40例胸腺肿瘤合并重症肌无力的手术治疗

报告４０例胸腺肿瘤合并重症肌无力（ＭＧ）的手术治疗效果。本组包括完全切除肿瘤和胸腺２６例，次全切除肿瘤１０例，组织活检４例。结果手术死亡１例（２．５％），术后１年内死亡８例（２０．５％）。３１例术后随访３～１２年，５年生存率为６１．３％，１０年生存率２７．７％；其中非浸润型胸腺瘤分别为７６．９％和３０．０％，浸润型胸腺瘤则为５０．０％和２５．０％。ＭＧ术后缓解改善率为８０．６％，术后肌无力危象发生率为４０．０％，抢救成功率为９３．８％，结论显示手术治疗胸腺肿瘤合并ＭＧ，如严格掌握手术指征，可获得较好的疗效和预后。     

重症肌无力合并胸腺瘤的外科治疗(附31例报告)

报告１９８０年至１９９６年１０月手术治疗３１例重症肌无力合并胸腺瘤的结果。３１例占同期手术治疗１２０例重症肌无力之２５．８％。按Ｍａｓａｏｋａ分期属Ｉ期７例，Ｉ期８例，ＩＩ期１５例，ＩＶ期１例，术后１５例发生危象，均采用气管切开及辅助呼吸，１例死于危象。随访半年至８年，平均３７个月，５年内死亡６例，其中ＩＩ期４例，Ｉ期２例。结论：重症肌无力合并胸腺瘤术后危象的发生率远较未合并胸腺瘤者高，及时气管切开行辅助呼吸是处理的关键；胸腺瘤的Ｍａｓａｏｋａ病理分期与预后明显相关，肌无力的严重程度对预后亦有重要影响     

胸腺瘤合并重症肌无力与单纯重症肌无力的临床特征及手术疗效分析

目的　探讨胸腺瘤合并重症肌无力 (MG)与单纯MG的临床特征及手术疗效。方法回顾性分析 1978年至 2 0 0 3年 2 4 3例MG患者临床资料 ,比较胸腺瘤合并MG组 (6 8例 )与单纯MG组 (175例 )的临床特点 ,以及术后并发症、缓解率、生存情况。结果　胸腺瘤合并MG组较单纯MG组年龄大 [平均年龄分别为 (41± 14 )与 (2 8± 16 )岁 ,t=6 .138,P =0 0 0 0 ]、病程短 (平均分别为 10、2 4个月 ,t =3 783,P =0 0 0 0 ) ,术后肌无力危象发生率高 [分别为 5 0 0 % (34/ 6 8)与 5 7% (10 / 175 ) ,χ2=6 4 77,P =0 0 0 0〗 ,两组Osserman分型差异无显著意义 (χ2 =7 6 78,P =0 10 4 )。胸腺瘤合并MG组肌无力症状完全缓解率、部分缓解率 ,术后 1年分别为 10 2 % (6例 )、6 2 7% (37例 ) ,术后 3年分别为 2 1 6 % (8例 )、75 7% (2 8例 ) ,低于单纯MG组 [术后 1年分别为 2 2 1% (30例 )、94 1% (12 8例 ) ,术后 3年分别为 4 4 4 % (44例 )、94 9% (94例 ) ,P值分别为 0 0 4 9、0 0 0 0、0 0 15、0 0 10 ];术后 5年两组比较肌无力症状完全缓解率、部分缓解率差异无显著意义 (P =0 4 5 7,P =0 6 99)。胸腺瘤合并MG组 3、5年生存率分别为 96 3%、84 4 % ,显著低于单纯MG组的 98     

胸腔镜胸腺切除术治疗重症肌无力500例

目的 总结胸腔镜胸腺切除术治疗重症肌无力(MG)的经验,对比胸腺瘤和非胸腺瘤MG患者的术后效果,分析胸腔镜联合纵隔镜和单纯胸腔镜治疗非胸腺瘤MG的远期效果.方法 2001年至2011年,采用胸腔镜胸腺扩大切除术治疗MG患者500例,根据是否合并胸腺瘤和术中是否联合纵隔镜分组:胸腔镜胸腺瘤组(A组)118例,胸腔镜非胸腺瘤组(B组)301例,胸腔镜联合纵隔镜非胸腺瘤组(C组)81例.结果 全组无术中死亡.完全电视胸腔镜下完成手术495例.A组手术(128.5±77.8) min,术后24.6％患者出现肌无力危象;B组手术(111.3±31.6) min,术后11.0％患者出现肌无力危象;C组手术(145.0 ±71.6) min,术后9.9％患者出现肌无力危象.术后随访3个月至11年,A、B、C组患者完全缓解率(CSR)分别为28.7％、37.3％、36.5％.无病生存曲线示术后3年B、C组CSR高于A组,术后5年C组CSR高于B组.术后第5年C组CSR接近60％,B组为50％,而A组仅为36％.结论 胸腔镜基础上联合纵隔镜胸腺扩大切除手术清除颈部、前纵隔脂肪组织及异位胸腺更为彻底,远期效果更加理想.与非胸腺瘤MG患者相比,胸腺瘤MG患者术后远期效果较差.     

