Video-assisted Thoracoscopic Extended Thymectomy Research Articles

Comparison of two-lung and one-lung ventilation in bilateral video-assisted thoracoscopic extended thymectomy in myasthenia gravis: a retrospective study.

BackgroundMyasthenia gravis (MG) is an autoimmune disease, and early thymectomy is recommended. Since the introduction of video-assisted thoracoscopic surgery, the safety and effectiveness of carbon dioxide insufflation in the thoracic cavity (capnothorax) has been controversial. This study aimed to compare the safety and effectiveness of ventilation methods in bilateral video-assisted thoracoscopic extended thymectomy (BVET) with capnothorax.MethodsWe retrospectively investigated the medical records of patients with MG who underwent BVET between August 2016 and January 2018. Patients were divided into two groups: group D (n = 26) for one-lung ventilation and group S (n = 28) for two-lung ventilation. We set nine anesthesia time points (T0–T8) and collected respiratory and hemodynamic variables, including arterial O2 index (PaO2/FiO2).ResultsSpO2 at T1–T3 and T8 was significantly lower in group D than in group S. The FiO2 in group S was lower than that in group D at all time points. The number of PaO2/FiO2 ≤ 300 and PaO2/FiO2 ≤ 200 events was significantly higher in group D than in group S. Hemodynamic variables were not significantly different between the two groups at any time point. The duration of surgery and anesthesia was shorter in group S than in group D.ConclusionsThis retrospective study suggests that anesthesia using two-lung ventilation during BVET with capnothorax is a safe and effective method to improve lung oxygenation and reduce anesthesia time.

Preferred Procedure and Clinical Outcomes of Three-Port Video-Assisted Thoracoscopic Extended Thymectomy in Patinets With Myasthenia Gravis

Purpose: Several reviews have demonstrated that video-assisted thoracoscopic (VAT) extended thymectomy is effective in the treatment of myasthenia gravis (MG); however, the preferred procedure is controversial. We performed three-port VATS extended thymectomy with a bilateral (left- and right-sided) approach. In case the lung was not resected, we did not insert chest tube. The aims of this study are to report the details of our current surgical procedure and clinical outcomes with three-port VAT extended thymectomy.

The entire technique of bilateral uniportal video-assisted sequential thoracoscopic extended thymectomy in a patient with myasthenia gravis associated to a little thymoma

The entire technique of bilateral uniportal video-assisted sequential thoracoscopic extended thymectomy in a patient with myasthenia gravis associated to a little thymoma

The entire technique of bilateral uniportal video-assisted sequential thoracoscopic extended thymectomy in a patient with myasthenia gravis and thymic hypertrophy

The entire technique of bilateral uniportal video-assisted sequential thoracoscopic extended thymectomy in a patient with myasthenia gravis and thymic hypertrophy

The entire technique of bilateral uniportal video-assisted sequential thoracoscopic extended thymectomy in a patient with thymoma without myasthenia gravis, with Lambert-Eaton myasthenic syndrome

The entire technique of bilateral uniportal video-assisted sequential thoracoscopic extended thymectomy in a patient with thymoma without myasthenia gravis, with Lambert-Eaton myasthenic syndrome

Anaesthesia for thymectomy in adult and juvenile myasthenic patients.

Myasthenia gravis, a chronic disease of the neuromuscular junction, is associated with an interaction with neuromuscular blocking agents (NMBAs). As thymectomy is often the method of choice for its treatment, anaesthetic management requires meticulous preoperative evaluation, careful monitoring, and adequate dose titration. The frequency of video-assisted thoracoscopic extended thymectomy (VATET) is also increasing, making the use of NMBA obligatory. The number of cases of the juvenile form has also increased over years; airway management in juvenile one-lung ventilation is another challenge. Sugammadex appears to be a safe choice to avoid prolonged action of NMBA also in patients with myasthenia gravis, although this information has to be confirmed in further series. The number of VATETs is increasing so that the experience with sugammadex will also increase in time. In non-VATET operations, use of NMBA should and can be avoided as much as possible. New scoring systems are defined to predict a postoperative myasthenic crisis. For VATET in juvenile cases, blockers can be a good option for the airway management. Anaesthetic management of thymectomy in myasthenia gravis requires experience concerning different approaches. Sugammadex should be considered as a possible further step toward postoperative safety.

