to control acid reflux [52, 217].
15% of perforations, which are usually located at the left postero- In general a specialist multidisciplinary approach, considering
lateral aspect of the distal oesophagus. Other causes for oesopha- the patients’ condition on one hand and the particular character-
geal perforation include trauma in 9% (blunt or penetrating), istics and dynamics of the oesophageal perforation on the other
intraoperative injury (2%) or malignancy (1%) [213]. hand, is the key to an optimal treatment [215, 218–223].
Once a perforation occurs, saliva, retained gastric contents, Over time a clear treatment shift towards less invasive treat-
bile and acid may enter the mediastinum and result in mediasti- ment options can be observed [52, 215, 217–223].
nitis. As the midoesophagus lies adjacent to the right pleura and
the distal oesophagus is next to the left pleura, perforations at
Surgical technique. Primary repair of the perforation site is
these locations usually directly lead to collections in the respect-
warranted whenever possible, even if the diagnosis is delayed
ive pleural cavity.
>24 h [220], but the likelihood for breakdown of the repair is con-
sidered to increase substantially with a diagnostic delay >72 h
History [224]. Exceptions from primary repair include cervical perfor-
A history of endoscopy in a patient with neck and/or chest pain ations that cannot be visualized/accessed (see ‘drainage only’),
in combination with fever is suggestive of an iatrogenic oesopha- diffuse mediastinal necrosis and/or large perforations without the
geal perforation with possible mediastinal involvement. On the possibility of reapproximation, oesophageal malignancy, end-
other hand, in patients with spontaneous perforation diagnosis stage benign oesophageal disease (e.g. achalasia), or if the patient
may be more difficult because the clinical presentation is highly is clinically unstable [225–227].
dependent upon the size and location of the injury and the time For primary repair, the affected mediastinal tissue is debrided,
after occurrence of the injury. Although in the early phase after the pleural space(s) are cleaned and the lung decorticated if ne-
spontaneous perforation, symptoms are often unspecific (e.g. cessary. Then, devitalized tissue at the perforation site is debrided
fever, chest pain, past or ongoing vomiting, tachycardia, and the muscular layer is incised longitudinally along the muscle
fibres superior and inferior to the perforation to expose the en- Nonoperative management. Nonoperative management in
tire extent of the mucosal injury. If possible, the mucosa is closed terms of medical treatment only is generally only possible in
separately with absorbable interrupted sutures and the muscula- small iatrogenic or rarely in traumatic injuries, which are often
ris layer is closed with interrupted nonabsorbable sutures. diagnosed at the time of occurrence or shortly thereafter and are
Otherwise, the defect is simply closed with full-thickness inter- associated with only minimal extraluminal contamination. The
rupted nonabsorbable sutures. The repair site should be cornerstone of nonoperative management is careful patient se-
enhanced with the use of a vascularized pedicled flap (e.g. inter- lection, wherewith an almost 100% survival rate can be achieved.
costal muscle, diaphragm, omentum or gastric fundus—depend- Iatrogenic cervical perforations are most commonly suitable for
ing on the location of the suture line), especially when there has nonoperative management due to the anatomical confinement
been a delay in diagnosis and/or substantial extraluminal con- of the oesophagus by the surrounding structures.
tamination was present [214]. In patients with more extensive, but still contained leakage, a
POSITION STATEMENT
As the anatomical structures of the neck typically confine more aggressive management including endoscopic intervention
extraluminal contamination to a limited space, cervical perfor- with or without percutaneous or even surgical drainage might be

