Treatment of Acute Mediastinitis Resulting from Oesophageal Perforation (Cervical or Thoracic)
Clinical Scenario
Oesophageal Perforation
This protocol addresses acute mediastinitis arising specifically from oesophageal perforation, which may occur at the cervical or thoracic level. Mediastinitis can result from either site and carries high mortality rates.
The presentation typically includes neck and/or chest pain combined with fever. A history of recent endoscopy in this setting is suggestive of iatrogenic oesophageal perforation with possible mediastinal involvement.
Management Approach
When primary repair of the oesophageal perforation is not possible, the protocol outlines several alternative interventional strategies — including endoscopic, surgical, and hybrid drainage approaches — selected according to the site of perforation, haemodynamic status, and underlying oesophageal condition.
The complete algorithm, including selection criteria, sequencing, and specific indications for each approach, is 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.
- Oesophageal endoscopic covered stents can be useful for the management of an oesophageal perforation in selected patients.
- ‘Oesophageal stenting in combination with pleural/mediastinal drainage’ maybe be considered in haemodynamically stable cases with a contained leakage from the oesophagus in the early course after perforation (<24 h).
- ‘Drainage alone’ should be used for perforations of the cervical oesophagus which cannot be visualized, but only in the absence of any distal obstruction (Class IIb, Level of Evidence C).
- ‘Oesophagectomy’ may be proposed in the presence of oesophageal malignancy or in case of irrepairable extensive oesophageal damage (Class IIb, Level of Evidence C).
- ‘Diversion’ may be an option when all of the above-mentioned treatment possibilities have been exhausted; especially when patients present with clinical instability and cannot tolerate an extensive operative procedure, or in cases of extensive oesophageal damage not amenable to primary repair (Class IIb, Level of Evidence C).
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