Approach For Thymectomy Research Articles

Initial Evaluation of the Safety and Performance of Single-Port Robotic-Assisted Thymectomy Through a Subxiphoid Incision.

Sternotomy is the traditional approach for thymectomy. However, over the last 2 decades, minimally invasive surgical approaches (multiport thoracoscopic and robotic-assisted surgery) have proven feasible, offering similar survival, lower morbidity, and shorter length of stay. Single-port (SP) subxiphoid thymectomy potentially offers less pain and allows bilateral visualization of the mediastinum. A prospective, multicenter, single-arm clinical study was conducted to evaluate the performance and safety of the da Vinci SP surgical system (Intuitive) for thymectomy through a subxiphoid incision. Primary performance end points included ability to achieve R0 resection and completion of the procedure without conversion. The primary safety end point was all adverse events up to 30 days postoperatively. The study enrolled 13 individuals (benign, n= 6; malignant, n= 7) at 6 centers in the United States. All SP thymectomy procedures were completed through a small (mean, 3.8 cm) subxiphoid incision without conversion to other minimally invasive or open approaches. For malignant cases, the rate of complete resection was 100%. No study participants experienced any intraoperative or serious adverse events. No unanticipated adverse device effects were reported. Thymectomy using the da Vinci SP surgical system through a subxiphoid approach is feasible, and there are no early indications of safety or procedural concerns. Larger clinical studies are warranted to further evaluate the relative benefits and limitations of the SP system compared with multiport robotic thymectomy.

Physiological and pathological roles of the thymus and value of thymectomy in myasthenia gravis: a narrative review.

Myasthenia gravis (MG) is a well-elucidated autoimmune disorder affecting the neuromuscular junction. Given the relationship between MG and thymic pathologies, with T cell and antibody-mediated pathogenesis, surgical (i.e., thymectomy) and non-surgical approaches remain a mainstay of management of the disease. This review seeks to outline the involvement of the thymus in the development of lymphocytes leading to MG. Different databases were searched exploring the role of thymectomy in treatment and outcomes in various MG patient subpopulations, including in ocular versus generalized disease, different age groups, and antibody status. Overall, the findings of multiple studies and reviews provide evidence to support the efficacy and long-term success of thymectomy in the management of MG; outcomes have included remission status, symptom severity, and need for adjunctive therapy. However, the heterogeneity in the MG population suggests that there are multiple factors that may confound the results of thymectomy and still need further examination. Separately, other autoimmune diseases develop following thymectomy, and further research is required to elucidate this susceptibility. Finally, our review will discuss the different surgical approaches for thymectomy, including their advantages, limitations, and perioperative complications. Overall, in light of the known pathogenesis and association of the thymus with MG, thymectomy remains an extremely effective approach for long-term management and improved clinical outcomes.

Are the minimally invasive techniques the new gold standard in thymus surgery for myasthenia gravis? Experience of a reference single-site in VATS thymectomy.

The thymus is the primary lymphoid organ responsible for the maturation and proliferation of T lymphocytes. During the first years of our lives, the activation and inactivation of T lymphocytes occur within the thymus, facilitating the correct maturation of central immunity. Alterations in the positive and negative selection of T lymphocytes have been studied as the possible origins of autoimmune diseases, with Myasthenia Gravis (MG) being the most representative example. Structural alterations in the thymus appear to be involved in the initial autoimmune response observed in MG, leading to the consideration of thymectomy as part of the treatment for the disease. However, the role of thymectomy in MG has been a subject of controversy for many years. Several publications raised doubts about the lack of evidence justifying thymectomy's role in MG until 2016 when a randomized study comparing thymectomy via sternotomy plus prednisone versus prednisone alone was published in the New England Journal of Medicine (NEJM). The results clearly favored the group of patients who underwent surgery, showing improvements in symptoms, reduced corticosteroid requirements, and fewer recurrences over 3 years of follow-up. In recent years, the emergence of less invasive surgical techniques has made video-assisted or robotic-assisted thoracoscopic (VATS/RATS) thymectomy more common, replacing the traditional sternotomy approach. Despite the increasing use of VATS, it has not been validated as a technique with lower morbidity compared to sternotomy in the treatment of MG. The results of the 2016 trial highlighted the benefits of thymectomy, but all the patients underwent surgery via sternotomy. Our hypothesis is that VATS thymectomy is a technique with lower morbidity, reduced postoperative pain, and shorter postoperative hospital stays than sternotomy. Additionally, VATS offers better clinical improvement in patients with MG. The primary objective of this study is to validate the VATS technique as the preferred approach for thymectomy. Furthermore, we aim to analyze the impact of VATS thymectomy on symptoms and corticosteroid dosage in patients with MG, identifying factors that may predict a better response to surgery.