ations are typically more easily treated than perforations of the necessary [53].
thoracic or intra-abdominal oesophagus. The cervical oesopha-
gus is best approached via a left cervical incision and can be Endoscopic stent placement
managed by drainage and primary repair. If the cervical perfor-
Oesophageal endoscopic covered stents can be useful for the
ation cannot be visualized, simple drainage is often sufficient to
management of an oesophageal perforation in selected patients
allow healing of the perforation, in the absence of any distal ob-
[53, 229]. However, precise stent placement can only restore lu-
struction [53].
minal integrity and prevent further extraluminal soilage. Control
and drainage of the extraluminal contamination are crucial for
Thoracic perforation—special considerations effective management of the oesophageal perforation. In a retro-
The level of the perforation of the thoracic oesophagus and the spective review of 191 patients by Freeman et al. the main inde-
site of pleural contamination determines the surgical approach pendent risk factors for stent failure were location of the injury in
to controlling the leak and repairing the perforation. A the proximal cervical oesophagus or injuries traversing the gas-
midoesophageal perforation is usually approached through a tro-oesophageal junction (no distal ‘anchoring’ because the distal
right thoracotomy, whereas a distal oesophageal perforation is end of the stent lies in the stomach) and length of injury longer
approached through a left thoracotomy. than 6 cm [230]. The most common complication is stent migra-
During thoracotomy an intercostal muscle flap as a potential tion (especially when used in close proximity to the gastro-
buttress of a primary repair can already be prepared. Pulmonary oesophageal junction) and stent obstruction.
decortication is performed if exudate and debris are present to When comparing plastic and metallic stents, stent migration
facilitate adequate lung expansion. A nasogastric tube is guided rates with the need for reintervention are significantly higher
past the site of repair and into the stomach, taking care to avoid with plastic stents, whereas metallic stents (especially partially
damaging the repair site. A jejunostomy feeding tube can be in- covered stents) show a significantly higher incidence of tissue in-
serted by a minilaparotomy procedure at the time of the growth and postoperative strictures [53].
oesophageal repair. This is particularly important if significant The basic principles of oesophageal stent implantation are as
extraluminal contamination is present (in anticipation of a pro- follows:
longed intensive care unit admission) or in patients who already
suffer from malnutrition. 1. Endoscopy to localize the perforation and measure the
length of the injury;
Postoperative management 2. If a percutaneous endoscopic gastrostomy tube placement is
considered, this should be performed prior to stenting (with
Patients should be kept nil by mouth for an adequate period
minimal insufflation), in order to prevent accidental stent
(i.e. at least 5 days). Jejunal tube feedings should be started 48–
dislocation;
72 h postoperative in stable patients without evidence of an
ileus. Broad-spectrum antibiotics are continued for 7–10 days 3. A covered stent, measuring at least 4 cm longer than the size
depending on the patients’ condition. A contrast oesophago- of the injury (allowing a proximal and distal overlap of at least
gram should be obtained around postoperative day 7, if the pa- 2 cm), is placed under fluoroscopic and endoscopic control;
tient is clinically stable. If there is no evidence of an 4. Debridement of the mediastinum and drainage of extralumi-
oesophageal leak or postoperative ileus, the nasogastric tube nal contamination;
can be removed and oral feedings initiated. Drains remain in 5. Postoperative contrast oesophagography to assess efficacy of
place until patients are tolerating oral feedings without any clin- stenting (correct placement and no/only minimal leakage).
ical evidence of a leak.
Endoscopic vacuum-assisted closure system
Alternatives to primary surgical repair
Negative pressure wound therapy is a well-established treatment
Whenever nonoperative management is advocated, patients method for superficial wounds that in recent years also has be-
need to be under close surveillance in order to detect any signs come more and more popular for the treatment of oesophageal
of clinical deterioration (e.g. fever, tachycardia) indicating that anastomotic leakage [231, 232]. The vacuum system is introduced
the patient might require surgical intervention to control extralu- endoscopically either into the paraoesophageal cavity or, in case
minal contamination and to restore luminal integrity. of a small orifice, at the level of the oesophageal leakage and
connected to a portable pump. The negative pressure therapy Concerning diagnostic delay a recent meta-analysis of 75 studies
continuously removes wound secretion as well as interstitial showed that overall mortality rates for diagnosis within 24 h is sig-
oedema and improves microcirculation, resulting in an acceler- nificantly lower compared with a >24 h delay (7.4% vs 20.3%) [55].
ated formation of granulation tissue and thus closure of the in-
fected internal wound. Experience with this novel method is
growing fast and its application shows promising results also for
the treatment of oesophageal perforation [54]. In case of larger
oesophageal defects, endoscopic VAC (E-VAC) can furthermore Summary of recommendations for diagnosis and
be combined with oesophageal stenting if necessary [231]. treatment of oesophageal perforation.
Importantly, vacuum therapy in general has to be accompanied
by proper cleansing and drainage of the extraluminal contamination. • ‘Cervicothoracoabdominal CT-scan’ with IV and oral contrast
is the diagnostic tool of choice and is preferentially performed
Drainage only prior to ‘oesophagoscopy’ (without air insufflation) (Class I,

