电视胸腔镜下胸腺切除术治疗重症肌无力

目的探讨电视胸腔镜手术(VATS)下行胸腺切除治疗重症肌无力的可行性和治疗效果。方法19例重症肌无力患者,按照Osserman临床分型标准,Ⅰ型10例,Ⅱa型5例,Ⅱb型3例,Ⅲ型1例,均在VATS下行胸腺扩大切除术。结果19例患者均顺利完成手术,无手术死亡,平均手术时间120min,术中出血量均小于100ml,术后发生重症肌无力危象3例,经及时治疗治愈。术后对所有患者均进行了随访,随访时间>6个月,重症肌无力病情完全缓解9例,好转6例,无变化4例,总有效率79%(15/19)。结论在VATS下行胸腺扩大切除术治疗重症肌无力是可行的,且创伤小、疼痛轻,以期望减少术后并发症。     

电视胸腔镜胸腺切除术与开放性手术的对比分析

目的 探讨电视胸腔镜手术与开放性手术进行胸腺切除的优劣.方法 回顾性分析2002年2月至2007年5月106例进行电视胸腔镜胸腺扩大切除术患者,以及1998年3月至2003年8月108例开放手术患者的临床资料.胸腔镜组男性64例,女性42例,平均年龄38岁;开放手术组男性68例,女性40例,平均年龄36岁.对两组手术时间、术中出血量、术后引流、术后住院日、住院费用以及术后并发症等进行分析.随访时间10～67个月,平均38.5个月.按照美国重症肌无力基金会重症肌无力评分法进行疗效评定.结果 胸腔镜组术中出血量(34±5)ml,低于开放手术组的(150±23)ml.术后引流量(42±18)ml,低于开放手术组的(168±31)ml.术后并发症率和平均住院日亦较开放手术组有明显降低.两组术后远期疗效相似(P>0.05).结论 电视胸腔镜胸腺切除术治疗重症肌无力可达到与开放手术相似的远期疗效,同时具有创伤小、并发症少、恢复快等优势.     

胸腔镜胸腺切除术治疗重症肌无力

2002年2月至2005年5月，我们采用胸腔镜行胸腺切除治疗重症肌无力（MG）病人70例，现总结报道如下。     

胸腔镜胸腺切除术治疗重症肌无力

电视胸腔镜手术（ＶＡＴＳ）为胸腺切除术提供了一个新的手术方法。自１９９３年６月至１９９５年５月，作者采用此方法成功施行了１０例胸腺切除术，以治疗重症肌无力。其中３例伴有胸腺瘤。通过手术中对胸腺床以及切除的胸腺标本检查，证实所有病例均达到完全切除胸腺的目的。本组无术中并发症及手术死亡。术后平均住院时间为４．１天（术后有一例需行辅助通气而无计算在内）。经过平均１０个月的随访观察（２～２０个月），显示所有病例的临床症状均有所改善。与另一组采用胸骨切开胸腺切除术的病例相对照，显示ＶＡＴＳ组在术后镇痛药用量及住院时间方面均有显著减少及缩短（Ｐ＜０．０５）。作者认为，采用ＶＡＴＳ技术进行完全的胸腺切除是可行的。与胸骨切开胸腺切除术相比，具有创伤小，术后恢复快的优点。但胸腔镜胸腺切除术治疗重症肌无力的远期疗效仍有待进一步观察，以便确定此技术在胸外科中的地位及作用。     

电视胸腔镜胸腺切除9例报告

目的　探讨电视胸腔镜下行胸腺切除的可行性及合并重症肌无力患者的远期疗效。　方法　 1996年 7月至 2 0 0 1年 4月 ,选择 9例胸腺相关疾病患者 ,应用电视辅助胸腔镜 (VATS)行胸腺切除 ,术后门诊或电话随访。　结果　胸腺囊肿 2例 ,胸腺瘤 1例 ,恶性胸腺瘤 1例 ,胸腺癌 1例 ,重症肌无力4例。重症肌无力据改良Osserman分型Ⅰ型 3例 ,Ⅱb型 1例 ,合并胸腺瘤 2例 ,胸腺增生 2例 ,手术总有效率 3/ 4。手术中转开胸 1例 ,手术后随访复发 1例 ,经胸骨正中切口行胸腺扩大切除术。　结论　VATS治疗部分胸腺疾病可行 ,VATS治疗重症肌无力疗效与常规手术相当。     

