ObjectiveTo analyze the research hotspots and progress of surgical treatment of myasthenia gravis. MethodsThe top 100 most cited articles on surgical treatment of myasthenia gravis were identified by searching the Web of Science database, and a bibliometric analysis was conducted. ResultsThe publication year of the top 100 most cited articles ranged from 1939 to 2021, and the number of citations ranged from 55 to 850 per article. Most of the included articles were original research articles (75/100), which were mainly retrospective studies (64/75). The United States was the country with the most published articles and most citations, and Annals of Thoracic Surgery was the most sourced journal (n=20). Through VOSviewer analysis, high-density keywords were thymectomy, maximal thymectomy, extended thymectomy, transcervical thymectomy, thymoma, and autoantibodies. ConclusionThe scope of surgical resection, surgical approach and pathogenesis are the current hotspots in the field of surgical treatment of myasthenia gravis. It is hoped that this paper can provide references for future researches in this field.
Myasthenia gravis (MG) is an autoimmune disease with indefinite pathogenesis. MG is closely related to thymic diseases, and thymectomy is an important way for MG treatment. However, there are some controversies regarding thymectomy, including indications, operation opportunities, operative procedures, surgical approaches, perioperative managements, and efficacy evaluations, etc. Therefore, based on the literature and the experience of Chinese experts, this consensus has been written after careful discussion and inquiry and 29 recommendations have been made, aiming to guide surgical treatment of MG and improve the clinical outcomes.
Objective To compare and analyze the occurrence of acute and chronic pain after subxiphoid and transcostal thoracoscopic extended thymectomy. MethodsA retrospective analysis was performed on 150 patients who underwent thoracoscopic extended thymectomy in our hospital from July 2020 to June 2022, among whome 30 patients received subxiphoid video-assisted thoracic surgery, and 120 patients received transcostal video-assisted thoracic surgery. The patients were matched by the propensity score matching method. Postoperative pain was evaluated by numeric rating scale (NRS). The intraoperative conditions and postoperative pain incidence were compared between the two groups. ResultsAfter matching, 60 patients were enrolled, 30 in each group, including 30 males and 30 females with an average age of 50.78±12.13 years. There was no difference in the general clinical data between the two groups (P>0.05), and no perioperative death. There were statistical differences in the intraoperative blood loss, postoperative drainage volume, postoperative catheter duration, postoperative hospital stay, postoperative pain on 1 d, 2 d, 3 d, 7 d, 3 months and 6 months after the surgery (P<0.05), but there was no statistical difference in the operation time or the postoperative 14 d NRS score (P>0.05). Further univariate and multivariate analyses for postoperative chronic pain showed that surgical method and postoperative 14 d NRS score were risk factors for chronic pain at the 3 months and 6 months after the surgery (P<0.05). Conclusion The subxiphoid thoracoscopic extended thymectomy has advantages over transcostal thoracoscopic surgery in the postoperative acute and chronic pain.
ObjectiveTo analyze the risk factors for post-thymectomy myasthenic crisis (PTMC) and prolonged mechanical ventilation, in myasthenia gravis patients who underwent extended thymectomy. MethodsWe retrospectively analyzed the clinical data of 79 patients including 38 males and 41 females who experienced PTMC and required mechanical ventilation in Daping Hospital between June 2008 and November 2014. Single factor analysis and multivariate analysis were conducted. ResultsMorbidity of PTMC was 20.6% (79/384). Result of single-factor analysis showed that postoperative pneumonia was one of the main reasons of prolonged mechanical ventilation (P < 0.05). Result of multiple-factor analysis showed that the operation time was positively correlated with mechanical ventilation time (P < 0.05). The risk factor of prolonged mechanical ventilation time in PTMC was not associated with sex, age, disease history, myasthenic crisis history, Osserman classification, dosage of pyridostigmine before and after the operation, surgical approach, bleeding volume, other therapies besides mechanical ventilation (P > 0.05). ConclusionMechanical ventilation is one the main therapy of PTMC, operation time, and postoperative pneumonia are the main factors to prolong mechanical ventilation time. In order to decrease morbidity of PTMC and shorten mechanical ventilation time, the operation time should be controlled and pulmonary infection should be avoided.
ObjectiveTo investigate the perioperative safety of patients with myasthenia gravis who take high doses of oral corticosteroids. MethodsA retrospective analysis was conducted on the clinical data of patients with myasthenia gravis who received oral corticosteroids and underwent thoracoscopic thymectomy at the Department of Thoracic Surgery, the University of Hong Kong-Shenzhen Hospital from April 2013 to October 2019. Patients were divided into a high-dose steroid group and a medium-to-low dose steroid group based on the dosage of oral steroids, and the clinical data of the two groups were compared. ResultsA total of 102 patients were included, including 19 (18.62%) males and 83 (81.37%) females, with an average age of (32.25±9.83) years. All patients in both groups successfully completed the surgery without major intraoperative bleeding, conversion to open chest surgery, delayed extubation, severe infection, or perioperative death. The daily oral steroid dose for the high-dose steroid group was (35.81±4.29) mg, and for the medium-to-low dose steroid group it was (15.29±2.17) mg. There was no statistical difference in the operation time [(124.69±23.51) min vs. (117.89±21.46) min, P=0.172] and intraoperative blood loss [(21.19±3.48) mL vs. (20.56±3.41) mL, P=0.419] between the two groups. Postoperatively, 12 (11.76%) patients developed complications: one patient of myasthenic crisis (medium-to-low dose steroid group), which was improved after short-term respiratory support and intravenous immunoglobulin treatment; 11 patients of respiratory/swallowing difficulties (9 in the low-dose steroid group and 2 in the high-dose steroid group), which were improved after anticholinergic treatment to reduce oral secretions and sputum suction, and the patients were discharged smoothly. There was no statistical difference in the incidence of postoperative complications between the two groups (P=0.637). ConclusionOn the basis of good perioperative management, it is safe and feasible for patients with myasthenia gravis who take high dose of oral steroids to undergo thymectomy, and they have the same perioperative safety as patients with medium-to-low dose steroids.
