Inclusion of the transcervical approach in video-assisted thoracoscopic extended thymectomy (VATET) for myasthenia gravis: a prospective trial

  • N. Shigemura
  • H. Shiono
  • M. Inoue
  • M. Minami
  • M. Ohta
  • M. Okumura
  • H. Matsuda
Article
First Online:
Received:
Accepted:

Abstract

Background

Because evidence-based data regarding the quality of video-assisted thoracoscopic thymectomy for the treatment of myasthenia gravis are lacking, a prospective trial comparing three different operative approaches was conducted to evaluate their efficacy.

Methods

This prospective study enrolled 20 consecutive patients with nonthymomatous myasthenia gravis. A series of three approaches for bilateral video-assisted thoracoscopic extended thymectomy (VATET) using the anterior chest wall–lifting method (original), the original method with a flexed-neck position (modified), and the original method with a transcervical approach (final) were prospectively performed in each patient for quantitative and pathologic evaluation of the residual thymus after each approach.

Results

Complete VATET required 242 ± 48 min, with the transcervical procedure requiring 23 ± 12 min. After the modified method, the residual thymus in the cervical region was 1.5 cm in size and weighed 0.8 g (0.8% of the entire thymus), as compared with a size of 2.2 cm and a weight of 1.3 g (3.2%) after the original method. Each value is the result of comparison with the final method. Histopathologic studies showed residual tissue in the germinal center as well as Hassall’s corpuscles in more than 70% of cases.

Conclusion

The findings show that VATET without the transcervical approach could be an immunologically incomplete treatment for myasthenia gravis. Therefore, the transcervical approach should be included in VATET procedures to ensure radicality.

Keywords

Extended thymectomy Germinal center Myasthenia gravis Thoracoscopic Transcervical approach VATET VATS thymectomy 
This is a preview of subscription content, log in to check access.

