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

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Abstract: Objective To evaluate the clinical value of video-assisted thoracoscopic surgery (VATS) in the treatment of myasthenia gravis. Met


Abstract: Objective To evaluate the clinical value of video-assisted thoracoscopic surgery (VATS) in the treatment of myasthenia gravis. Methods a total of 62 patients with myasthenia gravis were treated by video-assisted thoracoscopic surgery. The range of resection included the thymus tissue and the adipose tissue in the anterior mediastinum. Results all the operations were successful, the average operation time was 98 + 26.3min, the average intraoperative blood loss was + 28.6ml, and the average hospitalization time was 8.2 + 2.5d. All the patients were followed up from 5 to 48 months, with complete remission in all of the patients (n = 32.3%) and partial remission in all of the patients (n = 32). There were stable in all patients (n = 51.6%), and the deterioration was in all the patients (12.9%), and the total response rate was 83.9% (3.2%) in 2 patients (8). Objective to evaluate the feasibility and reliability of video-assisted thoracoscopic surgery in the treatment of myasthenia gravis.

Video assisted thoracoscopic surgery; thymectomy; myasthenia gravis

Myasthenia gravis (myasthenia gravis MG) is a involving neuromuscular nicotinic acetylcholine receptor in autoimmune diseases characterized by muscle weakness, fatigue [1-2], mild ptosis, severe life-threatening due to breathing difficulties. Recent studies have found that thymoma, thymic hyperplasia and anterior mediastinal fat tissue contains anti acetylcholine receptor antibody [3], the extended thymectomy has become an important means for the treatment of MG, the remission rate of up to 80%[4].

Object and method

1: Department of thoracic surgery the First Affiliated Hospital of Fujian Medical University from March 2005 to March 2009 underwent video-assisted thoracoscopic extended thymectomy for MG 62 cases, male 27 cases, female 35 cases, age 21 ~ 68 years old (32.3 + 8.5), duration of January ~ 16 years (26.3 + 4.3 months), 2 patients with hyperthyroidism. According to the 18 cases of type Ossermen type, 19 cases of type IIA, IIb type in 15 cases, 6 cases of type III, 4 cases of type iv..

2 cases: routine chest CT scan, the diameter more than 5cm or major vascular invasion, trachea and other organs do not consider minimally invasive thymoma. I can type as long as the symptoms of stable operation, type IIA above oral pyridostigmine bromide 60 ~ 180mg/d, prednisone 20 ~ 40mg/d, stabilization of symptoms more than January. Hyperthyroidism patients need to be treated with antithyroid drugs, symptoms stable above January.

3 operation methods: double lumen endotracheal intubation and one lung ventilation on the left, the left 30 degrees after supine position, the right chest approach, in the fifth intercostal axillary midline (thoracoscopic observation port), the fifth intercostal midclavicular line (the first operation) and third intercostal anterior axillary line (second mouth) each for a long about 1.5cm incision. The first exploration of the anterior mediastinum, with electrocantery phrenic nerve were cut along the frontier mediastinal pleura, exposure and endoscopic forceps of the retrosternal space under the right lobe of thymus, inward and upward to free the thymus left lobe and lower pole pole on the right lobe of thymus. Arrive at the brachiocephalic vein, careful dissection of thymic vein, closed or cut off by ultrasonic knife titanium clips, issued by the same method to cut off the internal thoracic artery thymic arteries. Then continued downward traction under the left lobe of thymus, separated by "peanuts" or endoscopic suction blunt, full pull neck root thymus left upper pole. Subsequently, the right anterior superior mediastinum and pericardial fat were removed with an endoscope forceps and an electric coagulation hook. Finally, the contralateral mediastinal pleura was dissected into the left chest to clean the left anterior superior mediastinum and pericardial fat.

4: according to the curative effect judgment MGFA (MGFA) standard is divided into: the complete remission without asymptomatic or mild symptoms of drug residues, for their daily work and life; the partial remission of symptoms were improved or taking anti cholinesterase drugs, hormone reduction; the stable operation, no improvement in symptoms after taking drugs, with the same dose preoperative; the deterioration of drug dosage increase or worsening symptoms, or some combination of the two death.

