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Bharath V. Myasthenia Gravis and Thymectomy. JOURNAL OF CARDIAC CRITICAL CARE TSS 2022. [DOI: 10.1055/s-0041-1739528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
AbstractMyasthenia gravis (MG) is a rare autoimmune neuromuscular disorder. Though MG was diagnosed four centuries ago, its rational management started in 1930s. In the present era, MG is managed by multimodality care including pharmacological agents, plasmapheresis, intravenous immunoglobulins, and surgical thymectomy. Thymectomy has evolved from open trans-sternal to video-assisted thoracoscopic and robotic thymectomy. In this article, the concise history of MG, its clinical features, diagnosis, and management are described.
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Affiliation(s)
- V Bharath
- Department of Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, New Delhi, India
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Aljaafari D, Ishaque N. Thymectomy in myasthenia gravis: A narrative review. SAUDI JOURNAL OF MEDICINE AND MEDICAL SCIENCES 2022; 10:97-104. [PMID: 35602390 PMCID: PMC9121707 DOI: 10.4103/sjmms.sjmms_80_22] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 03/20/2022] [Accepted: 04/21/2022] [Indexed: 11/04/2022] Open
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Xu J, Qian K, Deng Y, Zheng Y, Ou C, Liu J, Jiang L. Complications of robot-assisted thymectomy: A single-arm meta-analysis and systematic review. Int J Med Robot 2021; 17:e2333. [PMID: 34533876 PMCID: PMC9285085 DOI: 10.1002/rcs.2333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 08/21/2021] [Accepted: 09/16/2021] [Indexed: 11/09/2022]
Abstract
BACKGROUND Recently, thymectomy using minimally invasive approaches has been increasing with the development of robotic video-assisted thoracoscopic surgery (R-VATS). Although multimodal approach is effective for robot assisted thymectomy, it is necessary to determine the approach (left, right or subxiphoid) associated with the least complications. METHODS An electronic retrieval from PubMed, Embase, Web of Science, GreyNet International and The Cochrane Library. The single-arm meta-analysis was performed to compare the rate of complications of right- and left-side approaches by R-VATS. RESULTS A total of 21 studies including 930 patients were identified. The pooled incidence of total complications was 12.2% (confidence interval: 10.0%-14.8%) for all studies. The overall complication rate was 17.3% for the right-side compared with 7.4% for the left side (P < 0.001, odds ratio = 2.484, 1.601-3.852). The pooled incidence of air leak was significantly higher for the right versus left side (5.1% vs. 1.2%, respectively; p = 0.004). The incidence of atrial fibrillation was higher for the right-side compared with the left-side approach (4% vs. 1.2%, respectively; p = 0.004). The open conversion rate was significantly higher for the right versus the left-side (6.5% vs. 2.9%, respectively; p = 0.004). However, there was no significant difference in the pooled incidence of pleural effusion and thoracic duct fistula when comparing the right- and left-side approaches. In subgroup analysis, in the left approach, the incidence of overall complications (28.6% vs. 5.5%, respectively; p = 0.002) and pleural effusion (14.3% vs. 1%, respectively; p = 0.002) was higher for the 'Old Age' group compared with the 'Youth' group; However, In the subgroup analysis of gender, there was no significant difference in the incidence of complications after thymectomy. CONCLUSION Robotic video-assisted thoracoscopic surgery can be performed on the left- and right-sides; however, complications are minimal with the left-side approach. These data demonstrate that the incidence of overall complications, atrial fibrillation, open conversion ratios, and air leak rate of left-side R-VATS thymectomy are lower than those of right-side. Further subgroup analysis showed that the incidence of postoperative complications was higher in the older group.
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Affiliation(s)
- Jia‐Xin Xu
- Department of Cardio‐Thoracic surgeryInstitute of Yan'an Hospital Affiliated to Kunming Medical UniversityKunmingChina
| | - Kai Qian
- Faculty of Life and BiotechnologyInstitute of Kunming University of Science and TechnologyKunmingChina
- Department of Thoracic SurgeryInstitute of the First People's Hospital of Yunnan ProvinceKunmingChina
| | - Yi Deng
- Faculty of Life and BiotechnologyInstitute of Kunming University of Science and TechnologyKunmingChina
| | - Yan‐Yan Zheng
- Regenerative Medicine Research CenterInstitute of the First People's Hospital of Yunnan ProvinceKunmingChina
| | - Chun‐Mei Ou
- Department of Thoracic SurgeryInstitute of the First People's Hospital of Yunnan ProvinceKunmingChina
| | - Jie Liu
- Regenerative Medicine Research CenterInstitute of the First People's Hospital of Yunnan ProvinceKunmingChina
| | - Li‐Hong Jiang
- Department of Thoracic SurgeryInstitute of the First People's Hospital of Yunnan ProvinceKunmingChina
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Raza B, Dhamija A, Abbas G, Toker A. Robotic thymectomy for myasthenia gravis surgical techniques and outcomes. J Thorac Dis 2021; 13:6187-6194. [PMID: 34795970 PMCID: PMC8575861 DOI: 10.21037/jtd-2019-rts-10] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 09/10/2020] [Indexed: 11/30/2022]
Abstract
Myasthenia gravis (MG) is an autoimmune disorder in which antibodies are produced against post-synaptic acetylcholine receptors, thereby causing impairment of neuromuscular transmission. Diagnosis of MG is confirmed with the AChR antibody test and via an Electromyography. Although medical treatment with acetylcholinesterase inhibitors remains the main treatment of MG, in recent years thymectomy has become an integral part of the treatment algorithm. Numerous factors such as the Patient’s age, presence of AChR antibodies, or MuSK antibody, the severity of disease affect the decision of preforming the thymectomy. Historically thymectomy was preformed via sternotomy associated with significant morbidity. Advancement in the minimally invasive approaches to thymic resection has led to more acceptance of thymectomy in the management of MG. Among these approaches, robotic thymectomy is gaining popularity across the globe due to the unique advantages of the robotic platform like 3D visibility, enhanced dexterity, and wrist like articulating movements of instruments. This has led to less post-operative pain and morbidity; faster recovery and shorter hospital stay. Successful treatment of MG requires a multi-modality approach, which has led to the formation of MG teams in most academic centers, comprising of a specialist neurologist, intensivist, and thoracic surgeon. In this article, we describe the techniques and outcomes of the robotic thymectomy for MG.
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Affiliation(s)
| | - Ankit Dhamija
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WV, USA
| | - Ghulam Abbas
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WV, USA
| | - Alper Toker
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WV, USA
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Wilshire CL, Blitz SL, Fuller CC, Rückert JC, Li F, Cerfolio RJ, Ghanim AF, Onaitis MW, Sarkaria IS, Wigle DA, Joshi V, Reznik S, Bograd AJ, Vallières E, Louie BE. Minimally invasive thymectomy for myasthenia gravis favours left-sided approach and low severity class. Eur J Cardiothorac Surg 2021; 60:898-905. [PMID: 33538299 DOI: 10.1093/ejcts/ezab014] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 12/02/2020] [Accepted: 12/08/2020] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Complete thymectomy is a key component of the optimal treatment for myasthenia gravis. Unilateral, minimally invasive approaches are increasingly utilized with debate about the optimal laterality approach. A right-sided approach has a wider field of view, while a left-sided approach accesses potentially more thymic tissue. We aimed to assess the impact of laterality on perioperative and medium-term outcomes, and to identify predictors of a 'good outcome' using standard definitions. METHODS We performed a multicentre review of 123 patients who underwent a minimally invasive thymectomy for myasthenia gravis between January 2000 and August 2015, with at least 1-year follow-up. The Myasthenia Gravis Foundation of America standards were followed. A 'good outcome' was defined by complete stable remission/pharmacological remission/minimal manifestations 0, and a 'poor outcome' by minimal manifestations 1-3. Univariate and multivariable logistic regression analyses were performed to assess factors associated with a 'good outcome'. RESULTS Ninety-two percent of thymectomies (113/123) were robotic-assisted. The left-sided approach had a shorter median operating time than a right-sided: 143 (interquartile range, IQR 110-196) vs 184 (IQR 133-228) min, P = 0.012. At a median of 44 (IQR 27-75) months, the left-sided approach achieved a 'good outcome' (46%, 31/68) more frequently than the right-sided (22%, 12/55); P = 0.011. Multivariable analysis identified a left-sided approach and Myasthenia Gravis Foundation of America class I/II to be associated with a 'good outcome'. CONCLUSIONS A left-sided thymectomy may be preferred over a right-sided approach in patients with myasthenia gravis given the shorter operating times and potential for superior medium-term symptomatic outcomes. A lower severity class is also associated with a 'good outcome'.