Video-assisted thymectomy for myasthenia gravis: an update of a single institution experience

Objective: Video-assisted thymectomy was introduced in 1992 as a minimally invasive alternative for the treatment of myasthenia gravis. As experience with this technique is limited and follow-up short, we present this expanded and updated experience for purposes of validation of the technique. Methods: Thirty-eight video-assisted thymectomies for myasthenia gravis were performed in our institution between March 1992 and March 2002. Two patients were lost to follow-up. We analyzed clinical results of 36 patients (14 males and 22 females) with a mean age of 41.2 years. Preoperative clinical staging was assessed by the newly recommended Myasthenia Gravis Foundation of America Clinical Classification. Clinical status at follow-up was assessed by the Myasthenia Gravis Foundation of America Postintervention Status classification. Results: There was no perioperative mortality or long-term morbidity. One of 38 (2.6%) patients required conversion to limited thoracotomy for bleeding. The mean length of hospital stay was 1.64 days (range 0–8 days) with a median stay of 1 day. The mean length of follow-up is 53.24 months (range 4–126 months). Overall clinical improvement at follow-up was observed in 30 of 36 (83.0%) patients, with five of 36 (14.0%) patients in complete stable remission. Conclusions: Video-assisted thymectomy for myasthenia gravis provides acceptable clinical long-term results by a minimally invasive approach comparable to standard surgical approaches to the disease. The presented data is reported in accordance with the new guidelines by Myasthenia Gravis Foundation of America Task Force for valid comparison with future studies.     

胸腔镜胸腺扩大切除术治疗重症肌无力的疗效观察及影响因素分析

目的对胸腔镜胸腺扩大切除术治疗重症肌无力(myasthenia gravis,MG)的疗效进行总结,分析影响MG手术疗效的因素。方法回顾性研究我院2000年6月～2009年10月47例MG接受胸腔镜手术的临床资料,采用单因素分析和logistic回归模型对患者性别、年龄、病程、MGFA分型、胸腺病理类型等可能影响因素进行分析。结果 45例完成随访,随访16～111个月,平均51个月。根据MGFA提出的治疗后状况分类:完全稳定缓解占64.4%(29/45),药物缓解占17.8%(8/45),微小症状表现占8.9%(4/45),恶化占2.2%(1/45),复发占4.4%(2/45),死亡占2.2%(1/45)。年龄(β=0.059,P=0.027,OR=1.060,95%CI为1.007～1.117)和胸腺病理类型(β=1.558,P=0.025,OR=4.750,95%CI为1.214～18.584)是影响手术疗效的因素。结论 MG行电视胸腔镜下胸腺扩大切除术疗效满意,年龄和胸腺病理类型是手术疗效的影响因素。     

Colon carcinoma after thymectomy for myasthenia gravis: report of a case

A 74-year-old Japanese man was admitted to our hospital with anemia, 4 years after a thymectomy for thymoma associated with myasthenia gravis. A diagnosis of sigmoid colon carcinoma was confirmed, followed by surgical resection. This case is presented to reinforce that physicians should bear in mind the possibility of extrathymic malignancies in patients with thymoma. Received: June 28, 2001 / Accepted: January 8, 2002     

