Timectomía transesternal extendida en pacientes con miastenia grave / Extended Transsternal Thymectomy in Patients with Myasthenia Gravis

Introducción: La miastenia grave adquirida es un trastorno de la transmisión neuromuscular, causado por la unión de autoanticuerpos con los componentes de la placa neuromuscular, más frecuentemente con el receptor de acetilcolina. Objetivo: Evaluar los resultados quirúrgicos inmediatos, obtenidos con la timectomía extendida en pacientes con miastenia grave timomatosa y no timomatosa. Métodos: Se realizó un estudio observacional, prospectivo y descriptivo para evaluar los resultados postoperatorios inmediatos de 21 pacientes intervenidos por miastenia grave entre junio de 2015 y mayo de 2020. Las variables estudiadas fueron edad, sexo, lesiones tímicas asociadas y resultados inmediatos: complicaciones y mortalidad ocurridas hasta 30 días de la intervención. Los datos fueron obtenidos de una base en Microsoft Access. Resultados: Dieciséis (76,2 por ciento) pertenecían al sexo femenino y 5 (23, 8 por ciento) al masculino. El mayor número correspondió a la MG con timoma, seguido por la MG e hiperplasia tímica (8) y uno con MG y restos tímicos. Se complicaron tres pacientes (14,3 por ciento). Uno presentó dos complicaciones: enfisema subcutáneo y septicemia, el siguiente, fiebre sin causa aparente y, el último, infección superficial de la herida. No hubo fallecidos. Conclusiones: La timectomía transesternal extendida permite extirpar el timo y la mayor parte de los tejidos adiposo y tímico aberrante, en el cuello y el mediastino. En pacientes tratados por equipos multidisciplinarios, con experiencia en esta cirugía, las complicaciones y la mortalidad tempranas usualmente son favorables(AU)

Introduction: Acquired myasthenia gravis (MG) is a neuromuscular transmission disorder caused by the union of autoantibodies and the components of the neuromuscular plaque, most frequently with the acetylcholine receptor. Objective: To assess the immediate surgical outcomes of extended thymectomy in patients with thymomatous and nonthymomatous myasthenia gravis. Methods: An observational, prospective and descriptive study was carried out to assess the immediate postoperative outcomes of 21 patients operated on for myasthenia gravis between June 2015 and May 2020. The variables studied were age, sex, associated thymic lesions, and immediate outcomes: complications and mortality that occurred up to thirty days after the intervention. The data were obtained from a Microsoft Access database. Results: Sixteen (76.2 percent) belonged to the female sex and five (23.8 percent) to the male sex. The highest number corresponded to MG with thymoma, followed by MG and thymic hyperplasia (8) and one with MG and thymic remains. Three patients (14.3 percent) were complicated. One had two complications: subcutaneous emphysema and septicemia; the next had unexplained fever; and the last one had superficial wound infection. There were no deaths. Conclusions: Extended transsternal thymectomy allows removal of the thymus and most of the adipose and aberrant thymic tissues in the neck and mediastinum. In patients treated by multidisciplinary teams, with experience in this surgery, outcomes regarding early complications and mortality are usually favorable(AU)

VATS Uniportal, masterclass Guatemala / VATS Uniportal, masterclass Guatemala

En las dos últimas décadas la evolución de la cirugía mínimamente invasiva del tórax ha transmutado de un abordaje de tres puertos, siguiendo dos puertos hasta llegar a puerto único, conocido también como VATS Uniportal, procurando un confort mucho mejor para el paciente y resultados quirúrgicos similares. Objetivos. Presentar la técnica quirúrgica de VATS Uniportal en un hospital nacional, efectuadas por un experto internacional en este campo. Pacientes y Métodos. Se presentan dos casos clínicos quirúrgicos: El de una paciente con Miastenia Gravis a quien se le realizó timectomía por abordaje sub-xifoideo y otra paciente, a quien se le completó una lobectomía inferior derecha por hallazgos de patología posterior a la resección de un nódulo pulmonar solitario, reportado como cáncer primario de pulmón. Conclusiones. La técnica de cirugía mínimamente invasiva, VATS Uniportal, ofrece grandes beneficios para el paciente, tanto estéticos como funcionales y su aprendizaje es posible con la transmisión de conocimientos y experiencias directa con la presencia del experto o indirectas a través de la información publicada. (AU)

