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Rodriguez M, Milla L, Wee JO. The role of minimally invasive surgery in the management of giant mediastinal tumors: a narrative review. MEDIASTINUM (HONG KONG, CHINA) 2022; 6:37. [PMID: 36582972 PMCID: PMC9792823 DOI: 10.21037/med-21-38] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 04/11/2022] [Indexed: 06/17/2023]
Abstract
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.
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Affiliation(s)
- Maria Rodriguez
- Department of Thoracic Surgery, Clínica Universidad de Navarra, Madrid, Spain
| | - Lucia Milla
- Department of Thoracic Surgery, Clínica Universidad de Navarra, Madrid, Spain
| | - Jon O. Wee
- Division of Thoracic Surgery, Brigham and Women’s Hospital, Boston, Massachusetts, USA
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Lee Y, Samarasinghe Y, Patel J, Khondker A, McKechnie T, Samarasinghe N, Finley C, Hanna W, Shargall Y, Agzarian J. The short and long-term effects of open vs minimally invasive thymectomy in myasthenia gravis patients: a systematic review and meta-analysis. Surg Endosc 2022; 37:3321-3339. [PMID: 36539629 DOI: 10.1007/s00464-022-09757-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Accepted: 11/01/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Thymectomy has been utilized as a treatment for Myasthenia Gravis (MG) for many decades, with both open and minimally invasive surgical (MIS) techniques currently used. Although MIS has shown improved short-term results, long-term effects remain uncertain. This systematic review and meta-analysis aim to compare the post-operative and long-term outcomes of MIS versus open thymectomy in MG patients. METHODS MEDLINE, EMBASE and CENTRAL databases were searched from inception till January 2022 for keywords related to MG and open or MIS thymectomy. Primary outcome was complete stable remission (CSR), and secondary outcomes were clinical improvement, complications, length of stay, operation time, and blood loss. Grading of recommendations, assessment, development, and evaluation was used to assess the certainty of evidence. RESULTS 26 studies with 3588 patients were included in the analysis. At 1, 3 and 5 years, there was no statistical difference noted in CSR between open versus MIS thymectomy. However, CSR was improved at 1 year for MIS thymectomy in non-thymomatous MG (P = 0.03). There was no significant difference in rates of partial clinical improvement between techniques at 1-year. Although analyses on length of hospital stay and blood loss showed improvement following MIS thymectomy, operative time was shorter for open thymectomy. CONCLUSION This is the first systematic review and meta-analysis assessing long-term effects of MIS versus open thymectomy in MG patients. Given the lack of significant differences noted, either MIS or open thymectomy can be performed, based on surgeon preference. Further high-level, long-term research should be conducted to determine the benefit of each technique.
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Affiliation(s)
- Yung Lee
- Department of General Surgery, McMaster University, Hamilton, ON, Canada
| | | | - Janhavi Patel
- Department of Thoracic Surgery, McMaster University, Hamilton, ON, Canada
| | - Adree Khondker
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Tyler McKechnie
- Department of General Surgery, McMaster University, Hamilton, ON, Canada
| | - Nadeesha Samarasinghe
- Department of General Surgery, University of British Columbia, Vancouver, BC, Canada
| | - Christian Finley
- Department of Thoracic Surgery, McMaster University, Hamilton, ON, Canada
| | - Wael Hanna
- Department of Thoracic Surgery, McMaster University, Hamilton, ON, Canada
| | - Yaron Shargall
- Department of Thoracic Surgery, McMaster University, Hamilton, ON, Canada
| | - John Agzarian
- Department of Thoracic Surgery, McMaster University, Hamilton, ON, Canada.
- Division of Thoracic Surgery, Department of Surgery, McMaster University, 50 Charlton Avenue East T-2105, Hamilton, ON, L8N 4A6, Canada.
