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。     

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.     

电视胸腔镜辅助胸腺切除术

目的探讨电视胸腔镜辅助胸腺切除的临床应用价值. 方法 2002年9月～2004年6月,18例胸腺疾病和重症肌无力(myasthenia gravis,MG)行胸腔镜辅助下胸腺切除手术,其中胸腺全切7例,11例MG行胸腺扩大切除. 结果 17例在胸腔镜辅助下完成, 1例中转小切口(7 cm)开胸手术.3例MG术后须短暂呼吸机辅助通气(<12 h),二次气管插管1例,余无严重并发症,无手术死亡.手术时间47～115 min,平均95 min;胸腔引流时间1.2～2.6 d,平均2 d;术后住院时间4～9 d,平均5.5 d.9例良性胸腺瘤或胸腺囊肿随访3～20个月,平均13个月,无复发.11例MG随访3～19个月,平均10个月,4例症状完全缓解,7例都分缓解. 结论胸腔镜辅助下胸腺切除手术,具有创伤小、恢复快等优点,胸腔镜下胸腺扩大切除治疗重症肌无力在技术上是可行的.     

经胸腔镜胸腺扩大切除术治疗重症肌无力42例报告

目的总结胸腔镜胸腺扩大切除治疗重症肌无力的经验。方法42例重症肌无力患者行胸腔镜或胸腔镜辅助小切口手术,切除范围包括胸腺组织及前上纵隔的脂肪软组织。结果手术均顺利完成,全组均无中转开胸。平均手术时间116.3（65-165）min,术中平均出血量为81.7（52-110）ml,术后平均住院时间为8.5（6-16）d。术后发生重症肌无力危象2例,予机械辅助通气及对症处理后好转。术后病理示26例为胸腺增生,16例为胸腺瘤。35例获随访,平均27.2（4-43）月,完全缓解7例,改善27例,1例无明显改善。结论胸腔镜胸腺扩大切除治疗重症肌无力,方法可行、可靠,具有创伤小、恢复快的优点。     

双悬吊拉钩辅助剑突下胸腔镜胸腺扩大切除术在胸腺占位合并重症肌无力中的临床应用

目的探讨双悬吊拉钩辅助剑突下胸腔镜胸腺扩大切除治疗胸腺占位合并重症肌无力(myasthenia gravis,MG)的疗效。方法采用回顾性研究,选择2018年1月至2018年12月在我科住院的胸腺占位合并重症肌无力患者41例,均行双悬吊拉钩辅助剑突下胸腔镜胸腺扩大切除术。结果41例患者均顺利完成手术,平均手术时间(83.43±24.32)min,均完整切除胸腺及周围脂肪组织,无使用双悬吊拉钩相关并发症,无其他手术相关并发症。结论应用双悬吊拉钩辅助行剑突下胸腔镜胸腺扩大切除术治疗胸腺占位合并重症肌无力患者,能扩大手术视野及操作空间,手术创伤小,手术过程顺利,安全可靠,值得推广运用。     

电视胸腔镜胸腺切除9例报告

目的　探讨电视胸腔镜下行胸腺切除的可行性及合并重症肌无力患者的远期疗效。　方法　 1996年 7月至 2 0 0 1年 4月 ,选择 9例胸腺相关疾病患者 ,应用电视辅助胸腔镜 (VATS)行胸腺切除 ,术后门诊或电话随访。　结果　胸腺囊肿 2例 ,胸腺瘤 1例 ,恶性胸腺瘤 1例 ,胸腺癌 1例 ,重症肌无力4例。重症肌无力据改良Osserman分型Ⅰ型 3例 ,Ⅱb型 1例 ,合并胸腺瘤 2例 ,胸腺增生 2例 ,手术总有效率 3/ 4。手术中转开胸 1例 ,手术后随访复发 1例 ,经胸骨正中切口行胸腺扩大切除术。　结论　VATS治疗部分胸腺疾病可行 ,VATS治疗重症肌无力疗效与常规手术相当。     

经颈胸腺及胸腺瘤切除术21例

目的探讨利用自制改良经颈胸腺手术牵开器开展经颈切口胸腺及胸腺瘤切除术的效果。方法回顾性分析同济大学附属上海市肺科医院2010年2月至2011年6月21例患者的临床资料,其中男10例,女u例;年龄14～69岁,术前临床诊断均为胸腺瘤。所有患者均在全身麻醉下经颈切口行胸腺及胸腺瘤切除术,术中利用自制改良胸腺手术牵开器向上牵开胸骨,扩大前纵隔手术操作空间,确保经颈部切口可施行胸腺及胸腺瘤的完整切除。结果21例患者手术均成功。手术时间l～2h,术中出血量30～50ml,平均术后引流量20ml,住院时间2～4d。21例患者均在术后第2d拔除颈部引流管。21例患者术后病理诊断为胸腺瘤12例（2例伴重症肌无力）,重症肌无力l例（不伴胸腺瘤）,胸腺增生4例,胸腺囊肿3例,胸腺脂肪瘤1例。患者术后无并发症,无切口疼痛主诉,咳嗽、胸闷及眼睑下垂等症状较术前明显缓解。结论利用自制改良胸腺手术牵开器行经颈胸腺及胸腺瘤切除术,术中切口湿露好,肿瘤、胸腺及周围脂肪组织切除彻底,术后并发症少,患者疼痛感轻,切口美观,手术效果良好。     

