Robotic-assisted thymectomy: surgical procedure and results.

BACKGROUND: Thymectomy is an essential component in the treatment of myasthenia gravis (MG) and the best treatment for localized thymoma. Minimally invasive thymectomy has advanced to include robotic-assisted techniques. The acceptance of this approach is growing rapidly, while the debate on the adequate technique for thymectomy remains open. METHODS: We describe the technique of robotic-assisted thymectomy and its modifications. The worldwide registries and the literature are reviewed. The experience from the largest single-center database is analyzed. RESULTS: The unilateral three-trocar approach for robotic thymectomy from either left or right side has been standardized. More than 100 centers worldwide perform robotic thymectomy. The annual number of this procedure increased steadily and reached 1,000 in 2012, while the largest single-center experiences comprise almost 500 cases. The end points improvement of MG and recurrence of thymoma are comparable to open procedures. There are special advantages of robotic assistance for complete mediastinal dissection. The perioperative complication rate is below 2%. CONCLUSION: Robotic thymectomy combines minimal incisional discomfort with extensive mediastinal dissection. As its use expands, robotic thymectomy may become the standard for all indications of thymectomy.

Surgery of the thymus in Japan.

The thymus has long been an organ of mystery. Today, it is known to be central to the construction of our immune system. I focus on the days when no one was sure what the thymus's function was. I review the Japanese literature regarding the beginnings of surgery of the thymus, especially the surgery for thymoma and thymectomy, which was performed as a treatment for myasthenia gravis.

[The history of thymus surgery]. / Die Geschichte der Thymuschirurgie.

Thymus surgery was initially dominated by the erroneous interpretation of the organs' pathogenicity and associated thymus diseases. Misleadingly, the thymus gland was made responsible for dyspnoea in children and a transcervical ektropexia was performed in a child suffering from dyspnoea in 1896. After F. Sauerbruch's thymectomy in a patient with myasthenia gravis syndrome (MG), A. Blalock established thymectomy in the 1940s for the treatment of MG. At the same time, the drug treatment initiated by M.B. Walker increased in significance. Despite progress in surgical techniques and the molecular understanding of MG pathogenesis, randomized controlled trials, which would increase the evidence for surgical access and indications for surgery compared to immunosuppressive treatment in MG, are lacking.

[Sir Geoffrey Keynes 1887-1982. Surgical pioneer, medical historian, humanist]. / Sir Geoffrey Keynes 1887 - 1982. Kirurgisk pionjär, medicinhistoriker, humanist.

Sir Geoffrey Keynes (1887 - 1982), was a pioneer in the surgery of breast cancer and thymic deseases, n.b. in patients suffering from myastenia gravis. He strongly disapproved of the longstanding dogma of so called radical mastectomy in breast cancer, and advocated a more limited surgical approach, followed by radiation therapy. This was done more than fifty years before breastconserving surgery has become the therapy of choice and against considerable opposition from the surgical establishment of his days. He also became a pioneer in the surgical treatment of myastenia gravis by thymectomy, at a time when there was no real understanding of the pathophysiology of the disease and when considerable controversy existed as to the importance or non importance of concomitant tumour formation in the thymus. Besides being a busy surgeon Sir Geoffrey was a medical historian, writing the biography of among others William Harvey, a bibliographer with a special interest in the poet and artist William Blake and a bibliophil with a large book collection of great value to medical history.

A history of treatments for myasthenia gravis.

Much of the improvement in the treatment of myasthenia gravis (MG) over the past 125 years can be attributed to the effectiveness of general medical measures such as advances in respiratory care and the discovery of antibiotics. Although MG became the model of an antibody-mediated autoimmune disease in the 1970s (the most documented antigen being the muscle acetylcholine receptor at the neuromuscular junction), the pathogenesis of MG has not been the rationale for most treatments found to be useful for this disease. The serendipitous benefit of anticholinesterases for MG in the 1930s subsequently focused attention on the neuromuscular junction. The beginnings of the controversy over thymectomy for MG in the 1940s and 1950s preceded the discovery in 1960 of the function of the thymus. Before the autoimmune pathogenesis of MG was known, adrenocorticotropic hormone (ACTH) and steroids for MG were tried for reasons that turned out to be incorrect. Further immunosuppressive treatments for MG were largely empirical, following their use in organ transplantation and other autoimmune diseases. More specific treatments, based on our knowledge of pathogenesis, are still experimental but hopefully will be the history of the future.

[Forty-year experience of surgical treatment of generalized myasthenia]. / Sorokaletnii opyt khirurgicheskogo lecheniia generalizovannoi miastenii.