Surgical Treatment of Stage I and II Thymus Epithelial Tumors

Thymic epithelial tumors are the most common tumors of the anterior mediastinum, with an incidence of 0.18 per 100,000 population. Here, we present a review of the national and foreign literature on the surgical treatment of stage I and II thymic epithelial tumors. The Medline (PubMed) and Russian Science Citation Index (eLibrary) databases were used as search engines. The focus of the review is the problem of choosing the optimal minimally invasive surgical approach for thymectomy, and the need for lymph node dissection for thymic epithelial tumors. A number of issues remain currently unresolved in thymic epithelial tumors surgery, namely the justification of the preoperative histological verification of the tumor process, the choice of the optimal surgical access to the anterior mediastinum, the need for and prognostic effect of lymph node dissection, and the determination of the required volume of the planned operation.

Operative approaches for thymectomy: clinical characteristics and classification variant

Currently, surgical intervention is the gold standard treatment of thymus tumors. Radical removal of the thymus gland in a single block, including the tumor, adjacent lymph nodes, and surrounding tissue of the anterior mediastinum, is a prerequisite for achieving satisfactory immediate and long-term results. The need for maximum thymectomy together with anterior mediastinal fiber is attributed to the fact that, along with other long-term survival factors (stage of tumor progression and histological subtype of the tumor), 4550% of deaths in the long-term follow-up period are due to the recurrence of thymoma and 1520% are caused by a progressive course of myasthenia gravis. The results of domestic and foreign studies on the implementation of thymectomy from various surgical approaches are analyzed. These include traditional thoracotomy and sternotomy, video-assisted and robot-assisted interventions, and combined operative accesses. The data presented are based on systematic reviews, retrospective cohort studies, clinical cases, and experimental studies using text databases PubMed, Google Scholar, and eLibrary.ru. The clinical characteristics of each operative access are given with an emphasis on technical features and advantages and disadvantages of thymectomy. The immediate results of surgical treatment of patients with thymus gland neoplasms are presented. Additional methods of visualization and physical preparation of anterior mediastinal tissues are described separately, which help increase the safety and effectiveness of surgical intervention. Currently, low-traumatic video-assisted surgical interventions are widely used in thoracic surgery, gradually replacing traditional open operations. Nevertheless, the variety of proposed options for surgical access, lack of clear indications and contraindications to various interventions on the thymus gland, and discrepancies in the use of various terms determine the need to develop a modern classification of surgical accesses for performing thymectomy. Taking into account world literature data and our own experience, a classification of operative accesses for performing thymectomy is proposed.

An Overview of Thymectomy Approaches among Myasthenia Graves Patients: Review Article

An Overview of Thymectomy Approaches among Myasthenia Graves Patients: Review Article

Subxiphoid single-port thymectomy without CO2 insufflation: Experience of a single center.

The subxiphoid single-port approach for thymectomy has advantages compared with conventional lateral transthoracic approaches. Most of centers use CO2 insufflation to secure an appropriate surgical field during subxiphoid thymectomy, which causes fighting between surgical instruments and restrictions on the types of surgical instruments. The objective of this study is to introduce an effective method to establish the subxiphoid approach without CO2 insufflation using a retractor and steel wire. All consecutive 59 patients undergoing subxiphoid single-port thymectomy between August 2014 and August 2021 were reviewed retrospectively. We analyzed data of 59 patients (31 male and 28 female) with a median age of 59 years (range 50-68). Two (3.4%) patients presented postoperative complications. The conversion to a different approach was required in 4 (6.8%) cases. The median follow-up time was 23 months (range 10-41) and loco-regional recurrence was observed in one patient (1.7%). There were no intraoperative deaths and the postoperative mortality. No complications related to sternal wiring occurred. Subxiphoid single-port thymectomy without CO2 using a retractor and steel wire insufflation is a technically feasible method.