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Affiliation(s)
- Candice L Wilshire
- Department of Thoracic Surgery, Swedish Cancer Institute, Seattle, WA, USA
| | - Sandra L Blitz
- Department of Thoracic Surgery, Swedish Cancer Institute, Seattle, WA, USA
| | - Carson C Fuller
- Department of Thoracic Surgery, Swedish Cancer Institute, Seattle, WA, USA
| | - Jens C Rückert
- Department of Thoracic Surgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Feng Li
- Department of Thoracic Surgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Robert J Cerfolio
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, New York University Langone Medical Center, New York, NY, USA
| | - Asem F Ghanim
- Department of Thoracic Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Mark W Onaitis
- Department of Thoracic Surgery, University of California San Diego, San Diego, CA, USA
| | - Inderpal S Sarkaria
- Department of Thoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Dennis A Wigle
- Department of Thoracic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Vijay Joshi
- Department of Thoracic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Scott Reznik
- Department of Thoracic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Adam J Bograd
- Department of Thoracic Surgery, Swedish Cancer Institute, Seattle, WA, USA
| | - Eric Vallières
- Department of Thoracic Surgery, Swedish Cancer Institute, Seattle, WA, USA
| | - Brian E Louie
- Department of Thoracic Surgery, Swedish Cancer Institute, Seattle, WA, USA
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Parshad R, Verma E, Suhani S, Goyal V, Bhatia R, Sharma R, Datta Gupta S. Surgical and Neurological Outcome of Minimally Invasive Thymectomy in Patients With Myasthenia Gravis: An Experience of 100 Cases Over 6 Years at a Tertiary Care Center in North India. Surg Laparosc Endosc Percutan Tech 2020; 31:227-233. [PMID: 33122592 DOI: 10.1097/sle.0000000000000880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 09/22/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Minimally invasive thymectomy (MIT) is emerging as an effective alternative to open thymectomy in the management of patients with myasthenia gravis (MG). The primary objective of our study is to assess the surgical and neurological outcome of MIT in patients with MG. MATERIALS AND METHODS It is a retrospective evaluation of prospectively collected data of 100 patients with MG, who underwent MIT from April 2012 to January 2018 at a tertiary care center in India. Surgical outcome was assessed for success of minimal invasive approach, conversion, perioperative morbidity, and postoperative hospital course. Neurological outcome was assessed, after at least 1 year of follow-up, according to Myasthenia Gravis Foundation of America postintervention status. Factors predicting complete stable remission (CSR) were evaluated. RESULTS MIT was successfully performed in 98% patients with 2% conversion. There was no mortality. Overall, 10% of patients had perioperative morbidity with 5% having exacerbation of neurological symptoms. Two of these needed postoperative ventilation, whereas 3 recovered on conservative treatment. Median operative time and hospital stay were 140 minutes and 3 days, respectively. At a median follow-up of 47 months, CSR was seen in 20% with improvement in 73.3%. Overall, 63% patients were taken off steroids and patients requiring 3 drugs decreased by 70.7%. There was significant reduction in the dosage of pyridostigmine (P<0.001), prednisolone (P<0.001), and azathioprine (P=0.002) after thymectomy. Milder disease (Myasthenia Gravis Foundation of America class 1 and 2) predicted CSR on multivariate analysis. CONCLUSIONS MIT is a safe and effective procedure that leads to improvement in neurological status with significant reduction in number and dosage of medications after thymectomy. Mild disease predicts CSR.
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Comacchio GM, Marulli G, Mammana M, Natale G, Schiavon M, Rea F. Surgical Decision Making. Thorac Surg Clin 2019; 29:203-213. [DOI: 10.1016/j.thorsurg.2018.12.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Boisen ML, Sardesai MP, Kolarczyk L, Rao VK, Owsiak CP, Gelzinis TA. The Year in Thoracic Anesthesia: Selected Highlights From 2017. J Cardiothorac Vasc Anesth 2018; 32:1556-1569. [PMID: 29655515 DOI: 10.1053/j.jvca.2018.03.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Indexed: 11/11/2022]
Affiliation(s)
- Michael L Boisen
- Department of Anesthesiology, University of Pittsburgh, Pittsburgh, PA
| | - Mahesh P Sardesai
- Department of Anesthesiology, University of Pittsburgh, Pittsburgh, PA
| | - Lavinia Kolarczyk
- Department of Anesthesiology, University of North Carolina, Chapel Hill, NC
| | - Vidya K Rao
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, CA
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Lu Q, Zhao J, Wang J, Chen Z, Han Y, Huang L, Li X, Zhou Y. Subxiphoid and subcostal arch "Three ports" thoracoscopic extended thymectomy for myasthenia gravis. J Thorac Dis 2018; 10:1711-1720. [PMID: 29707325 DOI: 10.21037/jtd.2018.02.11] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background The approaches to thoracoscopic thymectomy in myasthenia gravis (MG) are debatable. We developed a novel approach via subxiphoid and subcostal arch, with a significantly shorter duration of operation and hospital stay, less estimated blood loss, and lower postoperative pain. Methods From December 2012 to December 2014, 77 myasthenia gravis patients with or without thymoma underwent thoracoscopic extended thymectomy at our hospital. Among them, 41 patients were operated via the subxiphoid and subcostal arch approach and the other 36 via the conventional unilateral approach. The patient outcomes were retrospectively reviewed and evaluated. Results The thoracoscopic extended thymectomy was performed safely via the subxiphoid and subcostal arch approach. In this approach, no drainage tube was inserted after operation except in the first two patients. Two of the 41 patients were switched to trans-sternal approach due to the tight adhesion between the thymoma and the left innominate vein. No major complications occurred. Compared with the unilateral approach, the duration of the procedure via subxiphoid and subcostal arch was significantly shorter, with less estimated blood loss, shorter hospital-stay and lower postoperative pain (P<0.001). The cosmetic scores were comparable between the two groups (P=0.369). Conclusions The novel subxiphoid and subcostal arch approach is technically feasible and safe. It is an acceptable alternative to conventional thoracoscopic extended thymectomy.