Nonintubated video-assisted thoracoscopic surgery using regional anesthesia and targeted sedation in a myasthenia gravis patient

Myasthenia gravis (MG) is a disease affecting the acetylcholine receptor in the neuromuscular junction. Symptoms of MG are muscle weakness and fatigue. Video-assisted thoracoscopic extended thymectomy (VATS-ET) is well established in the treatment of MG if medical treatment is failed. In the recent decade, VATS under nonintubated anesthesia has been intensively researched and reported, which has been advocated to be a preferred alternative to the conventional intubated anesthesia for pulmonary nodules. However, cases with MG receiving nonintubated VATS-ET have rarely been reported. Here, we described a successful anesthesia of a 44-year-old woman with MG undergoing nonintubated VATS-ET.

In Process Citation

Different methods of open or minimally invasive thymectomies have been recommended for the treatment of myasthenia gravis (MG). We compared the results of standard transsternal thymectomy (TS) and two different types of minimally invasive thymectomies [video-assisted thoracoscopic extended thymectomy (VATET) and classic Video-Assisted Thoracoscopic Surgery (cVATS)] performed at the same department. During three different time periods 71 patients (60 female and 11 male; mean age 31 [range, 14-84] years) underwent thymectomy for MG. Twenty-three underwent standard transsternal thymectomy (January 1995 - September 2004), 22 VATET (September 2004 - August 2009), and 26 cVATS (September 2009 - December 2011) thymectomy for the right side. Operative data, MG- and surgery-related postoperative morbidity and early improvement of MG during the initial 1-year follow-up period were compared among the three methods. There were no perioperative deaths during the study period. Operative time was 112, 211, and 116 minutes (p = 0.001) in the TS, VATET and cVATS, respectively, and the length of hospital stay was 8.9, 5.6, and 4.0 (p = 0.001) days. Postoperative MG-related neurological morbidity affected 21.7%, 18.2%, and 7.7% (p = 0.365) of the patients and the surgery-related morbidity rate was 4.3%, 13.7%, and 0% (p = 0.118) in the TS, VATET and cVATS groups, respectively. Symptom improvement rates were 91.3%, 94.7%, and 87.5% (p = 0.712), and complete remission rates were 13%, 10.5%, and 11.5% (p = 0.917) after TS, VATET and cVATS thymectomies, respectively. In terms of operative time and hospital stay the best results were found after cVATS. The use of a less invasive surgical intervention resulted in less surgical-, and MG related neurological complications. The improvement of MG symptoms was excellent and results were similar after different types of thymectomies.

Unilateral video-assisted thoracoscopic extended thymectomy offers long-term outcomes equivalent to that of the bilateral approach in the treatment of non-thymomatous myasthenia gravis.

Video-assisted thoracoscopic extended thymectomy (VATET) is commonly performed bilaterally to remove all the thymic tissue in the mediastinum for the surgical treatment of myasthenia gravis. We hypothesize that the therapeutic efficacy of unilateral thoracoscopic thymectomy (right-sided) is comparable to that of bilateral VATET. We retrospectively reviewed 103 consecutive patients who received VATET for non-thymomatous myasthenia gravis (NTMG), with a minimum follow-up period of 36 months. Bilateral VATET was performed in the first 31 patients and right-sided VATET in the following 72. No patients died perioperatively. The operating time in the right-sided VATET group was significantly shorter than that in the bilateral VATET group (169.3 ± 19.3 vs 152.6 ± 20.7 min, P<0.001). There were no significant differences between groups, in terms of blood loss, pain severity, drainage time, ICU stay, hospital stay and postoperative morbidity. The median follow-up was 5.2 years. Forty-eight patients achieved complete stable remission (CSR). The 5-year CSR rate, calculated by Life-table analysis, was 52% in the bilateral VATET group and 47% in the right-sided VATET group. These two operative methods did not differ significantly with respect to CSR by Kaplan-Meier analysis. Multivariate analysis identified shorter disease duration (<12 months) (P = 0.021, HR = 0.50) and thymic hyperplasia (P = 0.038, HR = 0.48) as independent predictors of higher CSR rates in patients who underwent thymectomy. The long-term outcome of right-sided VATET in the surgical treatment of NTMG, in terms of CSR, is comparable to that of bilateral VATET.

