Robotic thymectomy for myasthenia gravis

Thymoma resection and myasthenia gravis: what is the neurological outcome in patients older than 65 years?

To increase the neurological results in patients older than 65 years with myasthenia gravis after thymectomy, we retrospectively analysed this outcome in a large bicentric cohort of patients with myasthenia gravis (MG)years, for which surgery was indicated for a concurrent thymoma. From 1/2000 to 2/2022, 502 patients underwent thymectomy for thymic epithelial tumours (TETs) in two high-volume Institutions (167aged more than 65 years). Among them, 66 patients were affected by TET and MG, representing our final study group. The mean age for MG onset was 68.3 ± 6 years.At surgery, the Osserman score 2 was the most diffuse in our cohort (43, 65.1%), followed by 1 (20, 30.3%). In 11 cases, the MG diagnosis coincided with thymoma diagnosis. In the other cases, the interval between MG diagnosis and surgery was 1.7 years ± 1.9. The most common surgical approach was sternotomy (41,62.1%), followed by RATS (14,21.2%). The most frequent TNM stage was T1N0 (75.7%) and most patients had WHO type-B tumour. After radical thymectomy, 58 patients (88%) reported a significant neurological improvement. According to MGFA-PIS, after surgery we had 4 (6%) complete stable remission, 11 (16.7%) pharmacological remission, 43 (65.2%) minimal manifestation, 2 (3%) worsening/death for MG, and 5 (7.6%) unchanged. No association was found between neurological outcome and age of MG onset, kind of pharmacological therapy before surgery, surgical approach (sternotomy vs others), tumour dimension, the ITMIG stage and the preoperative Osserman score. For MG and thymoma-afftected patients over 65 years, thymectomy seems to be an effective treatment to improve neurological symptoms. We suggest to set up clinical trials to explore the neurological efficacy of mini-invasive thymectomy in clinically selected MG patients aged over 65 years.

National Multicenter Study on the Comparison of Robotic and Open Thymectomy for Thymic Neoplasms in Myasthenic Patients: Surgical, Neurological and Oncological Outcomes

Thymectomy is the gold standard in the treatment of thymic neoplasm and plays a key role in the therapeutic path of myasthenia gravis. For years, sternotomy has been the traditional approach for removing anterior mediastinal lesions, although the robotic thymectomy is now widely performed. The literature is still lacking in papers comparing the two approaches and evaluating long-term oncological and neurological outcomes. This study aims to analyze the postoperative results of open and robotic thymectomy for thymic neoplasms in myasthenic patients. Surgical, oncological and neurological data of myasthenic patients affected by thymic neoplasms and surgically treated with extended thymectomy, both with the open and the robotic approach, in six Italian Thoracic Centers between 2011 and 2021 were evaluated. A total of 213 patients were enrolled in the study: 110 (51.6%) were treated with the open approach, and 103 (48.4%) were treated with robotic surgery. The open surgery, compared with the robotic, presented a shorter operating time (p < 0.001), a higher number of postoperative complications (p = 0.038) and longer postoperative hospitalization (p = 0.006). No other differences were observed in terms of surgical, oncological or neurological outcomes. The robotic approach can be considered safe and feasible, comparable to the open technique, in terms of surgical, oncological and neurological outcomes.

The role of minimally invasive surgery in the management of giant mediastinal tumors: a narrative review

BACKGROUND AND OBJECTIVE

Beyond diagnosis, minimally invasive surgery has traditionally not been considered suitable for large tumors, those invading vital structures or high-risk patients. However, with the improvement of multimodality treatments able to reduce tumor size preoperatively, patient evaluation and selection, perioperative care (including both surgical and anesthesiological techniques) and postoperative management, the indications of minimally invasive surgery, even in giant mediastinal tumors, have increased and will continue to broaden in future years. This review aims to summarize the existing literature regarding the role of minimally invasive surgery in the management of giant mediastinal tumors. We have focused in the role minimally invasive surgery has in diagnosis and treatment of these tumors and we have tried to provide an updated perspective to identify future applications and work-directions.

METHODS

Data regarding minimally invasive surgery in giant mediastinal tumors are limited, including a proper definition of them. We performed a PubMed search of English and Spanish written studies until August 2021.

KEY CONTENT AND FINDINGS

There is limited data related to minimally invasive surgery in giant mediastinal tumors and much of the literature review we have performed has yielded isolated case reports, case series with a low number of cases or editorials. Although the role of minimally invasive surgery is well consolidated as a diagnostic approach, adequate patient selection, hospital volume and experience, multidisciplinary discussion of candidates, patient safety and adequate oncological resection remain the most important aspects to be taken into account when considering a minimally invasive approach for a giant mediastinal tumor.

