Cervico-thoracic hybrid approach with four-tube concomitant drainage for Endo type IIB descending necrotizing mediastinitis: a case report

Descending necrotizing mediastinitis (DNM) is a fatal infection with mortality rates of 20–40%. Endo type IIB DNM requires both cervical and thoracic drainage, but the optimal surgical approach remains controversial, especially in elderly patients with diabetes and multidrug-resistant (MDR) bacterial infections. This case report aims to share our clinical experience and put forward a tentative therapeutic hypothesis for this difficult disease. A 71-year-old diabetic male presented with cervicofacial infection progressing to Endo type IIB DNM (APACHE II score: 17, predicted mortality: 28.46%). Preoperative contrast-enhanced CT showed extensive mediastinal lesions and unilateral pleural effusion. Given high surgical risk, we performed a minimally invasive cervico-thoracic hybrid approach: transcervical drainage (2 cm), video-assisted thoracoscopic surgery (VATS) via right 6th intercostal port (1 cm) and 4th intercostal mini-thoracotomy (3 cm), plus subxiphoid drainage (2 cm). Four tubes were strategically placed (superior mediastinum, inferior mediastinum, right pleural cavity, subcutaneous neck) creating a vertical-horizontal interconnected drainage system. Postoperatively, daily mediastinal irrigation (500 mL saline + metronidazole) was performed. MDR Acinetobacter baumannii was detected via sputum and pleural effusion culture on postoperative day (POD) 2, prompting targeted therapy with tigecycline plus meropenem. The patient was extubated on POD 3, discharged from ICU on POD 12, and discharged home on POD 25. Follow-up CT showed complete resolution of mediastinal abscess. For high-risk Endo type IIB DNM patients, the cervico-thoracic hybrid approach with four-tube concomitant drainage and postoperative mediastinal irrigation offers effective source control. This single case report provides preliminary clinical experience and generates tentative therapeutic hypotheses for high-risk Endo type IIB DNM patients, rather than confirming the superiority of this hybrid drainage strategy. Timely monitoring of MDR pathogens, strict blood glucose control (8–10 mmol/L), and early weaning from mechanical ventilation are key measures to improve the prognosis of elderly patients with DNM.