Endoscopic debridement of paraesophageal, mediastinal abscesses: a prospective case series

• Published in: Gastrointestinal endoscopy 2005-09, Vol.62 (3), p.344-349
• Main Authors: Wehrmann, Till, MD, Stergiou, Nikos, MD, Vogel, Bernd, MD, Riphaus, Andrea, MD, Köckerling, Ferdinand, MD, Frenz, Markus B., MD
• Format: Article
• Language: English
• Subjects: Abscess - diagnostic imaging; Abscess - surgery; Adult; Aged; Bacterial diseases; Bacterial diseases of the respiratory system; Biological and medical sciences; Cohort Studies; Debridement - methods; Endosonography - methods; Esophageal Perforation - complications; Esophageal Perforation - diagnostic imaging; Esophagoscopy - methods; Esophagus; Feasibility Studies; Female; Follow-Up Studies; Gastroenterology and Hepatology; Gastroenterology. Liver. Pancreas. Abdomen; Human bacterial diseases; Humans; Infectious diseases; Male; Mediastinal Diseases - diagnostic imaging; Mediastinal Diseases - etiology; Mediastinal Diseases - surgery; Medical sciences; Middle Aged; Minimally Invasive Surgical Procedures - methods; Prospective Studies; Risk Assessment; Treatment Outcome
• ISSN: 0016-5107; 1097-6779
• DOI: 10.1016/j.gie.2005.03.001

Background Mediastinal abscesses after esophageal perforation or postoperative leakage nearly always require surgical intervention. Methods Patients with paraesophageal abscesses were treated with EUS-guided or endoscopic mediastinal puncture if the abscess was >2 cm and sepsis was present. Abscess cavities were entered with a 9.5-mm endoscope after balloon dilation to allow irrigation and drainage. Debris was removed with a Dormia basket. Concomitant pleural effusions were treated with transthoracic drains. Patients received intravenous antibiotics and enteral/parenteral nutrition. Results Twenty patients fulfilled the entry criteria. Simple drainage was sufficient in 4 cases, and puncture was impossible in one case. Of the 15 treated patients (age 39–76 years, 5 women) the etiology of perforation was Boerhaave's syndrome (n = 8), anastomotic leak (n = 3), and iatrogenic perforation (n = 4). Debridement was successful in all cases and required a median of 5 daily sessions (range 3-10). All patients became apyrexial, with a C-reactive protein < 5 mg/dL within a median of 4 days (range 2-8 days). Esophageal defects were closed with endoclips (n = 7), fibrin glue (n = 4), metal stents (n = 1), or spontaneously healed (n = 3). One patient died from a massive pulmonary embolism one day after successful debridement (mortality 7%). No other complications were seen. Median follow-up was 12 months (range 3-40 months). Conclusions Nonoperative endoscopic transesophageal debridement of mediastinal abscesses appears safe and effective.