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Affiliation(s)
- Qiang Lu
- Department of Thoracic Surgery, Tangdu Hospital, Fourth Military Medical University, Xi'an 710038, China
| | - Jinbo Zhao
- Department of Thoracic Surgery, Tangdu Hospital, Fourth Military Medical University, Xi'an 710038, China
| | - Juzheng Wang
- Department of Thoracic Surgery, Tangdu Hospital, Fourth Military Medical University, Xi'an 710038, China
| | - Zhao Chen
- Department of Thoracic Surgery, Tangdu Hospital, Fourth Military Medical University, Xi'an 710038, China
| | - Yong Han
- Department of Thoracic Surgery, Tangdu Hospital, Fourth Military Medical University, Xi'an 710038, China
| | - Lijun Huang
- Department of Thoracic Surgery, Tangdu Hospital, Fourth Military Medical University, Xi'an 710038, China
| | - Xiaofei Li
- Department of Thoracic Surgery, Tangdu Hospital, Fourth Military Medical University, Xi'an 710038, China
| | - Yongan Zhou
- Department of Thoracic Surgery, Tangdu Hospital, Fourth Military Medical University, Xi'an 710038, China
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Elsayed HH, Gamal M, Raslan S, Abdel Hamid H. Video-assisted thoracoscopic thymectomy for non-thymomatous myasthenia gravis: a right-sided or left-sided approach? Interact Cardiovasc Thorac Surg 2017; 25:651-653. [PMID: 28591868 DOI: 10.1093/icvts/ivx136] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2016] [Accepted: 04/03/2017] [Indexed: 11/14/2022] Open
Abstract
A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was in [patients undergoing video-assisted thoracoscopic thymectomy for myasthenia gravis (MG)] is a [left-sided approach] superior to a [right-sided approach] in terms of [clinical outcome]? Two hundred and fifty-nine papers were found using the reported search. In looking at both procedures, we selected studies with a sizeable number of patients performing or studying both procedures and comparing their outcome. Hence, only 4 studies represented the best evidence to answer the clinical question. The authors, journal, date, country, study type, patient group, relevant outcomes and results of these papers are tabulated. Two studies compared their clinical experience with a right-sided versus a left-sided video assisted thoracoscopic surgery thymectomy approach, while 1 study compared using a bilateral versus a unilateral right-sided approach in patients with non-thymomatous MG. The number of patients studied included 31, 107 and 103 patients, respectively. All 3 studies demonstrated no difference regarding surgical time, intraoperative blood loss, postoperative hospital stay, postoperative complications and therapeutic effects (the last study compared the 5-year complete stable remission rate). All 3 studies concluded that both approaches are feasible, effective and comparable in operative and long-term results for the treatment of non-thymomatous MG. One anatomical study compared both approaches in 10 cadavers, 5 in each group. They studied the size of the specimen resected and visualization of different anatomic sites via each approach. Visualization was superior using the left-sided approach, while a right-sided approach resulted in slightly higher chances of an incomplete resection. The study concluded that a left-sided approach achieves a better chance of radical thoracoscopic thymectomy due to anatomic considerations. In conclusion, despite 1 cadaveric study suggesting that a left-sided approach may achieve more complete resection, possibly due to anatomical considerations, there are no differences in outcomes with either unilateral approach in terms of complications, hospital stay or long-term symptom relief.
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Affiliation(s)
- Hany Hasan Elsayed
- Department of Thoracic Surgery, Ain Shams University Hospital, Cairo, Egypt
| | - Mahmoud Gamal
- Department of Cardiac Surgery, Nasser Institute for Research and Treatment, Cairo, Egypt
| | - Saleh Raslan
- Department of Cardiothoracic Surgery, Al Azhar University, Cairo, Egypt
| | - Hossam Abdel Hamid
- Department of Cardiothoracic Surgery, Ain Shams University Hospital, Cairo, Egypt
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Xie X, Gan X, Chen B, Shen Z, Wang M, Zhang H, Xu X, Chen J. Left- and right-sided video-assisted thoracoscopic thymectomy exhibit similar effects on myasthenia gravis. J Thorac Dis 2016; 8:124-32. [PMID: 26904220 DOI: 10.3978/j.issn.2072-1439.2016.01.40] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Unilateral video-assisted thoracoscopic (VATS) thymectomy features less operative trauma, improved cosmesis, and similar efficiency compared with transsternal (TS) thymectomy for treatment of patients with myasthenia gravis (MG). Unilateral VATS thymectomy can be easily performed from either side of the thorax, because thymus is located in the middle of mediastinum. Nevertheless, the side that provides better outcomes remains controversial. This study presents our experience on treatments for MG and reveals the differences between the unilateral VATS thymectomy performed on each side. METHODS Eighty-one consecutive patients with MG who underwent TS or VATS thymectomy on either side between January 2003 and December 2012 were enrolled in the study. Clinicopathologic data and surgical outcomes were retrospectively analyzed and compared among different surgical approaches. RESULTS TS thymectomy was administered in 50 patients, whereas unilateral VATS approaches were performed on the remaining 31 patients, 15 on the left side and 16 on the right side. The VATS group exhibited a significantly shorter surgery duration (P<0.001), less intraoperative blood loss (P=0.009), shorter postoperative hospital stay (P=0.025), smaller thoracic drainage volume (P=0.033), shorter thoracic drainage duration (P=0.006), and less postoperative complications (P<0.001) compared with the TS group. However, disease remission rates did not significantly differ among the groups (P=0.988). The left-sided group exhibited considerably longer thoracic drainage duration than the right-sided group (P=0.041). Moreover, surgical time (P=0.736), intraoperative blood loss (P=0.281), postoperative hospital stay (P=0.599), thoracic drainage volume (P=0.571), postoperative complications (P=0.742) and therapeutic effect (P=1.000) did not significantly differ among the groups. Multivariate analysis revealed that the ocular type of MG is the only independent factor for clinical remission (P=0.002). CONCLUSIONS Unilateral VATS thymectomy can reduce surgical risks and shorten hospitalization duration without threatening the therapeutic effect. This technique can be safely and effectively performed by experienced surgeons in either side of the thorax.
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Affiliation(s)
- Xuan Xie
- 1 Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, 2 Department of Thoracic Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou 510120, China ; 3 Department of Thoracic Surgery, General Hospital of Ningxia Medical University, Yinchuan 750004, China
| | - Xiangfeng Gan
- 1 Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, 2 Department of Thoracic Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou 510120, China ; 3 Department of Thoracic Surgery, General Hospital of Ningxia Medical University, Yinchuan 750004, China
| | - Baishen Chen
- 1 Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, 2 Department of Thoracic Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou 510120, China ; 3 Department of Thoracic Surgery, General Hospital of Ningxia Medical University, Yinchuan 750004, China
| | - Zhuojian Shen
- 1 Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, 2 Department of Thoracic Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou 510120, China ; 3 Department of Thoracic Surgery, General Hospital of Ningxia Medical University, Yinchuan 750004, China
| | - Minghui Wang
- 1 Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, 2 Department of Thoracic Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou 510120, China ; 3 Department of Thoracic Surgery, General Hospital of Ningxia Medical University, Yinchuan 750004, China
| | - Huizhong Zhang
- 1 Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, 2 Department of Thoracic Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou 510120, China ; 3 Department of Thoracic Surgery, General Hospital of Ningxia Medical University, Yinchuan 750004, China
| | - Xia Xu
- 1 Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, 2 Department of Thoracic Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou 510120, China ; 3 Department of Thoracic Surgery, General Hospital of Ningxia Medical University, Yinchuan 750004, China
| | - Ju Chen
- 1 Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, 2 Department of Thoracic Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou 510120, China ; 3 Department of Thoracic Surgery, General Hospital of Ningxia Medical University, Yinchuan 750004, China
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Abstract
In the past, mediastinal surgery was associated with the necessity of a maximum exposure, which was accomplished through various approaches. In the early 1990s, many surgical fields, including thoracic surgery, observed the development of minimally invasive techniques. These included video-assisted thoracic surgery (VATS), which confers clear advantages over an open approach, such as less trauma, short hospital stay, increased cosmetic results and preservation of lung function. However, VATS is associated with several disadvantages. For this reason, it is not routinely performed for resection of mediastinal mass lesions, especially those located in the anterior mediastinum, a tiny and remote space that contains vital structures at risk of injury. Robotic systems can overcome the limits of VATS, offering three-dimensional (3D) vision and wristed instrumentations, and are being increasingly used. With regards to thymectomy for myasthenia gravis (MG), unilateral and bilateral VATS approaches have demonstrated good long-term neurologic results with low complication rates. Nevertheless, some authors still advocate the necessity of maximum exposure, especially when considering the distribution of normal and ectopic thymic tissue. In recent studies, the robotic approach has shown to provide similar neurological outcomes when compared to transsternal and VATS approaches, and is associated with a low morbidity. Importantly, through a unilateral robotic technique, it is possible to dissect and remove at least the same amount of mediastinal fat tissue. Preliminary results on early-stage thymomatous disease indicated that minimally invasive approaches are safe and feasible, with a low rate of pleural recurrence, underlining the necessity of a "no-touch" technique. However, especially for thymomatous disease characterized by an indolent nature, further studies with long follow-up period are necessary in order to assess oncologic and neurologic results through minimally invasive approaches. Furthermore, increased robotic experience and studies, including randomized controlled trials, are needed to validate the findings of the current literature.
