Video-assisted thoracoscopic thymectomy for non-thymomatous myasthenia gravis: a right-sided or left-sided approach?

Perioperative outcomes of minimally invasive surgery for large malignant thymic epithelial tumors and for total thymectomy

PURPOSE

Minimally invasive surgery (MIS) for thymic tumors is now accepted widely, in line with improved surgical techniques; however, we occasionally encounter complicated cases of large tumors or of total thymectomy requiring prolonged operative duration or conversion to an open procedure (OP). We reviewed patients registered in a nationwide database to identify the technical feasibility of MIS for thymic epithelial tumors.

METHODS

Data on patients treated surgically between 2017 and 2019 were extracted from the National Clinical Database of Japan. Clinical factors and operative outcomes were calculated by tumor diameter using trend analyses. Perioperative outcomes of MIS for non-invasive thymoma were investigated using propensity score-matched analyses.

RESULTS

MIS was performed in 46.2% of the patients. The operative duration and conversion rate increased with the tumor diameter (p < .001). After propensity score-matching, operative duration and postoperative hospital stay were shorter (p < .001), and the transfusion rate was lower (p = .007) in patients who underwent MIS than in those who underwent OP for thymomas ≥ 5 cm. Among patients who underwent total thymectomy, blood loss was less (p < .001) and the postoperative hospital stay was shorter (p < .001) in those who underwent MIS than in those who underwent OP. There were no significant differences in postoperative complications and mortality.

CONCLUSIONS

MIS is technically feasible even for large non-invasive thymomas or for total thymectomy, although the operative duration and open conversion rate increase with the tumor diameter.

[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.

Magnesium sulfate reduces the rocuronium dose needed for satisfactory double lumen tube placement conditions in patients with myasthenia gravis

Background

Using a minimum dose of neuromuscular blockade (NMB) to achieve intubation condition is one of the goals in anaesthesia management of patients with myasthenia gravis (MG) for thoracoscopic (VATS) thymectomy. However, tracheal intubation with double lumen tube (DLT) could be challenging if intubation condition is not optimal. This double-blind randomised controlled study was designed to investigate whether magnesium sulfate would reduce the rocuronium dose needed for DLT intubation and improve the DLT placement condition for patients with MG who were scheduled for video-assisted thoracoscopic (VATS) thymectomy.

Methods

Recruited patients were randomly assigned to receive magnesium sulfate 60 mg.kg^− 1 or normal saline (control) prior to the administration of NMB. Titrating dose of rocuronium was administered to achieve train of four (TOF) ratio less than 10% before DLT intubation. The primary outcome was the rocuronium dose required to achieve TOF ratio less than 10%. The secondary outcome was intubation condition for DLT placement.

Results

Twenty-three patients had received magnesium sulfate and 22 patients had received normal saline before rocuronium administration. The required rocuronium dose [mean (standard deviation)] were 0.10 (0.05) mg.kg^− 1 and 0.28(0.17) mg.kg^− 1 in patients who had magnesium sulfate and normal saline respectively(P < 0.0001). With a similar depth of neuromuscular blockade and depth of anaesthesia, 100% of patients in the magnesium sulfate group and 72.7% of patients in the control group showed excellent intubation condition (P = 0.027) respectively. The patients in both groups had similar emergence characteristics.

Conclusions

Magnesium sulfate is associated with a decrease in rocuronium requirement for an optimal DLT intubation condition in patients with MG for VATS thymectomy.

Trial registration

Clinical Trial Registry of China (http://www.chictr.org.cn) identifier: ChiCTR-1800017696, retrospectively registered on August 10, 2018.

Modified unilateral video-assisted thoracoscopic extended thymectomy for myasthenia gravis using 5-mm incisions: A case report

RATIONALE

Myasthenia gravis (MG) is the most common cause of acquired neuromuscular junction disorder. Thymectomy has been established as an effective therapy for MG, as it attenuates the natural course of the disease and may result in complete remission.

PATIENT CONCERNS

We report the case of a 22-year-old female with a 6-year history of MG presented with bilateral ptosis, diplopia, and intermittent dysphagia. She denied shortness of breath, dysarthria, and fatigue.

DIAGNOSES

She had been diagnosed with MG 6 years previously at the Neurology Department of our hospital. A computed tomography (CT) scan revealed thymic hyperplasia INTERVENTIONS:: She was treated with modified unilateral VATET that minimized incision size.

OUTCOMES

Unilateral VATET was performed using two 5-mm incisions to minimize pressure on intercostal soft tissues/nerves and reduce postoperative pain.

LESSONS

The lesson learnt from this case report is that this modified VATET method could be a useful approach to the management of non-thymomatous MG. The ability to achieve complete dissection with good cosmetic results may lead to wider acceptance of this technique by patients with MG and their neurologists for earlier thymectomy and improved outcomes. Additional studies are needed to determine the superiority of this approach to established methods.

Video-assisted thoracoscopic thymectomy for thymoma: a single-center experience

Background Thymoma is a primary tumor derived from the epithelial cells of the thymus, which is commonly seen in the mediastinum. Surgical thymectomy is the radical treatment for thymoma. The recent introduction of video-assisted thoracoscopic surgery has improved the quality of thymectomy surgery. The clinical characteristics of thymoma and the outcomes of video-assisted thoracoscopic thymectomy in Vietnamese patients are still lacking. The objectives of this study were to investigate the clinical and laboratory characteristics of thymoma and to evaluate the early results of video-assisted thoracoscopic thymectomy for thymoma in Vietnamese patients. Methods All 53 thymoma patients with or without myasthenia gravis who underwent video-assisted thoracoscopic thymectomy in Military Hospital 103, Vietnam, from October 2013 to July 2017 were included. Results The mean age was 46.5 7.1 years, and the female/male ratio was 1.2:1. Myasthenia gravis, mostly stage IIA, was present in 84.9% of patients. There was no hospital mortality or major postoperative complication. The mean operative time was 65 min, intensive care unit stay was 22 ± 5 h, and postoperative hospital stay was 7.5 ± 1.7 days. Conclusion Thoracoscopic thymectomy for thymoma in Vietnamese patients achieved improved cosmesis and was safe for both non-myasthenia gravis and myasthenia gravis patients.