CONCLUSIONS

With careful and multidisciplinary perioperative planning, minimally invasive surgery has shown to be safe and to provide at least similar outcomes when compared to open approaches in well selected cases. Although data is still limited, improved surgical techniques and available technology will pave the way to increased indications of minimally invasive surgery in giant mediastinal tumors.

Learning Curve of Robot-Assisted Thymectomy: Single Surgeon's 7-Year Experience

Background

Robot-assisted thymectomy (RAT) has rapidly emerged as the preferred approach over open trans-sternal or video-assisted thoracoscopy for the surgical treatment of thymomas and non-thymomatous myasthenia gravis (MG). The aim of this study was to describe and discuss the learning curve (LC) of a single surgeon performing 113 consecutive RATs.

Methods

A single-center retrospective analysis of prospectively collected clinical data was performed on all patients who had been operated on by the same surgeon in an RAT setting between October 2013 and February 2020. The cumulative sum (CUSUM) analysis of the operative time was used to define the completion of the learning curve (CLC) in RAT. The CLC was separately calculated for myasthenic patients, non-myasthenic patients, and docking time.

Results

In myasthenic patients, the CLC cut-off was found in 19 patients. Considering the CLC cut-off of 19 patients, the mean operative time in phase 1 (first 19 cases) was 229.79 ± 93.40 min, while it was 167.35 ± 41.63 min in phase 2 (last 51 cases), p≪0.001. In non-myasthenic patients, the CLC cut-off was found in 16 cases. The mean operative time in phase 1 (first 16 cases) was 277.44 ± 90.50 min, while it was 169.63 ± 61.10 min in phase 2 (last 27 cases), p = 0.016. The LC for docking time was reached at 46 cases, recording a significant reduction of time after the first phase (28.09 ± 5.37 min vs. 19.75 ± 5.51 min, p≪0.001). The intraoperative and 30-day mortality were null in all phases of the LC in both myasthenic and non-myasthenic patients. There were no differences between the two phases of the LC in terms of blood loss, duration of postoperative drainage, and postoperative stay in both myasthenic and non-myasthenic groups. However, significantly higher hospital readmission at 30 days post surgery was recorded for myasthenic patients operated on during the first phase of the LC (2 cases vs. 0, p = 0.02).

Conclusions

According to our data, LC in RAT seems to be steep, and RAT confirms to be safe even before reaching CLC.

Minimal Access Surgery for Thymoma

Thymoma is a rare epithelial tumor of the thymus gland. Despite rarity, it is the most common tumor of the anterior mediastinum. Surgical resection in the form of extended thymectomy is the gold standard operation. Conventionally and even in the current era of significant advances in the minimally invasive surgery, open transsternal extended thymectomy is considered the gold standard, particularly for advanced-stage tumors. There is however significant evidence now available for the use of minimally invasive approaches for early-stage thymomas. This article aims to discuss the various minimally invasive approaches currently being employed for thymomas.

Minimally Invasive Thymectomy and Lung Volume Reduction in a Patient With Myasthenia Gravis

We describe the case of a patient with myasthenia gravis and severe pulmonary emphysema who underwent concomitant bilateral video/robotic-assisted thymectomy with unilateral lung volume reduction surgery. We review the important pathophysiologic considerations that must be appreciated to ensure safe surgery in this unusual situation with two diseases that independently affect the respiratory system-each of which requires preoperative optimization.

Robotically assisted thymectomy: a review of the literature

The aim of this literature review is to see where the robotic thymectomy stands nowadays. A thorough search of the PubMed revealed eighty-two related articles which reviewed comprehensively. The zero intraoperative mortality, the minimal intraoperative morbidity, as well as the recorded recurrence rate of 0-11.1% and complete stable remission rate of 0-40% suggests that the robotic-assisted thymectomy is a feasible, safe and an upcoming procedure. However, the lack of prospective randomized controlled trials prevents this technique to become the standard approach for the nonce.

Thymectomy in Myasthenia Gravis

In recent years, thymectomy has become a widespread procedure in the treatment of myasthenia gravis (MG). Likelihood of remission was highest in preoperative mild disease classification (Osserman classification 1, 2A). In absence of thymoma or hyperplasia, there was no relationship between age and gender in remission with thymectomy. In MG treatment, randomized trials that compare conservative treatment with thymectomy have started, recently. As with non-randomized trials, remission with thymectomy in MG treatment was better than conservative treatment with only medication. There are four major methods for the surgical approach: transcervical, minimally invasive, transsternal, and combined transcervical transsternal thymectomy. Transsternal approach with thymectomy is the accepted standard surgical approach for many years. In recent years, the incidence of thymectomy has been increasing with minimally invasive techniques using thoracoscopic and robotic methods. There are not any randomized, controlled studies which are comparing surgical techniques. However, when comparing non-randomized trials, it is seen that minimally invasive thymectomy approaches give similar results to more aggressive approaches.

