Thoracoscopic thymectomy in autoimmune myasthenia: results of left-sided approach

doi:10.1016/S0003-4975(00)01237-6

The Annals of Thoracic Surgery

Volume 69, Issue 5, May 2000, Pages 1537-1541

https://doi.org/10.1016/S0003-4975(00)01237-6 Get rights and content

Abstract

Background. We undertook to analyze the results of video-assisted thoracoscopic thymectomy through a left-sided approach in patients with autoimmune myasthenia.

Methods. Between 1993 and 1997, 31 patients underwent thoracoscopic thymectomy by a uniform left-sided approach. There were 8 men and 23 women with a mean age of 34 ± 12 years.

Results. Preoperative duration of disease was 14.8 ± 11 months. There were no operative deaths or major complications. The mean hospital stay was 5.2 ± 2.8 days. Mean follow-up was 39.6 ± 15 months and was 100% complete. At 48 months, remission and improvement rates were 36% and 96%, respectively. Shorter duration of symptoms (< 12 months) correlated with improved outcome (13 of 13 patients versus 10 of 14 patients; p = 0.036). Age, sex, Osserman class, corticosteroid therapy, presence of ectopic thymic tissue, and temporary postoperative symptom increase (deterioration) did not affect outcome.

Conclusions. Thoracoscopic thymectomy facilitated the goal of early thymectomy. Through a left-sided approach, improvement or remission was achieved in more than 95% of the patients. Thoracoscopic thymectomy should be considered a valid less invasive alternative to the most radical open approaches.

Section snippets

Material and methods

Between January 1993 and December 1997, 31 patients (8 men and 23 women) with autoimmune myasthenia (AM) underwent VATS thymectomy at two participating institutions (Tor Vergata University in Rome, Italy, and Catholic University in Leuven, Belgium). The thoracic surgeons at each institution had gained experience with various major thoracoscopic procedures before embarking on the study. Informed consent was obtained from all patients, who were given the basic information on the different

Results

Patient age ranged from 20 to 69 years with a mean of 34 ± 12 years. The preoperative mean Osserman class was 2.16 ± 0.7; 6 patients were in class 1, 13 in class 2, 10 in class 3, and 2 in class 4. The duration of symptoms ranged from 1 month to 46 months with a mean of 14.8 ± 11 months. Preoperatively, pyridostigmine bromide alone was used in 23 patients (74%), and corticosteroids were used in 8 patients (26%), either alone (1 patient) or in association with pyridostigmine (7 patients).

Comment

Video-assisted thoracoscopic surgery has provided a new approach for the surgical removal of the thymus. Proponents of VATS thymectomy believe that it combines the minimal surgical trauma of the transcervical approach and the excellent visualization of the anterior mediastinum of the transsternal approach. Also, VATS does not prevent easy access to the lower cervical area, thereby allowing complete removal of the superior thymic horns 8, 9, 10, 11. Recognized advantages of VATS over open

References (22)

D.B Sanders et al.
The treatment of patients with myasthenia gravis
Neurol Clin North Am
(1994)
A Jaretzki et al.
“Maximal” thymectomy for myasthenia gravis. Results
J Thorac Cardiovasc Surg
(1988)
A Masaoka et al.
Extended thymectomy for myasthenia gravis patientsa 20-year review
Ann Thorac Surg
(1996)
J.D Cooper et al.
An improved technique to facilitate transcervical thymectomy for myasthenia gravis
Ann Thorac Surg
(1988)
V.J DeFilippi et al.
Transcervical thymectomy for myasthenia gravis
Ann Thorac Surg
(1994)
T.C Mineo et al.
Adjuvant pneumomediastinum in thoracoscopic thymectomy for myasthenia gravis
Ann Thorac Surg
(1996)
A.P.C Yim et al.
Video-assisted thoracoscopic thymectomy for myasthenia gravis
Chest
(1995)
M.J Mack et al.
Results of video-assisted thymectomy in patients with myasthenia gravis
J Thorac Cardiovasc Surg
(1996)
M.J Mack et al.
Video-assisted thoracic surgeryhas technology found its place?
Ann Thorac Surg
(1997)
A Masaoka et al.
Distribution of thymic tissue at the anterior mediastinumcurrent procedure in thymectomy
J Thorac Cardiovasc Surg
(1975)

A Jaretzki et al.

“Maximal” thymectomy for myasthenia gravis. Surgical anatomy and operative techniques

J Thorac Cardiovasc Surg

(1988)

Cited by (117)

