VATS Thymectomy- Better Approach

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Journal Club

Video Assisted Thoracic Surgery Thymectomy:

The Better Approach

Calvin S H, Y P Wan and Anthony P C YIM

Division of Cardiothoracic Surgery, Prince of Wales Hospital,

The Chinese University if Hong Kong, Shatin, N.T., Hong Kong SAR

CHINA

Presented by RAM KUMAR SHRESTHA

Ann Thorac Surg 2010;89



History of Thymectomy

1911 Ferdinand Sauerbruch 1st Thymectomy – Zurich

1944 Alfred Blalock- Johns Hopkins – reported

improvement in MG patients after resection of normal

Thymus

Thymectomy + medical therapy – Mx of MG

Pascuzzi R. The history of myasthenia gravis. Neurol Clin 1994;12



Literature Review

Meta analysis of 28 controlled studies

Twice likely to attain medicine free remision 1.6 times more likely to become asymptomatic

1.7 times more likely to improve

MG patients undergoing Thymectomy

Gronseth GS, Barohn RJ. Practice Parameter: thymectomy for autoimmune MG(an evidence based review) Neurology 2000;55



Surgical Approaches

Open Thymectomy Technique

Median Sternotomy Transcervical (Minimally invasive approach)

Combined Transcervical with median

Sternotomy (T-incision)

Partial Sternotomy



Minimally Invasive Technique

Thoracoscopic Approach

VATS (unilateral) Thymectomy VATS extended Thymectomy

Endoscopic Robot-assisted thymectomy



Acceptance of Minimally Invasive technique

Low Procedural morbidity and mortality

Improved cosmesis

Lesser degree of access trauma and Post-op pain

Equivalent efficacy ?



Guidelines and controversies

Thymectomy for young patients with generalised MG

?? Role of Thymectomy

In MG patients with ocular symptoms only Ocular MG less likely respond to Thymectomy

Better prognosis even without thymectomy

30-70% ocular MG eventually generalized



VATS Thymectomy - Technique

Right sided approach 3 port technique

PAL in front of tip of scapula – 10mm port (0 or 30

degree telescope)

MAL 3rd ICS 5 mm instrument port

AAL 6th ICS 5 mm instrument port

Complete resection Brachiocephalic vein – skeletonized

Junction to form SVC clearly visualised



Limitation of VATS Thymectomy

Pleural Symphysis

Severe Lung disease or poor lung function

Very young Children



RESULTS

Duration of Study: 1992 to 2010

Total VATS Thymectomies: 64

Conversion: 2

4 Thymectomies were for other Conditions

8 VATS Thymectomies for Thymoma

Total VATS Thymectomies for nonthymomatous MG:

522 lost to follow up

Complete Data available for 50 patients.



Demography

50 patients (34 female, 16 male)

Mean age 31.6 years (9-75)

Mean duration of disease 29.1 month ( 2-204)

Prior Medications:

Anticholinesterase 100%Steroid 66.3%



MGFA Classification

class No of patients

I 13

IIA 16IIB 4

IIIA 7

IIIB 2

IV 2

V 8



Mean Operative duration:103 minutes (52-150)

No surgical mortality

Extubation within 24 hours except in 3 patients

Down syndrome with hx of asthma with post op

pneumonia

Already on mechanical ventilation prior to surgeryMultiple flare up requiring intubation within last 1

year



Final Pathology

Hyperplastic Thymus 30

Atrophic Thymus 8

Normal Thymus 12

Thymolipomas 2



MGFA Post Intervention Status

Complete Stable Remission CSR 12 (23.1%)

Pharmacologic Remission PR

Minimal Manifestation MM

MM-0

MM-1

MM-2 12(23.1%)

MM-3 23 (44.2%)



Status Change

Improved (I) 46 (88.5%)

Unchanged (U) 4(7.7%)

Worse (W)

Exacerbation (E)

Died of MG (D of MG) 1(1.9%)



Discussion

Optimal treatment of MG

Extent of Thymectomy ??