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Affiliation(s)
- Franca M A Melfi
- Division of Thoracic Surgery, 1 Chief of Robotic Multispecialities Center for Surgery, 2 CardioThoracic and Vascular Department, 3 Department of Surgical, Medical, Molecular, and Critical Area Pathology, University Hospital of Pisa, Italy
| | - Olivia Fanucchi
- Division of Thoracic Surgery, 1 Chief of Robotic Multispecialities Center for Surgery, 2 CardioThoracic and Vascular Department, 3 Department of Surgical, Medical, Molecular, and Critical Area Pathology, University Hospital of Pisa, Italy
| | - Alfredo Mussi
- Division of Thoracic Surgery, 1 Chief of Robotic Multispecialities Center for Surgery, 2 CardioThoracic and Vascular Department, 3 Department of Surgical, Medical, Molecular, and Critical Area Pathology, University Hospital of Pisa, Italy
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13
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Goldstein SD, Culbertson NT, Garrett D, Salazar JH, Van Arendonk K, McIltrot K, Felix M, Abdullah F, Crawford T, Colombani P. Thymectomy for myasthenia gravis in children: a comparison of open and thoracoscopic approaches. J Pediatr Surg 2015; 50:92-7. [PMID: 25598101 DOI: 10.1016/j.jpedsurg.2014.10.005] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Accepted: 10/06/2014] [Indexed: 11/30/2022]
Abstract
PURPOSE Thymectomy is an accepted component of treatment for myasthenia gravis (MG), but optimal timing and surgical approach have not been determined. Though small series have reported the feasibility of thoracoscopic resection, some studies have suggested that minimally invasive methods are suboptimal compared to open sternotomy owing to incomplete clearance of thymic tissue. Here we report the largest series of thymectomies for pediatric myasthenia gravis in the literature to date. METHODS A retrospective review of patients undergoing thymectomy for MG between 1990 and 2013 in a tertiary referral hospital was performed. Twelve patients who underwent thoracoscopic thymectomy were compared to 16 patients who underwent open thymectomy via median sternotomy. Postoperative outcomes were determined by electronic chart review in consultation with the treating pediatric neurologist. Disease severities were graded according to a modified Myasthenia Gravis Foundation of America (MGFA) Quantitative MG (QMG) score. RESULTS Overall, thoracoscopic resections tended to be performed on patients with earlier and less severe disease than open surgeries. Inpatient length of stay was significantly shorter after thoracoscopic surgery (mean 1.8 vs 8.0 days, p=0.045). The preoperative and postoperative MGFA QMG scores were equivalent between the two groups. Both groups experienced a decrease in disease severity (p<0.001) after median follow-up time of 23 months in the thoracoscopic group and 44 months in the open group. CONCLUSIONS Minimally invasive thymectomy for MG in children has increased in popularity as surgeons and neurologists compare the risks and benefits of surgery against other therapies. This analysis suggests that thoracoscopic thymectomy is not inferior to median sternotomy in terms of disease control in this small series, and that the morbidity of the thoracoscopic approach appears sufficiently low to be considered for early stage disease. Low perioperative morbidity and shortened hospital course make thoracoscopic thymectomy an attractive option in centers with sufficient medical and surgical experience.
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Affiliation(s)
- Seth D Goldstein
- Johns Hopkins Children's Center, Division of Pediatric Surgery, Baltimore MD, USA.
| | | | - Deiadra Garrett
- Johns Hopkins Children's Center, Division of Pediatric Surgery, Baltimore MD, USA
| | - Jose H Salazar
- Johns Hopkins Children's Center, Division of Pediatric Surgery, Baltimore MD, USA
| | - Kyle Van Arendonk
- Johns Hopkins Children's Center, Division of Pediatric Surgery, Baltimore MD, USA
| | - Kimberly McIltrot
- Johns Hopkins Children's Center, Division of Pediatric Surgery, Baltimore MD, USA
| | - Michelle Felix
- Johns Hopkins Children's Center, Division of Pediatric Surgery, Baltimore MD, USA
| | - Fizan Abdullah
- Johns Hopkins Children's Center, Division of Pediatric Surgery, Baltimore MD, USA
| | - Thomas Crawford
- Johns Hopkins Children's Center, Division of Pediatric Neurology, Baltimore MD, USA
| | - Paul Colombani
- Johns Hopkins Children's Center, Division of Pediatric Surgery, Baltimore MD, USA
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Lo CM, Lu HI, Hsieh MJ, Lee SS, Chang JP. Thymectomy for myasthenia gravis: Video-assisted versus transsternal. J Formos Med Assoc 2014; 113:722-6. [DOI: 10.1016/j.jfma.2014.05.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2014] [Revised: 04/27/2014] [Accepted: 05/30/2014] [Indexed: 11/29/2022] Open
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Abstract
The overall advantages of thoracoscopy over thoracotomy in terms of patient recovery have been fairly well established. The use of robotics, however, is a newer and less proven modality in the realm of thoracic surgery. Robotics offers distinct advantages and disadvantages in comparison with video-assisted thoracoscopic surgery. Robotic technology is now used for a variety of complex cardiac, urologic, and gynecologic procedures including mitral valve repair and microsurgical treatment of male infertility. This article addresses the potential benefits and limitations of using the robotic platform for the performance of a variety of thoracic operations.
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16
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Godoy DA, Mello LJVD, Masotti L, Di Napoli M. The myasthenic patient in crisis: an update of the management in Neurointensive Care Unit. ARQUIVOS DE NEURO-PSIQUIATRIA 2014; 71:627-39. [PMID: 24141444 DOI: 10.1590/0004-282x20130108] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/01/2013] [Accepted: 04/10/2013] [Indexed: 11/21/2022]
Abstract
Myasthenia gravis (MG) is an autoimmune disorder affecting neuromuscular transmission leading to generalized or localized muscle weakness due most frequently to the presence of autoantibodies against acetylcholine receptors in the postsynaptic motor end-plate. Myasthenic crisis (MC) is a complication of MG characterized by worsening muscle weakness, resulting in respiratory failure that requires intubation and mechanical ventilation. It also includes postsurgical patients, in whom exacerbation of muscle weakness from MG causes a delay in extubation. MC is a very important, serious, and reversible neurological emergency that affects 20-30% of the myasthenic patients, usually within the first year of illness and maybe the debut form of the disease. Most patients have a predisposing factor that triggers the crisis, generally an infection of the respiratory tract. Immunoglobulins, plasma exchange, and steroids are the cornerstones of immunotherapy. Today with the modern neurocritical care, mortality rate of MC is less than 5%.
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Muhammad MIA. Thymectomy by video-assisted thoracoscopy versus open surgical techniques. Asian Cardiovasc Thorac Ann 2014; 22:442-7. [DOI: 10.1177/0218492313479596] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective This study was conducted to compare operative variables and postoperative outcomes in adult patients with myasthenia gravis undergoing thymectomy through 3 different operative techniques: total median sternotomy, partial median sternotomy, and video-assisted thoracoscopy. Methods 30 patients aged 20–65 years were included in this study. They were subdivided into: group A: 8 patients undergoing thymectomy through a total median sternotomy; group B: 9 patients undergoing thymectomy through a partial median sternotomy; and group C: 13 patients undergoing thymectomy through video-assisted thoracoscopy. Preoperative, intraoperative, and postoperative variables, and mortality were compared among groups. Results Preoperative variables were well matched in all groups. Operative time was significantly longer in group C. There was no intraoperative complication in any group. Postoperative length of hospital stay was significantly shorter in group C. Postoperative complications occurred in 3 (10%) patients, mostly in groups A and B. There was no perioperative mortality in any group. Conclusions Video-assisted thymectomy is as effective as the traditional open surgical approaches for thymectomy in the management of patients with myasthenia gravis. In addition, the improved cosmesis of the video-assisted approach ideally should lead to earlier thymectomy in patients with myasthenia gravis.