Surgical drainage as the sole operative management is reserved for Level of Evidence C).
perforations of the cervical oesophagus when the perforation site • ‘Rapid diagnosis and treatment with a multidisciplinary ap-
cannot be completely visualized and when there is no distal ob- proach’ should be initiated in order to avoid high complica-
struction. Furthermore drainage only can be an option for small, tion and mortality rates (Class IIa, Level of Evidence C).
contained perforations of the thoracic oesophagus in stable pa- • ‘The two main principles of treatment’ include control of
tients. Drainage placement can either be performed CT-guided or oesophageal leakage and drainage/debridement of extralumi-
during thoracoscopy/thoracotomy for lavage of the hemithorax.
nal contamination:
• ‘Primary repair’ of the oesophageal perforation is recom-
mended whenever possible within the first 72 h after per-
Oesophagectomy. Primary repair is not advisable if there is
foration (Class I, Level of Evidence C).
perforated ulcerative cancer or a perforation proximal to un-
treated achalasia, an undilatable stricture or malignancy. In these • ‘Nonoperative, medical treatment’ should be reserved for
cases oesophagectomy with primary reconstruction can be per- clinically stable patients with only small contained perfor-
formed in highly selected and clinically stable patients with only ations (no drainage into pleura or peritoneum) and without
minimal contamination, otherwise diversion is often more advis- evidence of systemic inflammation (Class IIa, Level of
able [233]. Evidence C).
• ‘Drainage alone’ should be used for perforations of the cer-
vical oesophagus which cannot be visualized, but only in
Diversion. Diversion should be considered in unstable patients the absence of any distal obstruction (Class IIb, Level of
and/or if repair is not possible due to the size of the defect and Evidence C).
the friability of the surrounding tissue. This is particularly true in • ‘Oesophageal stenting in combination with pleural/medias-
the presence of a necrotic gastric tube after oesophagectomy. tinal drainage’ maybe be considered in haemodynamically
Diversion includes debridement and drainage of extraluminal
stable cases with a contained leakage from the oesophagus
contamination, left-sided externalization of the cervical oesopha-
in the early course after perforation (<24 h).
gus (i.e. cervical oesophagostomy), resection of the affected part
of the oesophagus, gastrostomy tube and/or positioning of a – Stable patients with early uncontained leakage may
jejunostomy feeding tube and finally the closure of the diaphrag- profit from stenting in combination with thoracoscopy
matic hiatus. for pleural lavage and drain placement
If the patient is haemodynamically unstable and critically ill, – Stenting may replace or bridge to definitive surgery in
adequate drainage and a diversion without an oesophageal re- patients with extensive comorbidities and the inability
section can be performed until the patient is stabilized in order to tolerate more extensive surgery (Class IIb, Level of
to allow definitive operative management. Evidence C).
Reconstruction of the oesophagus is typically performed after • Endoscopic vacuum-assisted closure system
full recovery, around 6–12 months after the perforation.
Restoration of alimentary tract continuity often requires a retro- E-VAC might be helpful in selected patients not only for small but
sternal colon interposition [234]. also for larger perforations in the absence of malignancy, if extra-
luminal contamination is controlled (either drained, surgically
controlled or contained leakage) (Class IIb, Level of Evidence C).
Outcome. The most common cause of death is sepsis leading to • ‘Oesophagectomy’ may be proposed in the presence of
multiorgan failure. The main variables associated with mortality oesophageal malignancy or in case of irrepairable extensive
are location and aetiology of the perforation on one hand, and
oesophageal damage (Class IIb, Level of Evidence C).
delay in diagnosis on the other hand. Concerning aetiology, mor-
• ‘Diversion’ may be an option when all of the above-men-
tality rates are described to be 15% for spontaneous perforation
(where diagnosis is frequently delayed), 13% for iatrogenic and tioned treatment possibilities have been exhausted; espe-
2% if secondary to foreign bodies. When differentiating between cially when patients present with clinical instability and
the location sites of the perforation, mortality rates are reported cannot tolerate an extensive operative procedure, or in
as follows: 6% in cervical (tissue planes limit spread of contamin- cases of extensive oesophageal damage not amenable to
ation) and 11% in thoracic perforations [55]. primary repair (Class IIb, Level of Evidence C).
Chronic fibrosing mediastinitis