Surgical approach in thymectomy: Our experience and review of the literature

AimThymectomy is the main treatment for thymoma and patients with myasthenia gravis (MG). The traditional approach is through a median sternotomy, but, recently, thymectomy through minimally invasive approaches is increasingly performed. Our purpose is an analysis and discussion of the clinical presentation, the diagnostic procedures and the surgical technique. We also consider post-operative complications and results, over a period of 5 years (May 2011–June 2016), in thymic masses admitted in our Thoracic Surgery Unit.MethodsWe analyzed 8 patients who underwent surgical treatment for thymic masses over a period of 5 years. 6 patients (75%) had thymoma, 2 patients (25%) had thymic carcinomas. 2 patients with thymoma (33%) had myasthenia gravis. We performed a complete surgical resection with median sternotomy as standard approach.ResultsOne patient (12%) died in the postoperative period. The histological study revealed 6 (75%) thymoma and 2 (25%) thymic carcinomas. Post-operative morbidity occurred in 2 patients (25%) and were: pneumonia in 1 case (12%), atrial fibrillation and pleural effusion in 2 patients (25%). One patient with thymoma type A recurred at skeletal muscle 2-years after surgery.ConclusionsThymic malignancies are rare tumors. Surgical resection is the main treatment, but a multimodal approach is useful for many patients. Radical thymectomy is completed removing all the soft tissue in the anterior mediastinum between the two phrenic nerves and this is the most important factor in controlling myasthenia and influencing survival in patients with thymoma. Open (median sternotomy) approach has been the standard approach for thymectomy for the better visualization of the anatomical structures. Actually, video-assisted thoracoscopic surgery (VATS) thymectomy and robotic video-assisted thoracoscopic (R-VATS) approach versus open surgery has an equal if not superior oncological efficacy, better perioperative complications and survival outcomes.     

胸腺瘤合并重症肌无力的外科治疗

目的报告1988年～2000年12月手术治疗36例胸腺瘤合并重症肌无力(MG)的结果.方法全部患者均行手术治疗,按Masaoka临床分期Ⅰ期6例,Ⅱ期15例,Ⅲ期12例,Ⅳ期3例.结果术后18例出现重症肌无力危象,均行气管切开及辅助呼吸,1例死于危象.术后随访半年～10年,3年内MG缓解率为72.2%,5年生存率为65.4%,10年生存率为24.8%.结论胸腺切除手术是治疗胸腺瘤合并重症肌无力的主要方法,术后肌无力危象发生率高,及时行气管切开及辅助呼吸是处理的关键.     

Thymectomy in myasthenia gravis : Results of 662 cases operated upon in 15 years

The results of thymectomy in the treatment of myasthenia gravis (MG) are reviewed in the light of a personal series of 662 MG patients, operated upon during the last 15 years. In 500 MG patients without thymoma, the following results have been achieved: remission 37.9%, improvement 49.4%, unchanged or worse 7.4%, dead 5.2%. There is no sex prevalence and the remission rate is higher in patients under 40 years of age (P < 0.01), with mild disease (P < 0.05), with a MG duration of less than 1 year (P < 0.05) and with a follow-up length of between 5 and 10 years (P < 0.01). No correlations are found between outcome and thymic histology. The results of 162 MG patients with thymoma are: remission rate 15.7%, improvement 60.3%, unchanged or worse 3.7% and dead 20.1%. The remission rate is higher with mild symptoms (P < 0.05) and when the tumour is encapsulated (P < 0.02). The postoperative mortality is 0.8% (none in the last 5 years) for non-thymomatous MG and 4.9% for thymomatous MG (2 of 8 patients died of pancytopaenia and 1 of pulmonary embolism).     

合并胸腺瘤对胸腺切除治疗重症肌无力效果的影响

目的 总结胸腔镜胸腺扩大切除治疗重症肌无力的远期疗效,并分析合并胸腺瘤对手术疗效的潜在影响.方法 2001年4月至2009年10月47例重症肌无力接受胸腔镜手术的患者分为有胸腺瘤组和无胸腺瘤组两组,评价肿瘤因素对重症肌无力胸腔镜手术效果的影响.结果 47例中男20例,女27例;平均年龄36.6岁.根据美国重症肌无力基金会(MGFA)分型:Ⅰ型18例、Ⅱa型14例、Ⅱb型14例、Ⅲa型1例.胸腺瘤组22例,无瘤组25例.随访至2011年6月,无瘤组随访20 ～ 122个月,平均57个月;失访2例.无瘤组完全稳定缓解(CSR) 78.3％,药物缓解(PR) 13.0％,微小症状表现(MM)4.3％,无恶化(W)0,无复发(E)0,死亡(D)(4.3％).胸腺瘤组分别为:50.0％、22.7％、13.6％、4.5％、9.1％和0.结论 胸腔镜胸腺扩大切除治疗重症肌无力远期疗效满意,无瘤组在完全缓解率上优于有瘤组,但在总有效率上两组差异无统计学意义.     