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Affiliation(s)
- Magdi Ibrahim Ahmad Muhammad
- Department of Cardiothoracic Surgery, Faculty of Medicine, Suez Canal University, Egypt; Department of Cardiothoracic Surgery, King Fahd Hospital, Al-Madina Al-Munawara, Saudi Arabia
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18
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Clinicopathological analysis of small-sized anterior mediastinal tumors. Surg Today 2013; 44:1817-22. [DOI: 10.1007/s00595-013-0727-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2013] [Accepted: 08/01/2013] [Indexed: 10/26/2022]
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Chen Z, Zuo J, Zou J, Sun Y, Liu W, Lai Y, Zhong B, Su C, Tan M, Luo H. Cellular immunity following video-assisted thoracoscopic and open resection for non-thymomatous myasthenia gravis. Eur J Cardiothorac Surg 2013; 45:646-51. [DOI: 10.1093/ejcts/ezt443] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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20
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Chung JW, Kim HR, Kim DK, Chun MS, Kim YH, Park SI, Kim SR, Lee DH. Long-term results of thoracoscopic thymectomy for thymoma without myasthenia gravis. J Int Med Res 2013. [PMID: 23206481 DOI: 10.1177/030006051204000539] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE To compare the feasibility and safety of thoracoscopic thymectomy with conventional sternotomy thymectomy for thymoma without myasthenia gravis. METHODS Data from 70 patients diagnosed with thymoma, who underwent thoracoscopic thymectomy (n = 25, Group T) or sternotomy thymectomy (n = 45, Group S) between March 2002 and March 2008, were retrospectively evaluated. RESULTS Mean follow-up durations were 78.0 ± 21.9 months and 70.0 ± 23.6 months in Groups T and S, respectively. No deaths occurred in Group T; seven deaths occurred in Group S, all > 1 month post follow-up. Durations of chest intubation and hospitalization were significantly shorter in Group T than in Group S. No significant between-group difference in the incidence of operative complications was observed. Tumour recurrence-free rates at 5 and 7 years postsurgery were 96% (both years) in Group T and 95% (both years) in Group S. CONCLUSIONS Long-term follow-up indicates that thoracoscopic thymectomy for thymoma without myasthenia gravis is effective and is well tolerated, and associated with low rates of operative complications and recurrence.
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Affiliation(s)
- J W Chung
- Department of Thoracic and Cardiovascular Surgery, Konkuk University Medical Centre, Konkuk University School of Medicine, Seoul, South Korea
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21
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Minimally invasive thoracic surgery in pediatric patients: the Taiwan experience. BIOMED RESEARCH INTERNATIONAL 2013; 2013:850840. [PMID: 23819123 PMCID: PMC3683426 DOI: 10.1155/2013/850840] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/07/2012] [Revised: 05/06/2013] [Accepted: 05/07/2013] [Indexed: 11/17/2022]
Abstract
Minimally invasive technology or laparoscopic surgery underwent a major breakthrough over the past two decades. The first experience of thoracoscopy in children was reported around 1980 for diagnosis of intrathoracic pathology and neoplasia. Up until the middle of the 1990s, the surgical community in Taiwan was still not well prepared to accept the coming era of minimally invasive surgery. In the beginning, laparoscopy was performed in only a few specialties and only relatively short or simple surgeries were considered. But now, the Taiwan's experiences over the several different clinical scenarios were dramatically increased. Therefore, we elaborated on the experience about pectus excavatum: Nuss procedure, primary spontaneous hemopneumothorax, thoracoscopic thymectomy, and empyema in Taiwan.
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Surgery of myasthenia gravis associated or not with thymoma: a retrospective study of 43 cases. Heart Lung Circ 2013; 22:738-41. [PMID: 23548337 DOI: 10.1016/j.hlc.2013.02.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2012] [Revised: 02/08/2013] [Accepted: 02/28/2013] [Indexed: 11/23/2022]
Abstract
OBJECTIVES Thymectomy is a surgical treatment of myasthenia gravis. Our goal is to report our experience in the surgical treatment of myasthenia gravis with or without thymoma and a review of the literature. MATERIALS AND METHODS This is a retrospective study over a period of 10 years (2001-2010) on 43 patients: 28 women and 15 men with a mean age of 39.3 years (range 16-68 years). The myasthenia gravis was confirmed by clinical, electromyographic data and the presence of antibodies to acetylcholine receptors. RESULTS Computed tomography objectified thymic mass in 14 cases (32.5%) enlarged thymus without visible mass in eight cases (18.6%). All patients received anticholinesterase, cortico steroids in 25 cases and in three cases plasmapheresis was required. The surgical approach was total sternotomy (n=32 cases), cervicotomy (n=2), cervical and manubriotomy (n=1), a manubriotomy (n=3) and a thoracotomy in five cases (lateralised thymoma). All patients underwent a total thymectomy associated or not with resection of the tumour. Intensive Care Unit was necessary for at least 24h up to six days. The postoperative course was marked by a myasthaenic crisis (n=2) and respiratory failure (n=3) with a favourable outcome. The prognosis was marked by a complete remission in 14 cases, partial remission in 11 patients, stabilisation (n=16 cases) and increasing crisis in two patients. CONCLUSION Thymectomy certainly allows clinical improvement and reduced crisis of myasthenia gravis. Long term monitoring will confirm the benefit of non-oncological thymectomy alone or in combination with standard treatments for patients with generalised myasthenia gravis without thymoma.
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Renaud S, Santelmo N, Renaud M, Falcoz P, Tranchant C, Massard G. Prise en charge chirurgicale de la myasthénie auto-immune (ou myasthenia gravis). ACTA ACUST UNITED AC 2013. [DOI: 10.1016/s1241-8226(12)59757-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Tomulescu V, Popescu I. Unilateral extended thoracoscopic thymectomy for nontumoral myasthenia gravis--a new standard. Semin Thorac Cardiovasc Surg 2013; 24:115-22. [PMID: 22920527 DOI: 10.1053/j.semtcvs.2012.06.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/14/2012] [Indexed: 11/11/2022]
Abstract
Myasthenia gravis (MG) is a heterogeneous disorder with a fluctuating, clinical, pathologic, and immunobiological picture. Today, it is believed that effective treatment of MG must include both immunosuppression and surgery. Thymectomy is recommended by neurologists for patients with nontumoral MG as an option to increase the probability of remission or improvement. Currently, thoracoscopic thymectomy is considered a good alternative to the standard open approach because of its higher rate of acceptance, low morbidity, and high efficacy, as measured by complete stable remission rates. We present a review of the experience of unilateral extended thoracoscopic thymectomy for nontumoral MG, a technique that could became a new standard in the complex management of MG treatment.
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Affiliation(s)
- Victor Tomulescu
- Department of General Surgery and Liver Transplantation, Fundeni Clinical Institute, Bucharest, Romania
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25
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Marulli G, Schiavon M, Perissinotto E, Bugana A, Di Chiara F, Rebusso A, Rea F. Surgical and neurologic outcomes after robotic thymectomy in 100 consecutive patients with myasthenia gravis. J Thorac Cardiovasc Surg 2013; 145:730-5; discussion 735-6. [PMID: 23312969 DOI: 10.1016/j.jtcvs.2012.12.031] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2012] [Revised: 09/24/2012] [Accepted: 12/10/2012] [Indexed: 10/27/2022]
Abstract
OBJECTIVE Thymectomy is a well-defined therapeutic option for patients with myasthenia gravis; however, controversies still exist about the surgical approach, indication, and timing for surgery. We reviewed our experience reporting surgical and neurologic results after robotic thymectomy in patients with myasthenia gravis. METHODS Between 2002 and 2010, 100 patients (74 female and 26 male; median age, 37 years) underwent left-sided robotic thymectomy using the da Vinci robotic system (Intuitive Surgical, Inc, Sunnyvale, Calif). The Myasthenia Gravis Foundation of America classification was adopted for pre- and postoperative evaluation. Preoperative Myasthenia Gravis Foundation of America class was I in 10% of patients, II in 35% of patients, III in 39% of patients, and IV in 16% of patients. RESULTS Median operative time was 120 (60-300) minutes. No death or intraoperative complications occurred. Postoperative complications were observed in 6 patients (6%) (bleeding requiring blood transfusions in 3, chylothorax in 1, fever in 1, and myasthenic crisis in 1). Median hospital stay was 3 days (range, 2-14 days). Histologic analysis revealed 76 patients (76%) with hyperplasia, 7 patients (7%) with atrophy, 8 patients (8%) with small thymomas, and 9 patients (9%) with normal thymus; ectopic thymic tissue was found in 26 patients (26%). Clinical follow-up showed a 5-year probability of complete stable remission and overall improvement of 28.5% and 87.5%. Remission was significantly associated with preoperative I to II Myasthenia Gravis Foundation of America class (P = .02). A significant improvement rate was found in Myasthenia Gravis Foundation of America class I to II (P = .03) and AbAchR+ (P = .04). A high percentage of patients interrupted or reduced their medications. CONCLUSIONS Robotic thymectomy is a safe and effective procedure. We observed a neurologic benefit in a great number of patients. A better clinical outcome was obtained in patients with early Myasthenia Gravis Foundation of America class.
