Video-assisted thoracoscopic thymectomy for myasthenia gravis

[Comparative analysis of thoracoscopic and open thymectomy for thymoma stage I-II]

OBJECTIVE

To improve the short-term postoperative outcomes in patients with thymoma stage I-II by using of thoracoscopic thymectomy (VATS TE) and to compare this technique with open (OTE) thymectomy.

MATERIAL AND METHODS

A retrospective analysis included 98 patients who had undergone surgery for thymoma stage I and II for the period from January 2001 to December 2019. VATS TE (main group) was performed in 53 (54.1%) cases, OTE (control group) - in 45 (45.9%) patients.

RESULTS

Duration of VATS TE and OTE was similar. VATS procedure was characterized by less intraoperative blood loss (50 vs 225 ml, p=0.000), lower pain scores and morphine consumption (p=0.000), shorter postoperative pleural drainage (1.5 vs 3.8 days, p=0.000), and postoperative hospital-stay (7.6 vs 12.7 days, p=0.000). Incidence of major complications was significantly less in the main group (9.4% vs. 1.9%, p=0.001).

CONCLUSION

VATS TE is effective and safe procedure for thymoma stage I-II. Postoperative period after VATS TE is characterized by less intraoperative blood loss, incidence of complications, duration of pleural drainage and hospital-stay.

A comparative study of the analgesic effects of intravenous ketorolac, paracetamol, and morphine in patients undergoing video-assisted thoracoscopic surgery: A double-blind, active-controlled, randomized clinical trial

Background:

Opioids are traditionally used as the drug of choice for the management of postoperative pain. However, their use is limited in patients undergoing Video-assisted thoracic surgery (VATS), due to their side effects, such as respiratory depression, nausea, and vomiting.

Aim:

In this double-blind active-controlled randomized study, we have compared the analgesic effects of ketorolac and paracetamol to morphine.

Methods:

Patients were randomly chosen from a pool of candidates who were undergoing VATS and were divided into three groups. During the first 24 h postsurgery, patients in the control group received a cumulative dose of morphine 20 mg, while patients in two treatment groups received ketorolac 120 mg and paracetamol 4 g in total. Doses were administered as bolus immediately after surgery and infusion during the first 24 h. Patients' pain severity was evaluated by visual analogue scale rating (VAS) at rest and during coughing episodes.

Results:

The average pain score at recovery time was 2.29 ± 2.13 and 2.26 ± 2.16 for ketorolac and paracetamol, respectively, and it was significantly lower than the morphine group with an average pain score of 3.87 (P = 0.003). Additionally, the VAS score during cough episodes was significantly higher in the control group throughout the study period compared to study groups. Comparison of mean morphine dose utilized as liberation analgesic (in case of patients had VAS >3) between three groups was not significantly different (P = 0.17).

Conclusion:

Our study demonstrates the non-inferiority of ketorolac and paracetamol to morphine in controlling post-VATS pain without causing any significant side effects. We also show that ketorolac and paracetamol are superior to morphine in controlling pain during 2 h postsurgery.

Is chest tube drainage necessary after subxiphoid thoracoscopic thymectomy?

Background

Subxiphoid thoracoscopic thymectomy has been increasingly performed in recent years. This study aimed to assess the differences in outcomes between subxiphoid thoracoscopic thymectomy with and without chest tube drainage.

Methods

Overall, 205 subxiphoid thoracoscopic thymectomy operations were performed for myasthenia gravis, including 90 cases without and 115 cases with chest tube drainage. The clinical characteristics and perioperative outcomes of the patients were compared.

Results

The patients included 112 women and 93 men, with a mean age of 41 years. Two patients in the group without and 5 patient in the group with chest tube drainage developed dyspnea. In the group without chest tube, 6 patients had residual pneumothorax or pleural effusion and had a thoracentesis after surgery (6/90). In the group with chest tube, 7 patients developed delayed pleural effusion and had a thoracentesis after chest tube removal (7/115). The patients in the group without chest tube drainage group yielded lower pain scores.

Conclusions

The omission of chest tube drainage may be a feasible and safe choice for patients with myasthenia gravis undergoing subxiphoid thoracoscopic thymectomy, but further prospective studies are required.

Long-term results of thoracoscopic thymectomy for thymoma without myasthenia gravis

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.

Management of myasthenic patients with thymoma

Myasthenia gravis (MG) associated with thymomas differs from nonthymomatous MG, and thymomas associated with MG are also different from non-MG thymomas. According to the World Health Organization classification, the incidence of MG in thymomas was the highest in the subtypes B2, B1, and AB. Transsternal approach is still regarded as the gold standard for surgical treatment of thymomas. Less-invasive techniques of thymectomy are promising, but it is too early to estimate their real oncological value. In the series including more than 100 patients, the prognosis for survival is better in patients with thymomas associated with MG than in those with non-MG thymomas, and the prognosis for patients with MG associated with thymoma is worse than that for patients with nonthymomatous MG.