A Comparative Study of Video-Assisted Thoracoscopic Surgery Versus Median Sternotomy Thymectomy in Myasthenia Gravis

Background: Thymectomy is a standard treatment for myasthenia gravis (MG) patients. Although there are different approaches for thymectomy available, the standard approach is still known as a median sternotomy. Currently, the video-assisted thoracoscopic (VATS) approach is increasing in popularity. It has shown benefits in less blood loss, less postoperative pain, and improvement of recovery after surgery. However, there are still controversies in the outcomes of these two approaches. Objective: To compare perioperative and neurological outcomes of thymectomy between the median sternotomy approach and the VATS approach. Materials and Methods: One hundred twenty-three patients underwent thymectomy between January 1, 2012 and December 30, 2020 and were enrolled in the present retrospective study. They were classified into two groups depending on the approach of the surgery. The perioperative and neurological outcomes were analyzed and compared between the two groups. The analyses were performed using students’ t-test, Mann-Whitney test, chi-square, or Fisher’s exact test. Results: There were 72 patients in the median sternotomy group and 51 patients in the VATS group, and no death in both groups. There were also no significant differences between the two groups regarding surgical time, postoperative pain, postoperative complications, and neurological outcomes. Intraoperative blood loss, intercostal drainage volume and duration, and length of hospital stay were significantly less in the VATS group. Complete remission was significantly higher in VATS group. The median follows up time was significantly longer in the median sternotomy group. Conclusion: The VATS approach for thymectomy had shown good outcomes, which were not inferior to the median sternotomy approach. Keywords: VATS Thymectomy; MG; Thymoma; Thymectomy; Minimally invasive thymectomy; Myasthenia gravis; Left VATS thymectomy; Subxiphoid VATS thymectomy; Anterior mediastinal tumor; Anterior mediastinal mass

Thymectomy via parasternal approach in patients with miasthenia

A new approach for thymectomy in case of mediastinal shifting is proposed. Parasternal access provides optimal conditions for performing an adequate thymectomy, does not require single lung ventilation and could be used after previously performed pneumonectomy.

Subxiphoid single‐port thymectomy: six‐year experience of a single center

The subxiphoid single-port approach for thymectomy has several advantages compared with conventional lateral transthoracic approaches. However, perioperative outcomes of subxiphoid single-port thymectomy are still lacking. The objective of this study is to present our 6-year experience of subxiphoid single-port thymectomy, including our learning curve. All consecutive 49 patients undergoing subxiphoid single-port thymectomy between August 2014 and September 2020 were reviewed retrospectively. We analyzed data of 49 patients (27 males and 22 females) with a median age of 58 years (range 49-68). Two patients presented postoperative complications. The conversion to a different approach was required in four cases. The median follow-up time was 17 months (range 3-35) and locoregional recurrence was observed in one patient. There were no intraoperative deaths and postoperative mortality. The operation time cumulative summation learning curve analysis revealed that the curves descended from the 24th case. The subxiphoid single-port approach for thymectomy is a safe and feasible modality with few complications.

Video-Assisted Thoracic Surgery Thymectomy: Transpleural Approach.

There are several types of minimally invasive approaches for thymectomy, of which the transpleural approach by video-assisted thoracoscopic surgery is particularly useful. In this approach, thymectomy is performed from either side of the thoracic cage. Thoracic surgeons should be familiar with the principles of the procedure, the anatomy of the region, and surgical strategies for successful thymectomy. The details of transpleural thymectomy are discussed herein.

Impact of the Surgical Approach to Thymectomy Upon Complete Stable Remission Rates in Myasthenia Gravis: A Meta-analysis.