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Affiliation(s)
- Giuseppe Marulli
- Division of Thoracic Surgery, Department of Cardiologic, Thoracic, and Vascular Sciences, University of Padua, Padua, Italy.
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Single-institution experience on robot-assisted thoracoscopic operations for mediastinal diseases. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2012; 6:316-22. [PMID: 22436708 DOI: 10.1097/imi.0b013e318235b783] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE : After the introduction of video-assisted thoracoscopic surgery 20 years ago, the minimally invasive techniques in thoracic surgery have found a growing application. The recent introduction of robotic technology has increased the potentiality of thoracoscopic technique leading to an expansion of indications and applications, particularly for the management of mediastinal diseases. We reviewed our experience in robot-assisted thoracoscopic resection of benign and malignant mediastinal diseases. METHODS : Between 2002 and 2010, 108 patients (79 women and 29 men; median age 38 y) underwent robot-assisted thoracoscopy using the "da Vinci" robotic system for several mediastinal diseases. There were 100 thymectomies, 3 resections of paravertebral tumors, 1 thymic cyst, 1 ectopic goitre, 1 ectopic mediastinal parathyroidectomy, 1 thymic carcinoid, and 1 foregut cyst. Ninety-five (87.9%) patients were affected by myasthenia gravis. RESULTS : All procedures were completed successfully using the da Vinci robot; no open conversions were required, but in three (2.8%) cases, a fourth access was added. There was no surgical mortality; four (3.6%) patients had postoperative complications (two hemothorax, one chylothorax, and one fever) treated conservatively. Median operation time was 120 (range 60-300) minutes and median hospitalization was 3 (range 2-14) days. Global benefit rate for patients with myasthenia gravis reached the value of 93.4% with progressive improvement over years. CONCLUSIONS : Several mediastinal operations may be feasible by using a robot-aided thoracoscopic approach. The technical innovations offered by robotic instrumentation make all procedures safer and easier when compared with standard thoracoscopic approach, with particular reference for application in mediastinal field.
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Nakamura H, Taniguchi Y. Robot-assisted thoracoscopic surgery: current status and prospects. Gen Thorac Cardiovasc Surg 2012. [PMID: 23197160 DOI: 10.1007/s11748-012-0185-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
The most favorable advantage of robotic surgery is the markedly free movement of joint-equipped robotic forceps under 3-dimensional high-vision. Accurate operation makes complex procedures straightforward, and may overcome weak points of the previous thoracoscopic surgery. The efficiency and safety improves with acquiring skills. However, the spread of robotic surgery in the general thoracic surgery field has been delayed compared to those in other fields. The surgical indications include primary lung cancer, thymic diseases, and mediastinal tumors, but it is unclear whether the technical advantages felt by operators are directly connected to merits for patients. Moreover, problems concerning the cost and education have not been solved. Although evidence is insufficient for robotic thoracic surgery, it may be an extension of thoracoscopic surgery, and reports showing its usefulness for primary lung cancer, myasthenia gravis, and thymoma have been accumulating. Advancing robot technology has a possibility to markedly change general thoracic surgery.
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Affiliation(s)
- Hiroshige Nakamura
- Division of General Thoracic Surgery, Tottori University Hospital, 36-1 Nishi-cho, Yonago, Tottori, 683-8504, Japan.
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Renaud S, Santelmo N, Renaud M, Fleury MC, De Seze J, Tranchant C, Massard G. Robotic-assisted thymectomy with Da Vinci II versus sternotomy in the surgical treatment of non-thymomatous myasthenia gravis: early results. Rev Neurol (Paris) 2012; 169:30-6. [PMID: 22682054 DOI: 10.1016/j.neurol.2012.02.013] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2011] [Revised: 01/26/2012] [Accepted: 02/13/2012] [Indexed: 10/28/2022]
Abstract
BACKGROUND The role of thymectomy in myasthenia gravis remains controversial. The remission rate 5years after surgery varies from 13 to 51% in the literature. Sternotomy is the standard technique, though unacceptable by patients because of significant esthetic sequelae. Our objective was to demonstrate that the robot-assisted technique using the Da Vinci Surgical Robot II is at least as efficient and leaves fewer scars than the standard surgical technique. METHODS We retrospectively reviewed the data of 31 consecutive patients suffering from myasthenia gravis who underwent surgery in our center from January 1998 to March 2010. Ten patients with thymoma were excluded from this study. Two groups were formed: group 1 corresponding to patients treated with sternotomy, group 2 patients with robot-assisted technique. The duration of the hospital stay, the pain on D1, the degree of improvement at 1year according to Myasthenia Gravis Foundation of America (MGFA) classification, the frequency of relapses, and perioperative treatment were studied. RESULTS Our sample consisted of 14 women and seven men. The mean age was 31.3years. The mean delay before surgery was 24months. Group 1 included 15 patients and group 2 had six patients. The complete remission rate at 1year was 9.5% (n=2). Surgery decreased the frequency of relapses after surgery (P=0.08) equally in the two groups. The duration of hospital stay and the pain level on D1 in group 2 were significantly lower than those in group 1 (P=0.02 and P<0.001). The degree of postoperative improvement was not significantly different between the two groups (P=0.31). CONCLUSION The results at 1year are fully comparable for sternotomy and the robot-assisted technique. The robot provides additional benefits of minimally invasive techniques: minimal esthetic sequelae in often young patients, less parietal morbidity (including pain), shorter hospital stays. Our complete remission rate, lower than those in the literature, must be considered taking into account the early nature of these results. The surgical robot, because of its many advantages, appears to be a promising technique and should facilitate the early management of these patients.
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Affiliation(s)
- S Renaud
- Service de chirurgie thoracique, pôle de pathologie thoracique, hôpitaux universitaires de Strasbourg, Nouvel Hôpital Civil, 1, place de l'Hôpital, BP 426, 67091 Strasbourg cedex, France
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Ten-year results of thoracoscopic unilateral extended thymectomy performed in nonthymomatous myasthenia gravis. Ann Surg 2012; 254:761-5; discussion 765-6. [PMID: 22005151 DOI: 10.1097/sla.0b013e31823686f6] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The aim of this study was to analyze the 10-year results of thoracoscopic unilateral extended thymectomy (TUET) performed in nontumoral myasthenia gravis according to the Myasthenia Gravis Foundation of America recommendations. BACKGROUND DATA Thoracoscopic unilateral extended thymectomy has the benefits of a minimally invasive approach. Previous data have shown promising midterm results but long-term results were lacking. METHODS Two hundred forty patients with nontumoral myasthenia gravis who underwent surgery between 1999 and 2009 were eligible for the study. The mean follow-up was of 67 months (range: 12-125), 134 patients completed follow-up assessments more than 60 months after TUET. RESULTS There were 39 males (16.3%) and 201 females (83.7%), with an age range from 8 to 60 years. The mean preoperative disease duration was 21.5 months. All patients underwent preoperative steroid therapy. Anticholinesterase drugs were required for 123 patients (51.3%), and immunosuppressive drugs were required for 87 (36.3%) patients. The pathologic findings were as follows: normal thymus in 13 patients (5.5%), involuted thymus in 65 patients (27%), and hyperplastic thymus in 162 patients (67.5%). The average weight of the thymus was 110 ± 45 g. Ectopic thymic tissue was found in 147 patients (61.3%). There was no mortality, and morbidity consisted of 12 patients (5%). Complete stable remission was achieved in 61% of the patients, and the cumulative probability of achieving complete stable remission was 0.88 at 10 years. CONCLUSIONS With zero mortality, low morbidity, and comparable long-term results to open surgery, TUET can be regarded as the best treatment option for patients undergoing surgery for myasthenia gravis.
