重症肌无力胸腺切除围术期处理

自１９６６～１９９１年期间行胸腺切除术治疗重症肌无力８３例，取得较好效果，与围手术期的正确处理有重要关系。现重点讨论手术前后处理、手术时机选择、麻醉及围手术期乙酰胆碱及肾上腺皮质激素的应用、呼吸机辅助呼吸、维持营养、调节电解质平衡等。强调重症肌无力危象及乙酰胆碱危象的预防及处理。     

胸骨部分劈开切口行扩大的胸腺切除术治疗重症肌无力

目的介绍胸骨部分劈开切口行扩大的胸腺切除术治疗重症肌无力的手术方法和效果。方法2000年1月至2005年12月,采用胸骨正中部分劈开切口,对32例重症肌无力患者进行了扩大的胸腺切除手术。结果6例肌无力症状完全缓解,19例症状显著改善,5例症状轻微改善,而仅有2例手术后症状完全没有好转。结论胸骨部分劈开切口是实施扩大的胸腺切除治疗重症肌无力的一种安全、有效的手术径路,并且对患者的创伤小,避免了手术后并发症,特别是肌无力危象的发生。     

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.     

胸腺切除治疗重症肌无力34例体会

自１９８０年４月至１９９５年９月，采用胸腺切除治疗重症肌无力３４例，年龄５～６２岁，术后早期死亡１例，死亡率２．９４％，３３例随访３个月至１２年，１年内缓解和改善率为８７．９％（２９／３３），１～３年缓解和改善率为８８．５％（２３／２６），３年以上缓解和改善率为８０．０％（４／５）。随访结果表明胸腺切除治疗重症无 力效果满意，延迟拔除气管插管或早期行气管切开术，是防治术后重症肌无力危象的有效措施。     

胸腺切除术治疗重症肌无力23例

目的:通过重症肌无力合并胸腺瘤及胸腺增生23例治疗体会的总结,探讨重症肌无力合并胸腺瘤及胸腺增生的外科治疗方法.方法:对23例重症肌无力合并胸腺瘤及胸腺增生患者的临床资料进行回顾性分析与总结.结果:全组均行手术切除胸腺,死亡3例,2例死于肌无力危象,1例死于成人呼吸窘迫综合征.随访1～8年,手术效果较好.结论:重症肌无力是一种自身免疫性疾病,胸腺被认为是参与发病的重要组织,胸腺切除是治疗重症肌无力的有效方法,如能尽早手术治疗,将能获得较好的疗效.     

电视胸腔镜与胸骨部分劈开行胸腺扩大切除治疗重症肌无力的随机对照研究

目的探讨电视胸腔镜手术（video-assited thoracoscopic surgery,VATS）治疗重症肌无力（myasthenia gravis,MG）的价值。方法采用前瞻性随机对照研究分析2005年7月～2008年7月采用VATS和胸骨部分劈开行胸腺切除治疗54例MG,比较2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26例手术顺利,1例因电凝钩伤及头臂静脉中转开胸。VATS组术中出血量（43.0±5.2）ml显著少于胸骨劈开组（117.6±17.2）ml（t=-21.196,P=0.000）;VATS组手术时间（89.4±15.0）min显著短于胸骨劈开组（98.4±12.5）min（t=-2.377,P=0.021）;VATS组术后放置胸管时间（2.2±1.6）d显著短于胸骨劈开组（4.2±1.3）d（t=-5.003,P=0.000）;VATS组术后住院时间（7.0±1.2）d显著短于胸骨劈开组（11.0±2.5）d（t=-7.379,P=0.000）。胸骨劈开组发生肌无力危象3例,VATS组无一例发生,2组肌无力危象发生率无统计学差异（P=0.236）;胸骨劈开组发生肺部感染9例,VATS组2例,2组有统计学差异（χ2=5.295,P=0.021）。54例随访6～24个月,平均18.6月,VATS组和胸骨劈开组有效率分别为80.8%（21/26）和85.2%（23/27）,2组无统计学差异（Z=-0.126,P=0.899）。结论VATS下胸腺扩大切除在技术是安全可行的,具有创伤小,并发症少,疗效可靠等优点,具有良好临床应用前景。     