Introduction. Chronic fibrosing mediastinitis or ‘sclerosing media-
stinitis’ is a more indolent form of mediastinitis and usually occurs as
a complication of granulomatous infections, most commonly due to
Histoplasma capsulatum or even more rarely Mycobacterium tuber-
culosis [235]. Histoplasma capsulatum is a dimorphic fungus that is
commonly found in soil that contains large amounts of bird or bat
droppings. It is not only prevalent in the USA (especially in the Ohio
and Mississippi River valleys) but also in parts of Central and South
America, Africa, Asia and Australia. In Europe the disease is excep-
POSITION STATEMENT
tionally rare. An infection with H. capsulatum is sub-clinical in the
vast majority of patients and begins as an asymptomatic pulmonary

infection, which then disseminates to the mediastinal lymph nodes.
The involved mediastinal lymph nodes can enlarge and coalesce
into an inflamed caseous mass (i.e. mediastinal granuloma) or can
lead to a sclerosing process (i.e. fibrosing mediastinitis). Although
mediastinal granuloma is discovered either incidentally or because it
compresses mediastinal structures such as the SVC, airways or the
oesophagus, fibrosing mediastinitis mainly leads to a progressive ob-
struction of the airways and great vessels (especially the SVC).
Fibrosing mediastinitis is believed to result from leakage of fungal
antigens from lymph nodes into the mediastinal space, leading to
an immunogenic reaction followed by an exuberant fibrotic re-
sponse [235]. It is a slowly progressive disease with a variable nat-
ural history. The mean interval between the development of
symptoms and death is reported to be <6 years in most reported
series, and death most frequently results from cor pulmonale or re-
lentless respiratory compromise due to recurrent infection, bron-
chial obstruction or haemoptysis [56, 236]. Nevertheless it has to be
noted, that the outcome reported in the literature may be worse
than in reality, because it is most likely associated with the prefer-
ential reporting of more severe cases in the medical literature.
Figure 3: (A) Phlebography showing complete obliteration of the SVC with
complete bilateral subclavian vein occlusion (arrows) in a 60-year-old female
History. The signs and symptoms of fibrosing mediastinitis de- patient suffering from chronic fibrosing mediastinitis. (B) After percutaneous
pend upon which structures of the mediastinum are involved transluminal stent implantation into the brachiocephalic vein with unob-
structed flow from the left subclavian vein into the SVC (arrows mark the ends
and the degree to which those structures are compromised. of the stent). SVC: superior vena cava.
Typical complications result from compromise of the airways,
heart and great vessels, or oesophagus. Airway compression can
lead to postobstructive pneumonia or atelectasis, most com- fibrosis and calcification with a high risk of bleeding from enlarged
monly occurring in the right upper lobe [237]. Heart and great collateral vessels. Serologic studies are of limited benefit because
vessel involvement can cause pulmonary artery and/or pulmon- they frequently fail to establish the diagnosis.
ary vein obstruction, constrictive pericarditis, or SVC syndrome.
SVC obstruction due to fibrosing mediastinitis typically develops
Management. There is no curative therapy for fibrosing mediasti-
slowly over a period of years, allowing the formation of an exten-
nitis and antifungal agents are generally ineffective, although several
sive collateral circulation that may be adequate to prevent both
case reports have suggested a potential benefit [56, 239, 240, 242].
stasis and elevated pressure in the tributaries of the SVC [56,
Glucocorticoids also do not appear to be generally beneficial, al-
238]. SVC obstruction is less common than tracheobronchial nar-
though controlled trials have not been performed [56, 243]. A pos-
rowing [56, 239]. Oesophageal compression can lead to dyspha-
sible exception is autoimmune fibrosing mediastinitis, which often
gia and/or odynophagia. Haemoptysis may also occur in
presents in a rather diffuse than localized pattern, and has been
fibrosing mediastinitis as a consequence of fibrous tissue invasion
