Treatment of Acute Mediastinitis Resulting from Oesophageal Perforation with Neck or Chest Pain and Fever
Mediastinitis arising from oesophageal perforation — whether at the cervical or thoracic level — carries high mortality. When neck or chest pain and fever follow a procedure such as endoscopy, mediastinal involvement must be considered and a structured management plan initiated without delay.
Clinical Scenario
This protocol applies to acute mediastinitis resulting from oesophageal perforation (cervical or thoracic), presenting with neck and/or chest pain and fever. A history of endoscopy in a patient with these findings is suggestive of an iatrogenic oesophageal perforation with possible mediastinal involvement.
Approach Overview
The structured protocol centres on surgical intervention directed at the oesophageal perforation site, encompassing management of the surrounding mediastinal tissue and reinforcement of the repair. The complete algorithm, timing parameters, technique selection, and step-by-step guidance are available in the full protocol →
References
DOI: 10.1093/ejcts/ezw326
- Mediastinitis can result from cervical as well as from thoracic oesophageal perforations and is associated with high mortality rates.
- A history of endoscopy in a patient with neck and/or chest pain in combination with fever is suggestive of an iatrogenic oesophageal perforation with possible mediastinal involvement.
- Primary repair of the perforation site is warranted whenever possible, even if the diagnosis is delayed >24 h, but the likelihood for breakdown of the repair is considered to increase substantially with a diagnostic delay >72 h.
- The repair site should be enhanced with the use of a vascularized pedicled flap (e.g. intercostal muscle, diaphragm, omentum or gastric fundus—depending on the location of the suture line), especially when there has been a delay in diagnosis and/or substantial extraluminal contamination was present.
- 'Primary repair' of the oesophageal perforation is recommended whenever possible within the first 72 h after perforation (Class I, Level of Evidence C).
View source ↗