胸腔镜胸腺扩大切除术治疗儿童重症肌无力

目的通过总结胸腔镜胸腺扩大范围切除术治疗儿童重症肌无力的临床经验,探讨胸腔镜胸腺扩大切除术的临床应用价值。方法2007年2月至2008年5月,共计16例重症肌无力患儿接受胸腔镜胸腺扩大范围切除术;手术采用右侧胸腔入路,切除胸腺和清扫前纵隔脂肪组织。结果所有患儿均顺利完成手术,无严重围手术期并发症;术后随访17～30个月,完全缓解5例,好转9例,无变化2例。结论胸腔镜胸腺扩大切除术手术切口小,出血少,体内无残留金属异物,术后疼痛轻,恢复快,切口疤痕轻微,手术中远期效果良好,适用于儿童重症肌无力。     

电视胸腔镜胸腺切除术与开放性手术的对比分析

目的 探讨电视胸腔镜手术与开放性手术进行胸腺切除的优劣.方法 回顾性分析2002年2月至2007年5月106例进行电视胸腔镜胸腺扩大切除术患者,以及1998年3月至2003年8月108例开放手术患者的临床资料.胸腔镜组男性64例,女性42例,平均年龄38岁;开放手术组男性68例,女性40例,平均年龄36岁.对两组手术时间、术中出血量、术后引流、术后住院日、住院费用以及术后并发症等进行分析.随访时间10～67个月,平均38.5个月.按照美国重症肌无力基金会重症肌无力评分法进行疗效评定.结果 胸腔镜组术中出血量(34±5)ml,低于开放手术组的(150±23)ml.术后引流量(42±18)ml,低于开放手术组的(168±31)ml.术后并发症率和平均住院日亦较开放手术组有明显降低.两组术后远期疗效相似(P>0.05).结论 电视胸腔镜胸腺切除术治疗重症肌无力可达到与开放手术相似的远期疗效,同时具有创伤小、并发症少、恢复快等优势.     

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

Background  

This study aimed to introduce the authors’ surgical technique of bilateral video-assisted thoracoscopic thymectomy (BVT) and to compare their early surgical results between BVT and transsternal extended thymectomy (T3-b thymectomy) for patients with myasthenia gravis (MG).     

Subxiphoid approach for video-assisted thoracoscopic extended thymectomy in treating myasthenia gravis

Previous experience using the transcervical, left or right thoracic approach for thymectomy, although demonstrating promising efficacy, involves some compromise of the surgical exposure. We performed subxiphoid video-assisted thoracoscopic extended thymectomy (SxVATET) on eight consecutive myasthenic patients. The mean operation time, weights of resected specimen, and thoracic drainage period were 156.9 min (range 120-200 min), 77.5 g (range 40-100 g), and 3.4 days (range 3-4 days), respectively. There were no surgical complications or mortalities, and the cosmesis is satisfying. Our experience demonstrates that SxVATET provides an excellent view of the bilateral pleural cavities. Subsequently, extended thymectomy, resecting ample mediastinal fatty tissue in addition to the thymic glands, can be safely undertaken.     

重症肌无力电视胸腔镜与胸骨部分劈开行胸腺扩大切除比较

目的 探讨电视胸腔镜手术(VATS)在重症肌无力(MG)治疗中的价值.方法 应用随机对照研究前瞻性分析2005年至2008年开展的VATS和胸骨部分劈开行胸腺切除治疗MG疗效,比较两组在手术时间、术中出血量、术后胸管放置时间、术后住院时间、术后发生重症肌无力危象及疗效等方面差异.结果 VATS组中26例手术顺利,1例因电凝钩伤及头臂静脉中转开胸.与部分胸骨劈开组比较,VATS组术中出血少、手术时间短、术后放置胸管时间及术后住院时间缩短.VATS组与胸骨劈开组比较发生肌无力危象0例对3例,肺部感染2例对9例,胸骨上窝或伤口感染0例对3例.随访6～24个月,VATS和胸骨劈开组有效率分别为81%(21/26例)和85%(23/27例),差异无统计学意义.结论 VATS下胸腺扩大切除治疗重症肌无力,技术是安全、可行的,具有创伤小、痛苦轻、并发症少、疗效可靠等优点,临床应用前景良好.     

Complete stable remission after extended transsternal thymectomy in myasthenia gravis.