经胸腔镜胸腺扩大切除术治疗重症肌无力42例报告

目的总结胸腔镜胸腺扩大切除治疗重症肌无力的经验。方法42例重症肌无力患者行胸腔镜或胸腔镜辅助小切口手术,切除范围包括胸腺组织及前上纵隔的脂肪软组织。结果手术均顺利完成,全组均无中转开胸。平均手术时间116.3（65-165）min,术中平均出血量为81.7（52-110）ml,术后平均住院时间为8.5（6-16）d。术后发生重症肌无力危象2例,予机械辅助通气及对症处理后好转。术后病理示26例为胸腺增生,16例为胸腺瘤。35例获随访,平均27.2（4-43）月,完全缓解7例,改善27例,1例无明显改善。结论胸腔镜胸腺扩大切除治疗重症肌无力,方法可行、可靠,具有创伤小、恢复快的优点。     

经右胸前侧入路电视胸腔镜下胸腺切除治疗重症肌无力

目的 探讨经右胸前侧入路电视胸腔镜手术(VATS)胸腺切除治疗重症肌无力(MG)的可行性及疗效.方法 回顾性分析2001年8月至2007年10月采用经右胸前侧入路VATS胸腺切除治疗MG的56例患者的临床资料.结果 55例患者通过VATS顺利完成胸腺(或胸腺瘤)与前纵隔脂肪切除.平均手术时间(96.2±52.1)min,平均术中出血量(68.7±21.4)ml.2例患者术中发生左头臂静脉损伤;1例术中结扎止血,1例中转开胸止血后完成手术.切除胸腺及纵隔脂肪组织平均(22.1±9.2)g.术后病理检查示胸腺增生38例,胸腺萎缩5例,胸腺瘤12例,胸腺囊肿1例.1例(1.8%)患者因出血于术后第8天死亡.1例(1.8%)患者术后发生重症肌无力危象.平均住院时间(7.9±2.9)d.术后MG完全缓解8例(14.3%),部分缓解39例(69.6%),无变化7例(12.5%),总有效率83.9%.结论 利用VATS经右胸前侧入路行胸腺切除安全可行,治疗MG效果满意.     

胸腔镜下胸腺扩大切除术患者的护理

对8例腰椎间盘突出症患者行人工髓核假体置换治疗。结果均顺利完成手术,随访3～l2个月．优6例．良2例。提出术前做好心理护理,术后密切观察病情变化、及时处理并发症、早期实施康复护理是手术成功的重要保证。     

胸腔镜胸腺扩大切除术治疗重症肌无力的疗效观察及影响因素分析

目的对胸腔镜胸腺扩大切除术治疗重症肌无力(myasthenia gravis,MG)的疗效进行总结,分析影响MG手术疗效的因素。方法回顾性研究我院2000年6月～2009年10月47例MG接受胸腔镜手术的临床资料,采用单因素分析和logistic回归模型对患者性别、年龄、病程、MGFA分型、胸腺病理类型等可能影响因素进行分析。结果 45例完成随访,随访16～111个月,平均51个月。根据MGFA提出的治疗后状况分类:完全稳定缓解占64.4%(29/45),药物缓解占17.8%(8/45),微小症状表现占8.9%(4/45),恶化占2.2%(1/45),复发占4.4%(2/45),死亡占2.2%(1/45)。年龄(β=0.059,P=0.027,OR=1.060,95%CI为1.007～1.117)和胸腺病理类型(β=1.558,P=0.025,OR=4.750,95%CI为1.214～18.584)是影响手术疗效的因素。结论 MG行电视胸腔镜下胸腺扩大切除术疗效满意,年龄和胸腺病理类型是手术疗效的影响因素。     

电视胸腔镜治疗胸腺瘤和重症肌无力

目的　探讨电视胸腔镜治疗胸腺肿瘤和重症肌无力 (MG)的手术方法和可行性。方法　1996年 3月至 2 0 0 2年 12月 ,2 2例病人行胸腺瘤和 (或 )重症肌无力胸腔镜手术治疗。其中男 16例 ,女 6例 ;年龄 14～ 77岁 ,平均 44 1岁。行胸腺全切 12例 ,合并MG者行胸腺扩大切除 10例。结果　所有手术均在胸腔镜下完成 ,无中转开胸者。 3例MG病例术后需短暂呼吸机辅助通气 ( <2 4h) ,二次气管插管1例 ,余无严重并发症 ,无手术死亡。平均手术时间 10 8min ,平均胸腔引流 2d ,平均术后住院 4 5d。结论　胸腔镜治疗Ⅰ期胸腺瘤较开胸手术具有创伤小、恢复快等显著优势 ,且符合该类肿瘤的外科治疗原则 ;胸腔镜胸腺扩大切除治疗重症肌无力在技术上是可行的。     

胸腔镜胸腺扩大切除加颈部切口治疗重症肌无力

目的 探讨胸腔镜胸腺扩大切除加颈部切口治疗重症肌无力的可行性和术后疗效.方法 2005年1月至2006年2月采用胸腔镜胸腺切除加颈部切口治疗重症肌无力患者41例,其中男性18例,女性23例,年龄18～67岁.病程1个月～3年.术中除完整切除胸腺外,还清除前纵隔区域及颈根部的异位胸腺和脂肪组织.结果 全组41例手术完全在电视胸腔镜下完成,平均手术时间162 min.术后发生肌无力危象7例.术后病理学诊断:4例颈部发现残存胸腺上极,35例患者气管前胸骨上间隙有肿大淋巴结(3～17枚).所有患者均痊愈出院.术后随访观察2年,完全缓解率41.4%,有效率达85.4%.结论 胸腔镜下胸腺切除术治疗重症肌无力能取得较为理想的治疗效果,胸腔镜扩大胸腺切除加颈部切口对于颈根部异位胸腺的清除是一补充.     

