Mid-term results of thoracoscopic thymectomy for myasthenia gravis.

CONTEXT: Video-assisted thoracic surgery (VATS) has been proposed as a less invasive technique for treatment of myasthenia gravis. MATERIALS AND METHODS: A total of 31 patients underwent a right-sided VATS to remove all anterior mediastinal fat and thymic tissue during a 4-year period in our institution. None of the patients had associated thymoma. RESULTS: All procedures were performed successfully with no conversion to sternotomy. The mean operating time was 190 minutes. The median intubation time and assisted ventilation were 24 and 18 hours, respectively. The median ICU and hospital stays were 3 and 7 days, respectively. The median time for post-operative chest drainage was 48 hours. There was no perioperative mortality. Eight significant complications occurred. One patient had atelectasis, 1 patient had aspiration pneumonia, and 3 patients had postoperative myasthenic crisis and required prolonged mechanical ventilation. Other complications were granuloma of the vocal cord, right recurrent laryngeal nerve palsy, and temporary brachial plexus injury due to poor intraoperative positioning. The mean length of follow-up was 20 months (range: 3-42 months). Overall, 27 patients (87%) had improved clinically and 11 patients (35%) had complete remission. The resulting scars were cosmetically acceptable for all patients. CONCLUSION: VATS provides an effective alternative approach to thymectomy and has several advantages over open techniques. VATS causes minimal postoperative complications, shortens hospital stay, and gives better cosmetic results.

Minimal access mediastinal surgery: One or two lung ventilation?

BACKGROUND: Minimal access mediastinal surgery (MAMS) is usually performed under general anaesthesia with double lumen tubes (DLT). The aim of this study is to evaluate two lung ventilation through single lumen tubes (SLT) during thoracoscopic sympathectomy for hyperhidrosis and thoracoscopic thymectomy for myasthenia gravis. METHODS: In this prospective non-randomized study, MAMS was performed in 58 patients with hyperhidrosis and 42 patients with myasthenia gravis, from January 2002 to December 2008. Patients were intubated with a DLT or SLT, 50 patients in each group. In the DLT group, endobronchial tubes were placed using the traditional blind approach and one lung ventilation was confirmed clinically. In the SLT group, the hemithorax was insufflated with CO2 in conjunction with two-lung anaesthesia. All the patients were evaluated for haemodynamic stability, oxygen saturation of haemoglobin (Spo2), end-tidal Pco2 (ETPco2), times required for intubation and surgery, satisfaction of surgeon with regard to exposure and postoperative complications. RESULTS: In the SLT group, all the patients had stable haemodynamic and ventilation parameters. In the DLT group, haemodynamic instability occurred in two, decrease in Spo2 in four and increase in ETPco2 in three patients. One patient in the DLT group developed vocal cord granuloma two months later. Time required for surgery and the surgeon's opinion with regard to exposure were similar for both groups. CONCLUSION: Thoracoscopic surgery when used in cases where a well-collapsed lung may not be essential, since surgery is not performed on the lung itself, does not require DLT. SLT is safe in MAMS. It provides good surgical exposure and decreases the cost, time and undesirable complications of DLT.