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Khanh HQ, Vinh VH, Khoi NV, Vuong NL. Videothoracoscopic versus open resection in the treatment of mediastinal tumors: a prospective study. Chirurgia (Bucur) 2021. [DOI: 10.23736/s0394-9508.20.05086-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Na KJ, Kang CH. Robotic thymectomy for advanced thymic epithelial tumor: indications and technical aspects. J Thorac Dis 2020; 12:63-69. [PMID: 32190355 DOI: 10.21037/jtd.2019.09.27] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Robotic thymectomy is widely accepted as a valuable treatment option for surgical resection of thymic epithelial tumor as minimally invasive surgery has shown better early clinical outcomes than open surgery. Technical advances in robotic surgery have expanded the indications for robotic thymectomy, and the technique can be used to perform complete resection of advanced thymic epithelial tumor requiring concomitant resection of adjacent structures. To ensure complete resection, a multi-disciplinary approach, with thorough preoperative evaluation, must be adopted to determine whether a patient shows surgical indications for advanced thymic epithelial tumor. The early clinical outcomes after robotic thymectomy to treat advanced thymic epithelial tumor are promising; however, the long-term oncologic outcomes should be evaluated in the further studies.
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Affiliation(s)
- Kwon Joong Na
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Chang Hyun Kang
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
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Abstract
Neuromuscular blockade (TOF count = 0) can improve tracheal intubation and microlaryngeal surgery. It is also frequently used in many surgical fields including both nonlaparoscopic and laparoscopic surgery to improve surgical conditions and to prevent sudden muscle contractions. Currently there is a controversy regarding the need and the clinical benefits of deep neuromuscular blockade for different surgical procedures. Deep neuromuscular relaxation improves laparoscopic surgical space conditions only marginally when using low intra-abdominal pressure. There is no outcome-relevant advantage of low compared to higher intra-abdominal pressures, but worsen the surgical conditions. Postoperative, residual curarisation can be avoided by algorithm-based pharmacological reversing and quantitative neuromuscular monitoring.
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Affiliation(s)
- C Unterbuchner
- Klinik für Anaesthesiologie, Universitätsklinikum Regensburg, Universität Regensburg, Franz-Josef-Strauß-Allee 11, 93051, Regensburg, Deutschland.
| | - M Blobner
- Klinik für Anaesthesiologie, Klinikum rechts der Isar, Technische Universität München, München, Deutschland
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Burt BM, Nguyen D, Groth SS, Palivela N, Ripley RT, Makris KI, Farjah F, Cornwell L, Massarweh NN. Utilization of Minimally Invasive Thymectomy and Margin-Negative Resection for Early-Stage Thymoma. Ann Thorac Surg 2019; 108:405-411. [DOI: 10.1016/j.athoracsur.2019.03.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Revised: 02/28/2019] [Accepted: 03/01/2019] [Indexed: 01/11/2023]
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Gu Z, Chen C, Wang Y, Wei Y, Fu J, Zhang P, Liu Y, Zhang R, Chen K, Yu Z, Pang L, Liu Y, Li Y, Han Y, Chen H, Zhou X, Cui Y, Tan L, Ding J, Shen Y, Liu Y, Fang W. Video-assisted thoracoscopic surgery versus open surgery for Stage I thymic epithelial tumours: a propensity score-matched study. Eur J Cardiothorac Surg 2019; 54:1037-1044. [PMID: 30016438 DOI: 10.1093/ejcts/ezy239] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Accepted: 05/31/2018] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVES Video-assisted thoracoscopic surgery (VATS) has been increasingly used in the management of thymic epithelial tumours. However, its oncological efficacy remains to be proved. The purpose of this study is to compare the oncological outcomes following thoracoscopic versus open surgery in the case-matched groups of patients with early-stage thymic tumours from the Chinese Alliance for Research in Thymomas (ChART) retrospective database. METHODS Between 1994 and 2012, a total of 1087 patients who underwent surgery for UICC (Union for International Cancer Control) pathological Stage I tumours from the ChART retrospective database were recruited for this study. A propensity score-matched analysis was used to compare the long-term