Enzymatic mediastinitis as a fearsome complication of pancreatic necrosectomy

Abstract

Several types of thoracic complications can be associated with severe acute pancreatitis. Some are very common, such as pleural effusion, whilst some others are very rare although life threatening, such as enzymatic mediastinitis (EM). Only a few cases of EM (when related to acute pancreatitis) have been described in the literature. Here we describe the case of a 76-year-old female who developed acute respiratory failure and atrial fibrillation during the postoperative period after an open pancreatic necrosectomy, due to an EM episode. The mediastinal collection was drained by thoracotomy, following an improvement of the patient's general condition. This is the first case of EM following surgical management for acute necrotizing pancreatitis. EM is a rare but life threatening complication that usually requires surgery.

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

“…Considering these, enzymatic mediastinitis is classified as ascending mediastinitis. More specifically, digestion of the parietal peritoneum by pancreatic enzymes and the passage of inflammation to the thoracic cage through the esophageal or aortic hiatus has been suggested as its possible mechanism [6,7]. This is generally associated with acute pancreatitis [7].…”

“…In reviewing the available literature on enzymatic mediastinitis, chronic pancreatitis was the reported main cause. As such, conservative management was first attempted, but surgical drainage of the mediastinum and abdominal control of the pancreatic leak such as endoscopic retrograde cholangiopancreatography (ERCP) were eventually required [6,7].…”

“…Descending mediastinitis Transcervical or transthoracic debridement Antibiotics [9] Direct mediastinitis Transthoracic debridement Muscle flaps and vacuum-assisted closure Antibiotics [1,2,21] Enzymatic mediastinitis Surgical drainage of the mediastinum Abdominal control of the pancreatic leak Antibiotics [6,7]…”

“…Among the few reports of mediastinitis induced by gastrectomy, rupture of esophagoenterostomy that directly affected the mediastinum was the main cause [3][4][5]. Abdominal infection rarely extends to the mediastinum; although it is rare, enzymatic mediastinitis is a type of acute mediastinitis caused by a pancreatic fistula [6,7]. To better illustrate this, we report two cases of enzymatic mediastinitis due to total gastrectomy.…”