OBJECTIVE: This study sought to determine the efficacy and prognostic factors of extended transsternal thymectomy as a treatment for myasthenia gravis (MG). METHODS: Medical records of 147 patients who underwent extended transsternal thymectomy for MG from January 1991 to December 2002 were reviewed retrospectively. The complete stable remission (CSR) rate and prognostic factors for CSR were assessed in 106 female and 41 male patients. RESULTS: The median age was 35 years (range 11-75 years). Ninety-eight patients had non-thymomatous MG and 49 patients had thymomatous MG. The median follow-up time was 89.7 months (range 12-167 months). Both non-thymomatous MG and thymomatous MG exhibited significant differences in population characteristics and CSR rates (29.6% vs 13.3% at 5 years, 45.2% vs 27.7% at 10 years, p = 0.022). Steroid therapy (hazard ratio: 0.234, p = 0.003) was a poor prognostic factor, while early onset (hazard ratio: 3.519, p = 0.048) was a good prognostic factor for CSR in non-thymomatous MG. In contrast, steroid therapy (hazard ratio: 0.061, p = 0.034) was poor prognostic factor for thymomatous MG. CONCLUSIONS: Extended transsternal thymectomy is a good treatment tool to achieve CSR in MG. Thymomatous MG and non-thymomatous MG were significantly different in patient characteristics and prognosis. Prognostic factors were steroid therapy and age of onset in non-thymomatous MG, and steroid therapy in thymomatous MG.     

胸腔镜胸腺扩大切除加颈部切口治疗重症肌无力

目的 探讨胸腔镜胸腺扩大切除加颈部切口治疗重症肌无力的可行性和术后疗效.方法 2005年1月至2006年2月采用胸腔镜胸腺切除加颈部切口治疗重症肌无力患者41例,其中男性18例,女性23例,年龄18～67岁.病程1个月～3年.术中除完整切除胸腺外,还清除前纵隔区域及颈根部的异位胸腺和脂肪组织.结果 全组41例手术完全在电视胸腔镜下完成,平均手术时间162 min.术后发生肌无力危象7例.术后病理学诊断:4例颈部发现残存胸腺上极,35例患者气管前胸骨上间隙有肿大淋巴结(3～17枚).所有患者均痊愈出院.术后随访观察2年,完全缓解率41.4%,有效率达85.4%.结论 胸腔镜下胸腺切除术治疗重症肌无力能取得较为理想的治疗效果,胸腔镜扩大胸腺切除加颈部切口对于颈根部异位胸腺的清除是一补充.     

Inclusion of the transcervical approach in video-assisted thoracoscopic extended thymectomy (VATET) for myasthenia gravis: a prospective trial

Background Because evidence-based data regarding the quality of video-assisted thoracoscopic thymectomy for the treatment of myasthenia gravis are lacking, a prospective trial comparing three different operative approaches was conducted to evaluate their efficacy. Methods This prospective study enrolled 20 consecutive patients with nonthymomatous myasthenia gravis. A series of three approaches for bilateral video-assisted thoracoscopic extended thymectomy (VATET) using the anterior chest wall–lifting method (original), the original method with a flexed-neck position (modified), and the original method with a transcervical approach (final) were prospectively performed in each patient for quantitative and pathologic evaluation of the residual thymus after each approach. Results Complete VATET required 242 ± 48 min, with the transcervical procedure requiring 23 ± 12 min. After the modified method, the residual thymus in the cervical region was 1.5 cm in size and weighed 0.8 g (0.8% of the entire thymus), as compared with a size of 2.2 cm and a weight of 1.3 g (3.2%) after the original method. Each value is the result of comparison with the final method. Histopathologic studies showed residual tissue in the germinal center as well as Hassall’s corpuscles in more than 70% of cases. Conclusion The findings show that VATET without the transcervical approach could be an immunologically incomplete treatment for myasthenia gravis. Therefore, the transcervical approach should be included in VATET procedures to ensure radicality.     

Long-term follow-up after thymectomy for myasthenia gravis: thoracoscopic vs open

Purpose

The aim of this study was to determine if patients are in remission or weaning off medication after thymectomy for myasthenia gravis (MG) and to examine the thoracoscopic versus open approaches.