outcomes in patients who received VATS or open surgery. RESULTS VATS resection was performed in 271 patients (24.9%) and open surgery in 816 patients (75.1%). Before propensity score matching, the VATS group had a smaller tumour size (P = 0.002), lower grade histology (P = 0.034), lower T stage (P < 0.001) and less adjuvant therapy (P < 0.001). Propensity score matching by gender, myasthenia gravis, tumour size, histological classification, pathological T stage, extent of thymectomy, adjuvant radiotherapy and adjuvant chemotherapy identified 110 patients in each group. After matching, there was no significant difference in patient demographics, tumour characteristics or adjuvant therapy. All matched patients had R0 resection. Overall survival, disease-free survival and cumulative incidence of recurrence were only predicted by WHO histology, but not by surgical approach, in both univariable and multivariable analyses. There was no significant difference in the overall survival (85.7% vs 93.1%, P = 0.539), disease-free survival (92.5% vs 91.9%, P = 0.773), cumulative incidence of recurrence (7.1% vs 5.8%, P = 0.522) and improvement rate of myasthenia gravis (83.3% vs 88.2%, P = 0.589) between the 2 groups. CONCLUSIONS This propensity score-matched study suggests that VATS and open surgeries are associated with similar oncological outcomes for Stage I thymic epithelial tumours. Minimally invasive surgery might be an acceptable surgical approach for early-stage thymic malignancies.
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Affiliation(s)
- Zhitao Gu
- Department of Thoracic Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Chun Chen
- Department of Thoracic Surgery, Fujian Medical University Union Hospital, Fuzhou, China
| | - Yun Wang
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Yucheng Wei
- Department of Thoracic Surgery, Affiliated Hospital of Qingdao University, Qingdao, China
| | - Jianhua Fu
- Department of Thoracic Surgery, Guangdong Esophageal Cancer Institute, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center of Cancer Medicine, Guangzhou, China
| | - Peng Zhang
- Department of Endocrinology, Tianjin Medical University General Hospital, Tianjin, China
| | - Yongyu Liu
- Department of Thoracic Surgery, Liaoning Cancer Hospital, Shenyang, China
| | - Renquan Zhang
- Department of Thoracic Surgery, First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Keneng Chen
- Department of Thoracic Surgery, Beijing Cancer Hospital, Beijing, China
| | - Zhentao Yu
- Department of Esophageal Cancer, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center of Cancer, Key Laboratory of Cancer Prevention and Therapy of Tianjin City, Tianjin, China
| | - Liewen Pang
- Department of Thoracic Surgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Yangchun Liu
- Department of Thoracic Surgery, Jiangxi People's Hospital, Nanchang, China
| | - Yin Li
- Department of Thoracic Surgery, Affiliated Cancer Hospital of Zhengzhou University, Zhengzhou, China
| | - Yongtao Han
- Department of Thoracic Surgery, Sichuan Cancer Hospital, Chengdu, China
| | - Hezhong Chen
- Department of Cardiothoracic Surgery, Changhai Hospital, Shanghai, China
| | - Xinming Zhou
- Department of Thoracic Surgery, Zhejiang Cancer Hospital, Hangzhou, China
| | - Youbin Cui
- Department of Thoracic Surgery, First Affiliated Hospital of Jilin University, Changchun, China
| | - Lijie Tan
- Department of Thoracic Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jianyong Ding
- Department of Thoracic Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yi Shen
- Department of Thoracic Surgery, Affiliated Hospital of Qingdao University, Qingdao, China
| | - Yuan Liu
- Department of Thoracic Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Wentao Fang
- Department of Thoracic Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
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Ectopic ACTH-secreting tumor of the thymus revealed by a Cushing’s syndrome: case report and review of literature. Indian J Thorac Cardiovasc Surg 2017. [DOI: 10.1007/s12055-017-0554-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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Qi K, Wang B, Wang B, Zhang LB, Chu XY. Video-assisted thoracoscopic surgery thymectomy versus open thymectomy in patients with myasthenia gravis: a meta-analysis. Acta Chir Belg 2016; 116:282-288. [PMID: 27426672 DOI: 10.1080/00015458.2016.1176419] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
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.