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Agasthian T. Can invasive thymomas be resected by video-assisted thoracoscopic surgery? Asian Cardiovasc Thorac Ann 2012; 19:225-7. [PMID: 21885546 DOI: 10.1177/0218492311407977] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Although video-assisted thoracic surgery can be used for well-encapsulated thymomas, its role in invasive thymomas remains controversial. Between 1998 and 2009, 77 patients aged 22-76 years underwent thymomectomy by video-assisted thoracic surgery. Tumors <5 cm without major invasion on preoperative computed tomography were selected. There were 13 invasive thymomas (Masaoka stage III and IV). A modified dissection technique was employed to prevent breaching the tumor capsule and risking tumor seedling. Limited resection of the phrenic nerve, pericardium, perithymic fat, and a wedge of lung was performed en bloc with the tumor. The mean duration of surgery was 138 min. Hospital stay was 3.6 days. Eleven patients had associated myasthenia gravis. There was 1 case of wound infection and no operative mortality. The mean size of the thymomas was 34 mm (range, 23-55 mm). All patients had adjuvant radiotherapy. During follow-up of 4.9 years (range, 1-10 years), there was one local recurrence. With the modified video-assisted thoracic surgery technique, selected invasive thymomas detected during surgery can be removed safely without resorting to sternotomy.
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Rea F, Schiavon M, Di Chiara F, Marulli G. Single-Institution Experience on Robot-Assisted Thoracoscopic Operations for Mediastinal Diseases. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2011. [DOI: 10.1177/155698451100600506] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Federico Rea
- Division of Thoracic Surgery, Department of Cardiologic, Thoracic and Vascular Sciences, University Hospital of Padova, Padova, Italy
| | - Marco Schiavon
- Division of Thoracic Surgery, Department of Cardiologic, Thoracic and Vascular Sciences, University Hospital of Padova, Padova, Italy
| | - Francesco Di Chiara
- Division of Thoracic Surgery, Department of Cardiologic, Thoracic and Vascular Sciences, University Hospital of Padova, Padova, Italy
| | - Giuseppe Marulli
- Division of Thoracic Surgery, Department of Cardiologic, Thoracic and Vascular Sciences, University Hospital of Padova, Padova, Italy
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Yeh CM, Chen HC, Chou CM, Hsu CP. Hybrid combination of small subxiphoid incision and thoracoscopic thymectomy for juvenile myasthenia gravis. J Pediatr Surg 2011; 46:780-783. [PMID: 21496556 DOI: 10.1016/j.jpedsurg.2010.11.044] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2010] [Revised: 11/22/2010] [Accepted: 11/23/2010] [Indexed: 11/26/2022]
Abstract
BACKGROUND/PURPOSE Myasthenia gravis is an autoimmune disease that usually responds positively to treatment with thymectomy. Various approaches via video-assisted thoracic thymectomy as a substitute for conventional sternotomy have been reported. We reported a less invasive technique for thymectomy in pediatric groups. METHODS Four adolescents with juvenile myasthenia gravis all underwent hybrid combination of small subxiphoid incision and thoracoscopic thymectomy at our institute. Clinical characteristics and surgical outcome were consecutively collected. RESULTS In these 4 patients, 2 presented with Osserman class III and 2 with class IIb. The mean operative time was 180 minutes. There was no conversion to sternotomy, and there was only minimal blood loss. Follow-up duration was 3 to 64 months. Postoperatively, 1 patient had complete remission and 3 patients had improvement in clinical symptoms. CONCLUSION Hybrid combination of small subxiphoid incision and thoracoscopic thymectomy may be an effective alternative with low surgical invasiveness for treating juvenile myasthenia gravis.
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Affiliation(s)
- Chou-Ming Yeh
- Division of Thoracic Surgery, Department of Health, Taichung Hospital, Executive Yuan, Taichung, Taiwan
| | - Hou-Chuan Chen
- Division of Pediatric Surgery, Department of Surgery, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Chia-Man Chou
- Division of Pediatric Surgery, Department of Surgery, Taichung Veterans General Hospital, Taichung, Taiwan.
| | - Chung-Ping Hsu
- Division of Thoracic Surgery, Department of Surgery, Taichung Veterans General Hospital, Taichung, Taiwan
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Huang CS, Cheng CY, Hsu HS, Kao KP, Hsieh CC, Hsu WH, Huang BS. Video-assisted thoracoscopic surgery versus sternotomy in treating myasthenia gravis: Comparison by a case-matched study. Surg Today 2011; 41:338-45. [DOI: 10.1007/s00595-010-4270-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2009] [Accepted: 01/14/2010] [Indexed: 12/01/2022]
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Keating CP, Kong YX, Tay V, Knight SR, Clarke CP, Wright GM. VATS Thymectomy for Nonthymomatous Myasthenia Gravis Standardized Outcome Assessment Using the Myasthenia Gravis Foundation of America Clinical Classification. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2011. [DOI: 10.1177/155698451100600205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | - Yu X. Kong
- Departments of Cardiothoracic Surgery, Melbourne, Australia
| | - Valerie Tay
- Neurology, St Vincent's Hospital, Melbourne, Australia
| | - Simon R. Knight
- Department of Thoracic Surgery, Austin Hospital, Melbourne, Australia
| | - C. Peter Clarke
- Department of Thoracic Surgery, Austin Hospital, Melbourne, Australia
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VATS Thymectomy for Nonthymomatous Myasthenia Gravis Standardized Outcome Assessment Using the Myasthenia Gravis Foundation of America Clinical Classification. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2011; 6:104-9. [DOI: 10.1097/imi.0b013e3182165cdb] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Objective Video-assisted thoracoscopic (VATS) thymectomy has been practiced in Australia for nearly two decades. Our aim was to assess the complete stable remission and asymptomatic disease rates after VATS thymectomy in nonthymomatous myasthenia gravis. There remains doubt that minimally invasive techniques achieve equal remission rates to open maximal operations. Therefore, we report our outcomes using the Myasthenia Gravis Foundation of America (MGFA) Clinical Classification and Kaplan-Meier analysis and compare the results to the literature. Methods A retrospective analysis of 78 consecutive patients undergoing right VATS thymectomy between April 1994 and March 2007 at two Thoracic Surgery Units in Melbourne, Australia, was undertaken. Patients with thymoma were excluded. Therefore, 57 patients were followed-up for a minimum of 12 months to apply the MGFA Clinical Classification. VATS thymectomy was performed by a three-port right side technique. Results The complete stable remission rate was 15% at 3 years and 28% at 5 years. The asymptomatic disease rate was 59% at 5 years. Median follow-up was 32 months. No prognostic factors for remission were identified. The overall morbidity rate was 14% (8/57). Conclusions Right VATS thymectomy achieves comparable remission and asymptomatic disease rates to other minimally invasive and open techniques when compared with studies using either MGFA or older criteria.