Thymectomy is the main treatment for thymoma and other thymic diseases. But the incidence of non-therapeutic thymectomy is high due to the difficulty in the differential diagnosis of anterior mediastinum lesions. Formerly, it was believed that the thymus gradually degraded and lost function with aging, and the preservation of the thymus was not valued. Recent studies have found that the removal of the thymus at all ages has adverse effects on overall health and leads to a significant increase in the risk of autoimmune diseases, malignancy, and all-cause mortality. Therefore, unnecessary thymectomy should be avoided. This article reviews the influence of thymectomy, including the changes of immunological indexes and clinical prognosis, and further discusses the current situation and avoidance methods of non-therapeutic thymectomy.
ObjectiveTo investigate the clinical characteristics of uniportal and three-port subxiphoid video-assisted thoracoscopic surgery (XVATS) extended thymectomy.MethodsThe clinical data of 60 consecutive patients of XVATS thymectomy in Xuzhou Central Hospital from January 2017 to May 2019 were retrospectively analyzed. There were 29 males and 31 females, with an average age of 53.1 (27.0-76.0) years. The patients were divided into an uniportal XVATS group (30 patients) and a three-port XVATS group (30 patients). The clinical effectiveness was compared between the two groups.ResultsThere was no significant difference in age, sex, body mass index, tumor size, intraoperative blood loss, postoperative time of thoracic tube indwelling and thoracic drainage, or postoperative hospitalization time between the two groups (P>0.05). There was no perioperative mortality, conversion to thoracotomy, thrombosis or mediastinal infection. The operation time of the uniportal XVATS group was significantly longer than that of the three-port group (87.5±19.0 min vs. 75.8±15.7 min, P=0.012). Besides, patients in the uniportal group had significantly lower pain score during 3-14 postoperative days than that of the three-port group (P=0.001).ConclusionUniportal XVATS extended thymectomy is feasible with less pain as compared with the patients using three-port XVATS, but it needs longer operation time at initial stage.
Objective To assess the long-term results and relevant influencing factors of extended thymectomy and medicine-alone treatment of non-thymomatous myasthenia gravis (MG) patients. Methods We retrospectively analyzed the clinical data of 174 patients with non-thymomatous MG diagnosed and treated in our department from December 2009 to April 2017, including 81 males and 93 females, aged 13-88 (47.1±17.8) years. According to the different treatment methods, the patients were divided into two groups: an operation group (91 patients receiving extended thymectomy) and a medicine-alone group (83 patients receiving medical therapy alone). The efficacy was evaluated according to the Myasthenia Gravis Foundation of America (MGFA). Survival curves of the patients were plotted using the Kaplan-Meier method to evaluate the remission rate and survival rate. Cox regression analysis was used to assess the influencing factors of the outcomes. Results The patients were followed up for 3 to 94 (39.1±26.9) months. As a result, 29 patients (31.9%) achieved complete remission in the surgery group and 13 patients (15.7%) were completely relieved in the medicine-alone group (P=0.014). Further analysis showed that treatment pattern (P=0.018) and MG type (P=0.021) were the main factors related to the efficacy. Conclusion For patients with non-thymomatous MG, extended thymectomy is superior to the medicine-alone in terms of complete remission rate and the postoperative immunosuppression ratio.
ObjectiveTo analyze the risk factors of myasthenia gravis crisis after thymectomy with myasthenia gravis (MG).MethodsSixty-five myasthenia gravis patients who had myasthenia crisis after thymectomy in Xuanwu Hospital, Capital Medical University from June 2006 to June 2019 were retrospectively enrolled, including 31 males and 34 females, aged 15-78 (45.7±17.8) years. The relationship between myasthenia crisis after thymectomy and surgical option, operation time, pathological type, et al. were anylyzed.ResultsOperation time and pathological type were the predictive factors of postoperative myasthenic crisis. The area under receiver operating characteristic curve (AUC) of MG type (Osserman) was 0.676, the cut-off value wasⅡB type, the sensitivity was 37.5%, the specificity was 90.5%, and the Youden’s index was 0.280. The AUC of thymoma stage (Masaoka) was 0.682, cut-off value was stageⅡ, sensitivity was 62.5%, specificity was 66.7%, and Youden’s index was 0.292. The AUC of blood loss was 0.658, the cut-off value was 90 mL, the sensitivity was 87.5%, the specificity was 69.6%, and the Youden’s index was 0.304.ConclusionPreoperative MG classification, pathological type, operation time and blood loss are the risk factors of postoperative myasthenic crisis. Therefore, adequate preoperative preparation, rapid and careful intraoperative operation and active postoperative management can reduce the occurrence of postoperative myasthenic crisis.
Myasthenia gravies is a common disease in the clinic. Extended thymectomy is an important way to treat myasthenia gravis. Median thoracotomy, thoracoscopy, and robots are important surgical methods. Da Vinci robot-assisted thoracoscopic surgery is more and more widely used in extended thymectomy, with high surgical safety and good stability. The surgical approach includes intercostal approach, subxiphoid approach, etc. Different surgical approaches have their own advantages, and their surgical effects are different. This article introduces the indications, technical steps, and effects of da Vinci robot-assisted thoracoscopic surgery, analyzes the advantages and limitations of treating myasthenia gravis, and looks forward to its development prospects.