Video-assisted thoracic surgery thymectomy: the better approach

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.

Harmonic Scalpel in Video-Assisted Thoracoscopic Thymic Resections

Video-assisted thoracoscopic thymectomy is safe, but the efficacy of this technique in thymomectomy is unproved. Data of 103 consecutive patients who had thoracoscopic thymectomy and thymomectomy between 1998 and 2006 were retrospectively reviewed. Conventional monopolar diathermy and endoscopic Liga clips were used in the first 50 patients, and the Harmonic Scalpel was employed in the next 53. Only mean tumor size differed between groups (56.6 ± 18.2 vs 40.0 ± 20.8 mm in Harmonic Scalpel group). A similar number of patients had myasthenia gravis in the first group (72%) and Harmonic Scalpel group (83%). There were 49 thymomas (22 in first group, 27 in Harmonic Scalpel group). Of the earlier patients, 2 were re-explored for excessive chest tube drainage, 1 had ipsilateral phrenic nerve injury, and 2 had left phrenic nerves sacrificed intraoperatively due to thymoma invasion, but there was no significant difference in complications between groups. At a mean follow-up of 3.40 ± 2.38 years (range, 0.04–8.52 years), there was 1 thymoma recurrence in the first group. Use of the Harmonic Scalpel in video-assisted thoracoscopic thymic resection is safe and confers some advantages over conventional methods of dissection.

Transsternal Thymectomy for Myasthenia Gravis: Surgical Outcome

BACKGROUND

Transsternal thymectomy is well established in the treatment of myasthenia gravis. Surgical strategy and patient selection, however, remain controversial. This paper reports the experience of a supraregional center looking into the influence of different preoperative risk factors on surgical outcome.

METHODS

Between 1987 and 1998, 85 consecutive patients (65 female; mean age, 30.5 years) were enrolled. The mean preoperative Myasthenia Gravis Foundation of America stage was 2.3. The preoperative, early, and late follow-up data were analyzed retrospectively.

RESULTS

Mean follow-up was 4.5 years (range, 1 to 14; 376 follow-up years). Mean duration of disease before surgery was 31 months. There were no operative or late deaths. Eight patients had major complications. Seventy-two patients were free from any early or late morbidity. Immunosupression therapy patients were more prone to have complications. At their last visit, 15 patients (17%) were in complete remission; 67 reported clinical improvement. Sixty-three were asymptomatic or in stage I on no or minimal treatment. Remission and clinical improvement were not predicted by patient's age, sex, duration of disease prior to surgery, thymic pathology, or antiacetylcholine receptor antibodies titer. Greater severity of symptoms before surgery was associated with greater subsequent improvement. Remission at 1 year predicted remission at the end of follow-up.

CONCLUSIONS

Transsternal thymectomy for myasthenia gravis is safe and effective. It benefits most patients, especially those with severe symptoms. The long interval from diagnosis to surgery demonstrates it is never too late for thymectomy.

Video-Assisted Thoracic Surgery Thymectomy for Nonthymomatous Myasthenia Gravis

STUDY OBJECTIVES

Minimal-access thymectomy has become increasingly popular as surgical treatment for patients with nonthymomatous myasthenia gravis (NTMG) because of its comparable efficacy, safety, and lesser degree of tissue trauma compared with conventional open surgery. We reviewed and analyzed our data on video-assisted thoracic surgery (VATS) thymectomy and present the clinical outcomes according to the Myasthenia Gravis Foundation of America classification.

DESIGN

A retrospective review of VATS thymectomy for NTMG in a university hospital over a 12-year period. Data were collected from the medical records and supplemented with telephone surveys. The impact of surgery and other variables potentially affecting complete stable remission (CSR) were calculated using Kaplan-Meier survival curves; comparisons between survival curves was performed using the log-rank test.

RESULTS

A total of 38 consecutive patients underwent VATS thymectomy for NTMG. Median postoperative stay was 3 days. Pathologic examination revealed thymic hyperplasia in 61.1% of cases, normal thymus in 22.2%, and thymic atrophy in 16.6%. There was no perioperative mortality; complications occurred in four patients. After a median follow-up of 69 months, 91.6% of patients experienced improvement, with crude CSR achieved in 22.2%. Kaplan-Meier survival curve demonstrated a 75% CSR rate at 10-year follow-up. On univariate analysis, only disease duration < or = 12 months (p = 0.03) was associated with a statistically significant improvement in CSR.

CONCLUSIONS

VATS thymectomy for NTMG results in symptomatic improvement in the vast majority of patients, with a high rate of CSR. The procedure is associated with low morbidity and no perioperative mortality. Future studies on thymectomy for myasthenia gravis should be reported in a standardized manner to allow accurate comparisons between results in the absence of randomized prospective trials.