shown to respond more favourably to glucocorticoid therapy, al-
of a bronchus, postobstructive necrotizing pneumonia or ob-
though these cases are difficult to identify [236].
struction of pulmonary venous return.
Surgery can be performed in highly selected cases to relieve
airway, vascular and/or oesophageal obstruction, as well as man-
Diagnosis. Chest CT-scan may show an infiltrative process in the aging tracheo-oesophageal fistula [238, 243]. However, extensive
mediastinum and can exclude malignancy. Typical findings are calci- fibrosis, calcification and collateral vascularization may limit the
fications within a mediastinal process in combination with calcified benefits of surgery and are associated with substantial morbidity
lymph nodes and splenic calcifications [56, 240, 241]. Other findings and mortality [56, 238, 243].
are vascular occlusion with collateral blood flow around obstructed Airway and vascular stents have been used to treat airway obstruc-
vessels, thickened interlobular septa and tracheobronchial narrowing tion and SVC obstruction, respectively [244–247], but it seems that
[239, 241]. Biopsies may be hazardous in the presence of dense there is a frequent need for reintervention in these patients (Fig. 3).
The same is true for oesophageal dilatation, which usually has to be [10] van Wingerden JJ, Ubbink DT, van der Horst C, de Mol B.
performed repeatedly. In case of an already fully occluded SVC, by- Poststernotomy mediastinitis: a classification to initiate and evaluate
reconstructive management based on evidence from a structured review
pass surgery to the SVC has been successfully performed for symp- J Cardiothorac Surg 2014;9:179.
tomatic patients with SVC obstruction [57]. [11] Loop FD, Lytle BW, Cosgrove DM, Mahfood S, McHenry MC,
Goormastic M, et al. J. Maxwell Chamberlain memorial paper. Sternal
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early and late mortality, morbidity, and cost of care. Ann Thorac Surg
Summary of recommendations for chronic fibrosing 1990;49:179–86; discussion 186–7.
[12] Wouters R, Wellens F, Vanermen H, De Geest R, Degrieck I, De Meerleer
mediastinitis.
F. Sternitis and mediastinitis after coronary artery bypass grafting.
• Diagnosis is made by ‘Chest CT’, which may show an infiltra- Analysis of risk factors. Tex Heart Inst J 1994;21:183–8.
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risk factors identified by multivariate analysis for patients undergoing
fied mediastinal lymph nodes
coronary artery bypass graft surgery. Infect Control Hosp Epidemiol
• (Class IIa, Level of Evidence C). 2002;23:372–6.

• Biopsy specimens may show signs of Histoplasmosis infection [14] Horan TC, Andrus M, Dudeck MA. CDC/NHSN surveillance definition
of health care-associated infection and criteria for specific types
or only mature collagen formations. Biopsy may be omitted if
of infections in the acute care setting. Am J Infect Control 2008;36:
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Ann Thorac Surg 2005;80:2205–12.
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[18] van Rijen MML, Bonten M, Wenzel RP, Kluytmans JA. Intranasal mupiro-
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European Journal of Cardio-Thoracic Surgery 51 (2017) 10–29 POSITION STATEMENT

doi:10.1093/ejcts/ezw326 Advance Access publication 12 December 2016

European Association for Cardio-Thoracic Surgery expert consensus

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Table 1: Methodology checklist Table 3: Classes of recommendations

Yes No Classes of Definition

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• Patient has at least one of the following signs or symptoms:

• Purulent drainage from mediastinal area;

The definition of post-sternotomy mediastinitis by van

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Diagnosis organism to others. Topical mupirocin is the most commonly

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1 Stable Reasonable TNP Class I, Level B

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decortications and debridement of the entire mediastinum.

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Chronic fibrosing mediastinitis

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