Bilateral thoracoscopic thymectomy using a novel positioning system.

Several techniques of bilateral video-assisted thoracoscopic extended thymectomy have been proposed, and each has its own proponents. We summarize our experience in 20 patients who underwent bilateral video-assisted thoracoscopic extended thymectomy, using a new patient positioning that amplifies the thoracoscopic view of the cardiophrenic regions which are often difficult to visualize with standard techniques. In all cases, en-bloc thymectomy with complete dissection of the mediastinal fatty tissue was achieved without sternal retractors or additional incisions.

Surgical effect of dysphagia in patients with bulbar myasthenia gravis

To retrospectively analyze the clinical data of 42 patients at our department with bulbar myasthenia gravis. They underwent video-assisted thoracoscopic extended thymectomy (VATET) from May 2003 to August 2010. Another 42 patients treated with medications alone were selected as controls. Compared with the control group(4.32±0.23), postoperative dysphagia scores improved significantly in patients undergoing VATET(9.21±0.41). And so did the dysphagia assessment classification (P<0.05). Thus VATET could effectively and definitely relieve dysphagia in patients with bulbar myasthenia gravis. Key words: Myasthenia gravis; Deglutition disorders

Video-Assisted Thoracoscopic Extended Thymectomy in Myasthenic Children

Myasthenia gravis (MG) is an autoimmune disease marked by weakness of voluntary musculature. Medical and surgical therapy of adult myasthenia is well documented. There is little pediatric surgical evidence, only a few case reports being available. The aim of this paper is to verify whether the surgical and anesthesiological techniques can warrant an early and safe discharge from the operating room. The secondary aim is to assess the presence of perioperative indicators that can eventually be used as predictors of postoperative care. During the years 2006–2009, 10 pediatric patients were treated according to a surgical approach based on video assisted thoracoscopic extended thymectomy (VATET). Standard preoperative evaluation is integrated with functional respiratory tests. Anesthetic induction was made with propofol and fentanyl/remifentanyl and maintenance was obtained with sevoflurane/desflurane/propofol ± remifentanyl. A muscle relaxant was used in only one patient. Right or left double-lumen bronchial tube (Rüsch Bronchopart® Carlens) placement was performed. Six patients were transferred directly to the surgical ward while 4 were discharged to the intensive care unit (ICU); ICU stay was no longer than 24 h. Length of hospital stay was 4.4±0.51 days. No patient was readmitted to the hospital and no surgical complications were reported. Volatile and intravenous anesthetics do not affect ventilator weaning, extubation or the postoperative course. Paralyzing agents are not totally contraindicated, especially if short-lasting agents are used with neuromuscular monitoring devices and new reversal drugs. Perioperative evaluation of the myasthenic patient is mandatory to assess the need for postoperative respiratory support and also predict timely extubation with early transfer to the surgical department. Availability of new drugs and of reversal drugs, the current practice of mini-invasive surgical techniques, and the availability of post anesthesia care units are the keys to the safety and successful prognosis of patients affected by MG who undergo thymectomy.

Video-Assisted Thoracoscopic Surgery for Ectopic Middle Mediastinal Thymoma in a Patient With Myasthenia Gravis

We present a rare case of middle mediastinal thymoma with myasthenia gravis. A 51-year-old man presented with right ptosis and muscle weakness, and received a diagnosis of generalized myasthenia gravis. Computed tomography of the chest showed a 20-mm nodule in the middle mediastinum, suggesting a possible ectopic thymoma. He underwent video-assisted thoracoscopic extended thymectomy and resection of the tumor. Histologic examination revealed an ectopic thymoma and ectopic thymic tissue around the tumor. One year after the operation, his condition remains well controlled solely with tacrolimus. Careful preoperative radiologic examination concerning possible ectopic thymoma outside the dissection area of the extended thymectomy is recommended.

