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Časopis Neurology – Článok Transcervical – subxiphoidal – bilateral vats “maximal” thymectomy for myasthenia gravis or thymoma – initial experiences

Neurology

Reviewed, postgraduate scietific medical journal.
Period 3x per year
1336-8621
The journal is indexed in the Slovak National Bibliography, Bibliographiia Medica Slovaca (BMS) and listed to citation database CiBaMed. All articles are reviewed. The publisher does not bear any responsibility for data and opinions of particular authors of the articles or advertisements. The articles on grey pages are company promotions or non reviewed information, an author is responsible for the content. Any reproduction of the content is allowed only with direct consent of the editorial office.
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Neurology
Neurology
Reviewed, postgraduate scietific medical journal.
Period 3x per year
Predplatné
Téma: Original Works

Transcervical - subxiphoidal - bilateral vats “maximal” thymectomy for myasthenia gravis or thymoma - initial experiences

Tibor Krajč1, Peter Špalek2, Miroslav Janík1, Martin Lučenič1, Roman Benej1, Svetozár Haruštiak1

Introduction: Thymectomy (TE) is indicated in patients with seropositive myasthenia gravis (MG) with thymic hyperplasia, aged under 50, and in patients with MG associated with thymoma (MGAT). The extent of thymectomy for seropositive MG correlates positively with the long-term results of treatment. In MGAT the necessary extent of TE should always include removal of thymoma along with the thymus gland. Most of the minimally invasive approaches do not guarantee adequate extensivity when compared to maximal thymectomy via sternotomy and might leave a significant amount of ectopic thymic tissue behind. Zieliński’s transcervical – subxiphoidal – bilateral VATS “maximal” thymectomy combines cervical and subxiphoidal incisions with a double sternal traction and two thoracoscopic ports. Patients and methods: During 2009-2010 we performed 28 minimally invasive thymectomies using the Zieliński approach. There were 16 patients aged under 50 with seropositive MG, 7 patients with MG associated with thymoma and 5 patients with thymoma non-associated with MG. All MG patients were scheduled for surgery in a state of pharmacological remission or apparent clinical improvement achieved by immunosuppressive treatment and cholinesterase inhibitor administration. Results: We encountered no serious intra-operative complications such as large vessel injury or laryngeal recurrent or phrenicvizualinerve lesion. One laceration injury of lung parenchyma was sutured with an endostapler. Operating times ranged from 480 to 180 min (median 225 min), using a single-team approach. 24 patients were weaned in the operating theater, 3 required ventilatory support for 6-12 hours, one patient remained on support for 4 days and required intravenous immunoglobulin until her myasthenia improved. Chest tubes were removed after 2 to 5 days, overall hospital stay ranged from 4 to 9 days. No vocal cord or diaphragm palsy were noted. Thymomas removed were stage Masaoka I-IIB, all 12 patients are being followed up or treated at the oncology department, 5 underwent adjuvant radiotherapy for stage Masaoka II. All the myasthenia patients continue their medical treatment under supervision of a neurologist at the Center for neuromuscular diseases. 7 of them are in complete remission (all medication withdrawn), 10 in pharmacological remission (sustaining /maintaining immunosuppressive medication) and 6 have improved significantly but are still on immunosuppressants and cholinesterase inhibitor. Discussion: Transcervical – subxiphoidal – bilateral VATS „maximal“ thymectomy is equivalent to maximal thymectomy via sternotomy in its extent. In comparison to the open approach it provides a more detailed visualisation of the phrenic and recurrent laryngeal nerves, a more detailed dissection under magnification, less post-operative pain and faster recovery and also better cosmesis. It allows for a safe and oncologically sound removal of thymomas in Masaoka stage I-II and in some cases even III, with or without associated myasthenia. The main disadvantages of the Zieliński method are longer operating times, mirror image and worse ergonomics in some parts of the subxiphoidal phase. The limits for removal of a thymoma via this minimally invasive approach are its size (6-7 cm diameter in the smallest cross-section), doubts about the histological diagnosis and suspected dissemination. Relative limitations are represented by pleural adhesions and lung parenchyma infiltration. With respect to the above limits, we approach typical encapsulated anterior mediastinal masses starting with VATS on the side of tumor with an intention to perform a minimally-invasive „maximal“ thymectomy even if histological diagnosis is absent. Continuing supervision by an experienced neurologist is vital for successful long-term outcome of thymectomy in MG patients as long-term immunosuppressive treatment may be necessary.

myasthenia gravis, thymoma, minimally invasive thymectomy
Neurológia 2011; 6 (1): 24-30

Ročník 2011  Témy časopisu Neurology 1 / 2011

Overview works

Peter Špalek1, Peter Kosoň1,2
František Cibulčík
Mucska Imrich

Original Works

Tibor Krajč1, Peter Špalek2, Miroslav Janík1, Martin Lučenič1, Roman Benej1, Svetozár Haruštiak1

Case Studies

Ladislav Gurčík, Zuzana Gajdošová, Anna Tomášová, Peter Galik, Veronika Gašparíková, Anna Jarošová, Paulína Kubaľová, Slávka Lišková
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Neurology
Neurology
Reviewed, postgraduate scietific medical journal.
Period 3x per year
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