Unilateral extended thoracoscopic thymectomy for nontumoral myasthenia gravis--a new standard

Advances in Understanding and Managing Myasthenia Gravis: Current Trends and Future Directions

Myasthenia gravis (MG) is an autoimmune illness characterized by autoantibodies against the acetylcholine receptor (AChR), muscle-specific tyrosine kinase (MuSK), and an increasing number of extra postsynaptic proteins. Pathogenic autoantibodies reduce the number of functional AChRs in the neuromuscular junction's (NMJ) muscle end plate. The cause of the autoimmune response is unknown, but thymic abnormalities and immune regulatory deficiencies are significant. The disease's incidence is likely influenced by genetic predisposition, with sex hormones and exercise playing a role. MG can affect any age, race, or gender and can be caused by any stressor, with infections being the most frequent cause. Treatment focuses on airway support and the triggering incident. MG is a rare autoimmune disease causing fatigue-inducing weakness in the axial, respiratory, leg, and bulbar muscles. Initially affecting the eyes, most MG patients experience at least one worsening symptom during their illness. The disease is mainly caused by antibodies against the AChR, dependence on the immune system within cells, and engagement of the complement system. The complement system plays a significant role in MG, and complement inhibition can both prevent the onset and slow its development. Ocular MG affects around 15% of people, with most patients having blocking antibodies against the cholinergic receptor. There may be correlations between thymoma and other autoimmune conditions, especially thyroid illness. Treatment and management for MG involve removing autoantibodies from circulation or blocking effector mechanisms using techniques such as complement inhibition, plasmapheresis, and B-cell elimination.

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.

The resident's point of view in the learning curve of thymic MIS: why should I learn it?

Minimally invasive surgery (MIS) in thoracic surgery became quite popular during the last years. The aim of introducing and performing more MIS is to reduce surgical trauma, pain and complications in patients. Training in MIS increases operative time and thus cost in theatre but thus improves with experience. For a resident, the cases should be well selected with experienced supervision in a suitable setting with supporting staff and optimal instruments. Understanding the anatomy of the lung, using simulators, and attending workshops makes the learning curve shorter.

Surgical and oncological outcomes of thoracoscopic thymectomy for thymoma

Thymoma remains the most common primary anterior mediastinal neoplasm. Surgical resection remains central to the treatment of thymoma, with thoracoscopic thymectomy (TT) being increasingly performed. This present review article aimed to summarize current studies comparing TT and open thymectomy (OT). Recently, most patients with Masaoka stage I-II thymoma have been receiving TT. This procedure is associated with a significantly shorter post-operative hospital stay, decreased intraoperative blood loss, and fewer complications compared with OT. Recurrence rates of thymoma after TT range from 0% to 6.7%, and the 5-year disease-free survival (DFS) ranges from 83.3% to 96%. The oncological outcomes of TT are comparable to that of OT. Masaoka stage and the World Health Organization (WHO) type classification are valuable predictors of the prognosis of thymoma; hence, the optimal treatment for thymoma should be performed according to these two. TT is less invasive, with equivalent oncological outcomes, when compared with the OT. Minimally invasive surgery including TT for stage I-II thymomas is becoming the mainstay of therapy.

Video-assisted thoracoscopic surgery versus sternotomy in thymectomy for thymoma and myasthenia gravis

Thymectomy involves the removal of all the soft tissue in the pre-vascular plane of the anterior mediastinum between the two phrenic nerves. Surgical success in controlling myasthenia and the most important factor influencing survival in patients with thymoma depends on complete clearance of thymic tissue. Currently there is a perception that the open (median sternotomy) approach offers better visualisation of the thymic tissue. This perceived advantage is thought to justify the invasive nature of the procedure associated with increased morbidity. Video-assisted thoracoscopic surgery (VATS) for thymectomy has evolved significantly over the last decade, including bilateral and unilateral VATS (either left or right) approaches. The laterality of the approach remains largely on surgeon preferences, with the decision influenced by their experience and training. VATS offers superior illumination and magnification, particularly with the availability of advanced cameras with variable angles that provide better exposure and lighting of the operative field. The use of three-dimensional-operating imaging has also revolutionised the VATS technique. VATS thymectomy is a superior and radical technique in minimising access trauma and removing all thymic tissue that may be scattered in the anterior mediastinum and cervical fat. Other advantages of VATS include less intraoperative blood loss, early removal of chest drains, less requirement for blood products, decreased inflammatory cytokine response, shorter hospital stay and superior cosmesis. There is also a decreased risk of respiratory and cardiac related complications compared to the open (sternotomy) technique. Furthermore, no significant difference has been found in long-term complications and survival rate between VATS and open approaches. Subsequently, the VATS approach should be encouraged as more surgeons are adopting the minimally invasive practice as routine.

Comparative study of video-assisted thoracic surgery versus open thymectomy for thymoma in one single center

BACKGROUND

Due to the popularity of video-assisted thoracic surgery (VATS) techniques in clinical, thymoma patients via VATS thymectomy are increasing rapidly. However, compared with open thymectomy, the potential superiorities and defects of VATS thymectomy remain controversial.

METHODS

A number of 129 patients who underwent thymectomy of early stage thymoma (Masaoka stage I and stage II) in one single center from January 2007 to September 2013 were selected in this retrospective study. Of those patients, 38 thymoma patients underwent VATS thymectomy (VATS group) and 91 underwent open thymectomy (open group) via either transsternal [44] or transthoracic approach [47] in the same period. The postoperative variables, which included postoperative hospital length of stay (LOS), the intensive care unit (ICU) LOS, the entire resection ratio, the number of thoracic drainage tubes, the quantity of output and duration of drainage, were analyzed. Meanwhile, the operation time and blood loss were considered as intraoperative variables.

RESULTS

All thymoma patients in the analysis included 19 thymoma patients with myasthenia gravis, among which five patients via VATS thymectomy and 14 patients via open thymectomy respectively. There was no death or morbidity due to the surgical procedures perioperatively. The ICU LOS, operation time, entire resection ratio, and the number of chest tubes were not significantly different in two groups. The postoperative hospital LOS of VATS thymectomy was shorter than that of open thymectomy (5.26 versus 8.32 days, P<0.001). The blood loss of VATS thymectomy was less than open thymectomy (114.74 versus 194.51 mL, P=0.002). Postoperatively, the quantity of chest tubes output in VATS group was less than that in open thymectomy group (617.86 versus 850.08 mL, P=0.007) and duration of drainage in VATS group was shorter than that in open thymectomy group (3.87 versus 5.22 days, P<0.001).

CONCLUSIONS

VATS thymectomy is a safe and practicable treatment for early-stage thymoma patients. Thymoma according with Masaoka staging I-II without evident invading seems to be performed through VATS approach appropriately, which has shorter postoperative hospital LOS, less blood loss and less restrictions to activities, hence patients will recover sooner.

Robotic thymectomy for myasthenia gravis

Robotic thymectomy with the da Vinci robotic system is the latest development in the surgery of thymic gland. Thymectomy for myasthenia gravis is best offered to patients with seropositive acetylcholine receptor antibodies and who are seronegative for muscle-specific kinase protein. The robotic operation technique is indicated in all patients with myasthenia gravis in association with a resectable thymoma, typically Masaoka-Koga stages I and II.