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Affiliation(s)
- Kang Qi
- Department of Thoracic Surgery, Chinese PLA General Hospital, Beijing, P.R. China
| | - Bo Wang
- Department of Thoracic Surgery, Chinese PLA General Hospital, Beijing, P.R. China
| | - Bin Wang
- Department of Thoracic Surgery, Chinese PLA General Hospital, Beijing, P.R. China
| | - Lian-Bin Zhang
- Department of Thoracic Surgery, Chinese PLA General Hospital, Beijing, P.R. China
| | - Xiang-Yang Chu
- Department of Thoracic Surgery, Chinese PLA General Hospital, Beijing, P.R. China
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Burt BM, Yao X, Shrager J, Antonicelli A, Padda S, Reiss J, Wakelee H, Su S, Huang J, Scott W. Determinants of Complete Resection of Thymoma by Minimally Invasive and Open Thymectomy: Analysis of an International Registry. J Thorac Oncol 2016; 12:129-136. [PMID: 27566187 DOI: 10.1016/j.jtho.2016.08.131] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Revised: 07/06/2016] [Accepted: 08/15/2016] [Indexed: 10/21/2022]
Abstract
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.
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Affiliation(s)
| | | | - Joseph Shrager
- Stanford University School of Medicine, Stanford, California
| | | | - Sukhmani Padda
- Stanford University School of Medicine, Stanford, California
| | - Jonathan Reiss
- University of California Davis Medical Center, Sacramento, California
| | - Heather Wakelee
- Stanford University School of Medicine, Stanford, California
| | - Stacey Su
- Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - James Huang
- Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Walter Scott
- Fox Chase Cancer Center, Philadelphia, Pennsylvania
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Lee HS, Lee HS, Lee HE, Bae MK, Chung KY, Shin HY, Choi YC, Kim SM. Predictive factors for myasthenic crisis after videoscopic thymectomy in patients with myasthenia gravis. Muscle Nerve 2015; 52:216-20. [DOI: 10.1002/mus.24531] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/25/2014] [Indexed: 11/11/2022]
Affiliation(s)
- Hyung Seok Lee
- Department of Neurology; Yonsei University College of Medicine; 50 Yonsei-ro, Seodaemun-gu Seoul 120-752 Republic of Korea
| | - Hye Sun Lee
- Department of Biostatistics; Yonsei University College of Medicine; Seoul Republic of Korea
| | - Hyo Eun Lee
- Department of Neurology; Yonsei University College of Medicine; 50 Yonsei-ro, Seodaemun-gu Seoul 120-752 Republic of Korea
| | - Mi Kyung Bae
- Department of Thoracic and Cardiovascular Surgery; Yonsei University College of Medicine; Seoul Republic of Korea
| | - Kyung Young Chung
- Department of Thoracic and Cardiovascular Surgery; Yonsei University College of Medicine; Seoul Republic of Korea
| | - Ha Young Shin
- Department of Neurology; Yonsei University College of Medicine; 50 Yonsei-ro, Seodaemun-gu Seoul 120-752 Republic of Korea
| | - Young-Chul Choi
- Department of Neurology; Yonsei University College of Medicine; 50 Yonsei-ro, Seodaemun-gu Seoul 120-752 Republic of Korea
| | - Seung Min Kim
- Department of Neurology; Yonsei University College of Medicine; 50 Yonsei-ro, Seodaemun-gu Seoul 120-752 Republic of Korea
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Shen H, Wang J, Li W, Yi W, Wang W. Assessment of health-related quality of life of patients with esophageal squamous cell carcinoma following esophagectomy using EORTC quality of life questionnaires. Mol Clin Oncol 2014; 3:133-138. [PMID: 25469283 DOI: 10.3892/mco.2014.434] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2014] [Accepted: 09/03/2014] [Indexed: 11/06/2022] Open
Abstract
Esophageal cancer is one of the leading causes of cancer-related mortality and surgery is currently the main treatment modality for resectable esophageal cancer. To assess health-related quality of life (HRQL) of patients with esophageal squamous cell carcinoma (ESCC) following esophagectomy, 62 consecutive patients with middle ESCC were randomly assigned into hand video-assisted thoracoscopic surgery (HVATS) (n=33) and Ivor-Lewis surgery (ILS) (n=29) groups. Quality of life questionnaires (QLQ)-C30 and QLQ-OES18, published by the European Organization for Research and Treatment of Cancer, were used prior to treatment and at regular intervals until 6 months following surgery. The results of QLQ-C30 and QLQ-OES18 demonstrated that i) patients with comorbidities and advanced tumor stage (III-IV) exhibited increased risk of poor HRQL, while their gender, age, body mass index and anastomosis location were not associated with HRQL at 6 months after