Two, results

All operations were successful. No conversion to open surgery, the operation time ranged from 67 to 183 min (98 + 26.3 min), the amount of bleeding was 40 ~ 120ml (60 + 28.6 ml). Postoperative thoracic closed drainage 1 ~ 5D (+ + 2.2 d), postoperative hospitalization time was from 6 to 15 d (8.2 + 2.5 D). Myasthenia crisis occurred in 3 cases after operation, all nasotracheal intubation mechanical ventilation in 3 ~ 5 days, parallel "dry" therapy improved after symptomatic treatment. 13 cases of pathological report after the resection of the thymoma, thymic hyperplasia in 24 cases, 2 cases of thymic cyst, thymus atrophy in 14 cases, 9 cases of normal thymus. 62 patients were followed up for a period of time from 5 to 48 months (range: 25.2 + / - 11.6 months), complete remission was found in all the patients (n = 32.3%), partial response was found in all of the patients (n = 51.6%), and there were stable in all the patients (8) in the treatment group (12.9%), and the deterioration in all cases was 2 (3.2%). The total response rate was 83.9%. Table four exact test indicated that the type I group complete remission rate comparison with a II B, II, III and IV group, P = 0.054, 0.018, 0.013, 0.045; the course of < 0.5 years group complete remission rate and 0.5 ~ 1, 1 ~ 3, 3 ~ 5. More than 5 years group, P = 0.174, 0.533, 0.033, 0.048.

Three, discussion

The traditional sternal splitting surgical trauma is huge, long hospital stay, the incidence rate of myasthenia crisis high [5]. Video assisted thoracoscopic extended resection of thymus is minimally invasive, less pain, faster recovery, fewer complications, so the use of this technology has increased by [6-7]. Video assisted thoracoscopic surgery to choose what way, each experience is not a [7]. The group was through right thoracic approach, its advantage is that can clearly reveal the superior vena cava, innominate vein and right phrenic nerve, but also avoid the aortic arch and the heart of the thymus, mediastinal fat cover, guarantee the operation flexibility, completeness and safety of [8-9].

According to the cases, experience and experience are: (1) laparoscopic exploration: first explore the thymus and its surrounding relationship, if there is no obvious adhesion, thymoma is less than 5cm, can be completed by vats. (2) the sequence of operations: follow the easier after the first principle first free double pole, after right upper pole, and finally left upper pole. (3) the treatment of blood vessels: the thymus, the vein needs the titanium clip to close, the ultrasonic knife is also very good choice, the thicker blood vessel is best to use the endoscopic vascular lock (Hemolok) after the two ends of the clamp. Once the accident is bleeding, immediately with a small ball of yarn oppression, endoscopic debridement aspirator to attract wild, and then use the endoscopic forceps accurate clipping damaged blood vessels, small blood vessels can be electro coagulation is more important vessels should use the general forest line endoscopic suturing. (4) the scope of operation must be up to the root of the neck, pericardium and heart septal angle, both sides to the mediastinal pleura. The pericardial fat around the need to cut the mediastinal pleura, with a long handle oval forceps into the left pleural, pericardial fat gradually left traction before resection.

The group of 3 cases of postoperative myasthenic crisis, the main reasons are: the long duration of the disease (> 2 years), long-term use of neostigmine, acetylcholine receptor leads to excessive destruction, the activity decreased; postoperative associated with respiratory tract infection. Therefore, after the operation should be alert to shortness of breath, chest pain and shortness of breath, myasthenia crisis warning, early detection and early treatment. The key treatment measures include: first once the myasthenic crisis threatened, improved after the treatment failed to actively, should act decisively, nasotracheal intubation or tracheostomy ventilation; the "dry" therapy: discontinuation of pyridostigmine 3-5 days, to fully get the acetylcholine receptor "rest", to restore its the activity and drug sensitivity; the anti infection, immunoglobulin, steroids and enteral nutrition supporting treatment.

The follow-up data showed that the complete remission rate and total remission rate of MG were higher than that of [3, 6, 10, 11]. Type I group complete remission rate as high as 61.1%, although compared with the type IIA group had no significant difference, but was significantly higher than that of B II, III and IV group, the patients with type I MG during early stage. The duration of the disease was 63.6%, which was significantly higher than that of the group of 5 ~ (3), which was significantly higher than that of the 5 year old group, so the earlier the operation was, the greater the hope of complete remission.

In a word, it is feasible and reliable to treat MG by video-assisted thoracoscopic surgery. It has the advantages of minimal invasion and rapid recovery. It is a promising method for the treatment of MG.


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