3种不同术式治疗重症肌无力的比较

目的探讨不同时期不同手术方式治疗重症肌无力的疗效。方法回顾分析我院1991～2006年有随访资料的269例重症肌无力采用不同术式胸腺切除术治疗的临床资料,根据不同时期开展不同术式分为3组：胸骨劈开组（1991年1月～2002年5月,n=161）胸腔镜组（2002年2月～2005年7月,n=67）、胸腔镜联合颈部切口组（2005年2月～2006年11月,n=41）。结果胸骨劈开组手术时间（97.5±17.5）min显著短于胸腔镜组（130.3±31.5）min（q=12.991,P〈0.05）和胸腔镜联合颈部切口组手术时间（152.2±33.9）min（q=18.005,P〈0.05）。胸骨劈开组术后发生肌无力危象41例显著高于胸腔镜组4例和胸腔镜联合颈部切口组4例（χ^2=14.394,P=0.000）,但后2组肌无力危象发生率无统计学差异（χ^2=0.532,P=0.466）。胸骨劈开组术后第1年完全稳定缓解率26.7%（43/161）,与胸腔镜组25.4%（17/67）和胸腔镜联合颈切口组31.7%（13/41）差异无统计学意义（χ^2=0.554,P=0.758）。胸骨劈开组术后第2、3年的完全稳定缓解分别为31.7%（51/161）、35.4%（57/161）,与胸腔镜组无统计学差异31.3%（21/67）、43.3%（29/67）（χ^2=0.002,P=0.961;χ^2=1.251,P=0.263）。结论胸腔镜下胸腺切除术能取得胸骨正中劈开手术同样理想的中远期治疗效果,胸腔镜联合颈部切口胸腺切除术是否能够提高远期疗效,有待进一步随访观察。     

胸腔镜隐蔽切口手术11例

目的总结11例胸腔镜隐蔽切口手术的治疗经验,探讨胸腔镜隐蔽切口手术的可行性和安全性。方法回顾性分析2011年9～11月四川大学华西医院11例行隐蔽切口胸腔镜手术患者的临床资料,其中男2例,女9例;年龄34.0(16～59)岁。术前临床诊断重症肌无力4例,胸腺瘤4例,胸腺囊肿2例,手汗症1例。胸腔镜胸腺扩大切除(extended thoracoscopic thymectomy,ETT)10例,胸腔镜交感神经干切断(endoscopic thoracic sympathectomy,ETS)1例。结果全组患者均顺利完成胸腔镜手术,无术中、术后并发症发生。手术时间70.5(30～105)min,术中出血量均<5 ml,术后胸腔引流管留置时间均<48 h,胸腔引流量55.5(30～80)ml,术后住院时间3.5(2～4)d,切口创伤小、隐蔽而美观。10例行ETT患者术后病理诊断胸腺增生4例,胸腺瘤4例,胸腺囊肿2例。结论隐蔽切口胸腔镜手术安全可行,可满足患者对切口隐蔽美观的要求。     

经剑突入路胸腔镜胸腺扩大切除治疗重症肌无力的临床分析CSCD

目的探讨结合肋缘下切口的剑突入路胸腔镜胸腺扩大切除治疗重症肌无力的手术安全性与临床疗效。方法回顾性分析2015年10月至2016年4月期间我院心胸外科收治的23例重症肌无力合并胸腺疾病患者的临床资料。其中男8例、女15例,年龄11~70(40.70±17.31)岁。所有患者采用经剑突入路胸腔镜胸腺扩大切除手术。结果所有手术均成功,无中转开胸或延长手术切口长度患者。患者切口长度平均(2.76±0.40)cm,手术时间平均(138.4±35.4)min,术中出血量平均(35.2±28.6)ml,术后呼吸机辅助时间平均(13.40±9.84)h,采用延迟拔管1例,术后并发症2例,其中少量胸腔积液1例、肺炎1例。术后疼痛视觉模拟(VAS)评分平均2.77分。结论剑突入路胸腔镜胸腺扩大切除技术是安全可行的手术方式,具有容易操作、清扫彻底、手术创伤小、恢复快、美容效果好等优点,值得深入研究及进一步推广。     

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.     