surgery; ii) all the patients had worse functional, symptom and global scores within 6 months after surgery; iii) patients in the HVATS group had similar baseline functional and symptom scores to those of patients in the ILS group; however, their functional and global scores were higher and their symptom scores were lower compared to those of patients in the ILS group; iv) the HRQL of patients in the HVATS group returned to preoperative levels within a shorter time period compared to patients in the ILS group. There were significant differences in global health, physical functioning, fatigue and pain scales between the two groups. In QLQ-OES18, the dysphagia and gastroesophageal reflux scales were improved in both the HVATS and ILS groups, but no significant differences were observed between the two groups. In addition, the overall survival rate was similar in the two groups. Taken together, our findings indicated that HVATS is a safe procedure, associated with less disturbance to short-term HRQL compared to ILS. Therefore, it appears reasonable to select HVATS for patients with early-stage middle esophageal cancer.
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Affiliation(s)
- Hongchang Shen
- Departments of Chemotherapy and Affiliated to Shandong University, Jinan, Shandong 250021, P.R. China
| | - Jue Wang
- Departments of Breast and Thyroid Surgery, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong 250021, P.R. China
| | - Wenhuan Li
- Departments of Chemotherapy and Affiliated to Shandong University, Jinan, Shandong 250021, P.R. China
| | - Weiwei Yi
- Departments of Chemotherapy and Affiliated to Shandong University, Jinan, Shandong 250021, P.R. China
| | - Weibo Wang
- Departments of Chemotherapy and Affiliated to Shandong University, Jinan, Shandong 250021, P.R. China
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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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Toker A, Erus S, Ziyade S, Ozkan B, Tanju S. It is feasible to operate on pathological Masaoka stage I and II thymoma patients with video-assisted thoracoscopy: analysis of factors for a successful resection. Surg Endosc 2012; 27:1555-60. [DOI: 10.1007/s00464-012-2626-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2012] [Accepted: 09/25/2012] [Indexed: 11/29/2022]
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Shen H, Li X, Meng L, Ni Y, Wang G, Dong W, Du J. Confirmation of histology of PET positive lymph nodes recovered by hand-video-assisted thoracoscopy surgery. Gene 2012; 509:173-7. [PMID: 22909799 DOI: 10.1016/j.gene.2012.07.060] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2012] [Accepted: 07/30/2012] [Indexed: 12/22/2022]
Abstract
PET/CT (Positron Emission Tomography-Computed Tomography) is an advanced diagnostic imaging device that combines both PET and an X-ray CT. This study evaluates the effects of PET/CT on detecting primary tumors and metastases, and looks at the therapeutic effect of minimally invasive surgery on esophageal cancer patients. Eighty patients with esophageal cancer were enrolled in the study between January, 2004 and December, 2007, who were randomly divided into two groups of 40, one of which was treated with hand-video-assisted thoracoscopy surgery (HVATS) esophagectomy and one of which was treated with conventional surgery. All patients underwent a PET/CT scan 2-3 weeks before their operation, and their cervical, thoracic and upper abdominal lymph nodes were biopsied. All the primary esophageal lesions showed high FDG uptake. The maximum standardized uptake value (SUV) was 3.78-25.64 (11.73±5.32), while the mean SUV was 3.65=16.92 (9.12±4.37). Using 2.5 as the SUV standard, all esophageal lesions were detected by PET/CT image. Of the 80 patients, 53 had lymph nodal metastases, with a total of 142 metastatic lymph nodes, which showed high FDG uptake. The maximum SUV was 2.77-14.63 (7.98±3.25), and the mean SUV was 2.31-12.84 (5.34±3.19). The visual analysis from the PET/CT scan showed a sensitivity of 86.62%, a specificity of 95.85%, a positive predictive value of 93.89%, a negative predictive value of 90.69% and an accuracy of 91.94%. The PET/CT scan showed a high sensitivity and specificity in detecting primary esophageal cancer and lymph nodal metastases. The mean post-surgery life expectancies for patients undergoing HVATS and conventional surgery are 27.93 months and 28.05 months, respectively. The two groups showed no statistically significant difference. We thus conclude that PET/CT combined with HVATS is a new choice for esophageal carcinoma patients.