Methods

A retrospective review of all patients who underwent thymectomy for MG at a tertiary referral center between 1992 and 2004 (N = 14). Six patients (42.9%) underwent thoracoscopic resection. Eight patients underwent open resection; 5 (35.7%) had median sternotomy and 3 (21.4%) by transcervical approaches. Follow-up was obtained in 12 (85.7%) of 14 patients by both chart review and telephone. The mean follow-up was 43.0 months (range, 4-111 months). Statistical significance was determined by Student's t test or Fisher's Exact Test.

Results

The thoracoscopic group had a mean operating time of 138.8 minutes compared with 139.8 minutes in the open group (P = .9). The thoracoscopic group had a mean estimated blood loss of 7.5 mL compared with 52.5 mL in the open group (P = .02). The mean length of stay for the thoracoscopic group was 1.5 days (range, 1-2 days) and was 10.6 days (range, 3-41 days) in the open group (P = .13). Three (60%) of 5 patients were entirely off medication in the thoracoscopic group at the time of follow-up compared with 3 (50%) of 6 patients in the open group (P = 1.0). In the thoracoscopic group, 5 (83.3%) of 6 were in class 1 to 3 of the DeFilippi classification (complete remission or improved with decreased medication requirements). One patient had no change in symptoms (class 4). In the open group, 5 (83.3%) of 6 were classified as DeFilippi 1 to 3 at the time of follow-up, and one patient had worsening symptoms (class 5).

Conclusions

Both thoracoscopic and open approaches to thymectomy in patients with MG are effective, with more than 80% of patients in both groups in remission or with improvement at the time of follow-up. The thoracoscopic group has the added benefits of decreased estimated blood loss, decreased length of hospital stay, and improved cosmesis. We advocate the thoracoscopic approach for thymectomy in the treatment of juvenile MG.     

电视胸腔镜胸腺扩大切除治疗重症肌无力107例临床分析

目的探讨电视胸腔镜下胸腺扩大切除术治疗重症肌无力的临床效果。方法对1995年6月至2004年6月,台湾长庚纪念医院胸外科和北京大学人民医院胸外科根据临床表现及肌电图检查诊断证实为单纯重症肌无力,行电视胸腔镜胸腺完整切除及前纵隔脂肪组织廓清术治疗的107例患者的临床资料进行回顾分析。结果术后随访1—98个月,完全缓解34例,改善55例,全组完全缓解及改善率为83％,无手术死亡病例。结论电视胸腔镜下手术切除胸腺及前纵隔脂肪组织治疗重症肌无力临床效果良好,安全,创伤较小。     

Anesthetic management for video-assisted extended thymectomy of patients with myasthenia gravis

BACKGROUND: Thymectomy is one of therapeutic modalities for patients with myasthenia gravis. Since 1998, we have performed video-assisted extended thymectomy, which is much less invasive than traditional method. However, its optimal perioperative management has not been established. METHODS: From April 1998 to December 2003, 40 patients with myasthenia gravis underwent video-assisted extended thymectomy in our hospital. Anesthesia was maintained with propofol, sevoflurane and epidural anesthesia. No muscle relaxant was used. Operations were performed in supine position and required differential lung ventilation of both sides in turn for manipulation. A central venous catheter was inserted in the femoral vein to prepare for unexpected bleeding or other hemodynamic changes. RESULTS: Seven patients presented hypoxemia under differential lung ventilation and needed bilateral lung ventilation or addition of CPAP to nondependent lung. Unexpected bleeding from the left innominate vein occurred in two patients and required median sternotomy. Severe hypotension caused by compression of the heart during operation was observed in twenty-one patients. Extubation in the operating room was successful in all patients except one with severe bulbar paralysis before preoperative period. CONCLUSIONS: It is important to examine both surgical techniques of video-assisted surgery and physiological features of myasthenia gravis for anesthetic management of video-assisted extended thymectomy.     

电视胸腔镜胸腺切除治疗重症肌无力症

目的探讨电视胸腔镜手术(video-assisted thoracoscopic surgery,VATS)胸腺切除治疗重症肌无力症(myasthenia gravis,MG)的可行性. 方法 18例MG采用VATS经右胸前侧径路行胸腺切除联合纵隔脂肪清扫. 结果 17例顺利完成手术,1例因电凝钩伤及左头臂静脉干而中转开胸止血.平均手术时间105 min,术中失血量平均80 ml.全组无术后死亡及危象发生.18例随访1～20个月,平均11.3个月.按Osserman疗效评价,缓解5例(27.8%),明显改善6例(33.3%),部分改善4例(22.2%),无变化3例(16.7%),有效率83.3%(15/18). 结论 VATS经右胸前侧径路行完全胸腺切除可行,且具有创伤小、恢复快等优点.     