Forty-year experience with surgical treatment of generalized myasthenia (GM) based on 2977 cases is analyzed. Role of special methods of mediastinum examination (CT, MRT) is demonstrated, indications to thymectomy are validated. It is noted that developed diagnostic algorithm, surgical technique, management before and after surgery improved significantly immediate and long-term results. Development of clinical, immunological and morphologic criteria of thymectomy effect permitted to predict course of GM and to optimize complex therapy after surgical treatment.

[Surgery of the thymus]. / A thymus sebészete.

On the occasion of the 50th anniversary of Gyula Sebestény's death, an overview was prepared on the surgery of the thymic gland that was closely connected to his thoracic surgical activity. His results with thymectomy in myasthenia gravis were published as the second study on this topic in Europe and the first in Hungary. The early thymic surgery was based on pathological observations. Myasthenia gravis, a well-known disease for long, occurred frequently with pathological lesions of the thymus. Autopsies suggested potential causative relationship. The early period of thymic surgery was characterised by sporadic interventions and high mortality. The new period of the thymic surgery started with the American Blalock's 20 operations, and accomplished by the operative activity of Keynes including 281 thymectomies. They were followed by many European, American and Asian surgeons. Even today, there are many hotly debated topics, like indication and type of operation, prognostic factors, perioperative care, diagnosis, treatment and pathology of the thymic tumor. With fine-tuning the indication, the development of operation techniques, neurology, anaesthesiology and intensive care, imaging techniques and oncology and with introduction of new drugs the early and late results are improving. Thanks to Dr. Sebestény, Hungarian thoracic surgeons joined early the international thoracic surgical activities. Currently in Hungary there are two major centers for myasthenia gravis surgery, and all important thoracic surgical departments in the country treat thymic tumor cases.

The history of surgery of the thymus gland.

The history of surgery of the thymus gland is presented through highlights and landmark publications ranging from prehistoric times to the present day. The evolution of surgical techniques includes transcervical and transthoracic thymectomy along with other techniques such as current thoracoscopic VATS procedures. The significance of myasthenia gravis, autoimmunity, thymic oncology, adjuvant developments, and speculation on the future is discussed.

Uso de opioides transoperatorios y ventilación mecánica postoperatoria prolongada, en timectomía transesternal para miastenia gravis

El manejo anestésico del paciente con miastenia gravis a quien se realiza timectomía, es un tema sobre el cual hay aún aspectos controvertidos. En el caso particular de la administración transoperatoria de opioides, algunos autores han argumentado, sin que exista documentación al respecto, que su administración excesiva puede conducir a un prolongado soporte ventilatorio postoperatorio, recomendando el uso de estos en dosis pequeñas, algunas veces insuficientes para alcanzar una alagesia postoperatoria óptima. Para establecer la existencia de asociación entre el uso de opioides y ventilación mecánica prolongada en pacientes miasténicos sometidos a timectomía, se obtuvo información de las historias clínicas y registros anestésicos de 69 pacientes con miastenia gravis sometidos a timectomía transesternal. La relación entre los potenciales predictores de ventilación mecánica postoperatoria prolongada y el desenlace de interés se evaluó en forma univariable, usando como medida de asociación el riesgo relativo y en forma multivariable, con análisis de regresión logística. El impacto de la administración del opioide se evaluó mediante la prueba t de student. Se encontró que la dosis promedio del opioide no fue diferente entre los dos grupos de pacientes (1.9 mg.kg(1) entre los extubados antes de tres horas y 2.2 mg.kg(1) entre los que recibieron ventilación mecánica postoperatoria prolongada p=0.44). El riesgo relativo (indirecto) debido al uso de fentanyl no fue clínica ni estadísticamente significativo; sin embargo las diferencias encontradas en las variables, capacidad vital menor de 2.9 Lt. y evolución de la miastenia mayor de seis años, si se consideraron clínicamente significativas, siendo esto concordante con los hallazgos de Leventhal(2)

The thymus: maestro of the immune system.

The thymus has been an enigmatic organ for centuries. Its true function was revealed only in 1961 when it was shown to be responsible for the proper development of the immune system. This finding has revolutionized the science of immunology and has led to a better understanding of the mechanisms involved in resistance to infections and of the pathogenesis of autoimmune and immunodeficiency diseases.

Alfred Blalock and thymectomy for myasthenia gravis.

In 1936, Alfred Blalock performed the successful removal of a thymic tumor in a patient with myasthenia gravis. The patient experienced marked and sustained improvement for several years. Blalock prophesized then that exploration of the thymic region would be indicated in all patients with severe myasthenia gravis. A few years later, in 1941, he applied this theory by introducing thymectomy for nonthymomatous myasthenia and achieved similar improvement. Despite modern sophisticated knowledge about the disease and advances in thoracic surgical techniques, Blalock's original observations remain valid, and thymectomy has become a standard treatment for myasthenia gravis the world over.