To determine whether the available operative techniques for thymectomy in myasthenia gravis (MG) confer variable chances for achieving complete stable remission (CSR), we performed a meta-analysis of comparative studies of surgical approaches to thymectomy. Meta-analysis was done of all studies providing comparative data on thymectomy approaches, with CSR reported and minimum 3-year mean follow-up. Twelve cohort studies and 1 randomized clinical trial, containing 1,598 patients, met entry criteria. At 3 years, CSR from MG was similar after video-assisted thoracoscopic (VATS) extended vs both basic (relative risk [RR] 1.00, p = 1.00, 95% confidence interval [CI] 0.39-2.58) and extended (RR 0.96, p = 0.74, 95% CI 0.72-1.27) transsternal approaches. CSR at 3 years was also similar after extended transsternal vs combined transcervical-subxiphoid (RR 1.08, p = 0.62, 95% CI 0.8-1.44) approaches. VATS extended approaches remained statistically equivalent to extended transsternal approaches through 9 years of follow-up (RR 1.51, p = 0.05, 95% CI 0.99-2.30). The only significant difference in CSR rate between a traditional open and a minimally invasive approach was seen at 10 years when the now-abandoned basic (non-sternum-lifting) transcervical approach was compared to the extended transsternal approach (RR 0.4, p = 0.01, 95% CI 0.2-0.8). A significant difference in the rate of CSR among various surgical approaches for thymectomy in MG was identified only at long-term follow-up and only between what might be considered the most aggressive approach (extended transsternal thymectomy) and the least aggressive approach (basic transcervical thymectomy). Extended minimally invasive approaches appear to have CSR rates equivalent to those of extended transsternal approaches and are therefore appropriate in the hands of experienced surgeons.

National Use and Short-term Outcomes of Video and Robot-Assisted Thoracoscopic Thymectomies

BackgroundTranssternal open thymectomy has long been the most widely used approach for thymectomy, but recent decades have seen the introduction of minimally invasive surgery (MIS), such as video-assisted thoracoscopic surgery (VATS) and robot-assisted thoracoscopic surgery (RATS) thymectomy. This retrospective cohort study provides a national comparison of trends, outcomes, and resource utilization of open, VATS, and RATS thymectomy. MethodsAdmissions for thymectomies from 2008 to 2014 were identified in the National Inpatient Sample. Patients were identified as undergoing open, VATS, or RATS thymectomy. Propensity score-matched analyses were used to compare overall complication rates, length of stay (LOS), and cost of VATS and RATS thymectomies. ResultsAn estimated 23,087 patients underwent thymectomy during the study period: open in 16,025 (69%) and MIS in 7217 (31%). Of the MIS cohort, 4119 (18%) underwent VATS and 3097 (13%) underwent RATS. Performance of RATS and VATS thymectomy increased while that of open thymectomy declined. Baseline characteristics between VATS and RATS were similar, except more women underwent VATS thymectomy. No differences in LOS or overall complication rates were appreciable in this study. VATS was associated with the lowest cost of the 3 approaches. ConclusionsOur findings demonstrate the increasing adoption of MIS and declining use of the open surgical approach for thymectomy. There are no differences in overall complication rates between RATS and VATS thymectomy, but RATS is associated with greater cost and lower cardiac complication rates.

Evaluation of extended thymectomy approaches based on residual fat tissue.

This study analysed the patterns of extraction ranges, characteristics, advantages and disadvantages of median sternotomy (MS) and subxiphoid (SX) approaches for extended thymectomy. This study included patients with anterior mediastinum tumour and myasthenia gravis who underwent extended thymectomy at our institution between 2015 and 2018. There were 5 MS and 6 SX extended thymectomy surgeries with the VINCENT software. On preoperative computed tomography, the thymus area and fat tissue surrounding the thymus, which were planned for extraction, were traced using VINCENT (Ver. 4.0). We then constructed three-dimensional images and calculated the volumes. Evaluation of the extended thymectomy approach based on the residual fat tissue was required to determine the area of extended thymectomy. No significant differences in operation time (min) [SX: 197.3 ± 34.0, MS: 206.6 ± 91.4, drainage duration (days), SX: 2.2 ± 1.0, MS: 2.2 ± 0.4, hospital stay (days), SX: 11.8 ± 1.2, MS: 13.4 ± 2.1, residual rate (%), SX: 29.9 ± 17.5, MS: 58.7 ± 18.0 (P = 0.0519)] were observed between the 2 groups. Bleeding was significantly lower for SX than for MS. The residual rate was lower for SX than for MS. Considering the amount of the residual fat tissue, the SX approach allows an adequate dissection area for extended thymectomy compared with the MS approach.

