Endoscopic transcervical mediastinal drainage for treating descending necrotizing mediastinitis.

INTRODUCTION

Descending necrotizing mediastinitis (DNM) is a severe complication of deep neck infection when the mediastinum is involved. Currently, the optimal surgical treatment for DNM, especially for Endo IIA DNM, has not been defined. We aimed to describe a standardized ETMD procedure emphasizing safe catheter placement into the main mediastinal abscess cavities and to evaluate its association outcomes compared with non-ETMD approaches in patients with DNM.

METHODS

This multicenter retrospective cohort study included adult patients (≥ 18 years) diagnosed with descending necrotizing mediastinitis (DNM) secondary to deep neck infection between 2008 and 2024. Patients who received incomplete treatment or were unable to undergo surgery were excluded. Clinical, laboratory, and imaging data were collected. Surgical management was classified as endoscopic transcervical mediastinal drainage (ETMD) or non-ETMD. The primary outcome was the requirement for secondary drainage. Secondary outcomes included hospital stay, drainage duration, and major complications. Statistical analyses were performed using t-tests, Mann-Whitney U tests, chi-square tests, and multivariable models where appropriate. Multivariable regression and supplementary inverse probability of treatment weighting (IPTW) analyses were performed to adjust for potential confounding.

RESULTS

Among 95 patients enrolled, 49 received ETMD. The secondary drainage rate was significantly lower in patients who received ETMD (10.2% vs. 43.5%; risk difference, -33.3%; 95% CI, -49.9% to -16.6%; P < 0.001). After IPTW adjustment, ETMD remained associated with a lower risk of secondary drainage (OR = 0.184; 95% CI, 0.050-0.677; P = 0.013). In the exploratory Endo IIA subgroup analysis, ETMD reduced secondary drainage rate and shortened selected perioperative recovery measures.

CONCLUSION

In this multicentre retrospective cohort, ETMD reduced the requirement for secondary drainage in patients with DNM, particularly in the exploratory Endo IIA subgroup analysis. These findings suggest that ETMD may be a potential minimally invasive approach for selected patients, but further prospective studies are needed to validate its role.

LEVEL OF EVIDENCE: Level III.