In the last two decades, the evolution of minimally invasive chest surgery has transmuted from a three-port approach, following two ports until reaching a single port, also known as VATS Uniportal, seeking much better comfort for the patient and similar surgical results. Objective. Present the VATS Uniportal surgical technique in a national hospital, performed by an international expert in this field. Patients and Methods. Two surgical clinical cases are presented: that of a patient with Myasthenia Gravis who underwent thymectomy through the sub-xiphoid approach and another patient, who underwent a right lower lobectomy due to findings of pathology after the resection of a pulmonary nodule. solitary, reported as primary lung cancer. Conclusions. The minimally invasive surgery technique, VATS Uniportal, offers great benefits for the patient, both aesthetic and functional and its learning is possible with the transmission of knowledge and experiences directly with the presence of the expert or indirectly through published information. (AU)

Perioperative challenges and neuromuscular blockade concerns in robotic thymectomy for myasthenia gravis / Desafios perioperatórios e pontos de atenção no bloqueio neuromuscular durante timectomia robótica para miastenia gravis

Abstract Myasthenia Gravis (MG) is an autoimmune disease characterized by weakness and fatigability of skeletal muscles, with improvement following rest. It is a disease of great significance to the anesthesiologist because it affects the neuromuscular junction. Robotic thymectomy has come up in recent times due to the minimally invasive nature and its advantages. This presents a new set of challenges for the anesthesia team, and here we present the various anesthesia considerations and perioperative management in a series of 20 patients who underwent robotic thymectomy. As it is a recent upcoming procedure, there is a paucity of literature on this topic, and most of the available literature talks about One-Lung Ventilation (OLV) and thoracic epidurals. To our notice, this is the first literature without the use of OLV and thoracic epidural for the management of robotic thymectomy.

Resumo Miastenia Gravis (MG) é uma doença autoimune que se caracteriza por fraqueza e fadiga da musculatura esquelética, com melhora após o repouso. É uma doença de grande interesse para o anestesiologista, pois compromete a junção neuromuscular. Recentemente, a timectomia robótica tem sido empregada por apresentar as vantagens da abordagem minimamente invasiva. O procedimento introduz uma série de novos desafios para a equipe de anestesia. Relatamos aqui as várias considerações anestésicas e o cuidado perioperatório em uma série de 20 pacientes submetidos a timectomia robótica. Sendo um procedimento recente, há limitada literatura discutindo esse tópico e, além disso, a maior parte da literatura disponível concentra a atenção na Ventilação Monopulmonar (VMP) e na peridural torácica. A nosso ver, este é a primeiro relato na literatura sem o emprego de VMP e peridural torácica para o manejo da timectomia robótica.

Miastenia gravis: resultados inmediatos y alejados de la timectomía transesternal extendida / Results of extended transsternal thymectomy for Myasthenia gravis: experience with 58 patients

Background: Thymectomy improves clinical outcomes and decreases the need for medical treatment in patients with myasthenia gravis (MG). Aim: To describe the immediate and long-term results of extended transsternal thymectomy (ETT) in patients with MG. Material and Methods: A review of databases, surgical protocols, clinical records and interviews of patients subjected to extended transsternal thymectomy for MG between 1990 and 2016. Perioperative clinical characteristics, anticholinesterase treatment, immediate and remote surgical results were analyzed and patients were followed from one to 10years. Results: We studied 58 patients aged 35 ± 14years (72%) women. In the preoperative period, according to Osserman classification, nine patients (15,5%) were in grade I, eight (13,8%) in grade IIA 8 and 40 (69%) in grade IIB. The pathological study of the surgical piece showed thymic hyperplasia in 39 cases (67,2%). Four patients had postoperative complications but none died. In the Follow-up at 1, 3, 5, 8 and 10years the Masaoka palliation rate was 71.7, 77.5, 67.7, 70.0 and 70,6% respectively. The figures for remission rate were 13.0, 15.0,19.4, 35.0 and 35,3% respectively. The figures for Zielinski positive results were 79.6, 87.5, 87.1, 90.0 and 82,4% respectively. The DeFilippi score improved by 80.4, 87.5, 87.1, 90.0 and 82.4% respectively. The Myasthenia Gravis Foundation of America Post-Intervention State improved by 67.4, 77.5, 77.5, 75.0 and 70,6% respectively. Mean Myasthenia Gravis Activities of daily living (MGADL) and Myasthenia Gravis Quality of life scale 15 (MGQOL 15) were 1.65 and 6.31 respectively. Conclusions: In selected patients with MG, extended transsternal thymectomy in MG has good immediate and long-term results.