Prognostic factors for myasthenic crisis after transsternal thymectomy in patients with myasthenia gravis

OBJECTIVE

The purpose of this study was to assess which clinical features of patients with myasthenia gravis predict postoperative respiratory problems due to myasthenic crisis after transsternal thymectomy.

METHODS

One hundred twenty-two patients who underwent transsternal thymectomy in our institute were analyzed retrospectively. Fourteen of those experienced myasthenic crisis and required prolonged (48 hours or more) postoperative mechanical ventilation. The following factors were evaluated: sex, age, body mass index, grade of symptom, disease interval, existence of thymoma, history of preoperative crisis, doses of anticholinesterase drugs, steroid use, pulmonary function, serum anti-acetylcholine receptor antibody, history of pulmonary disease, presence of other disease, operation time, and blood loss.

RESULTS

Univariate analysis revealed preoperative bulbar symptoms (odds ratio = 14.246, P =.001), history of preoperative myasthenic crisis (7.091,.018), and preoperative serum level of anti-acetylcholine receptor antibody > 100 nmol/L (4.098,.044) were prognostic factors for postoperative myasthenic crisis. On the other hand, multivariate logistic regression analysis revealed preoperative bulbar symptoms (33.333,.004), preoperative serum level of anti-acetylcholine receptor antibody > 100 nmol/L (7.874,.020), and intraoperative blood loss > 1000 mL (18.519,.048) were prognostic factors for postoperative myasthenic crisis.

CONCLUSIONS

In this study, postoperative myasthenic crisis after transsternal thymectomy in 122 patients with myasthenia gravis was affected by the existence of preoperative bulbar symptoms, history of preoperative myasthenic crisis, preoperative serum level of anti-acetylcholine receptor antibody > 100 nmol/L, and intraoperative blood loss > 1000 mL. Meticulous preoperative and postoperative care should be carried out to prevent postoperative myasthenic crisis in patients with these prognostic factors.

Thymectomy for myasthenia gravis: analysis of controversies--patient management

BACKGROUND

Debate continues regarding the effectiveness of thymectomy in the treatment of nonthymomatous autoimmune myasthenia gravis primarily because there have been no controlled prospective studies. The debate is compounded by the lack of recognition that all thymectomies are not equal in extent or effectiveness and by the fact that all the studies are retrospective without common definitions of myasthenia gravis manifestations or response to therapy. In addition, the analysis of data is often inappropriate.

REVIEW SUMMARY

Evidence is presented demonstrating that the extent of the various thymic resectional techniques is very variable and often incomplete and that the more complete the thymic resection the better the results. The indications for thymectomy, the selection of the technique of the resection, the reoperations issue, the perioperative management of the myasthenia gravis patient, morbidity and mortality, and appropriate methods of outcome research are also reviewed.

CONCLUSION

In view of the impressive results associated with a complete thymic resection in the treatment of myasthenia gravis, patients should not be denied this operation because of lack of prospective proof to-date, and when a thymectomy is performed a total resection is indicated.

Thymectomy by partial sternotomy for the treatment of myasthenia gravis

BACKGROUND

Myasthenia gravis is an autoimmune disease characterized by weakness and fatigue of voluntary muscles. Surgical treatment of choice for myasthenia gravis has been thymectomy. However, thymectomy indications and surgical approach are still controversial. The purpose of this study is to evaluate the efficacy of partial median sternotomy approach to the thymus.

METHODS

From 1973 to 1999, 478 patients with myasthenia gravis underwent thymectomy through a partial median sternotomy.

RESULTS

Sixty-one patients (12.7%) had complete remission of symptoms, 299 (62.5%) had a significant improvement, and 83 (17.4%), a mild improvement; whereas 35 patients (7.4%) had no improvement of clinical symptoms.

CONCLUSIONS

Partial median sternotomy has shown to be a useful surgical approach to the thymus, as demonstrated by the good functional and aesthetic results, associated with low morbidity and no mortality.

Paradigm shift in surgical approaches to thymectomy

BACKGROUND

Thymectomy is an established therapy in the management of myasthenia gravis (MG) used in conjunction with medical treatment. The optimal surgical approach to thymectomy, however, has remained controversial.

METHOD

The present review discusses the author's experiences of and the literature regarding the management of MG using the video-assisted thoracic surgery (VATS) approach.

RESULTS

This approach was shown to be technically safe in experienced hands and associated with less postoperative pain, better preservation of lung function in the early postoperative period and better cosmetic results than alternative techniques. The intermediate term results of VATS are comparable to those of more radical approaches. It is hoped that this patient-friendly approach will lead to greater support by patients and their neurologists, for earlier surgery.

CONCLUSION

VATS is an attractive, alternative approach to thymectomy.

