胸腔镜胸腺扩大切除治疗重症肌无力及围术期处理

目的：总结胸腔镜胸腺扩大切除治疗重症肌无力及围术期处理。方法：2000年1月至2007年8月胸腺扩大切除治疗重症肌无力102例，分为常规正中开胸手术组（常规组）和胸腔镜手术组（胸腔镜组），两组各51例，比较分析两组患者手术时间、术中出血量、术后引流量、危象发生率、术后住院时间及术后1年总有效率。术前正确处理合并症及控制肌无力症状，术中完整切除胸腺并清扫前纵膈脂肪，术后联合使用激素、胆碱酯酶抑制剂及血浆交换疗法防治肌无力危象。结果：全组患者无手术及住院死亡，两组患者手术时间［分别为（128.14±34.82），（130.46±28.71） min］和术后1年总有效率（分别为85.8%，87.2%）比较，差异无统计学意义（P>0.05）。常规组术中失血量、术后引流量、危象发生率及术后住院天数［（93.77±21.64） mL，（174.65±39.18） mL，7.84%，（14.23±3.17） d］均高于胸腔镜组［（45.42±10.96） mL，（101.33±28.76） mL，1.96%，（8.37±1.18） d］，差异有统计学意义（P<0.05）。结论：胸腔镜胸腺扩大切除治疗重症肌无力安全有效、手术创伤小、失血少，结合细致的围术期处理，能减少术后危象的发生，血浆交换是治疗术后危象的有效方法。

Perioperative management and video-assisted thoracoscopic extended thymectomy for myasthenia gravis

Objective To investigate the perioperative management and video-assisted thoraco-scopic (VATS) extended thymectomy for myasthenia gravis ( MG ). Methods A total of 102 patients who received extended thymectomy for MG from June 2000 to August 2007 were divided into 2 groups by operative approach: 51 in the VATS group and 51 in the full median sternotomy group. The clinical features, including operation time, operation blood loss, post-operative drainage, inci-dence of crisis, hospital stay, and the 1-year total effective rate after the operation were compared. Complications were treated exactly and cholinesterase inhibitors were applied to control the symptom of MG before the operation. The whole thoracic gland and fat in the anterior mediastinum were removed. Steroid, cholinesterase inhibitors and plasmapheresis were used to prevent and cure masthemic crisis after the operation. Results No patients died in the operation and hospitalization. There was no sig-nificant difference in the operation time (128.14±34.82) min vs. (130.46±28.71) min] and the 1-year total effective rate after the operation (85.8% vs. 87.2% )in the 2 groups(P>0.05).The operation blood loss, postoperative drainage, incidence of crisis, and postoperative hospital stay in the median sternotomy group were higher or longer than those in the VATS group (93.77±21.64) mL vs. (45.42±10.96)mL,P<0.05; (174.65±21.64)mL vs. (101.33±28.76) mL,P <0.01;7.84% vs. 1.96%, P<0.05;(14.23±3.17)d vs. (8.37±1.18)d, P<0.05)]. Conclusion VATS extended thymectomy for myasthenia gravis is safe, less invasive and effective. Preoperative preparation and the perioperative managemant can decrease the incidence of crisis. The plasmapheresis is the key of curing masthemic crisis.