影像引导机器人系统在微创治疗的临床应用进展

影像引导的微创治疗技术在临床诊疗工作中发挥着越来越重要作用。随着科技进步,影像引导机器人技术逐步成熟,并可完成一定的临床微创治疗工作,弥补了手术过程中的诸多不足。本文主要对影像引导机器人系统的发展现状及其在微创治疗中应用进行综述。     

达芬奇机器人在胸腺扩大切除术治疗Ⅰ型重症肌无力的应用

目的 探讨达芬奇机器人系统在胸腺扩大切除术治疗Ⅰ型重症肌无力中的应用价值和技术细节。 方法回顾性分析2012年3～9月沈阳军区总医院使用达芬奇机器人系统行胸腺扩大切除治愈3例重症肌无力患者的临床资料,均为眼肌型（Ⅰ型）,其中男2例,分别是33岁和66岁;女1例,年龄21岁。分析手术疗效。 结果 3例患者均顺利完成机器人胸腺扩大切除,未使用辅助操作口,无中转开胸或术后开胸止血,术中出血量5～10 ml,手术总时间95～138 min,分离时间26～80 min,未出现肌无力危象及其他并发症。术后胸腔闭式引流时间3～9 d,术后住院时间10～15 d。2例随访6～12个月无复发。 结论 机器人行扩大胸腺切除手术安全可行,效果确切。     

胸腔镜胸腺切除术治疗重症肌无力(附2例报告)

目的:探讨胸腔镜胸腺切除术治疗重症肌无力的可行性。方法:2例重症肌无力合并胸腺增生(胸腺瘤)的患者行胸腔镜胸腺切除术。结果:2例患者胸腺均在胸腔镜下完整切除,无中转开胸及并发症。术后通过4个月电话随访,症状都有明显改善。结论:胸腔镜胸腺切除术具有创伤小,术后疼痛轻,并发症少,住院时间短,恢复快等优点,是一种非常有前途的技术。     

Duodenopancreatectomy: Open or minimally invasive approach?

BackgroundMinimally invasive pancreaticoduodenectomy (MIPD) is a complex procedure, offered to selected patients at institutions highly experienced with the procedure. It is still not clear if this approach may enhance patient recovery and reduce postoperative complications comparing to open pancreaticoduodenectomy (OPD), as demonstrated for other abdominal procedures.MethodsA systematic literature review was conducted to identify studies comparing MIPD and OPD. Perioperative outcomes (e.g., morbidity and mortality, pancreatic fistula rates, blood loss) constituted the study end points. Metaanalyses were performed using a random-effects model.ResultsFor the metaanalysis, 8 studies including 204 patients undergoing MIPD and 419 patients undergoing OPD were considered suitable. The patients in the two groups were similar with respect to age, sex and histological diagnosis, and different with respect to tumor size, rate of pylorus preservation, and type of pancreatic anastomosis. There were no statistically significant differences between MIPD and OPD regarding development of delayed gastric emptying (DGE), pancreatic fistula, wound infection, or rates of reoperation and overall mortality. MIDP resulted in lower post-operative complication rates, less intra-operative blood loss, shorter hospital stays, lower blood transfusion rates, higher numbers of harvested lymph nodes, and improved negative margin status rates. However, MIPD was associated with longer operating times when compared to OPD.ConclusionsThe MIPD procedure is feasible, safe, and effective in selected patients. MIPD may have some potential advantages over OPD, and should be performed and further developed by use in selected patients at highly experienced medical centers.     

Modified version of minimally invasive open thyroidectomy using an unilateral incision

Background/objectiveOpen thyroidectomy has been the standard approach for patients undergoing thyroidectomy. However, this approach leads to prominent scars, hypesthesia, paresthesia, and uncomfortable sensations. We aimed to describe our modified technique of minimally invasive open thyroidectomy (MIT) and to compare the results with those of conventional thyroidectomy.MethodsThis study included 880 patients who underwent surgery between January 2016 and December 2016. Modified MIT was performed in 249 patients (28.3%), and conventional thyroidectomy was performed in the remaining 631 patients.ResultsLobectomy was performed in the majority of cases (MIT 204 [81.9%] vs. conventional 429 [67.9%]). There were no significant differences in complications between the two approaches (6 [2.4%] vs. 8 [1.3%]). Patients who underwent surgery using the minimally invasive approach had a shorter operative time (77.99 ± 34.5 vs. 91.23 ± 36.58 min) and were discharged earlier (2.4 ± 0.8 vs. 3.2 ± 0.8) than those who underwent conventional thyroidectomy.ConclusionModified MIT is a safe alternative to standard open thyroidectomy and allows the performance of bilateral total thyroidectomy with proper central compartment neck dissection.Level of evidence2b.     