Ectopic Cervical Thymoma Accompanied by Good&amp;apos;s Syndrome

Ectopic cervical thymoma (ECT) is a rare tumor that is frequently misdiagnosed as a thyroid tumor or other malignancy. A 34-year-old male with a right palpable neck mass had been mistakenly diagnosed with T-cell lymphoblastic lymphoma even after an open biopsy. The atypical clinical course, including hypogammaglobulinemia, led us to the correct diagnosis; ECT accompanied by Good's syndrome (GS). After the intravenous infusion of gammaglobulin, tumor resection and a subsequent video-assisted thoracoscopic extended thymectomy were performed. The final diagnosis was type AB thymoma, Masaoka stage I. This report is, to the best of our knowledge, the first description of this extremely rare combination.

Outcome of an Original Video-Assisted Thoracoscopic Extended Thymectomy for Thymoma

Video-assisted thoracoscopic extended thymectomy (VATET) for a thymoma larger than 5 cm in size is still technically difficult. Thirty-five patients with clinical Masaoka stage I thymoma underwent an original VATET procedure between November 1998 and December 2009. All patients successfully underwent VATET, and none required conversion to a median sternotomy. Two patients also underwent partial resection of the lung and pericardium. Although there were no perioperative deaths, 3 patients experienced minor complications. The average tumor size was 5.2 cm. Fifteen tumors were larger than 5 cm. Pathologically, 15 were Masaoka stage I, 19 were stage II, and one was stage III. There were no significant differences in the tumor size between stages I and II. There were two type A, eight type AB, 15 type B1, five type B2, and three type B3 tumors and two thymic carcinomas. Twenty tumors were located in the right side of the body, five were in the middle, and ten were on the left. There were no differences in tumor size or pathologic stage according to location. There were also no differences in pathologic stage according to tumor size. The average follow-up period was 65 months. One patient showed recurrence to the bilateral lung 3.5 years after the procedure. After resection, this patient was free of disease 5 years after the first procedure. There has been no recurrence in any of the other patients. Our original VATET procedure may be indicated for patients with clinical Masaoka stages I and II thymoma and in those with tumors larger than 5 cm.

Invited Commentary

Invited Commentary

A standardized protocol for the perioperative management of myasthenia gravis patients. Experience with 110 patients

Video-assisted thoracoscopic extended thymectomy (VATET) is well established in the treatment of myasthenia gravis; however, patient selection remains controversial. Perioperative management protocol is lacking, and concerns regarding post-operative myasthenic crisis still remain. We performed a retrospective observational study evaluating the impact of the introduction of a protocol in the perioperative management of patients with myasthenia gravis who underwent VATET. The perioperative management protocol was developed by a team of neurologists and anesthesiologists who reviewed the literature and their previous experience on myasthenia gravis patients. Respiratory, clinical, and neurological patient features were included in the protocol evaluation. A retrospective review of patients who underwent VATET before and after introduction to the protocol was finally performed. The medical records of 66 patients (pre-protocol group) and 44 patients (protocol group) were available for the study. In the pre-protocol group, 17 patients (26%) were admitted to intensive care unit (ICU) during the post-operative period, while three patients (6.8%) of the protocol group met the criteria for ICU post-operative admission. This resulted in a reduction of 73.5% of patients admitted to ICU (P = 0.023) and in an 80% (P = 0.002) reduction of the use neuromuscular blocking agents. Two post-operative myasthenic crises preceded by bulbar symptoms (1.8%) were identified in the pre-protocol group patients. Although the application of our protocol results in a substantial reduction in the recovery of patients in the ICU and in hospital costs, there was no substantial difference in mortality and morbidity between patients admitted to the surgical ward or to ICU.

