mediastinal abscess is a rare yet emergent infection of the thoracic cavity connective tissue , resulting from multiple potential sources : esophageal perforation ( boerhaave s syndrome ) , odontogenic and peritonsillar abscess ( descending necrotizing mediastinitis ) , cardiovascular or thoracic surgical procedures , trauma or rarely due to hematogenous spread ( 1,2 ) .
clinical diagnostic signs include dysphagia , dyspnea , fever , and chest pain with the potential for septic shock , as the disease progresses ( 3 ) .
water - soluble barium contrast swallow , transcutaneous ultrasound , chest radiograph , and ct are frequently utilized tools for visualization and prognosis ( 3,4 ) .
the foremost aim in management of mediastinal abscess is early debridement and drainage ( 5 ) .
while thoracotomy remains the gold standard of treatment , this approach carries significant risk of complication in certain populations ( 3,5 ) . minimally invasive options such as ,
video - assisted thoracoscopic surgery ( vats ) , ct guided percutaneous drainage , cervical drainage ( irrigation / suction ) and trans - esophageal endoscopic ultrasound ( eus ) represent safe and effective management strategies , in certain cases ( 4 - 6 ) .
herein is reported a novel application of laparoscopy as an additional alternative approach to drainage of anterior inferior mediastinal abscess .
a 54-year - old female with a history significant for alcohol abuse , surgical correction of annular pancreas 20 years ago and chronic pancreatitis presented to a rural emergency department with a 1-week history of worsening severe epigastric pain , nausea and vomiting .
she was in baseline health until 2 months prior when she first noticed episodic epigastric pain that was stabbing in nature .
the patient was transferred to our institution for surgical evaluation based on an external department ct raising concern of possible diaphragmatic herniation versus fluid collection .
re - scan of the abdomen confirmed a fluid collection of 8 - 10 cm in the extra - peritoneal space of the intra - abdominal wall , extending superiorly to the anterior mediastinum .
subsequent laparoscopy revealed dense omental adhesions encapsulating an abscess cavity , which tracked into the inferior mediastinum .
purulent material was evacuated , fluid was sampled for bacterial culture and a blake drain was placed .
the patient was afebrile without leukocytosis throughout the hospital course and was discharged with clinic follow - up after 3 days of post - operative evaluation . at the one - month post - operative clinic visit , symptoms had resolved .
development of mediastinal abscess is inclusive of multiple etiologies ( 1,2 ) . given the location and encapsulation of the abscess in the presented case , descending mediastinitis from an oropharyngeal source seems unlikely .
similarly , the patient remained afebrile without leukocytosis throughout the hospital course thereby precluding hematogenous spread .
most recent procedural history includes an unremarkable esophagogastroduodenoscopy and mrcp 2 years prior to presentation .
abscess fluid cultures from drainage revealed prevotella intermedia , haemophilus parainfluenzae and streptococcus spp . at the time of procedure
, the patient was not known to be immunosuppressed or receiving long - term corticosteroids . taken together
, these findings do not provide a definitive etiology for abscess development , though a role for recent instrumentation in the context of chronic inflammation and extensive abdominal surgical history may be suspected .
the management of mediastinal abscess is three - fold : early diagnosis , surgical drainage and appropriate antibiotic therapy ( 5 ) . location and extent of abscess and are both important factors in this determination .
transcervical drainage has been recommended by prior studies for management of mediastinal abscess at or above the level of the carina whereas thoracotomy or sub - xipoid incision is recommended for extensive sub - carinal abscesses ( 6 ) .
recently , several investigators have shown video - assisted thoracoscopic surgery to be a successful alternative to open methods in mediastinitis management from multiple etiologies ( 3 ) .
moreover , the effectiveness of non - invasive techniques has been demonstrated in cases of sub - carinal abscess ( 7 ) .
such therapies may be preferable to more aggressive methods due to reduced risk of complication , less pain and more rapid recovery ( 5 ) .
successful employment of minimally invasive technique has also been shown recently in the management of boerhaave s syndrome ( 8,9 ) . in this context
, laparoscopy is utilized for primary repair of esophageal tear , gastrostomy , feeding jejunostomy , esophagomyotomy and harvesting of omentum ( 8) . while local debridement of the posterior mediastinum is possible utilizing laparoscopic approach , thoracoscopy and vats are often additionally utilized due to delays in diagnosis , extensive pleural contamination and post - procedural complication ( 9 ) .
percutaneous drainage is an alternative to surgical management of mediastinal abscess in subacute or well - defined fluid collections ( 10 ) .
moreover , it represents the preferred course of treatment for intra - abdominal abscess and is a viable alternative to open drainage ( 10 ) . despite these factors ,
laparoscopy was undertaken in the present case due to the need for adequate inspection of the abdomen to exclude sources of pathology causal to abscess .
the treatment for mediastinal abscess remains controversial . while invasive technique may still represent the gold standard of therapy ( 6 )
, we report the successful treatment of anterior inferior mediastinal abscess by laparoscopy in a 54 year - old female , without further complication .
this method represents a novel approach to the management of abscess in this location without subsequent need for thoracoscopy or thoracotomy .
 mediastinal abscess can be managed through a variety of both invasive and minimally invasive methods , as determined by location and spread of infection . 
 thoracotomy remains the gold standard in treatment and is often employed . in the present case , a 54-year - old female with chronic pancreatitis presented with a 1-week history of severe epigastric pain , nausea and vomiting . 
 on ct scan , a large abscess was discovered in the anterior inferior mediastinum . 
 she was taken to the operating room and underwent laparoscopic drainage of the abscess . 
 laparoscopy represents a novel approach in management of anterior inferior mediastinal abscess . 
INTRODUCTION
CASE REPORT
DISCUSSION