Timectomía videotoracoscópica para el tratamiento de la miastenia gravis

Video-assisted thoracoscopic surgery thymectomy versus open thymectomy in patients with myasthenia gravis: a meta-analysis

BACKGROUND

Video-assisted thoracoscopic surgery (VATS) thymectomy has become a feasible treatment for myasthenia gravis (MG) in recent years. The objective of the present meta-analysis was to evaluate the perioperative characteristics, safety, and completely stable remission rate in patients with MG who received VATS or open thymectomy (OT).

METHODS

We searched PubMed, Embase, ScienceDirect, Web of Science, and CNKI for related articles using combinations of the search terms video-assisted thoracoscopic thymectomy, transsternal thymectomy, and MG. The inter-study heterogeneity was assessed by χ²-based Q statistics, and the extent of inconsistency was generated by I² statistics.

RESULTS

A total of 12 studies with 1173 patients were included, and there was no difference in the operation time (p = 0.08) and ICU time (p = 0.14) between the two groups, but VATS thymectomy was associated with less intra-operation blood loss and hospital time (p < 0.00001). VATS was also associated with lower rates of total complication (OR =0.59; 95% CI, 0.37-0.94; p = 0.03) and myasthenic crisis (OR = 0.51; 95% CI, 0.28-0.92; p = 0.03), but the rates of pneumonia (OR = 0.59; 95% CI, 0.29-1.32; p = 0.21) and complete remission rate (CSR) (OR = 0.64; 95% CI, 0.38-1.09; p = 0.10) had no obvious differences between the VATS and OT groups.

CONCLUSION

Patients with MG undergoing VATS thymectomy achieved better surgical outcomes and fewer complications than those who received OT.

[Thoracoscopic thymectomy with carbon dioxide insufflation in the mediastinum]

The case is presented of a 71 year-old male, diagnosed with a thymoma. A thoracoscopic thymectomy was performed using the carbon dioxide insufflation technique in the mediastinum. During the procedure, while performing one-lung ventilation, the patient's respiration worsened. The contralateral lung had collapsed, as carbon dioxide was travelling from the mediastinum to the thorax through the opened pleura. Two-lung ventilation was decided upon, which clearly improved oxygenation in the arterial gases and airway pressures. Both pH and pCO2 stabilized. The surgical approach and the carbon dioxide technique were continued because 2-lung ventilation did not affect the surgical procedure. This technique has many serious complications and it should always be performed using 2-lung ventilation.

Preliminary results of VATS thymectomy for pediatric myasthenia gravis

Myasthenia gravis (MG) is a debilitating disease which necessitates long-term medical therapy. If left untreated, it can have a high mortality rate. The commonest variety in children, the autoimmune variety, often requires recourse to immunomodulation including prolonged usage of high-dose steroids. Thymectomy has not been a popular option among treating clinicians. There is evidence to suggest that if thymectomy is performed early in the disease, it has a high success rate in reducing the doses of the oral steroid medication and also in inducing remission of the disease. We have performed video-assisted thoracoscopic surgery (VATS) thymectomy in four patients with the autoimmune variety of MG. In this study, we have had a fair and comparable success rate as with the other adult series. On the basis of this preliminary study, we recommend that the option of VATS thymectomy should be offered to select patients of MG.