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Affiliation(s)
- Hongchang Shen
- Institute of Oncology, Provincial Hospital affiliated to Shandong University, Jinan 250012, China
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GRITTI P, SGARZI M, CARRARA B, LANTERNA LA, NOVELLINO L, SPINELLI L, KHOTCHOLAVA M, POLI G, LORINI FL, SONZOGNI V. A standardized protocol for the perioperative management of myasthenia gravis patients. Experience with 110 patients. Acta Anaesthesiol Scand 2012; 56:66-75. [PMID: 22092037 DOI: 10.1111/j.1399-6576.2011.02564.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/26/2011] [Indexed: 11/26/2022]
Abstract
BACKGROUND Video-assisted thoracoscopic extended thymectomy (VATET) is well established in the treatment of myasthenia gravis; however, patient selection remains controversial. Perioperative management protocol is lacking, and concerns regarding post-operative myasthenic crisis still remain. We performed a retrospective observational study evaluating the impact of the introduction of a protocol in the perioperative management of patients with myasthenia gravis who underwent VATET. METHODS The perioperative management protocol was developed by a team of neurologists and anesthesiologists who reviewed the literature and their previous experience on myasthenia gravis patients. Respiratory, clinical, and neurological patient features were included in the protocol evaluation. A retrospective review of patients who underwent VATET before and after introduction to the protocol was finally performed. RESULTS The medical records of 66 patients (pre-protocol group) and 44 patients (protocol group) were available for the study. In the pre-protocol group, 17 patients (26%) were admitted to intensive care unit (ICU) during the post-operative period, while three patients (6.8%) of the protocol group met the criteria for ICU post-operative admission. This resulted in a reduction of 73.5% of patients admitted to ICU (P = 0.023) and in an 80% (P = 0.002) reduction of the use neuromuscular blocking agents. Two post-operative myasthenic crises preceded by bulbar symptoms (1.8%) were identified in the pre-protocol group patients. CONCLUSIONS Although the application of our protocol results in a substantial reduction in the recovery of patients in the ICU and in hospital costs, there was no substantial difference in mortality and morbidity between patients admitted to the surgical ward or to ICU.