Left thoracoscopic thymectomy in children

Background In the management of autoimmune myasthenia, thymectomy is recognized as effective surgical therapy. The necessity of complete radical thymectomy to achieve maximal improvement has been emphasized. Video-assisted thoracoscopic surgery has been successfully used for thymectomy in adults, and more recently in children, and has been described as achieving the same radicality and functional improvement as median sternotomy or as transcervical thymectomy. The aim of this work is to report our first thoracoscopic experience in this indication.Methods Patients with myasthenia gravis on anticholinesterase drugs and/or steroids are discussed for surgery in case of clinical deterioration despite increasing doses of medication or in case of no improvement. We decided to perform thoracoscopic thymectomies by a left-sided approach. Preoperative localization of thymic tissue is done by a thoracic CT exam. Patients are placed on their right side with a thoracic tilt under the thorax. Four thoracoscopic ports are used, a 10-mm for the camera and three 5-mm operating ports. The left lung was collapsed by selective intubation (double-lumen endotrachial intubation).Results Two boys, 7.5 and 14 years old, were addressed by the department of neurology for radical thymectomy. They presented an ocular myasthenia gravis for 2 years and a mild general myasthenia gravis for 7 years. The operative times were 120 and 240 min. There was no intraoperative or postoperative complication. Duration of thoracic drainage was 2 days. The children were discharged on the third postoperative day. For the second procedure, an ultrasound exam during surgery was necessary to localize the thymus exactly, thus enabling its complete resection without the need for a conversion. The follow-up is 19 and 7 months with a clinical improvement enabling the diminution of medication for both children, the end of ptosis for the first child, and the general improvement of muscle strength for the second.Conclusions Thoracoscopic thymectomy in children with juvenile myasthenia gravis seems to offer a complete surgical resection, as do open techniques. In case of difficulties in finding the thymus, an ultrasound exam is feasible to enable complete resection. The left-sided thoracoscopic approach gives a good mediastinal and cervical exposition. Furthermore, being less painful in the postoperative period, it presents a less pronounced impairment of pulmonary function, and it presents good cosmetic effect.     

电视胸腔镜胸腺切除治疗重症肌无力症

目的探讨电视胸腔镜手术(video-assisted thoracoscopic surgery,VATS)胸腺切除治疗重症肌无力症(myasthenia gravis,MG)的可行性. 方法 18例MG采用VATS经右胸前侧径路行胸腺切除联合纵隔脂肪清扫. 结果 17例顺利完成手术,1例因电凝钩伤及左头臂静脉干而中转开胸止血.平均手术时间105 min,术中失血量平均80 ml.全组无术后死亡及危象发生.18例随访1～20个月,平均11.3个月.按Osserman疗效评价,缓解5例(27.8%),明显改善6例(33.3%),部分改善4例(22.2%),无变化3例(16.7%),有效率83.3%(15/18). 结论 VATS经右胸前侧径路行完全胸腺切除可行,且具有创伤小、恢复快等优点.     

Video-assisted transcervical thymectomy

Background The optimal surgical approach for complete removal of the thymus gland has long been debated. In this report, the excision of the entire gland through a transcervical incision using video-assisted techniques is described.Methods Ten patients, including one with thymoma and myasthenia gravis, underwent surgery via the transcervical approach. After standard dissection up to the level of the innominate vein and ligation of the thymic vessels, a laparoscope was inserted into the mediastinum. In the patient with thymoma, the operation was completed by a small incision in the third intercostal space.Results No perioperative mortality or long-term morbitity was observed. The mean hospital stay was 69.6 h. After a mean follow-up period of 63.8 months, eight patients displayed complete remission, whereas one continued to receive minimal medication. The patient with thymoma showed considerable improvement, but remained on same medical regimen No complications were seen throughout the study.Conclusion Video-assisted thymectomy improves effectiveness of the transcervical approach for thymectomy with a minimum of trauma and excellent results.     