Current status of robotic surgery in Japan

The da Vinci S surgical system (Intuitive Surgical) was approved as a medical device in 2009 by the Japanese Ministry of Health, Labour and Welfare. Robotic surgery has since been used in gastrointestinal, thoracic, gynecological, and urological surgeries. In April 2012, robotic-assisted laparoscopic radical prostatectomy (RALP) was first approved for insurance coverage. Since then, RALP has been increasingly used, with more than 3,000 RALP procedures performed by March 2013. By July 2014, 183 institutions in Japan had installed the da Vinci surgical system. Other types of robotic surgeries are not widespread because they are not covered by public health insurance. Clinical trials using robotic partial nephrectomy and robotic gastrectomy for renal and gastric cancers, respectively, have recently begun as advanced medical treatments to evaluate health insurance coverage. These procedures must be evaluated for efficacy and safety before being covered by public health insurance. Other types of robotic surgery are being evaluated in clinical studies. There are several challenges in robotic surgery, including accreditation, training, efficacy, and cost. The largest issue is the cost-benefit balance. In this review, the current situation and a prospective view of robotic surgery in Japan are discussed.

Metastatic Thymic Carcinoid: Does Surgeon Have a Primary Role.

Thymic carcinoids are rare mediastinal tumours. These are aggressive tumours that often present late and have poor prognosis. Primary surgical treatment is recommended even in metastatic tumours since the role of adjuvant therapy is not well established. We present a case of metastatic thymic carcinoid managed with surgical excision.

Resultado de la timectomía en los tumores epiteliales / Result of thymectomy in epithelial tumors

Introducción: el timoma describe las neoplasias que no presentan atipia manifiesta del componente epitelial, cuando se exhibe claramente atipia citológica se le conoce como carcinoma tímico, y la cirugía es el tratamiento de elección. Nuestro objetivo es evaluar la eficacia de la timectomía en los enfermos con tumores epiteliales del timo (timoma, carcinoma tímico). Métodos: se estudiaron 26 enfermos entre enero 2007 a enero 2012 que, con este diagnostico, fueron operados en nuestro centro. Resultados: la miastenia gravis estuvo presente en 16 (61,5 por ciento) pacientes, de ellos en el posoperatorio se extubaron 11 (68,7 por ciento) después de 12 horas. La esternotomía total fue el abordaje principal 13 (50 por ciento), cuando la lesión era superior a los 7 centímetros fue más probable la ampliación a un hemitórax. Cuando se necesitó resección de pulmón, pericardio o ambos, el tiempo quirúrgico fue superior a los 120 minutos. Se complicaron 7 (29,6 por ciento), de ellos 5 (71,4 por ciento) de causa respiratoria. En 19 (73,9 por ciento) los tumores se clasificaron como estadio I de Masaoka y en 6 (23,1 por ciento) hubo carcinoma tímico.Tuvimos 1 fallecido (3,8 por ciento). Todos los miasténicos tuvieron remisión completa o farmacológica, en 2 hubo recidiva local y en ninguno fallecimiento durante el seguimiento. Conclusiones: la timectomía transesternal es el tratamiento de elección, y se necesita ampliar a un hemitórax cuando la lesión es más de 7 cm con resección de pericardio, pulmón o ambos. En este caso, se obtendrán resultados favorables en los miasténicos y en el control del tumor durante el seguimiento(AU)

Introduction: Thymomea describes the neoplasias that do not present evident atypia of the epithelial component; the clear cytological atypia indicated thymic carcinoma and surgery is the treatment of choice. The objective of this paper was to evaluate the efficacy of thymectomy aimed at patients with epithelial tumors in the thymus (thymoma, thymic carcinoma). Methods: Twenty six patients under study from January 2007 to January 2012, they were operated on after this diagnosis. Results: Myasthenia gravis was present in 16 patients (61.5 percent), 11 of them (68.7 percent) were removed their intubation after 12 hours of surgery. Total sternotomy was the main approach in 13 patients (50 percent); in case of an over 7cm long injure, the approach was extended to hemithorax. Resection of lung, pericardium or both required more than 120min surgical time. Seven patients (29.6 percent) suffered complications, 5 of them (71.4 percent) respiratory complications. Nineteen patients (73.9 percent) had Masaoka's staging I tumors whereas 6 (23.1 percent) had thymic carcinoma. One patient died (3.8 percent). All these patients with myasthenia gravis showed complete or pharmacological remission, 2 experienced local relapse and no patient died in the follow-up period. Conclusions: Transsternal thymectomy is the treatment of choice. It is required to extend it to hemithorax when there is an over 7 cm long injure, with resection of the pericardium, the lung or both. In this case, the favorable results will be achieved in myasthenic patients and in the tumor control during the follow-up phase(AU)