Subxiphoid Versus Unilateral Video-assisted Thoracoscopic Surgery Thymectomy for Thymomas: A Propensity Score Matching Analysis
2022, Annals of Thoracic Surgery
The appropriate approach for video-assisted thoracoscopic surgery for early stage thymoma remains unclear. The present study aimed to explore the safety and feasibility of subxiphoid and subcostal arch thoracoscopic thymectomy in comparison with unilateral thoracoscopic thymectomy for treatment of early stage thymoma.
The outcomes of 237 patients without myasthenia gravis who had undergone thoracoscopic thymectomy for Masaoka stage I and II thymoma from January 2015 to May 2019 at our center were retrospectively evaluated (subxiphoid and subcostal arch approach, 39; unilateral video-assisted thoracoscopic surgery approach, 198). A propensity score matching analysis was generated to control for selection bias due to nonrandom group assignment in a 1:1 manner.
There was no surgery-related mortality in included patients. Matching of patients according to propensity score resulted in a cohort that consisted of 39 patients in both groups. Patients had similar clinical characteristics in both groups. Compared with patients in the unilateral group, patients in the subxiphoid group yielded lower pain scores at 24 and 72 hours after operation, respectively (P < .01). In addition, the operation time was longer in the subxiphoid group (147.5 ± 43.6 vs 93.2 ± 33.8 minutes, P < .01). There were no significant differences in blood loss, total volume and time of drainage, complications, or postoperative hospital stays between the two groups.
Subxiphoid and subcostal arch thoracoscopic thymectomy for early stage thymoma appears to be a safe and feasible procedure. It is considered to be less invasive as it may cause minimal postoperative pain compared with the unilateral video-assisted thoracoscopic surgery approach.
Approach to the Mediastinum: Transcervical, Transsternal, and Video-Assisted
2021, Surgery of the Thyroid and Parathyroid Glands
Indications for exploring the mediastinum in the setting of thyroid and parathyroid disease include benign substernal goiter, thyroid malignancy, metastatic lymph nodes arising from thyroid malignancy, and mediastinal parathyroid adenoma. Although these mediastinal pathologies can often be resected through a transcervical approach, a thoracic approach to the mediastinum may be required for complete exposure and resection depending on the lesion’s size, location, and relationship to adjacent structures. These thoracic approaches can include full sternotomy, partial sternotomy, trapdoor incision, and thoracotomy as well as minimally invasive approaches such as mediastinoscopy, thoracoscopy, and robot-assisted thoracoscopic surgery. In cases where a thoracic approach may be required, preoperative consultation and intraoperative collaboration with a cardiothoracic surgeon can facilitate an optimal approach for resection of these intrathoracic mediastinal pathologies.
Video-assisted thoracoscopic surgery for myasthenia gravis with thymoma: A six-year single-center experience
2021, Asian Journal of Surgery
Citation Excerpt :
The majority of patients in our study were extubated after surgery within 48 h (68.9%). Nonetheless, our postoperative hospital stay was 9.8 ± 5.9 days (5–37 days) with 45.9% less than 7 days, which is however still longer than results from other authors, ranging from 2.28 to 5 days.14,22,23,16 Favorable outcomes after thymectomy for MG with thymoma have been reported with VATS.
To investigate clinical and histopathological characteristics of Vietnamese patients with thymoma and myasthenia gravis (MG), and the outcomes of surgical management using video-assisted thoracoscopic surgery (VATS) thymectomy.
A prospective study was carried out on 61 patients undergoing VATS thymectomy for MG class I, IIA with thymoma in the period from 10/2013 to 5/2019. The WHO histopathological classification, Masaoka’s stages and MG grading using the guidelines of the Medical Scientific Advisory Board of the Myasthenia gravis foundation of America (MGFA) were used. All patients were followed up at 1 month, 6 months and over 1 year postoperatively.
The average patient age was 47.3 ± 10.8 years (21–70). The female/male ratio was 0.91.80.3% of patients had MG class IIA. Most of the patients were at Masaoka’s stage I and stage II (75.4%). Only 1 patient (1.7%) had highly malignant type B3 thymoma. Conversion to open surgery was required in 8 patients. The surgical time was 91.8 ± 49.9 min and blood loss was 37.3 ± 31.5 ml. Most patients (68.9%) were extubated in the operating room. The postoperative hospital stay was 9.8 ± 5.9 days (5–37 days). 22.6% of patients relapsed after one-year. Refractory MG declined to 5.7% after surgical treatment.
VATS thymectomy for MG with thymoma was safe and effective, with a lower rate of intraoperative complications, shorter hospitalization, and better long-term outcomes. This approach could be applicable for patients of all age groups with thymomas at early Masaoka’s stages.
Robotic thymectomy: a review of techniques and results
2023, Kardiochirurgia i Torakochirurgia Polska
Efficiency of ectopic thymectomy by three surgical approaches in non-thymomatous myasthenia gravis
2022, Updates in Surgery
Subxiphoid-subcostal thoracoscopic thymectomy for seropositive myasthenia offers equivalent remission rates and potentially faster recovery
2022, Interactive Cardiovascular and Thoracic Surgery

View all citing articles on Scopus

View full text

Original articles: General thoracicThoracoscopic thymectomy in autoimmune myasthenia: results of left-sided approach

Abstract

Section snippets

Material and methods

Results

Comment

Neurol Clin North Am

J Thorac Cardiovasc Surg

Ann Thorac Surg

Ann Thorac Surg

Ann Thorac Surg

Ann Thorac Surg

Chest

J Thorac Cardiovasc Surg

Ann Thorac Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

Original articles: General thoracic
Thoracoscopic thymectomy in autoimmune myasthenia: results of left-sided approach