电视胸腔镜胸腺扩大切除治疗重症肌无力107例临床分析

目的探讨电视胸腔镜下胸腺扩大切除术治疗重症肌无力的临床效果。方法对1995年6月至2004年6月,台湾长庚纪念医院胸外科和北京大学人民医院胸外科根据临床表现及肌电图检查诊断证实为单纯重症肌无力,行电视胸腔镜胸腺完整切除及前纵隔脂肪组织廓清术治疗的107例患者的临床资料进行回顾分析。结果术后随访1—98个月,完全缓解34例,改善55例,全组完全缓解及改善率为83％,无手术死亡病例。结论电视胸腔镜下手术切除胸腺及前纵隔脂肪组织治疗重症肌无力临床效果良好,安全,创伤较小。     

Comparison between the right side and subxiphoid bilateral approaches in performing video-assisted thoracoscopic extended thymectomy for myasthenia gravis

Background This study aimed to compare the efficacy of the right thoracoscopic (RtT) approach and the subxiphoid bilateral thoracoscopic (SxBiT) approach in performing thymectomy for myasthenia gravis.Methods Between March 2001 and April 2003, 27 myasthenic patients were enrolled in this prospective study. The operations were conducted by two surgical teams in a single institute. The surgical procedures included RtT for 12 patients and SxBiT for 15 patients. The operation time, resected thymus weights, and thoracic drainage periods were compared.Results Subxiphoid video-assisted thoracoscopic extended thymectomy (SxVATET) and right-side thoracoscopic extended thymectomy (RtVATET) were performed for 27 consecutive myasthenic patients. The mean operation time, weights of resected specimens, and duration of hospital stay for the SxVATET and RtVATET groups were, respectively, 151.3 min (range, 120–200 min) versus 191.5 min (range, 120–225 min) (p = 0.0012), 73.3 g (range, 40–90 g) versus 50.8 g (range, 5–90 g) (p = 0.0029), and 3.1 days (range, 2–4 days) versus 3.8 days (range, 2–4 days) (p = 0.914). Ten patients (37%) had complete remission, observed during a mean follow-up period of 18.5 months (range, 6–30 months).Conclusions During this consecutive experience, both the RtT and SxBiT approaches showed satisfactory results for nonthymomatous myasthenic patients. However, a better view of the bilateral pleural cavities and more radical thymectomy could be achieved only by the SxBiT approach.     

Subxiphoid thoracoscopic thymectomy for myasthenia gravis

We investigated the efficacy of subxiphoid thoracoscopic thymectomy in patients with myasthenia gravis. The data of 37 consecutive cases were reviewed. 2 cases of postoperative myasthenia gravis crisis and 4 cases of residual mediastinal fat tissue were recorded. Moreover, 29 patients presented the neurological outcomes, and complete stable remission was achieved in 5 (17.2%) cases. Subxiphoid thymectomy is technically feasible. High-quality evidence is warranted before this approach can be recommended.     

Long-term follow-up after thymectomy for myasthenia gravis: thoracoscopic vs open

Purpose

The aim of this study was to determine if patients are in remission or weaning off medication after thymectomy for myasthenia gravis (MG) and to examine the thoracoscopic versus open approaches.

Methods

A retrospective review of all patients who underwent thymectomy for MG at a tertiary referral center between 1992 and 2004 (N = 14). Six patients (42.9%) underwent thoracoscopic resection. Eight patients underwent open resection; 5 (35.7%) had median sternotomy and 3 (21.4%) by transcervical approaches. Follow-up was obtained in 12 (85.7%) of 14 patients by both chart review and telephone. The mean follow-up was 43.0 months (range, 4-111 months). Statistical significance was determined by Student's t test or Fisher's Exact Test.

Results

The thoracoscopic group had a mean operating time of 138.8 minutes compared with 139.8 minutes in the open group (P = .9). The thoracoscopic group had a mean estimated blood loss of 7.5 mL compared with 52.5 mL in the open group (P = .02). The mean length of stay for the thoracoscopic group was 1.5 days (range, 1-2 days) and was 10.6 days (range, 3-41 days) in the open group (P = .13). Three (60%) of 5 patients were entirely off medication in the thoracoscopic group at the time of follow-up compared with 3 (50%) of 6 patients in the open group (P = 1.0). In the thoracoscopic group, 5 (83.3%) of 6 were in class 1 to 3 of the DeFilippi classification (complete remission or improved with decreased medication requirements). One patient had no change in symptoms (class 4). In the open group, 5 (83.3%) of 6 were classified as DeFilippi 1 to 3 at the time of follow-up, and one patient had worsening symptoms (class 5).

Conclusions

Both thoracoscopic and open approaches to thymectomy in patients with MG are effective, with more than 80% of patients in both groups in remission or with improvement at the time of follow-up. The thoracoscopic group has the added benefits of decreased estimated blood loss, decreased length of hospital stay, and improved cosmesis. We advocate the thoracoscopic approach for thymectomy in the treatment of juvenile MG.