The thoracoscopic thymectomy for myasthenia gravis

Myasthenia gravis (MG) is a chronic autoimmune disease that usually responds positively to treatment with thymectomy. Standard surgical procedures have been shown to result in a favorite outcome. The optimal surgical access, however, is under discussion. PATIENTS AND METHOD: In a prospective study conducted between 8/97 and 4/05, 173 patients with MG underwent thoracoscopic thymectomy, for which a left-sided approach was generally applied. An analysis of the intraoperative and postoperative course was performed in 137 patients (8/97 and 12/03), as well as of the impact of the surgical procedure on further development of the disease. The results obtained were compared with those published in the literature, with particular reference to results obtained with open surgery. In 8 patients, the procedure was converted to an anterolateral thoracotomy or sternotomy, so we examined 129 patients, which were operated thoracoscopically. RESULTS: The patients in this study were 93 females and 36 males, with a mean age of 35.8 (range: 9-83) years. The mean preoperative duration of the disease was 22.9 (range: 1-140) months. The duration of operation was 50 to 85 minutes, the blood loss was lower than 100 ml. The mean follow up was 24.7 (range: 1-57) months. Complete remission was noted in 30 patients (23.3 %), and improvements reflected either in a reduction of the required medication, or a decrease in symptom severity, were seen in a total of 86 patients (66.6 %). CONCLUSION: Complete thoracoscopic thymectomy is a technically feasible operation, and as effective as conventional open surgery. Remissions or symptomatic improvements were observed in more than 89 % of the patients. The low morbidity rate, in combination with excellent cosmetic results, has led to increasing acceptance of the operation both by patients and neurologists. Therefore, thoracoscopic thymectomy represents a new, alternative method for treatment of patients with MG.     

Comparison between the right side and subxiphoid bilateral approaches in performing video-assisted thoracoscopic extended thymectomy for myasthenia gravis

Background This study aimed to compare the efficacy of the right thoracoscopic (RtT) approach and the subxiphoid bilateral thoracoscopic (SxBiT) approach in performing thymectomy for myasthenia gravis.Methods Between March 2001 and April 2003, 27 myasthenic patients were enrolled in this prospective study. The operations were conducted by two surgical teams in a single institute. The surgical procedures included RtT for 12 patients and SxBiT for 15 patients. The operation time, resected thymus weights, and thoracic drainage periods were compared.Results Subxiphoid video-assisted thoracoscopic extended thymectomy (SxVATET) and right-side thoracoscopic extended thymectomy (RtVATET) were performed for 27 consecutive myasthenic patients. The mean operation time, weights of resected specimens, and duration of hospital stay for the SxVATET and RtVATET groups were, respectively, 151.3 min (range, 120–200 min) versus 191.5 min (range, 120–225 min) (p = 0.0012), 73.3 g (range, 40–90 g) versus 50.8 g (range, 5–90 g) (p = 0.0029), and 3.1 days (range, 2–4 days) versus 3.8 days (range, 2–4 days) (p = 0.914). Ten patients (37%) had complete remission, observed during a mean follow-up period of 18.5 months (range, 6–30 months).Conclusions During this consecutive experience, both the RtT and SxBiT approaches showed satisfactory results for nonthymomatous myasthenic patients. However, a better view of the bilateral pleural cavities and more radical thymectomy could be achieved only by the SxBiT approach.     

Subxiphoid thoracoscopic thymectomy for myasthenia gravis

We investigated the efficacy of subxiphoid thoracoscopic thymectomy in patients with myasthenia gravis. The data of 37 consecutive cases were reviewed. 2 cases of postoperative myasthenia gravis crisis and 4 cases of residual mediastinal fat tissue were recorded. Moreover, 29 patients presented the neurological outcomes, and complete stable remission was achieved in 5 (17.2%) cases. Subxiphoid thymectomy is technically feasible. High-quality evidence is warranted before this approach can be recommended.