Survival Outcomes in Patients with Thymoma after Thymectomy in an Indian Scenario.

Thymomas are relatively slow growing with late presentation. Because of rarity and underreporting in India, there is an unmet need for evaluating the patient characteristics and assessing the factors affecting survival for standardizing the ideal modality of treatment in Indian population. A retrospective analysis of 96 patients with thymoma was done between 1998 and 2018. Patient characteristics, histopathological characteristics, operative outcomes, local recurrences, and survival outcomes were recorded. Survival analysis was done using Kaplan-Meier method, and statistical data were analyzed using SPSS version 25 (IBM). The incidence of thymoma was relatively high in 6th decade with no sex predilection. Common presenting symptoms were cough and dyspnea. Myasthenia gravis was noted in 30.2%, which resolved after thymectomy in 65.5% of patients. Most patients presented with Masaoka stages I and II, and predominant WHO histological types were B1 and AB. Complete resection was done in 69.8% cases, and local recurrence was noted in 15.6%. Median sternotomy was the most frequently used approach for thymectomy. The 5-year overall survival was 76%, with an excellent 5-year survival of 95% and 86% in stages I and II patients. Masaoka stage, WHO histologic type, completeness of surgery, and local recurrence did affect the survival significantly. Masaoka stages III and IV, histological type B3, incomplete resection during surgery, and presence of local recurrence did independently predict a worse overall survival.

Subxiphoid and subcostal thoracoscopic surgical approach for thymectomy.

The continuous evolvement of minimally invasive thymectomy over the last decades has potential advantages over trans-sternal thymectomy with similar oncologic outcomes of thymoma and complete remission for myasthenia gravis patients. A variety of different minimally invasive approaches have been described previously. The aim of this article is to present our subxiphoid and subcostal approaches in thymectomy for patients with myasthenia gravis and thymomas and to investigate the early surgical outcomes of these patients. A retrospective analysis was performed of 95 patients who underwent thymectomy via a subxiphoid and subcostal approach for MG and/or thymoma at our department during the period of 2015 to 2017. The clinical characteristics and early surgical outcomes of these patients were reviewed and analyzed. Complete thymectomy and extended thymectomy was accomplished through the subxiphoid and subcostal approach in 93 of the 95 (97.9%) patients. Two patients (3.2%) required conversion to sternotomy for the invasion of a thymoma. The mean operative time was 109min (range 70-170min), with the mean estimated blood loss of 47ml (range 20-350ml). Postoperative complications included two cases of myasthenic crisis: one case of pleural effusion and one case of wound infection. In a mean follow-up of 31months no patients showed recurrence of the tumor. In 41 MG patients followed up for 31months, the improvement rate was 87.8% and the rate of complete remission was 29.3%. Subxiphoid and subcostal thoracoscopic thymectomy may be a safe and feasible approach for treating MG and anterior mediastinal tumors.

Robotic-assisted thoracoscopy thymectomy for juvenile myasthenia gravis

Abstract Introduction Juvenile myasthenia gravis (JMG) is a rare debilitating and potentially fatal autoimmune disease, with unclearify pathogenesis. Surgical immunomodulation with thymectomy has been repeatedly demonstrated to be a safe and effective treatment for JMG in both adult and pediatric patients. In the last few years, minimally invasive approach and above all robotic assisted thoracoscopy, replaced sternotomy which is widely used in adult patients. We report our experience in a case of robot-assisted thoracoscopic thymectomy approach in a 12 years old boy for juvenile myasthenia gravis (JMG). Case report Procedure was performed with the Da Vinci surgical robot (Xi) using left-sided approach. Left lung was kept out from mechanic ventilation. A 8 mm port for the 3-D camera was introduced on the V intercostal space on the anterior axillary line. Others two 8mm thoracic ports were placed under vision after the induction of a low-pressure pneumothorax, respectively on the midaxillary line on the III intercostal space and on the parasternal space on the V intercostal space. Bulk resection of gland was made using Maryland grasper and Harmonic scalpel, starting at level of the left pericardiophrenic angle and continuing cranially. Thymus was unstick from the posterior face of the sternum until the right pleura releasing lower thymic horns. After that, controlateral right-side thymectomy was continued into the neck to include the upper horns and finally it was removed with an endocatch bag. Histopathological examination showed a benign thymic hyperplasia. There were no perioperative and postoperative complications. The discharge was on IV post-operative day. After thymectomy, patient reported an improvement in symptoms and stopped medical therapy with pyridostigmine. Conclusions VATS and Robotic thoracoscopic thymectomy have increasingly taken hold in recent years. The surgical treatment offered to patient an improvement in clinical status. Surgery by robotic assistance has demonstrable advantages, including three-dimensional visualization and articulating instruments. Left lateral approach provided excellent visualization of the thymic veins, anonymous vases and phrenic nerves. Three-dimensional visualization as well as articulating arms greatly facilitated the dissection compared with standard thoracoscopic technique. In Literature very few series of robotic approach for surgical treatment of JMG in children are reported, for these reasons further studies are needed.