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。     

Video-assisted thoracoscopic extended thymectomy (VATET) with cervical approach for myasthenia gravis--initial experience

Complete thymectomy plays an important role in the myasthenia gravis (MG) pacient's treatment. Many different surgical techniques have been developed to achieve thymectomy. Of these, thoracoscopic technique is the most recent. There still are many controversies about the most suitable approach for thymectomy. The paper presents in detail the video-assisted thoracoscopic extended thymectomy--VATET-technique, and initial results with this procedure. Prospective data was obtain according to the Myasthenia Gravis Foundation of America (MGFA) recommendations. From Mai 2007 to December 2009, 15 patients with MG underwent the VATET procedure with cervical access. There was no conversion to sternotomic approach. Mean operating time for complete VATET was 215 min (150-280 min), with the cervical procedure requiring 44 min (25-60 min). There was no mortality or intraoperative complications. It was a single case with a thoracoscopic second look for hemothorax from intercostals bleeding. At this time, due to the reduced number of cases, we can't evaluate the therapeutic effectiveness of the VATET. We consider VATET as a valuable surgical option to treat myasthenic patients, with an optimal report between radicality and invasiveness.     

"Maximal" thymectomy for myasthenia gravis. Results

Thymectomy has been shown to be effective in the treatment of myasthenia gravis. The logical goal of operation has been complete removal of the thymus, but there has been controversy about the surgical technique and its relation to results. Surgical-anatomic studies have shown gross and microscopic thymus widely distributed in the neck and mediastinum. We believe that an en bloc transcervical-transsternal "maximal" thymectomy is required to remove all thymic tissue predictably. Ninety-five patients with generalized myasthenia gravis underwent "maximal" thymectomy consecutively between 1977 and 1985 and were evaluated 6 months to 89 months after operation. In Group A (N = 72), myasthenia gravis without thymoma, the uncorrected data revealed that 96% (69) had benefited from operation: 79% (57) had no symptoms; 46% (33) were in remission; 33% (24) were symptom free when receiving minimal doses of pyridostigmine; and none were worse. Life table analysis yielded a remission rate of 81% at 89 months. In group B (N = 8), myasthenia gravis without thymoma for which patients underwent reexploration for incapacitating weakness after earlier transcervical or transsternal operations, residual thymus was found in all. One patient was in remission, two were symptom free when receiving medication, one was unchanged, and none were worse. In group C (N 15), myasthenia gravis and thymoma, two patients were in remission and nine were symptom free when receiving medication. Two patients in this group died 2 and 4 years postoperatively in crisis. Response to thymectomy in group A was greater in patients with mild myasthenia gravis and may have been better in patients who had symptoms for less than 60 months preoperatively, but the response did not depend on age, sex, presence or absence of thymic hyperplasia or involution, or titers of acetylcholine receptor antibodies. The response to thymectomy in group B was striking but slower than in group A, perhaps because symptoms were more severe and of longer duration. The response in group C was also less good than in group A and proportionately fewer benefited. These results support the recommendation for thymectomy in the treatment of patients with generalized myasthenia gravis and indicate the desirability of a maximal procedure. For persistent or recurrent severe symptoms after previous transcervical or submaximal transsternal resections, reoperation by this technique is also recommended.     

Effects of thymectomy in myasthenia gravis.

Factors influencing onset of remission in myasthenia gravis were evaluated in 2062 patients, of whom 962 had had thymectomy. Multivariate analysis showed that appearance of early remissions among all patients was significantly and independently influenced by thymectomy, by milder disease, and by absence of coexisting thymomas. Patients with mild generalized symptoms treated with thymectomy reached remission more frequently, even when compared with those with ocular myasthenia treated without surgery. Short duration of disease before thymectomy in mild cases was another factor associated with earlier remissions. Mortality for all patients was significantly and independently influenced by severity of symptoms, age, associated thymomas, and failure to remove the thymus. Patients without thymectomy and with thymomas had, in addition, earlier onset of extrathymic neoplasms. Morbidity after the transcervical approach was minimal. This study demonstrates that early thymectomy by the transcervical approach, when technically feasible, has significant clinical advantages over the transthoracic approach and should be advocated for all patients with myasthenia gravis, including those with ocular disease.     

Notice from the American Board of Thoracic Surgery

Sixty-five patients with thymomatous myasthenia gravis were investigated. Thymomas were present in 44% of the male patients and 19% of the female patients with myasthenia gravis. The incidence of thymomatous disease in male patients was higher than in female patients in all age groups. Eighty percent of men more than 50 years old and women more than 60 years old had myasthenia gravis with thymoma. Germinal center formation in the thymus of patients with thymomatous myasthenia gravis was positive in 91% and was high grade.The prognosis for patients undergoing extended thymectomy of thymomatous myasthenia gravis was significantly better than in those having transsternal simple thymectomy, but it was worse than the prognosis for patients with nonthymomatous myasthenia gravis. No increase in the rate of remission or palliation was seen one year after thymectomy. It is concluded that early thymectomy is effective in control of myasthenia gravis in thymomatous myasthenia gravis.