Video-assisted thoracoscopic surgery or transsternal thymectomy in the treatment of myasthenia gravis?

Abstract

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was how video-assisted thoracoscopic surgery (VATS) compares to median sternotomy in the surgical management of patients with myasthenia gravis (MG)? Overall 74 papers were found using the reported search, of which 15 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results are tabulated. We conclude that VATS produces equivalent postoperative mortality and complete stable remission (CSR) rates, with superior results in terms of hospital stay, operative blood loss and patient satisfaction at the expense of a doubling of operative time. Six studies comparing VATS and transsternal sternotomy in non-thymomatous myasthenia gravis (NTMG) patients found VATS to have lower operative blood loss (73.8±70.7 vs. 155.3±91.7 ml; P<0.05), reduced total hospital stay (5.6±2.2 vs. 8.1±3.0 days; P=0.008), whilst maintaining equivalent remission rates (33 vs. 44.7%; P=0.16) and mass of thymic tissue resection (37 vs. 34 g; P>0.05). One study comparing video-assisted thoracoscopic extended thymectomy to transsternal thymectomy in only thymoma-associated myasthenia gravis (T-MG) patients found equivalent CSR (11.3 vs. 8.7%, P=0.1090) at six-year follow-up. Thymoma recurrence rate (9.64%) was not significantly different (P=0.1523) between the two groups. Eight studies comparing VATS and transsternal approach in mixed T-MG and NTMG patients found a lower hospital stay (1.9±2.6 vs. 4.6±4.2 days, P<0.001), reduced need for postoperative medication (76.5 vs. 35.7%, P=0.022), lower intensive care unit stay (1.5 vs. 3.2 days, P=0.018), greater symptom improvement (100 vs. 77.9%, P=0.019) and better cosmetic satisfaction (100 vs. 83, P=0.042) with VATS. In concordance with NTMG and T-MG alone patient groups, VATS and transsternal methods had equivalent complication rates (23 vs. 19%, P=0.765) with no mortalities in either group. Even though VATS has a longer operative time (268±51 vs. 177±92 min, P<0.05), its improved cosmesis, reduced need for postoperative medication and equivalent disease resolution outcomes make it a preferable surgical option to the transsternal approach.

Single port VATS mediastinal tumor resection: Taiwan experience

“…Advocates of single-port VATS have emphasized its benefits, including better cosmesis, less pain and faster recovery in the early postoperative period. These positive outcomes have also been observed in our limited experience (1,11,12).…”

A comparison of three approaches for the treatment of early-stage thymomas: robot-assisted thoracic surgery, video-assisted thoracic surgery, and median sternotomy

“…In the early 1990s, Roviaro (11) reported on video-assisted thymectomy. Comparing VATS and MS for the treatment of MG, it has been shown that VATS is typically associated with reduced blood loss and a shorter operative time and hospital stay, while VATS may also lower the incidence rate of postoperative complications by reducing tissue damage, postoperative pain, and the risk of infection (12,13). When comparing RATS (the newest MG surgical therapy) and MS for the treatment of MG, it has been demonstrated that RATS has favorable outcomes in terms of surgical complications and hospital stay (14).…”

Ectopic Cervical Thymoma Accompanied by Good&apos;s Syndrome

“…6) In the present case, resection of the tumor through a cervical incision and subsequent video-assisted thoracoscopic extended thymectomy with the sternum-lifting method were performed because the patient had elevated AchR-Ab, although he lacked symptoms of MG. The outcomes of video-assisted thoracoscopic extended thymectomy have been reported to be comparable to those of trans-sternal extended thymectomy in patients with MG. 7) On the other hand, resection of the thymoma and extended thymectomy does not usually reverse the immunological abnormalities of GS. Therefore, regular follow-up with close attention to the development of infections is necessary.…”