Video-assisted thoracoscopic surgery versus sternotomy in treating myasthenia gravis: Comparison by a case-matched study

To clarify the efficacy of a right-sided video-assisted thoracoscopic extended thymectomy (RtVATET) as a surgical alternative for myasthenia gravis (MG) and to determine the optimal timing for a thymectomy. Thirty-three patients who underwent RtVATET in two institutes were enrolled in this study. Another 66 paired, traditional trans-sternal extended thymectomy (TET) patients from the registered database were used to compare these two surgical modalities for MG. Mean blood loss was 88.5 ml in RtVATET and 226.8 ml in TET group patients (P < 0.001). Mean operation duration was 207.3 min for RtVATET and 172.8 min for TET patients (P = 0.003). Complete stable remission (CSR) rates and total improvement rates for the RtVATET and TET patients were 42.4% vs 60.6% (P = 0.087) and 87.9% vs 90.1% (P = 0.637), respectively. Furthermore, when we focused on the minor grades (classes I and IIa), TET groups showed significantly better CSR than the RtVATET groups (P = 0.012), but there was no statistically significant difference for the more severe grades (classes IIb and III, P = 0.827). Both RtVATET and TET are effective for treating MG, although this study does indicate an advantage for TET. We suggest that a thymectomy should therefore be performed earlier, or that the procedures should be extensive enough to remove all of the tissue that contains thymic tissue.

Video-assisted thoracoscopic extended thymectomy for myasthenia gravis: report of 62 cases

To evaluate the clinical value of video-assisted thoracoscopic extended thymectomy for myasthenia gravis(MG). Sixty-two MG cases underwent video-assisted thoracoscopic extended thymectomy. The operative extension included thymus tissue and adipose tissue in anterior superior mediastinum. All operations were performed successfully. The mean operating duration, mean intraoperative blood loss and mean postoperative hospital stay was 98 ± 26 minutes, 60 ± 29 ml and 8.2 ± 2.5 days respectively. All cases were followed up for 5 to 48 months. Among them, 20 (32.3%) patients achieved a complete relief, 32 (51.6%) had their improved symptoms, 8 (12.9%) remained stable and 2 (3.2%) became worse. And the overall relief rate was 83.9%. Video-assisted thoracoscopic extended thymectomy is both feasible and reliable for MG with the advantages of a minimal trauma and a rapid recovery.

Video-assisted thoracoscopic surgery or transsternal thymectomy in the treatment of myasthenia gravis?

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was how video-assisted thoracoscopic surgery (VATS) compares to median sternotomy in the surgical management of patients with myasthenia gravis (MG)? Overall 74 papers were found using the reported search, of which 15 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results are tabulated. We conclude that VATS produces equivalent postoperative mortality and complete stable remission (CSR) rates, with superior results in terms of hospital stay, operative blood loss and patient satisfaction at the expense of a doubling of operative time. Six studies comparing VATS and transsternal sternotomy in non-thymomatous myasthenia gravis (NTMG) patients found VATS to have lower operative blood loss (73.8±70.7 vs. 155.3±91.7 ml; P<0.05), reduced total hospital stay (5.6±2.2 vs. 8.1±3.0 days; P=0.008), whilst maintaining equivalent remission rates (33 vs. 44.7%; P=0.16) and mass of thymic tissue resection (37 vs. 34 g; P>0.05). One study comparing video-assisted thoracoscopic extended thymectomy to transsternal thymectomy in only thymoma-associated myasthenia gravis (T-MG) patients found equivalent CSR (11.3 vs. 8.7%, P=0.1090) at six-year follow-up. Thymoma recurrence rate (9.64%) was not significantly different (P=0.1523) between the two groups. Eight studies comparing VATS and transsternal approach in mixed T-MG and NTMG patients found a lower hospital stay (1.9±2.6 vs. 4.6±4.2 days, P<0.001), reduced need for postoperative medication (76.5 vs. 35.7%, P=0.022), lower intensive care unit stay (1.5 vs. 3.2 days, P=0.018), greater symptom improvement (100 vs. 77.9%, P=0.019) and better cosmetic satisfaction (100 vs. 83, P=0.042) with VATS. In concordance with NTMG and T-MG alone patient groups, VATS and transsternal methods had equivalent complication rates (23 vs. 19%, P=0.765) with no mortalities in either group. Even though VATS has a longer operative time (268±51 vs. 177±92 min, P<0.05), its improved cosmesis, reduced need for postoperative medication and equivalent disease resolution outcomes make it a preferable surgical option to the transsternal approach.