Prognostic drivers beyond anatomy: towards tailored surgical management in descending necrotizing mediastinitis

The management of descending necrotizing mediastinitis (DNM) is challenging due to diagnostic delays and a lack of consensus on optimal therapeutic. While the Endo classification describes anatomical extent, its link to patient outcomes remains unclear. This study aimed to evaluate the prognostic utility of the Endo classification and identify key factors predictive 90-day mortality and prolonged hospitalization. We performed a retrospective, single-center cohort study spanning 2015-2025 that included 52 consecutive patients with descending necrotizing mediastinitis who were managed surgically. Demographic characteristics, clinical features, Endo classification, operative approaches, and postoperative outcomes were systematically evaluated. Univariable regression and correlation analyses were applied to determine factors associated with 90-day mortality and length of postoperative hospital stay. The cohort (median age 54 years, 65.4% male) had an 11.5% 90-day mortality rate. The Endo classification guided surgical approach but was not significantly associated with mortality or hospital stay. Instead, preoperative hypoalbuminemia (odds ratio (OR) 1.29 per 1 g/L decrease, p = 0.032), postoperative white blood cell count (OR 1.40 per × 10⁹ decrease, p = 0.046) and odontogenic of infection (OR 0.122, p = 0.026) were significant risk factors for mortality. A shorter symptom-to-diagnosis interval (r = - 0.386, p = 0.008) and the presence of empyema (median stay 34.5 vs. 25.5 days, p = 0.020) were independently associated with a longer postoperative hospital stay. In lower mediastinitis (Types IIA-C), a thoracic approach was associated with a lower incidence of the composite outcome (reoperation/death) compared to a transcervical approach (9.1% vs. 33.3%), though this difference was not statistically significant (p = 0.227). In DNM, physiological reserve and disease tempo are more powerful prognostic indicators than anatomical extent alone. A fulminant presentation and nutritional status are key prognostic indicators. These findings support a management paradigm that integrates early physiological optimization with tailored surgical intervention and postoperative care based on disease extent.