vats thymectomy- better approach
DESCRIPTION
journal presentation- VATS ThymectomyTRANSCRIPT
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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
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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
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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
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Surgical Approaches
Open Thymectomy Technique
Median Sternotomy Transcervical (Minimally invasive approach)
Combined Transcervical with median
Sternotomy (T-incision)
Partial Sternotomy
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Minimally Invasive Technique
Thoracoscopic Approach
VATS (unilateral) Thymectomy VATS extended Thymectomy
Endoscopic Robot-assisted thymectomy
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Acceptance of Minimally Invasive technique
Low Procedural morbidity and mortality
Improved cosmesis
Lesser degree of access trauma and Post-op pain
Equivalent efficacy ?
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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
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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
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Limitation of VATS Thymectomy
Pleural Symphysis
Severe Lung disease or poor lung function
Very young Children
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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.
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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%
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MGFA Classification
class No of patients
I 13
IIA 16IIB 4
IIIA 7
IIIB 2
IV 2
V 8
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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
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Final Pathology
Hyperplastic Thymus 30
Atrophic Thymus 8
Normal Thymus 12
Thymolipomas 2
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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%)
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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%)
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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”
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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
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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)
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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
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Other Advantages
Cosmetic (Female predominance in younger adults)
Pulmonary function better preserved
Faster recovery
Decreased post op pulmonary infections
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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
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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
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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.
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Thank You
MGFA Clinical Classification
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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
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MGFA MG Therapy Status
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MGFA post intervention Status
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Thymectomy Classification- MGFA