Determinants of Complete Resection of Thymoma by Minimally Invasive and Open Thymectomy: Analysis of an International Registry

INTRODUCTION

Minimally invasive thymectomy (MIT) is a surgical approach to thymectomy that has more favorable short-term outcomes for myasthenia gravis than open thymectomy (OT). The oncologic outcomes of MIT performed for thymoma have not been rigorously evaluated. We analyzed determinants of complete (R0) resection among patients undergoing MIT and OT in a large international database.

METHODS

The retrospective database of the International Thymic Malignancy Interest Group was queried. Chi-square and Wilcoxon rank sum tests, multivariate logistic regression models, and propensity matching were performed.

RESULTS

A total of 2514 patients underwent thymectomy for thymoma between 1997 and 2012; 2053 of them (82%) underwent OT and 461 (18%) underwent MIT, with the use of MIT increasing significantly in recent years. The rate of R0 resection among patients undergoing OT was 86%, and among those undergoing MIT it was 94% (p < 0.0001). In propensity-matched MIT and OT groups (n = 266 in each group); however, the rate of R0 resection did not differ significantly (96% in both the MIT and OT groups, p = 0.7). Multivariate analyses were performed to identify determinants of R0 resection. Factors independently associated with R0 resection were geographical region, later time period, less advanced Masaoka stage, total thymectomy, and the absence of radiotherapy. Surgical approach, whether minimally invasive or open, was not associated with completeness of resection.

CONCLUSIONS

The use of MIT for resection of thymoma has been increasing substantially over time, and MIT can achieve rates of R0 resection for thymoma similar to those achieved with OT.

Olfactory and gustatory dysfunction in Myasthenia gravis: A study in Turkish patients

OBJECTIVE

Myasthenia gravis (MG) is commonly viewed as a muscle disorder. Less is known about neurosensory function and dysfunction in MG. We aim to evaluate olfactory and gustatory behavior in Turkish patients with MG, and compare these results with age and sex-matched healthy controls.

MATERIAL/METHODS

30 individuals with MG, and 30 healthy volunteers were studied. Olfactory function was studied with the Sniffin' sticks test. Taste strip test was used for studying taste function. The t-test was used for analyzing continuous variables, and the chi-square test for categorical data. Clinical staging and medication status were included in a model analyzed using analysis of variances.

RESULTS

MG patients showed significantly lower olfactory (p<0.001) and gustatory scores (p<0.001) than the healthy controls. In addition, olfactory loss correlated with the severity of the disease. Medications for MG did not influence these results.

CONCLUSION

This study replicates the olfactory dysfunction found elsewhere in MG. Further, gustatory dysfunction, an activity unrelated to muscle strength, was also unveiled. Medications used for treating MG must not be blamed for the chemosensory dysfunction found in this neurological disorder.

Robotic thoracic surgery: The state of the art

Minimally invasive thoracic surgery has come a long way. It has rapidly progressed to complex procedures such as lobectomy, pneumonectomy, esophagectomy, and resection of mediastinal tumors. Video-assisted thoracic surgery (VATS) offered perceptible benefits over thoracotomy in terms of less postoperative pain and narcotic utilization, shorter ICU and hospital stay, decreased incidence of postoperative complications combined with quicker return to work, and better cosmesis. However, despite its obvious advantages, the General Thoracic Surgical Community has been relatively slow in adapting VATS more widely.

The introduction of da Vinci surgical system has helped overcome certain inherent limitations of VATS such as two-dimensional (2D) vision and counter intuitive movement using long rigid instruments allowing thoracic surgeons to perform a plethora of minimally invasive thoracic procedures more efficiently.

Although the cumulative experience worldwide is still limited and evolving, Robotic Thoracic Surgery is an evolution over VATS. There is however a lot of concern among established high-volume VATS centers regarding the superiority of the robotic technique. We have over 7 years experience and believe that any new technology designed to make minimal invasive surgery easier and more comfortable for the surgeon is most likely to have better and safer outcomes in the long run. Our only concern is its cost effectiveness and we believe that if the cost factor is removed more and more surgeons will use the technology and it will increase the spectrum and the reach of minimally invasive thoracic surgery.

This article reviews worldwide experience with robotic thoracic surgery and addresses the potential benefits and limitations of using the robotic platform for the performance of thoracic surgical procedures.