Review of the practical manual for physicians «Mediastinitis» by M. M. Abakumov (Moscow, MK, 2020: 296. (In Russ.))

A review of the manual for physicians «Mediastinitis» published in 2020, written by the famous Russian surgeon and scientist Professor Mikhail Mikhailovich Abakumov, is presented. The manual is based on the study of pathogenesis and practical experience in the diagnosis and treatment of patients with various forms of mediastinitis at the Sklifosovsky Research Institute for Emergency Medicine for 40 years. Sections of the manual include the history of the problem, terminology and classification issues, pathogenesis, clinical presentation and diagnosis, surgery and postoperative treatment of mediastinitis. The manual is intended for a wide range of surgeons who may be involved in acute mediastinitis diagnosis and treatment.

Pancreatic enzymatic mediastinitis followed by total gastrectomy with splenectomy: report of two cases

Background Acute mediastinitis is a rare disease that rapidly progresses with a high mortality rate. Its most common cause is direct injury of the mediastinum, including iatrogenic causes such as cardiac surgery or upper endoscopy. Enzymatic mediastinitis is a rare complication of a pancreatic fistula caused by the inflammatory digestion of the parietal peritoneum spreading to the mediastinum. Here, we present two cases of enzymatic mediastinitis caused by total gastrectomy with splenectomy. One of them was successfully treated and cured after early diagnosis and transabdominal drainage. Case presentation Case 1 was that of a 60-year-old man (body mass index [BMI] 27) with a medical history of diabetes and hypertension who was diagnosed with advanced gastric cancer in the upper body of the stomach. A total gastrectomy with splenectomy was performed. The patient experienced acute respiratory failure 24 h after surgery. Pulmonary embolism was suspected, so a computed tomography (CT) scan was performed; however, no relevant causes were found. Although he was immediately intubated and treated with catecholamine, he died in the intensive care unit (ICU) 40 h after surgery. Post-mortem findings revealed retroperitonitis caused by a pancreatic fistula spreading towards the mediastinum, causing severe mediastinitis; a review of the CT scan revealed pneumomediastinum. We concluded that the cause of death was enzymatic mediastinitis due to post-gastrectomy pancreatic fistula. Case 2 involved a 61-year-old man (BMI 25) with a medical history of appendicitis who was diagnosed with advanced gastric cancer at the gastric angle between the lesser curvature and the pylorus, spreading to the upper body of the stomach. A total gastrectomy with splenectomy was also performed. The patient had a high fever 3 days after the surgery, and a CT scan revealed pneumomediastinum, indicating mediastinitis. As the inflammation was below the bronchial bifurcation, we chose a transabdominal approach for drainage. The patient was successfully treated and discharged. Conclusion Acute mediastinitis caused by gastrectomy is rare. The acknowledgment of abdominal surgery as a cause of mediastinitis is important. In treating mediastinitis caused by abdominal surgery, transabdominal drainage may be a minimally invasive yet effective method if the inflammation is mainly located below the bifurcation of the trachea.

Acute mediastinitis associated with tracheobronchial tuberculosis and aspergillosis: a case report and literature review

Acute mediastinitis (AM) is a rare but life-threatening disease. Here, we report a case of AM secondary to endobronchial tuberculosis (EBTB) and pseudomembranous Aspergillus tracheobronchitis (PMATB) co-infection. EBTB was confirmed by tissue culture for Mycobacterium tuberculosis and GeneXpert MTB/RIF (Cepheid, Sunnyvale, CA, USA) detection (simultaneous detection of M. tuberculosis and resistance to rifampin) using endobronchial biopsies; PMATB was confirmed by histopathology. Even with antibiotic treatment and systemic support treatment, the patient died of massive hemoptysis on day 10 after admission. When immunocompromised hosts have AM, especially with central airway involvement, EBTB and aspergillosis should be considered potential causes. Bronchoscopy is helpful for rapid diagnosis and administering precise treatment.

THE ANALYSIS OF RENDERING ASSISTANCE BY A SICK ACUTE DESCENDING MEDIASTINITIS

Summary. Objective — to lead the analysis of diagnostics and treatment of patients with an acute descending mediastinitis for improvement of results of their treatment. Materials and methods. The analysis of results of treatment of 34 patients is presented by an acute mediastinitis. Patients with a descending mediastinitis made up — 61,8 % (21). The reasons of it became dontogenous phlegmons — 8 (23,5 %) and phlegmons of a neck owing to nonspecific lymphadenites and paratonsillar abscesses — 13 (38,2 %) Results. For a while from the beginning of disease up to a mediastinotomy the choice of additional methods of research influenced: at carrying out of roentgenography it has made (11,0±2,3) day, at carrying out of a computer tomography — (4,0±0,5) day. The lethality among group of a descending mediastinitis made up 19,0 % (4 patients). Direct authentic correlation of a lethality and augmentation of a leukocytic index of an intoxication (LII) in 10 days after operative treatment noted. Conclusions. The computer tomography is most diagnostically valuable (up to 100 %) research in monitoring a condition of the patient at stages of his treatment. The leukocytic index of an intoxication can serve as accessible supervising and prognostic criterion of a condition of the patient at an acute mediastinitis.