Comparative effectiveness and cost-efficiency of surgical approaches for thymectomy

BackgroundWe compared the clinical outcomes and cost-efficiency of surgical approaches (sternotomy-open, video assisted thoracoscopic surgery, and robotic assisted thoracic surgery) for thymectomy. MethodsThis is a retrospective review of 220 consecutive patients who underwent thymectomy between January 1, 2007, and January 31, 2017. Surgical approach was determined by the surgeon, but we only included cases that could be resected using any of the 3 approaches. ResultsOpen approach was used in 69 patients, whereas minimally invasive technique was used in 151 (97, video assisted thoracoscopic surgery; 54, robotic assisted thoracic surgery). Open surgery was associated with greater total hospital cost ($22,847 ± $20,061 vs $14,504 ± $10,845, P < .001). Open group also revealed longer duration of intensive care unit (1.2 ± 2.8 vs 0.2 ± 1.3 days, P < .001) and hospital stay (4.3 ± 4.0 vs 2.0 ± 2.6 days, P < .001). There were no differences in major adverse clinical outcomes. Long-term recurrence-free survival after resection of thymoma was similar between the groups. ConclusionMinimally invasive techniques were equally efficacious compared with the open approach in the resection of the thymus. Additionally, their use was associated with decreased hospital duration of stay and reduced cost. Hence the use of minimally invasive approaches should be encouraged in the resection of thymus.

BENEFITS OF THYMECTOMY IN MYASTHENIA GRAVIS

In recent years, thymectomy has become a widespread procedure in the treatment of myasthenia gravis (MG). Likelihood of remission was highest in preoperative mild disease classification (Osserman classification 1, 2A). In absence of thymoma or hyperplasia,there was no relationship between age and gender in remission with thymectomy. In MG treatment,randomized trials that compare conservative treatment with thymectomy have started,recently.As with non-randomized trials, remission with thymectomy in MG treatment was better than conservative treatment with only medication.There are four major methods for the surgical approach:transcervical,minimally invasive,transsternal,and combined transcervical transsternal thymectomy. Transsternal approach with thymectomy is the accepted standard surgical approach for many years. In recent years, the incidence of thymectomy has been increasing with minimally invasive techniques using thoracoscopic and robotic methods.There are not any randomized, controlled studies which are comparing surgical techniques.However,when comparing non-randomized trials,it is seen that minimally invasive thymectomy approaches give similar results to more aggressive approaches.

Thoracoscopic Thymectomy for Large Thymic Cyst: Myasthenia Gravis With Thymoma Concealed by Thymic Cyst

We herein report a case of myasthenia gravis (MG) in which thoracoscopic thymectomy was performed for a large thymic cystic lesion using a subxiphoid approach. We have previously suggested the usefulness of the subxiphoid approach in thymectomy. The indications of thoracoscopic thymectomy were recently expanded to include large thymic cystic lesions without intraoperative rupture of the lesions. The pathologic diagnosis of the lesion in the present case was multilocular thymic cyst with type A thymoma and micronodular thymoma. The postoperative complications were minimal without MG crisis. Thoracoscopic thymectomy using a subxiphoid approach seems to be an ideal procedure, even for large thymic cystic lesions. In addition, early-onset MG with a large thymic cystic lesion may suggest the presence of a small thymoma even if the lesion is not detected on a preoperative radiologic examination.