单纯眼肌型重症肌无力胸腺切除的适应证探讨

目的许多学者对单纯眼肌型重症肌无力（ＰＯＭＧ）不主张手术治疗，为此，探讨ＰＯＭＧ胸腺切除的适应证。方法回顾性分析了１９８０～１９９６年１０月期间所行胸腺切除治疗ＰＯＭＧ２３例。结果２３例ＰＯＭＧ占所有重症肌无力１１７例的１７．９％，术后１例病理证实为胸腺瘤；随访１年有效率为９５．７％，１～３年８８．２％，３～５年９０．９％，超过５年为８７．５％。单纯眼肌型重症肌无力多见于儿童，合并胸腺瘤甚为罕见。结论单纯眼肌型病例行胸腺切除应严格控制，特别是儿童，只有症状严重而长时间对抗胆碱酯酶药物反应不佳或疑有胸腺瘤时才施行手术。     

外科治疗重症肌无力的疗效分析

目的评价外科治疗重症肌无力的效果,探讨影响术后肌无力危象发生的因素以及预防治疗要点。方法回顾性分析1985年6月至2005年6月78例接受外科治疗重症肌无力患者的临床资料,对影响术后肌无力危象发生及程度的因素进行分析,比较不同围手术期处理方案的疗效差异。结果肌无力症状完全缓解21例,明显改善38例,改善11例,无变化8例。病程长短、血清抗乙酰胆碱受体抗体水平、Osserman分期和胸腺病理类型均是术后肌无力危象发生的独立相关危险因素。在围手术期处理方面,新方案疗效明显优于旧方案。结论外科治疗重症肌无力具有良好的效果和可行性。     

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.     

Videothoracoscopic thymectomy for nonthymomatous myasthenia gravis: Results of 90 patients

Background Videothoracoscopic thymectomy is an alternative surgical procedure for patients with nonthymomatous myasthenia gravis. The aim of this study is to present our experience and to analyze the factors contributing to the operative morbidity. Methods Ninety myasthenia gravis patients were operated through right-sided videothoracoscopy from June 2002 to September 2006. Prospective data recording was performed. Surgeon-related conversion to open surgery, length of the operation, chest tube duration time, duration of hospital stay, amount of drainage, pain score, and complications were evaluated. Factors contributing to longer operation time and longer postoperative stay were studied. Results The mean length of chest tube duration and postoperative hospital stay was 26.7 ± 18.6 hours and 2.2 days ± 1.1 days respectively. Visual analogue scale (VAS) values for pain evaluation were 2.0 ± 1.4. Surgeon-related open conversion occured in two patients (2.2%). Body mass index (BMI) was the sole significant factor for longer operation time. (23.04 ± 2.93 versus 25.61 ± 2.70 (p = 0.001). The amount of pyridostigmine was the only significant factor for longer hospital stay (213.3 ± 101.5 mg versus 270. 0 ± 122.6 mg (p = 0.044). Conclusions This study demonstrates the right-sided videothoracoscopy is a safe procedure. The only contributing factors were: BMI >25.61 for longer operation time, and pyridostigmine level >270 mg for duration of postoperative stay.     

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.     

Surgical outcome of thymectomy for myasthenia gravis

Background The medical treatment for myasthenia gravis has been reported to have remission rates as low as 15%. Thymectomy on the other hand has been reported to have clinical remission rates up to 80% and therefore has become the accepted mode of treatment. Methods 57 patients diagnosed with myasthenia gravis underwent thymectomy at the Christian Medical College and Hospital, Vellore from January 1994 to December 2003. The aim of this study was to determine the outcome for myasthenia gravis after thymectomy. Results Our results indicated that female sex had a better over all prognosis, Ossermann stage, I, IIA, & III was associated with higher incidence of complete clinical remission and the response to thymectomy decreased with increasing Ossermann stage. Post operative medication requirement reduced significantly as compared to the preoperative requirement. Conclusion We therefore conclude that trans-sternal thymectomy was found to be beneficial to all patients of mild to moderate myasthenia gravis, with 70.2% patients showing improvement postoperatively. We also advocate thymectomy for ocular myasthenia gravis.     