Timectomía videotoracoscópica en miastenia gravis: técnica quirúrgica y experiencia inicial / Thymectomy in myasthenia gravis thoracic: surgical technique and initial experience

Introducción: Desde la década del 40 se reconoce el beneficio de la timectomía en el tratamiento de la miastenia gravis. La misma se realizó tradicionalmente por esternotomía o cervicotomía. La videotoracoscopia permite la extirpación tímica con menor agresión quirúrgica y recuperación más temprana. Material y Métodos: En los últimos 4 años se realizó un total de 14 timectomía por videotoracoscopia a pacientes portadores de miastenia gravis. Los pacientes eran 11 mujeres y 3 varones, con una edad media de 34,1 años, con un rango entre 16 y 53 años. En todos los casos se realizó mediante videotoracoscopía de 3 trocares, con acceso por hemitorax derecho. Resultados: Se realizó timectomía total exclusivamente toracoscópica en todos los casos, sin conversiones ni reoperaciones. Un solo paciente requirió ARM posterior menor a 4hs de postoperatorio, en 4 pacientes se extubó en UTI durante las 2 hs de postoperatorio y los 9 restantes salieron sin tubo endotraqueal de quirófano. La mortalidad postoperatoria fue nula. Conclusiones: la timectomía videotoracoscópica es útil en el tratamiento de la miastenia gravis y tiene como ventaja una mejor recuperación del paciente, y una mejor visión quirúrgica, que redunda en menor morbimortalidad quirúrgica.

Introduction: From the 40 recognized the benefit of thymectomy in the treatment of myasthenia gravis. The same was done traditionally by sternotomy or neck incision. VATS allows removal thymic less aggressive surgery and early recovery. Material and Methods: In the last 4 years was a total of 14 video-assisted thymectomy in patients with myasthenia gravis. Patients were 11 women and 3 men, mean age of 34.1 years, ranging between 16 and 53 years. In all cases was performed by video-assisted thoracoscopy of 3 trocars, accessible by right hemithorax. Results: We performed thoracoscopic thymectomy only com­plete in all cases without conversion or reoperation. One patient required subsequent ARM less than 4 hrs after surgery in 4 patients were extubated in the ICU during the 2 hrs after surgery and the remaining 9 endotracheal tube left without surgery. Postoperative mortality was nil. Conclusions: VATS thymectomy is useful in the treatment of myasthenia gravis and has the advantage of better patient recovery, and better surgical view, resulting in less surgical morbidity.

Timectomía videotoracoscópica en la miastenia gravis / Video-laparoscopic thymectomy in myasthenia gravis

Introducción: el tratamiento videotoracoscópico permite la exéresis del timo y de la grasa peritímica, como en la cirugía abierta, pero con las ventajas del mínimo acceso. Objetivo: evaluar los resultados de esta vía con nuestros primeros pacientes. Métodos: se realizó un estudio descriptivo y prospectivo de 10 pacientes con miastenia gravis desde enero de 2007 hasta agosto de 2008, en el hospital Hermanos Ameijeiras. Los resultados se presentaron en por cientos y para la relación de las variables se empleó chi cuadrado. Resultados: según la clasificación de Osserman de la miastenia, 8 se ubicaron en el grado II B, y 2 en el II A. El 50 por ciento (5 de ellos) tenía un timoma asociado. En el 50 por ciento se emplearon 3 puertos de entrada. El tiempo quirúrgico varió de 60 a 180 minutos. Hubo un 37,5 por ciento (3) de complicaciones posoperatorias sin mortalidad. En el informe anatomopatológico de la pieza (4) el 50 por ciento tenía un timoma, todos en el estadio I de Masaoka. El 50 por ciento (4) se encuentra en remisión y el otro 50 por ciento en mejoría significativa. Conclusiones: la timectomía videotoracoscópica tiene grandes ventajas, ya que sin cambiar la técnica quirúrgica los pacientes se benefician de todas las ventajas del mínimo acceso(AU)