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Affiliation(s)
- P. GRITTI
- Department of Anesthesia and Intensive Care; Ospedali Riuniti di Bergamo; Bergamo; Italy
| | - M. SGARZI
- Department of Neurology; Ospedali Riuniti di Bergamo; Bergamo; Italy
| | - B. CARRARA
- Department of Anesthesia and Intensive Care; Ospedali Riuniti di Bergamo; Bergamo; Italy
| | - L. A. LANTERNA
- Department of Neurosurgery; Ospedali Riuniti di Bergamo; Bergamo; Italy
| | - L. NOVELLINO
- Department of Medical and Surgical Sciences; Surgical Clinic; A.O. Bolognini; Bergamo; Italy
| | - L. SPINELLI
- Department of Medical and Surgical Sciences; Surgical Clinic; A.O. Bolognini; Bergamo; Italy
| | - M. KHOTCHOLAVA
- Department of Anesthesia and Intensive Care; Ospedali Riuniti di Bergamo; Bergamo; Italy
| | - G. POLI
- Department of Anesthesia and Intensive Care; Ospedali Riuniti di Bergamo; Bergamo; Italy
| | - F. L. LORINI
- Department of Anesthesia and Intensive Care; Ospedali Riuniti di Bergamo; Bergamo; Italy
| | - V. SONZOGNI
- Department of Anesthesia and Intensive Care; Ospedali Riuniti di Bergamo; Bergamo; Italy
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Mohite PN, Rana SS, Sadasivan P, Deshpande S. Thymectomy through lateralized partial sternotomy. J Cardiovasc Dis Res 2011; 2:190-1. [PMID: 22022149 PMCID: PMC3195200 DOI: 10.4103/0975-3583.85268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
A young woman with nonthymomic myasthenia gravis with failure of medical treatment was offered thymectomy through partial sternotomy. Shifting of vertical arm of “L” incision laterally avoids fracture of opposite sternal flange and provides better sternal stability postoperatively.
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Affiliation(s)
- Prashant N Mohite
- Department of Cardiothoracic and Vascular Surgery, Postgraduation Institute of Medical Research and Education, Chandigarh, India
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Robot-assisted thymectomy is superior to transsternal thymectomy. Surg Endosc 2011; 26:261-6. [DOI: 10.1007/s00464-011-1879-7] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2011] [Accepted: 07/11/2011] [Indexed: 10/17/2022]
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Limmer KK, Kernstine KH. Minimally Invasive and Robotic-Assisted Thymus Resection. Thorac Surg Clin 2011; 21:69-83, vii. [DOI: 10.1016/j.thorsurg.2010.08.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Bilateral video-assisted thoracoscopic thymectomy has a surgical extent similar to that of transsternal extended thymectomy with more favorable early surgical outcomes for myasthenia gravis patients. Surg Endosc 2010; 25:849-54. [DOI: 10.1007/s00464-010-1280-y] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2010] [Accepted: 07/19/2010] [Indexed: 10/19/2022]
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Bachmann K, Burkhardt D, Schreiter I, Kaifi J, Schurr P, Busch C, Thayssen G, Izbicki JR, Strate T. Thymectomy is more effective than conservative treatment for myasthenia gravis regarding outcome and clinical improvement. Surgery 2009; 145:392-8. [PMID: 19303987 DOI: 10.1016/j.surg.2008.11.009] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2008] [Accepted: 11/20/2008] [Indexed: 11/26/2022]
Abstract
BACKGROUND Myasthenia gravis (MG) is an autoimmune disease with a tremendous impact on the quality of life. Controversies over which patients should be operated on because they may benefit most from thymectomy are still ongoing. The aim of this study was to report our long-term results of patients with MG with comparison of thymectomy and conservative treatment. METHODS We report a series of 252 patients with MG. Survival data were generated. Patients were seen in the outpatient clinic, where a modified Osserman score and quality of life score were evaluated at the end of the follow-up period for all surviving patients. RESULTS A total of 172 patients with MG were followed after thymectomy or with conservative treatment for a median time of 9.8 years. Patients who underwent thymectomy had significantly greater rates of remission and improvement compared with conservative treatment. Furthermore, they had a significantly greater survival. CONCLUSION Currently, different effective modalities of treatment are available in patients with MG. In our long-term follow-up, thymectomy was superior to conservative treatment regarding overall survival, clinical improvement, and remission rate. Therefore, thymectomy should be considered strongly for all patients with generalized MG.
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Affiliation(s)
- Kai Bachmann
- Department of General, Visceral, and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Germany.