Long-term evaluation of extended thymectomy with anterior mediastinal dissection for myasthenia gravis

BACKGROUND

Thymectomy for the treatment of myasthenia gravis (MG) is well established. The extent of resection, however, remains a source for debate. Outcomes for newer surgical techniques need to be compared to more extensive procedures.

METHODS

A retrospective review was done of 64 consecutive patients who underwent transsternal thymectomy with extended anterior mediastinal dissection for MG between 1979 and 2000 and who were operated on by a single surgeon.

RESULTS

Fifty-six patient charts were available, providing 58 operative procedures. Three patients had died of unrelated causes. The mean age of symptom onset was 36.0 +/- 2.5 years, with a mean duration of 3.3 +/- 0.5 years until surgery was undertaken. The mean length of follow-up was 6.8 +/- 0.8 years. Operative procedures were associated with a 10.3% major morbidity rate and no mortality. Drug-free remission was achieved in 50.0% of the patients, and symptoms were absent or improved in 76.8% of the patients. Patients followed up long-term (>10 years) achieved the greatest remission rate (71.4%) and symptomatic improvement (85.7%). After thymectomy, the mean dosages of prednisone and Mestinon decreased by 69.3% and 58.8%, respectively.

CONCLUSIONS

Extended thymectomy provides excellent overall symptom improvement, which is enhanced over time. This review provides a basis for long-term comparison with other less invasive and perhaps less extensive procedures.

Video-assisted thoracoscopic thymectomy in juvenile myasthenia gravis

As video-assisted thoracoscopic surgery for thymectomy has been reported to be as effective as traditional open surgical approaches in predominantly adult patients with myasthenia gravis, we applied this procedure to juvenile patients with this condition. Six patients underwent total thymectomy using the video-assisted technique (1997-98). Six patients in whom a median transsternal approach was used (1989-95) formed the comparison group. The two patient groups were similar in terms of age at thymectomy and preoperative clinical severity. There were no serious perioperative complications in either group. Minimum post-thymectomy duration of follow-up in the video-assisted thoracoscopic surgery patients was 2.3 years (mean 2.7 years), with all patients clinically improved over their baseline status. Preliminary results suggest that video-assisted thymectomies are comparably effective to transsternal procedures in treating generalized juvenile myasthenia gravis and can be safely performed in children as young as 20 months of age. In addition, video-assisted surgeries are less invasive than transsternal approaches, significantly shorten the postoperative hospital stay, and have superior cosmetic results.

Current neuro-ophthalmic therapies

The clinical characteristics, differential diagnosis, and treatment options are presented for five different categories of neuro-ophthalmic disease. Nystagmus, optic neuritis, diplopia, pseudotumor cerebri, and temporal arteritis, are frequently encountered in neuro-ophthalmic practice. This article focuses on current therapies for these neuro-ophthalmic disorders. Potential differences in approach to pediatric versus adult patients are emphasized.

Pulmonary function after thoracoscopic thymectomy versus median sternotomy for myasthenia gravis

BACKGROUND

Impaired pulmonary function due to myasthenia gravis (MG) is further compromised by thymectomy, which is necessary in most cases. Thoracoscopic thymectomy (tThx) can achieve the same resection and functional improvement of MG as median sternotomy (sThx). The possible advantage of tThx in maintaining better perioperative lung function was quantified.

METHODS

In a prospective trial, 20 patients with MG were randomly allocated to undergo tThx (n = 10) by three-trocar left-sided approach or sThx (n = 10) performed as an extended procedure. Complete pulmonary function was measured at 12-hour intervals, beginning 6 hours postoperatively. Effective postoperative pain control in both groups was achieved by patient-controlled analgesia with morphine sulfate assessed by a visual analogue scale. Statistical analysis for comparison of tThx and sThx was performed using the Mann-Whitney U test.

RESULTS

Postoperative vital capacity, forced vital capacity, forced expiratory volume per second, and peak expiratory flow, measured as a percentage of the individual preoperative capacity, were significantly better with tThx compared with sThx. Immediate postoperative lung function was reduced to 35% and 65% after tThx and sThx, respectively. By the third postoperative day, recovery of pulmonary function was complete after tThx but only 55% after sThx.

CONCLUSIONS

Less pronounced impairment and faster recovery of pulmonary function after tThx characterize this new approach for thymectomy as minimally invasive. These results could make tThx the preferred surgical treatment of MG, which was improved to the same extent as after sThx.

Pulmonary function after cardiac and thoracic surgery

Cardiac and thoracic surgery cause alterations in ventilatory function that can lead to significant postoperative pulmonary complications. These complications often occur among patients with pre-existing pulmonary dysfunction and cause significantly longer hospital stays. This review explores some of the recent literature concerning this issue, including the effects of lung reduction surgery.