Introduction: the video-laparoscopy treatment allows the thymus exeresis and the peri-thymic fat like in the open surgery, but with the advantages of a minimal access. Objective: to assess the results of this route achieved in our first patients. Methods: a prospective and descriptive study was conducted in 10 patients presenting with myasthenia gravis from January, 2007 to August, 2008 admitted in the Hermanos Ameijeiras Clinical Surgical Hospital. The results were showed in percentages and for the relation of variables chi² was used. Results: according to the Osserman's classification of the myasthenia, 8 were located in the IIB degree and 2 in the IIA one. The 50 percent (5 of them) had an associated thymoma. In the 50 percent three approaches were used. The surgical time fluctuates from 60 to 180 minutes. The was a 37.5 percent (3) of postoperative complications without mortality. The anatomical-pathological report of the sample (4) the 50 percent had a thymoma all in I Masaoka's stage. The 50 percent of patients are in remission and the other 50 percent in a significant improvement. Conclusions: the video-thoracoscopy thymectomy has many advantages, since without a change in surgical technique, the patients to benefit of all the advantages of the minimal access(AU)

Tumores del timo y cirugía / Tumors of thymus and surgery

Los tumores del timo constituyen menos del 1 por ciento de todas las neoplasias, y es la cirugía el tratamiento de elección. Objetivos: conocer el tipo de tratamiento quirúrgico y la magnitud de la resección, así como la relación con el tamaño del tumor, el sangrado, el tiempo quirúrgico, la morbilidad y la mortalidad. Métodos: se realizó un estudio prospectivo en 22 pacientes con tumor mediastinal, que tuvieron criterios de cirugía durante el ingreso en los servicios de neurología o cirugía general del hospital Hermanos Ameijeiras, desde enero de 2007 hasta febrero de 2009. Los resultados se presentan en por cientos y se empleó el chi cuadrado en la relación de variables. Resultados: 12 fueron del sexo femenino (54,5 por ciento ). El tratamiento más empleado fue la esternotomía total en 9 pacientes (40,9 por ciento ), el tiempo quirúrgico varió de 50 a 260 min con mediana de 127,5, mientras el sangrado por encima de 100 mL estuvo asociado a un tiempo quirúrgico de 61 a 180 min (p= 0,036). Se complicaron 11 pacientes (50 por ciento ) y hubo 1 fallecido (4,5 por ciento ). El tamaño del tumor varió de 3,5 a 20 cm. El paciente con tumor neuroendocrino recidivó a los 10 meses, mientras los pacientes con timomas no muestran hasta la fecha recidiva local ni se ha comprobado actividad metastásica. Conclusión: la cirugía constituye el paso más importante en el tratamiento de los tumores mediastinales, y se logra, en la gran mayoría, la resección completa, a pesar del tamaño y la relación con estructuras vecinas(AU)

Introduction: the tumors of thymus account for less than 1 percent of all neoplasms and the choice treatment is the surgery. Objectives: to know the type of surgical treatment and the magnitude of resection, as well as the relationship with the tumor size, bleeding, surgical time and morbidity and mortality. Methods: a prospective study was conducted in 20 patients presenting with mediastinum tumor with surgery criteria over the admission in the services of neurology or general surgery of the Hermanos Ameijeiras Clinical Surgical Hospital from January, 2007 to February, 2009. Results are showed in percentages and variables relation Chi2 was the test used. Results: twelve patients were of female sex (54.5 percent). The more applied treatment was the total sternotomy in 9 patients (40.9 percent), surgical time varied from 50 to 260 min with a mean of 127,5, whereas the bleeding over of 100 mL was associated with a surgical time from 61 to 180 min (p= 0.036). Eleven patients have complications (50 percent) with a death (4.5 percent). The tumor size varied from 3,5 to 20 cm. The patients with neuroendocrine tumor have a relapse at 10 months, whereas in patients with thymoma until now there was neither relapse nor metastatic activity. Conclusion: surgery is the more important step in the treatment of mediastinum tumors and in most of them it is possible a total resection despite its size and the relationship with neighbouring structures(AU)