Thymic carcinoma with myasthenia gravis: Two case reports

IntroductionMyasthenia gravis (MG) has been reported to correlate with earlier-stage thymoma, and theoretically does not accompany thymic carcinoma. However, we encountered two cases of thymic carcinoma with MG.Presentation of casesCase 1 involved a 54-year-old man who had been diagnosed with MG based on symptoms and detection of anti-acetylcholine receptor antibody (ARAB). Computed tomography (CT) revealed an anterior mediastinal tumor 30 mm in diameter. Prednisolone (PSL) and tacrolimus were administered without surgery at that time. Six years after diagnosis of MG, he was admitted to our hospital and underwent extended thymectomy. Pathological examination revealed type B2-B3 thymoma according to World Health Organization criteria, comprising 80% of the tumor with small cell carcinoma as 20%. Case 2 involved a 51-year-old woman. She had been diagnosed with MG based on eyelid ptosis and detection of ARAB. Ten years after diagnosis of MG, diaphragm elevation was detected on chest X-ray. CT revealed an anterior mediastinal tumor, 47 mm in diameter. We suspected tumor invasion to the right phrenic nerve, right atrium, and superior vena cava. We therefore performed extended thymectomy after preoperative radiotherapy (40 Gy). Pathological examination revealed squamous cell carcinoma.DiscussionMost cases of thymic carcinomas appear to arise de novo, but appearance in thymomas has been described. In both our cases, MG was treated with pharmacotherapy alone without extended thymectomy, and thymic carcinoma was considered to have developed from the thymoma during long-term follow-up.ConclusionThymic carcinoma can accompany MG.     

Pain after minimally invasive videoassisted and after minimally invasive open thyroidectomy—results of a prospective outcome study

Background Substantial modifications in surgical treatment of thyroid disease have changed the postoperative management of thyroidectomized patients. The reduction of postoperative pain permit a short-stay surgery. Materials and methods We have analyzed the patients treated in our Unit from July 2006 to December 2006, with minimally invasive cervicotomy and mini-invasive video-assisted thyroidectomy. We have registered the postoperative pain applying an evaluation protocol numeric scale. The results were analyzed by t test. Results One hundred thirteen patients were divided in two groups: group A, minimally invasive cervicotomy (15 male and 46 female patients); group B, mini-invasive video-assisted thyroidectomy (9 male and 43 female patients). Upon returning to the ward, the pain scale group A vs B was 2.77 ± 1.16 vs 2.5 ± 0.762 (p = 0.22) .At 24 h after surgery, the pain scale in group A was 1.82 ± 1.258 vs 1.031 ± 0.8608 (p < 0.005). Conclusions Both methods are safe, but mini-invasive video-assisted thyroidectomy gives not only a better cosmetic result but a reduction of postoperative pain especially at 24 h.     

胸腔镜手术切除胸腺瘤治疗重症肌无力

目的探讨胸腔镜手术治疗胸腺瘤伴重症肌无力的可行性。方法2005年7月-2006年2月，采用电视胸腔镜在双腔气管插管静脉复合麻醉下行胸腺、胸腺瘤切除术10例，胸腺瘤最大6cm×4cm×3cm。于腋中线第5肋间做1cm胸腔镜口，腋前线与锁骨中线中点第4肋间做3cm主操作孔，腋前线第6肋间做1．5cm辅助操作孔。术中沿胸廓内动脉与锁骨下动脉分叉下方、胸廓内动脉内侧，剪开纵隔胸膜暴露同侧胸腺及部分对侧胸腺；沿上腔静脉或膈神经前方剪开胸膜，暴露同侧胸腺下极，自下而上游离同侧胸腺，沿头臂干静脉前方解剖、结扎胸腺静脉，同法游离对侧并切除。术后全部进行4000cGy放疗。结果手术时间70—130rain，平均110min。术中出血〈100ml。术后Masaoka分期Ⅰ期7例，Ⅱ期3例。术后无死亡，未出现心肺并发症和重症肌无力危象。术后1周重症肌无力症状缓解。10例随访8—15个月，平均13．0月，均无复发、转移，重症肌无力症状无明显加重。结论采用胸腔镜手术切除Ⅰ期或部分Ⅱ期胸腺瘤技术上是可行的，创伤小，术后并发症少，且不影响美观。