Üst gastrointestinal cerrahiler sonrasý mediastinitte erken ve geç tanýnýn klinik sonuçlara etkisi

AMAÇ: Üst gastrointestinal (GIS) cerrahiler sonrasý geliþen mediastinit nadir ancak yaþamý tehdit eden bir komplikasyondur. Perioperatif takipteki geliþmelere raðmen taný zamanlamasýnýn prognoz üzerindeki etkisi net deðildir. Erken geliþen ve geç dönem geliþen mediastinitin klinik, mikrobiyolojik ve cerrahi sonuçlar üzerindeki etkisinin ortaya konmasý, yönetim stratejileri için kritik öneme sahiptir.
GEREÇ VE YÖNTEM: 2015–2025 yýllarý arasýnda merkezimizde üst gis cerrahisi sonrasý mediastinit tanýsý alan 27 hasta retrospektif olarak incelendi. Hastalar, cerrahi sonrasý mediastinit geliþim zamanýna göre erken (≤14 gün) ve geç dönem (>14 gün) gruplara ayrýldý. Demografik veriler, ek hastalýklar, sigara öyküsü, malignite varlýðý, taný zamaný, kültür sonuçlarý, cerrahi giriþimler, yoðun bakým ihtiyacý, yoðun bakým kalýþ süresi, hastanede yatýþ süresi, antibiyoterapi süresi, komplikasyonlar ve mortalite oranlarý karþýlaþtýrýldý.
BULGULAR: Median yaþ 64 [IQR 54–74.5] olup, hastalarýn %55.6’sý erkekti. Olgularýn %70.4’ünde malignite mevcuttu, en sýk mide adenokarsinomu (n=6) izlendi. Yoðun bakým ünitesi (YBÜ) ihtiyacý %81.5 olup median kalýþ süresi 2 gündü; mortalite 8 hastada (%29.6) görüldü. Kültür pozitifliði 16 hastada (%59.3) idi; en sýk Klebsiella pneumoniae, Proteus mirabilis ve Enterobacter spp. izole edildi. Erken geliþen mediastinit grubunda YBÜ kalýþ süresi (median 1 ve 6.5 gün, p=0.020), hastanede yatýþ süresi (16 ve 41 gün, p=0.003) ve antibiyoterapi süresi (14 ve 35 gün, p=0.002) istatistiksel olarak anlamlý þekilde daha kýsaydý. Erken geliþen grupta mortalite oraný, geç dönem geliþen gruba kýyasla daha düþük saptandý (%17.6 ve %50, p=0.102). Geç dönemde geliþen grupta kültür pozitifliði daha yüksekti. Bu grupta kompleks cerrahi giriþimler video yardýmlý torakoskopik cerrahi (VATS), torakotomi, endoskopik stent daha fazla uygulandý. Toplam 13 hastada (%48.1) reoperasyon gerekti. Reoperasyonlar batýn ve toraks cerrahisi giriþimleri olarak sýnýflandýrýldýðýnda, batýn cerrahisi reoperasyonlarý daha çok geç dönem geliþen grupta (5/8, %62.5), toraks cerrahisi reoperasyonlarý ise erken geliþen grupta (4/5, %80) gözlendi. Reoperasyon uygulanmayan hastalar kohortun %51.9’unu oluþturdu (14/27).
SONUÇ: Üst GIS cerrahisi sonrasý geliþen mediastinitte erken taný prognozu belirgin olarak iyileþtirmektedir. Erken taný; mortaliteyi, yoðun bakým ve hastane kalýþ süresini, antibiyotik tedavi süresini ve kompleks cerrahi ihtiyacýný azaltmaktadýr. Geç taný ise yüksek mikrobiyal yük, sýk reoperasyon ve olumsuz klinik sonuçlarla iliþkilidir.

Anahtar Kelimeler: Mediastinit, üst GIS cerrahisi, erken taný, postoperatif komplikasyonlar, cerrahi tedavi.

Impact of early versus late-onset mediastinitis on outcomes after upper gastrointestinal surgery

BACKGROUND: Mediastinitis is a rare but life-threatening complication after upper gastrointestinal (GI) surgery. Although advances in perioperative care have improved outcomes, the prognostic impact of the timing of onset remains unclear. Clarifying whether early-onset versus late-onset mediastinitis influences clinical, microbiological, and surgical outcomes is essential to guide management.
METHODS: We retrospectively analyzed 27 patients with mediastinitis after upper gastrointestinal surgery treated at our center between 2015 and 2025. Our institution is a tertiary-level, high-volume center performing complex upper GI procedures. During this period, 728 patients underwent upper GI surgery, among whom anastomotic leakage occurred in 44 (6.1%), and mediastinitis developed in 27 (3.7%). Patients were classified into early-onset (≤14 days) and late-onset (>14 days) mediastinitis groups based on the postoperative interval. Demographic and clinical variables, comorbidities, smoking history, malignancy status, microbiological culture results, surgical interventions, intensive care unit (ICU) admission and duration, hospital stay, duration of antibiotic treatment, complications, and mortality were recorded and compared.
RESULTS: During the 10-year study period, 728 patients underwent upper gastrointestinal surgery at our institution, and mediastinitis developed in 27 patients (3.7%) following esophageal or gastric procedures. The median age was 64 years [interquartile range: 54–74.5], and 55.6% were male. Malignancy was present in 70.4%, most frequently gastric adenocarcinoma (n=6). Overall, ICU admission was 81.5%, with a median ICU stay of two days, and mortality occurred in eight patients (29.6%). Culture positivity was observed in 16 patients (59.3%), most commonly with Klebsiella pneumoniae, Proteus mirabilis, and Enterobacter spp. Compared with late-onset mediastinitis, early-onset mediastinitis was associated with significantly shorter ICU stay (median 1 vs. 6.5 days, p=0.020), hospital stay (16 vs. 41 days, p=0.003), and antibiotic duration (14 vs. 35 days, p=0.002). The early-onset group demonstrated a lower mortality rate than the late-onset group (17.6% vs. 50.0%, p=0.102). Late-onset mediastinitis correlated with higher culture positivity and a greater need for complex surgical procedures, including video-assisted thoracic surgery (VATS), thoracotomy, and endoscopic stenting. Reoperations were required in 13 patients (48.1%). When stratified into abdominal and thoracic procedures, abdominal re-operations were more frequently observed in the late-onset group (5/8, 62.5%), whereas thoracic reoperations predominated in the early-onset group (4/5, 80%). Patients without reoperation constituted 51.9% of the cohort (14/27).
CONCLUSION: Early-onset mediastinitis after upper GI surgery is associated with improved outcomes. It correlates with better survival, shorter ICU and hospital stay, reduced antibiotic treatment, and a lower need for complex surgical procedures, whereas late-onset mediastinitis is linked to higher microbial burden, more frequent reoperations, and poorer outcomes.

Keywords: Mediastinitis, upper gastrointestinal surgery, early diagnosis, postoperative complications, surgical management.