The cost-effectiveness of open or thoracoscopic thymectomy compared to medical treatment in managing Myasthenia gravis without thymomas / Costo efectividad de timectomía abierta y toracoscópica frente al tratamiento médico, en el manejo de Miastenia gravis sin timoma

Objective Assessing the cost-effectiveness of open or thoracoscopic thymectomy compared to medical therapy in managing myasthenia gravis not associated with thymoma. Methods A Markov model was designed for evaluating three strategies' cost-effectiveness. Transition probabilities were taken from the pertinent literature; the costs were estimated from official tariff manuals. Incremental cost-effectiveness ratios were estimated and probabilistic and deterministic sensitivity analysis was used for clinical variables, costs and the model's assumptions. Results Thoracoscopic thymectomy was the most effective and least costly strategy and dominated the other two alternatives. The cost per life year gained was Col § 1 129 531 without discount and Col § 805 179 with discount. Univariate sensitivity analysis showed that the main variables affecting the results were the effects' discount rate, the cost of a myasthenic crisis and the probability of complete remission. Thoracoscopy thymectomy was the most cost-effective strategy for different thresholds of willingness to pay in probabilistic analysis. Conclusions Thoracoscopic thymectomy is a cost-effective strategy in the treatment of MG without thymoma.

Objetivo Evaluar la costo efectividad de las timectomía abierta y toracoscópica frente a la terapia mé,dica en el manejo de miastenia gravis sin timoma. Mé,todo Se construyó un modelo de Markov para evaluar la costo efectividad de las 3 estrategias. Las probabilidades de transición se obtuvieron de la literatura. Los costos se estimaron a partir de las tarifas oficiales. Se calculó la costo-efectividad incremental. Se realizaron análisis de sensibilidad probabilísticos y determinísticos para las variables clínicas, los costos supuestos del modelo. Resultados La timectomía toracoscópica es la estrategia más efectiva y menos costosa, y domina a las otras dos alternativas. El costo por año de vida ganado fue de § 1 129 531 y § 805 179 pesos colombianos, con y sin descuento. El análisis de sensibilidad univariado mostró que las principales variables que afectan los resultados son la tasa de descuento, el costo de una crisis miasté,nica y la probabilidad de remisión completa. En el análisis de sensibilidad probabilístico, la timectomía toracoscópica es la estrategia costo-efectiva para los diferentes umbrales de disponibilidad a pagar. Conclusiones La timectomía toracoscópica es una estrategia costo-efectiva en el tratamiento de miastenia gravis sin timoma.

Thymoma Associated with Myasthenia Gravis in Infancy.

Thymomas are associated with various autoimmune disorders in adults, most commonly with myasthenia gravis (MG). In MG antibodies developed against acetylcholine (ACh) receptors, resulting weakness of muscle after repeated use and recovery following a period of rest. However, MG due to thymoma is extremely rare in pediatric age group.1We report an infant with MG due to invasive thymoma.

Transsternal Maximal Thymectomy is Effective for Extirpation of Cervical Ectopic Thymic Tissue in the Treatment of Myasthenia Gravis

PURPOSE: Extensive extirpation of cervico-mediastinal adipose tissue increases the chance of removing ectopic thymic tissues, thus potentially improving the prognosis of myasthenia gravis after thymectomy. We sought to increase efficacy and safety of transsternal maximal thymectomy (TSMT). MATERIALS AND METHODS: Twenty four patients who underwent TSMT from July 2006 to June 2007 were retrospectively reviewed and compared with 73 patients who underwent transsternal extended thymectomy (TSET) from January 2004 to May 2006. Ectopic thymic tissue in additionally excised cervicomediastinal fat tissue was examined histologically. RESULTS: In TSMT group, operation time, amount of cumulative drainage and duration of drainage were significantly higher than TSET group. However, the difference in hemoglobin count, amount of transfusion, duration of intensive care, postoperative hospital stay, and complication rates were not statistically different. There was no operative mortality in either group. Ectopic thymic tissue was found in 50% of patients. All patients had ectopic thymic tissues in the cervical area. Two patients had additional ectopic tissue in the aortopulmonary window, and 1 patient had ectopic tissue at posterior of the left bracheocephalic vein and lateral of the right phrenic nerve. CONCLUSION: TSMT is more effective in the extirpation of ectopic thymic tissues than TSET without significant impairment of safety, especially in the cervical area.