扩大胸腺切除治疗重症肌无力的结果分析

目的：总结1990年2月至1999年10月手术治疗重症肌无力的随访结果，并分析其预后因素。方法：54例病人均行扩大胸腺切除术，按改良Osserman标准分为I型15例，Ⅱa型14例，Ⅱb型16例，Ⅲ型9例，随访结果按完全缓解，改善，无效，差进行评价。结果：手术后完全缓解29．6％，改善48．1％，无效13．0％，差9．3％，手术疗效与术前病程长短及Osserman分型有关，与性别，年龄，胸腺病理类型无关，结论：扩大胸腺切除术是治疗重症肌无力的有效方法，对重症肌无力病人应及早手术治疗。     

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.     

横断胸骨扩大胸腺切除治疗全身型重症肌无力

目的探讨经横断胸骨入路行扩大胸腺切除治疗重症肌无力的临床疗效。了解该入路的特点及临床疗效有助于该领域胸外科医师在临床实践中进行更好的临床决策。 方法对1998至2008年在复旦大学附属华山医院胸心外科行横断胸骨治疗全身型重症肌无力的211例患者的临床资料进行回顾性研究,分析患者术中和术后基本情况。并对术后5年进行随访的患者根据是否合并胸腺瘤进行分组,采用χ²检验比较两组间的疗效。 结果经横断胸骨入路能满足对合并Masaoka-Koga Ⅰ期及Ⅱ期胸腺瘤患者及无瘤患者实施扩大胸腺切除的需要,手术并发症较低,便于围术期护理,恢复迅速。对173例患者进行术后5年随访,总缓解率达到79.8%(138/173),无肿瘤复发。合并胸腺瘤组的总缓解率为81.9%(59/72),未合并胸腺瘤组的总缓解率为78.2%(79/101),两组间比较差异无统计学意义(χ²＝0.362,P＝0.548)。 结论与其他常用手术入路相比,横断胸骨入路的特点值得该领域胸外科医师关注。     

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.     

胸腺切除对重症肌无力病人外周血T细胞的远期影响及意义

目的 探讨胸腺切除对重症肌无力（MG）病人外周血T细胞的远期影响及意义。方法 应用流式细胞术检测25例胸腺切除（手术组）、21例胸腺未切除（非手术组）MG病人和25名健康人（对照组）的外周血T细胞亚群CD4^＋T、CD8^＋T、CD4^＋／CD8^＋、CD4^＋CD25^＋T细胞的变化，应用ELISA法检测外周血IFN-γ、IL-4水平。结果 MG病人胸腺切除后完全缓解9例（36％），部分缓解13例（52％）。手术组与对照组比较CD4^＋CD25^＋T％显著降低（t=2．917，P=0．005）。手术组与非手术组比较CD4^＋CD25^＋T％、CD8^＋T％显著增高（t=7．935，P=0．000；t=2．619，P=0．012），CD4^＋CD8^＋显著降低（t=3．060，P=0．004）。手术组外周血IFN-γ水平显著低于非手术组（t=5．060，P：0．000），但显著高于对照组（t=3．709，P=0．001）。胸腺切除后部分缓解者CD4^＋CD25^＋T％显著低于完全缓解者（t=2．292，P=0．033），但高于无效者（t=5．225，P=0．000）。结论 MG病人外周血T细胞紊乱在胸腺切除后远期有一定程度的改善，但未完全恢复正常。CD4^＋CD25^＋调节性T细胞可能与MG发生、发展及预后有关。