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Learning curve in videothoracoscopic thymectomy: how many operations and in which situations? Eur J Cardiothorac Surg 2008; 34:155-8. [PMID: 18374595 DOI: 10.1016/j.ejcts.2007.12.056] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2007] [Revised: 11/27/2007] [Accepted: 12/10/2007] [Indexed: 10/22/2022] Open
Abstract
OBJECTIVE Videothoracoscopic learning curve is known to vary among different surgeons, and may be influenced by patients and various situations. We aimed to analyze the learning curve of a surgeon in videothoracoscopic thymic surgery for myasthenia gravis. METHODS This is a descriptive single-center study using collected clinical data from 90 patients undergoing videothoracoscopic thymic surgery between June 2002 and September 2006. Cumulative summation (CUSUM) model was used to evaluate the learning curve for videothoracoscopic thymectomy operations. Unsuccessful situations were accepted as longer operation time, surgeon-related open conversions, readmissions and postoperative complications. Factors affecting longer operation time (patients with operation time longer than the average) and longer postoperative stay (patients with postoperative hospital stay longer than average) were analyzed. RESULTS Body mass index (BMI) was the only predictor of longer operation time (23.04+/-2.93 vs 25.61+/-2.70 (p=0.001) independent samples test). The amount of prescribed pyridostigmine was the only factor for longer hospital stay (213.3+/-101.5 mg vs 270. 0+/-122.6 mg (p=0.044) Mann-Whitney U-test). CUSUM analysis demonstrated a learning curve with success rates of 80%, 90% and 98%, respectively in the first 30 patients, the next 31-60 patients and after 60 patients. Median operative time declined with surgeons' experience (p<0.001). CONCLUSIONS A chest surgeon can have a high success rate in videothoracoscopic thymectomy (98%) after 60 operations.
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Long-term outcome and quality of life after open and thoracoscopic thymectomy for myasthenia gravis: analysis of 131 patients. Surg Endosc 2008; 22:2470-7. [DOI: 10.1007/s00464-008-9794-2] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2007] [Revised: 12/29/2007] [Accepted: 01/18/2008] [Indexed: 11/12/2022]
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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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Toker A, Tanju S, Sungur Z, Parman Y, Senturk M, Serdaroglu P, Dilege S, Deymeer F. Videothoracoscopic thymectomy for nonthymomatous myasthenia gravis: Results of 90 patients. Surg Endosc 2007; 22:912-6. [PMID: 17704865 DOI: 10.1007/s00464-007-9507-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2006] [Revised: 02/06/2007] [Accepted: 02/28/2007] [Indexed: 12/01/2022]
Abstract
BACKGROUND Videothoracoscopic thymectomy is an alternative surgical procedure for patients with nonthymomatous myasthenia gravis. The aim of this study is to present our experience and to analyze the factors contributing to the operative morbidity. METHODS Ninety myasthenia gravis patients were operated through right-sided videothoracoscopy from June 2002 to September 2006. Prospective data recording was performed. Surgeon-related conversion to open surgery, length of the operation, chest tube duration time, duration of hospital stay, amount of drainage, pain score, and complications were evaluated. Factors contributing to longer operation time and longer postoperative stay were studied. RESULTS The mean length of chest tube duration and postoperative hospital stay was 26.7 +/- 18.6 hours and 2.2 days +/- 1.1 days respectively. Visual analogue scale (VAS) values for pain evaluation were 2.0 +/- 1.4. Surgeon-related open conversion occured in two patients (2.2%). Body mass index (BMI) was the sole significant factor for longer operation time. (23.04 +/- 2.93 versus 25.61 +/- 2.70 (p = 0.001). The amount of pyridostigmine was the only significant factor for longer hospital stay (213.3 +/- 101.5 mg versus 270. 0 +/- 122.6 mg (p = 0.044). CONCLUSIONS This study demonstrates the right-sided videothoracoscopy is a safe procedure. The only contributing factors were: BMI >25.61 for longer operation time, and pyridostigmine level >270 mg for duration of postoperative stay.
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Affiliation(s)
- Alper Toker
- Department of Thoracic Surgery, Istanbul University, Istanbul Medical School, Istanbul, Turkey.
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