Columbia-Presbysterian advocated en-bloc

thymectomy with ant. Mediastinal exenteration

Clinical improvement - no difference compared with

transsternal or transcervical approach alone

Ectopic thymus tissue – clinically not relevent

Jaretzki A etc al “maximal thymectomy for MG

Shrager JB et al “ Transcervial thymectomy for Mg achieves results comparable to Thymectomy by sternotomy”



Transcervical thymectomy

Reference SurgicalTechnique

Follow-upDuration

(yrs)

CompleteStable

Remission(%)

Bril et al (1998) Transcervical 8.4 44.2

DeFilippi et al(1994) Transcervical 5.0 43.0

Papatestas et al(1981) Transcervical 5.0 24.0

Shrager et al (2002) Transcervical 4.6 39.7

Cooper et al (1998) Transcervical 3.4 52.3



Maximal Thymectomy

Author Date Institute Cases, N RR PR

Olanow 1982 Durham 47 (nT+T) 61% (crude) 83%

Fischer 1987 Cincinnati 27 (nT+T) 63% (crude) 90%

Ashour 1995 Riyadh 48 (nT) 34.8% (crude) 86.8%

Bulkley 1997 Baltimore 127 (nT+T) 86%(5y)

Jaretzki 1997 New York72 (nT)15 (T)

46% (crude)13% (crude)



Transcervical vs VATSTranscervical VATS

quicker

Panoramic view of hemithorax

No crowding and sword

fighting of instruments

No need of double lumenintubation

Easier control of complications like bleeding

?out patient procedure

Completion Thymectomy,

search for residual thymictissue*

*Pompeo E Thorocoscopic conpletion thymectomy in refractory nonthymomatous myasthenia



Other Advantages

Cosmetic (Female predominance in younger adults)

Pulmonary function better preserved

Faster recovery

Decreased post op pulmonary infections



Series in Minimal access thymectoy Author Year Approach

Number

F/uMeanm

Remission %

Improvement

Meyer et al 2009 VATS 48 72 34.9 95.4

Tomulescu et al 2006 VATS 105 36.4 59.5 97.2

Manlulu et al 2005 VATS 36 69 22.2 91.6

Savcenko et al 2002 VATS 36 53 14 83

Wright et al 2002 VATS 26 19.5 27 81

Mineo et al 2000 VATS 31 40 36 96

Zielinski et al 2004 TC-Sx-VATS 25 24 32 83.3

Hsu et al 2004 SxVATET 15 18.5 37 NA

Mantegazza et al 2003 VATET 159 72 33.3 NA

Shrager et al 2006 TC 151 83 37.1 79.5

De Perrot et al 2003 TC 120 48 41 NA

Shrager et al 2003 TC 78 54.6 39.7 NA

Calhoun et al 1999 TC 100 63.6 35 85

Infrasternal



Factors Contributing to CSR

American Academy of Neurology – More severe the

degree of MG larger the magnitude of improvement

Medical therapy : More patients on medications prior

to surgery- more patients needed to wean off to

achiever CSR

Shorter disease duration- better outcome after surgery



Conclusion

The most widespread method is extended thymectomy.

The result of VATS thymectomy seems impressive but

Prospective randomized clinical trial is needed to evaluate and comparevarious thymectomy technique.

The use of clinical research standards is required. ? MGFA

recommendations for clinical research

Quality-of-life evaluation should be employed.



Thank You

MGFA Clinical Classification



MGFA Clinical Classification

Class I : Any ocular muscle weakness; may have weakness of eye closure. Allother muscle strength is normal.Class II:Mild weakness affecting muscles other than ocular muscles; may also have

ocular muscle weakness of any severity.IIa. Predominantly affecting limb, axial muscles, or both. May also have lesser Involvement of oropharyngeal muscles.IIb. Predominantly affecting oropharyngeal, respiratory muscles, or both. Mayalso have lesser or equal involvement of limb, axial muscles, or both.

Class III:Moderate weakness affecting muscles other than ocular muscles; may also

have ocular muscle weakness of any severity.IIIa. Predominantly affecting limb, axial muscles, or both. May also have lesser involvement of oropharyngeal muscles.IIIb. Predominantly affecting oropharyngeal, respiratory muscles, or both. Mayalso have lesser or equal involvement of limb, axial muscles, or both.

Class IV:Severe weakness affecting muscles other than ocular muscles; may also

have ocular muscle weakness of any severity.IVa. Predominantly affecting limb, axial muscles, or both. May also have lesser involvement of oropharyngeal muscles.IVb. Predominantly affecting oropharyngeal, respiratory muscles, or both. Mayalso have lesser or equal involvement of limb, axial muscles, or both.

Class V: Defined as intubation, with or without mechanical ventilation, except when

employed during routine postoperative management. The use of a feedingtube without intubation places the patient in class



MGFA MG Therapy Status



MGFA post intervention Status



Thymectomy Classification- MGFA

VATS Thymectomy- Better Approach

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