References

  1. 1.
    Bramis J, Diamantis T, Tsigris C, Pikoylis, Papaconstantinou I, Nikolaou A, Leonardou P, Bastounis E (2004) Video-assisted transcervical thymectomy. Surg Endosc 18: 1535–1558PubMedCrossRefGoogle Scholar
  2. 2.
    Cooper J, Al-Jilaihawa A, Pearson F, Humphrey J, Humphrey HE (1988) An improved technique to facilitate transcervical thymectomy for myasthenia gravis. Ann Thorac Surg 45: 242–247PubMedCrossRefGoogle Scholar
  3. 3.
    Jaretzki A (1997) Thymectomy for myasthenia gravis: analysis of the controversies regarding technique and results. Neurology 48: S52–S63Google Scholar
  4. 4.
    Jaretzki A (2003) Thymectomy for myasthenia gravis: analysis of controversies—patient management. Neurology 9: 77–92Google Scholar
  5. 5.
    Jaretzki A, Barohn RJ, Erntoff RM, Kaminski HJ, Keesey JC, Penn AS, Sanders DB (2000) Myasthenia gravis: recommendations for clinical research standards. Neurology 55: 16–23PubMedGoogle Scholar
  6. 6.
    Jaretzki A, Wolff M (1988) Maximal thymectomy for myasthenia gravis: surgical anatomy and operative technique. J Thorac Cardiovasc Surg 96: 711–716PubMedGoogle Scholar
  7. 7.
    Joseph BS, Johns TR (1973) Recurrence of nonneoplastic thymus after thymectomy for myasthenia gravis: report of two cases. Neurology 23: 109–116PubMedGoogle Scholar
  8. 8.
    Mack MJ, Landreneau RD, Yim AP, Hazelrigg SR, Scruggs GR (1996) Results of video-assisted thymectomy in patients with myasthenia gravis. J Thorac Cardiovasc Surg 112: 1352–1360PubMedCrossRefGoogle Scholar
  9. 9.
    Masaoka A, Monden Y (1981) Comparison of the results of transsternal simple, transcervical simple, and extended thymectomy. Ann N Y Acad Sci 377: 755–765PubMedGoogle Scholar
  10. 10.
    Masaoka A, Monden Y, Seike Y, Tanioka T, Kagotani K (1982) Reoperation after transcervical thymectomy in myasthenia gravis. Neurology 32: 83–85PubMedGoogle Scholar
  11. 11.
    Masaoka A, Yamakawa Y, Niwa H, Fukai I, Kondo S, Kobayashi M, Fujii Y, Monden Y (1996) Extended thymectomy for myasthenia gravis patients: a 20-year review 62: 853–859Google Scholar
  12. 12.
    Miller RG, Filler-Katz A, Kiprov D, Roan R (1991) Repeat thymectomy in chronic refractory myasthenia gravis. Neurology 41: 923–924PubMedGoogle Scholar
  13. 13.
    Mineo TC, Pompeo E, Lerut TE, Bernardi G, Coosemans W, Nofronti I (2000) Thoracoscopic thymectomy in autoimmune myasthenia: results of left-sided approach. Ann Thorac Surg 69: 1537–1541PubMedCrossRefGoogle Scholar
  14. 14.
    Ohta M, Hirabayashi H, Okumura M, Minami M, Matsuda H (2003) Thoracoscopic thymectomy using anterior chest wall lifting method. Ann Thorac Surg 76: 1310–1311PubMedCrossRefGoogle Scholar
  15. 15.
    Okumura M, Ohta M, Takeuchi Y, Shiono H, Inoue M, Fukuhara K, Kadota Y, Miyoshi S, Fujii Y, Matsuda H (2003) The immunologic role of thymectomy in the treatment of myasthenia gravis: implication of thymus-associated B-lymphocyte subset in reduction of the anti-acetylcholine receptor antibody titer. J Thorac Cardiovasc Surg 126: 1922–1928PubMedCrossRefGoogle Scholar
  16. 16.
    Ruckert JC, Czyzewski D, Pest S, Muller JM (2000) Radicality of thoracoscopic thymectomy: an anatomical study. Eur J Cardiothorac Surg 18: 735–736PubMedCrossRefGoogle Scholar
  17. 17.
    Ruckert JC, Sobel HK, Gohring S, Einhaupl KM, Muller JM (2003) Matched-pair comparison of three different approaches for thymectomy in myasthenia gravis. Surg Endosc 17: 711–715PubMedCrossRefGoogle Scholar
  18. 18.
    Ruckert JC, Walter M, Muller JM (2000) Pulmonary function after thoracoscopic thymectomy versus median sternotomy for myasthenia gravis. Ann Thorac Surg 70: 1656–1661PubMedCrossRefGoogle Scholar
  19. 19.
    Scelsi L, Novellino L, Mantegazza R, Comelio F, Porta M, Longoni C, Pezzuoli G (1996) Detection and morphology of thymic remnants after video-assisted thoracoscopic thymectomy (VATET) in patients with myasthenia gravis. Int Surg 81: 14–17PubMedGoogle Scholar
  20. 20.
    Shiono H, Fujii Y, Okumura M, Takeuchi Y, Inoue M, Matsuda H (1997) Failure to downregulate Bcl-2 protein in thymic germinal center B cells in myasthenia gravis. Eur J Immunol 27: 805–809PubMedGoogle Scholar
  21. 21.
    Sims GP, Shiono H, Wilcox N, Scott DI (2001) Somatic hypermutation and selection of B cells in thymic germinal centers responding to acetylcholine receptor in myasthenia gravis. J Immunol 15: 1935–1944Google Scholar
  22. 22.
    Yim AP, Kay RL, Ho JK (1995) Video-assisted thoracoscopic thymectomy for myasthenia gravis. Chest 108: 1440–1443PubMedGoogle Scholar
  23. 23.
    Younger D, Worrall BB, Penn AS (1997) Myasthenia gravis: historical perspective and overview. Neurology 48: S1–S7Google Scholar
  24. 24.
    Zielinski M, Kuzdzal J, Szlubowski A, Soja J (2004) Comparison of late results of basic transsternal and extended transsternal thymectomy in the treatment of myasthenia gravis. Ann Thorac Surg 78: 253–258PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, Inc. 2006

Authors and Affiliations

  • N. Shigemura
    • 1
  • H. Shiono
    • 1
  • M. Inoue
    • 1
  • M. Minami
    • 1
  • M. Ohta
    • 2
  • M. Okumura
    • 1
  • H. Matsuda
    • 1
  1. 1.Department of SurgeryOsaka University Graduate School of MedicineSuitaJapan
  2. 2.The Division of Thoracic SurgeryNational Kinki-Chuo Hospital for Chest DiseasesJapan

Personalised recommendations