Anesthesia for thoracoscopic thymectomy: modified non-muscle relaxant technique: case reports

Anesthesia for thymectomy in myasthenia gravis is challenging. The anesthetic experience of that technique is quite large. It involves either muscle relaxant or non-muscle relaxant techniques. However, the literature is deficient of st and ard anesthetic technique for thoracoscopic thymectomy. Therefore we present in this report a modified non-muscle relaxant technique for thoracoscopic thymectomy [TT]. We report two cases who underwent TT under general anesthesia using sufentanil and propofol for induction and local anesthesia spray to the vocal cords to facilitate endobronchial intubation using non-muscle relaxant technique. The intubating, operating and postoperative conditions were excellent. To the best of our knowledge, this is the first report on modified non-muscle relaxant technique for TT in myasthenia gravis. Further cases have to be done to verify our technique

Video-assisted thoracoscopic versus transsternal thymectomy for myasthenia gravis: our early experience

Thymectomy is an accepted surgical modality of therapy for patients with myasthenia gravis. This study aimed at examining the thoracoscopic and transsternal approaches and to compare their surgical outcomes. A prospective cohort study of twenty patients with myasthenia gravis who underwent thymectomy between November 2003 and October 2004. Ten patients [50%] had thoracoscopic surgery while the other ten patients underwent resection by the transsternal route. The patients were followed up for twelve months. Statistical significance was determined by the Student t test or the Fisher's Exact Test. The thoracoscopic group had a mean operating time of 65.5 minutes compared to 76.3 minutes in the transsternal group [P=0.004]. The mean postoperative tube drainage was 54.5 mIs in the thoracoscopic group while it was 118.3 mls in the transsternal group [P=0.0001]. Surgical site infection was the most common complication in the transsternal group occurring in 30% of patients compared to 0% in the thoracoscopic group [P=0.05]. While four patients in the thoracoscopic group [40%] were in remission at 12 months, there were three [30%] in the transsternal group though this was not significant [P=0.23]. Thymectomy through the thoracoscopic approach is a safe and prefecred option for non-thymomatous myasthenia gravis as well as for very small encapsulated thymomas due to the shorter operating time, low complication rates and shorter hospital stay. However, both thoracoscopic and the transsternal routes achieved similar response rates in the short-term

Resultado da timectomia ampliada no tratamento de pacientes com Miastenia gravis / Extended thymectomy for treating patients with Myasthenia gravis (MG)

INTRODUÇAO: Diversas variações da timectomia podem ser realizadas, dentre elas a transesternal ampliada. A literatura sugere que, quanto mais extenso o procedimento para ressecção da glândula e tecidos do mediastino anterior, melhores os resultados e prognóstico. OBJETIVO: Avaliar retrospectivamente a resposta à timectomia ampliada em portadores de Miastenia gravis. MÉTODO: Foram avaliados 46 portadores de Miastenia gravis, submetidos à plasmaferese pré-operatória e à timectomia ampliada, entre agosto de 1992 e janeiro de 2003, divididos em três grupos, segundo o tempo decorrido desde o início dos sintomas: menor que 12 meses, 13 a 24 meses e maior que 25 meses. RESULTADOS: Trinta e um pacientes eram do sexo feminino e 15 do masculino. A média de idade foi de 30 anos. O tempo médio de evolução da doença foi de 26,3 meses. O acompanhamento ambulatorial pós-operatório foi em média de 26,6 meses. Quanto ao grau de resposta à timectomia, 89 por cento dos pacientes tiveram boa resposta, sendo que 50 por cento apresentaram remissão completa. Ocorreu um óbito nesta série. O exame anatomopatológico demonstrou que a hiperplasia tímica foi o achado mais freqüente. Apenas 3 pacientes (6,5 por cento) apresentaram timomas benignos. Em 5 pacientes (10,8 por cento) encontramos tecido tímico extraglandular: na gordura peritímica em 2 deles, na gordura pericárdica em 1, junto ao nervo frênico esquerdo em outro e na janela aorto-pulmonar em outro. CONCLUSAO: A timectomia ampliada para tratamento da Miastenia gravis mostrou-se segura, eficiente, e apresentou alta porcentagem de remissão completa. Houve a detecção de tecido tímico extraglandular em alguns pacientes. Tão logo seja feito o diagnóstico, está indicada como terapêutica associada à plasmaferese pré-operatória e à medicamentosa, independentemente da idade, patologia tímica, e início dos sintomas.