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Subxiphoid and subcostal arch "Three ports" thoracoscopic extended thymectomy for myasthenia gravis.

ABSTRACT: Background:The approaches to thoracoscopic thymectomy in myasthenia gravis (MG) are debatable. We developed a novel approach via subxiphoid and subcostal arch, with a significantly shorter duration of operation and hospital stay, less estimated blood loss, and lower postoperative pain. Methods:From December 2012 to December 2014, 77 myasthenia gravis patients with or without thymoma underwent thoracoscopic extended thymectomy at our hospital. Among them, 41 patients were operated via the subxiphoid and subcostal arch approach and the other 36 via the conventional unilateral approach. The patient outcomes were retrospectively reviewed and evaluated. Results:The thoracoscopic extended thymectomy was performed safely via the subxiphoid and subcostal arch approach. In this approach, no drainage tube was inserted after operation except in the first two patients. Two of the 41 patients were switched to trans-sternal approach due to the tight adhesion between the thymoma and the left innominate vein. No major complications occurred. Compared with the unilateral approach, the duration of the procedure via subxiphoid and subcostal arch was significantly shorter, with less estimated blood loss, shorter hospital-stay and lower postoperative pain (P<0.001). The cosmetic scores were comparable between the two groups (P=0.369). Conclusions:The novel subxiphoid and subcostal arch approach is technically feasible and safe. It is an acceptable alternative to conventional thoracoscopic extended thymectomy.

SUBMITTER: Lu Q

PROVIDER: S-EPMC5906355 | biostudies-literature | 2018 Mar

REPOSITORIES: biostudies-literature

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Subxiphoid and subcostal arch "Three ports" thoracoscopic extended thymectomy for myasthenia gravis.

Lu Qiang Q Zhao Jinbo J Wang Juzheng J Chen Zhao Z Han Yong Y Huang Lijun L Li Xiaofei X Zhou Yongan Y

Journal of thoracic disease 20180301 3

<h4>Background</h4>The approaches to thoracoscopic thymectomy in myasthenia gravis (MG) are debatable. We developed a novel approach via subxiphoid and subcostal arch, with a significantly shorter duration of operation and hospital stay, less estimated blood loss, and lower postoperative pain.<h4>Methods</h4>From December 2012 to December 2014, 77 myasthenia gravis patients with or without thymoma underwent thoracoscopic extended thymectomy at our hospital. Among them, 41 patients were operated ...[more]

PMID: 29707325

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Project description:BackgroundApproaches of thoracoscopic thymectomy for myasthenia gravis (MG) are debatable. The subxiphoid approach is widely utilized recent years for its better visualization of the anterior mediastinum. In the present study, we compared perioperative outcomes and mid-term effects of the extended thymectomy for MG between the subxiphoid approach and the routine right-thoracic approach.MethodsOne hundred and thirty-one MG patients treated with thoracoscopic extended thymectomy were analyzed. Among them, 68 patients were operated on via the subxiphoid approach and the other 63 via the conventional right-side unilateral approach. The patient outcomes were retrospectively reviewed and evaluated. Mid-term clinical outcome was assessed according to the classification system proposed by the Myasthenia Gravis Foundation of America (MGFA). Clinical efficacy and variables influencing outcome were evaluated by the Kaplan-Meier method and Cox proportional hazards regression analysis.ResultsCompared with the right thoracic approach, the duration of the procedure via the subxiphoid approach was significantly shorter (P=0.035), the rates of total thymectomy were higher (P=0.028), and the pain scores on postoperative days 1, 3, and 7 were significantly lower (P<0.001, P<0.001, and P=0.03, respectively). A total of 112 patients with MG were followed up. The subxiphoid approach group reported higher rates of complete stable remission (CSR) and effective treatment of MG, although these differences were not statistically significant (Z=-0.484, P=0.627). By multivariate Cox proportional hazards modes analysis, the chance of CSR was significantly increased when age <40 (OR: 2.623, 95% CI: 1.150-5.983, P=0.022), non-thymomatous MG (OR: 1.078, 95% CI: 1.101-3.316, P=0.021) and MGFA clinical classification (OR: 2.024, 95%:1.164-3.523, P=0.013).ConclusionsThe subxiphoid approach has shorter operation time, higher rates of total thymectomy and better quality of life compared with the lateral thoracoscopic approach. Preoperative age, pathological diagnoses and MGFA Clinical Classification are the independent risk factors for non-complete stable remission (NCSR) after thymectomy.

Project description:BackgroundThymectomy has been a mainstay in the treatment of myasthenia gravis, but there is no conclusive evidence of its benefit. We conducted a multicenter, randomized trial comparing thymectomy plus prednisone with prednisone alone.MethodsWe compared extended transsternal thymectomy plus alternate-day prednisone with alternate-day prednisone alone. Patients 18 to 65 years of age who had generalized nonthymomatous myasthenia gravis with a disease duration of less than 5 years were included if they had Myasthenia Gravis Foundation of America clinical class II to IV disease (on a scale from I to V, with higher classes indicating more severe disease) and elevated circulating concentrations of acetylcholine-receptor antibody. The primary outcomes were the time-weighted average Quantitative Myasthenia Gravis score (on a scale from 0 to 39, with higher scores indicating more severe disease) over a 3-year period, as assessed by means of blinded rating, and the time-weighted average required dose of prednisone over a 3-year period.ResultsA total of 126 patients underwent randomization between 2006 and 2012 at 36 sites. Patients who underwent thymectomy had a lower time-weighted average Quantitative Myasthenia Gravis score over a 3-year period than those who received prednisone alone (6.15 vs. 8.99, P<0.001); patients in the thymectomy group also had a lower average requirement for alternate-day prednisone (44 mg vs. 60 mg, P<0.001). Fewer patients in the thymectomy group than in the prednisone-only group required immunosuppression with azathioprine (17% vs. 48%, P<0.001) or were hospitalized for exacerbations (9% vs. 37%, P<0.001). The number of patients with treatment-associated complications did not differ significantly between groups (P=0.73), but patients in the thymectomy group had fewer treatment-associated symptoms related to immunosuppressive medications (P<0.001) and lower distress levels related to symptoms (P=0.003).ConclusionsThymectomy improved clinical outcomes over a 3-year period in patients with nonthymomatous myasthenia gravis. (Funded by the National Institute of Neurological Disorders and Stroke and others; MGTX ClinicalTrials.gov number, NCT00294658.).

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Subxiphoid and subcostal arch "Three ports" thoracoscopic extended thymectomy for myasthenia gravis.

Publications

Subxiphoid and subcostal arch "Three ports" thoracoscopic extended thymectomy for myasthenia gravis.

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