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Rückert JC, Swierzy M, Ismail M. Comparison of robotic and nonrobotic thoracoscopic thymectomy: A cohort study. J Thorac Cardiovasc Surg 2011; 141:673-7. [DOI: 10.1016/j.jtcvs.2010.11.042] [Citation(s) in RCA: 84] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2010] [Revised: 11/17/2010] [Accepted: 11/29/2010] [Indexed: 10/18/2022]
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Agasthian T, Lin SJ. Clinical outcome of video-assisted thymectomy for myasthenia gravis and thymoma. Asian Cardiovasc Thorac Ann 2010; 18:234-9. [PMID: 20519290 DOI: 10.1177/0218492310369017] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
We reviewed our experience of video-assisted thoracoscopic thymectomy for myasthenia gravis and thymomas in 119 patients, aged 12-83 years, who were treated between 1998 and 2007. Disease severity was graded using the Osserman classification. To prevent rupture of the tumor capsule and tumor seeding, thymomas were resected using a modified no-touch technique. Thymoma diameters were 10-90 mm (mean, 50 mm). There were no operative deaths, 12 (10%) patients had complications, and 87 (73.1%) improved by 1 or more Osserman grades postoperatively. After follow-up of 1.9-10 years (mean, 4.9 years), 74 (62%) patients remained asymptomatic, with 21% in complete stable remission. Using multivariate regression analysis, there were no statistical differences in median pre- and postoperative Osserman grades with regards to age, sex, duration of symptoms, and presence of thymoma. Video-assisted thoracoscopic thymectomy for myasthenia gravis and selected thymomas can achieve long-term clinical outcomes comparable to those of standard approaches.
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Shrager JB. Extended transcervical thymectomy: the ultimate minimally invasive approach. Ann Thorac Surg 2010; 89:S2128-34. [PMID: 20493996 DOI: 10.1016/j.athoracsur.2010.02.099] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2009] [Revised: 02/05/2010] [Accepted: 02/12/2010] [Indexed: 11/28/2022]
Abstract
The ideal operative technique for thymectomy in myasthenia gravis remains controversial. Most surgeons perform thymectomy through median sternotomy; more recently, thoracoscopic and robotic approaches have been described. "Extended transcervical thymectomy" is an out-patient procedure that appears less morbid and costly than other approaches. It allows a complete extracapsular thymic resection. Kaplan-Meier complete stable remission rates after transcervical thymectomy are 33% and 35% at 3 and 6 years (higher including patients remaining on single-drug immunosuppression). The major surgical complication rate is 0.7%. We believe that this less morbid and less costly operation is a very reasonable choice in the surgical treatment of myasthenia gravis.
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Affiliation(s)
- Joseph B Shrager
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California 94305, USA.
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Video-assisted thoracic surgery thymectomy: the better approach. Ann Thorac Surg 2010; 89:S2135-41. [PMID: 20493997 DOI: 10.1016/j.athoracsur.2010.02.112] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2009] [Revised: 02/09/2010] [Accepted: 02/12/2010] [Indexed: 11/20/2022]
Abstract
Minimally invasive video-assisted thoracic surgery (VATS) thymectomy has evolved significantly over the last decade. The most common indication for VATS thymectomy is the treatment of myasthenia gravis (MG). Video-assisted thoracic surgery thymectomy results in less postoperative pain, better preserved pulmonary function, and improved cosmesis, which can be particularly important to many young female MG patients. Results of VATS thymectomy, in terms of complete stable remission from MG and symptomatic improvement, as well as safety, are comparable with conventional surgical techniques. This more patient-friendly approach would lead to wider acceptance by MG patients and their neurologists for earlier thymectomies and improved outcomes.
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Mineo TC, Pompeo E. Extended videothoracoscopic thymectomy in nonthymomatous myasthenia gravis. Thorac Surg Clin 2010; 20:253-63. [PMID: 20451136 DOI: 10.1016/j.thorsurg.2010.01.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Myasthenia gravis (MG) is an uncommon, organ-specific, autoimmune chronic neuromuscular disorder involving the production of autoantibodies directed against the nicotinic acetylcholine receptors (anti-AchRab). It is characterized by weakness and rapid fatigability of voluntary muscles. Thymectomy is performed early in the course of the disease and is indicated for adults less than 70 years old. For many years, the clinical efficacy of thymectomy has been questioned and so far, its benefits in nonthymomatous MG have not been firmly established. Furthermore, the precise mechanisms of action of thymectomy are unknown although possible explanations include removal of the source of continued antigen stimulation and of the AchRab-recruiting B-lymphocytes as well as immunomodulation. However, thymectomy remains indicated in patients with MG and is widely applied to increase the probability of improvement or remission. This article presents the evolution of technical and surgical advances achieved within the authors' program of extended endoscopically assisted thymectomy since 1995. The use of video-assisted thoracic surgery and its variants for performing thymectomy in MG patients is now well established and will continue to evolve for further improvement in the results.
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Affiliation(s)
- Tommaso C Mineo
- Department of Thoracic Surgery, Myasthenia Gravis Unit, Fondazione Policlinico Tor Vergata, Tor Vergata University, Viale Oxford 81, Rome 00133, Italy.
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Goldstein SD, Yang SC. Assessment of Robotic Thymectomy Using the Myasthenia Gravis Foundation of America Guidelines. Ann Thorac Surg 2010; 89:1080-5; discussion 1085-6. [DOI: 10.1016/j.athoracsur.2010.01.038] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2008] [Revised: 01/06/2010] [Accepted: 01/07/2010] [Indexed: 10/19/2022]
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Prokakis C, Koletsis E, Salakou S, Apostolakis E, Baltayiannis N, Chatzimichalis A, Papapetropoulos T, Dougenis D. Modified Maximal Thymectomy for Myasthenia Gravis: Effect of Maximal Resection on Late Neurologic Outcome and Predictors of Disease Remission. Ann Thorac Surg 2009; 88:1638-45. [DOI: 10.1016/j.athoracsur.2009.07.036] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2009] [Revised: 07/21/2009] [Accepted: 07/23/2009] [Indexed: 10/20/2022]
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Meacci E, Cesario A, Margaritora S, Porziella V, Tessitore A, Cusumano G, Evoli A, Granone P. Thymectomy in myasthenia gravis via original video-assisted infra-mammary cosmetic incision and median sternotomy: long-term results in 180 patients. Eur J Cardiothorac Surg 2009; 35:1063-9; discussion 1069. [DOI: 10.1016/j.ejcts.2009.01.045] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2008] [Revised: 01/22/2009] [Accepted: 01/24/2009] [Indexed: 10/21/2022] Open
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Magee MJ, Mack MJ. Surgical Approaches to the Thymus in Patients with Myasthenia Gravis. Thorac Surg Clin 2009; 19:83-9, vii. [DOI: 10.1016/j.thorsurg.2008.09.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Meyer DM, Herbert MA, Sobhani NC, Tavakolian P, Duncan A, Bruns M, Korngut K, Williams J, Prince SL, Huber L, Wolfe GI, Mack MJ. Comparative Clinical Outcomes of Thymectomy for Myasthenia Gravis Performed by Extended Transsternal and Minimally Invasive Approaches. Ann Thorac Surg 2009; 87:385-90; discussion 390-1. [DOI: 10.1016/j.athoracsur.2008.11.040] [Citation(s) in RCA: 79] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2008] [Revised: 11/13/2008] [Accepted: 11/17/2008] [Indexed: 10/21/2022]
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Augustin F, Schmid T, Sieb M, Lucciarini P, Bodner J. Video-Assisted Thoracoscopic Surgery versus Robotic-Assisted Thoracoscopic Surgery Thymectomy. Ann Thorac Surg 2008; 85:S768-71. [DOI: 10.1016/j.athoracsur.2007.11.079] [Citation(s) in RCA: 84] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2007] [Revised: 10/27/2007] [Accepted: 11/28/2007] [Indexed: 11/28/2022]
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Coletti L, De Simone P, Catalano G, Spinelli C, Carrai P, Montin U, Urbani L, De Liperi A, Biancofiore G, Falaschi F, Filipponi F. Multi-locular thymic cysts after acute pancreatitis in a liver transplant recipient. Transpl Int 2007; 21:395-6. [PMID: 18069919 DOI: 10.1111/j.1432-2277.2007.00614.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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