TY - JOUR
T1 - Surgical treatment of myasthenia gravis: evident benefits and insidious pitfalls of mini-invasive techniques.
AU - Granone, Pierluigi
AU - Lococo, Filippo
AU - Cesario, Alfredo
AU - Meacci, Elisa
AU - Margaritora, Stefano
PY - 2013
Y1 - 2013
N2 - When surgery is indicated in the treatment of myasthenia gravis
(MG), a total thymectomy is mandatory; this should be accomplished
to achieve complete remission from symptoms.
The embryology and anatomy of the mediastinal region and
the thymus gland make the removal of all the thymic tissue—a
prerequisite for symptom control given the autoimmune nature
of the MG—a difficult surgical task that is usually performed
in the vast majority of cases via an open-access transsternal
approach. However, this approach significantly affects the postoperative
morbidity, pain, and cosmesis; in recent years, many
efforts have been undertaken to develop and validate less invasive
techniques [1, 2]. All these approaches invariably use innovative
video-assisted thoracic surgery technologies.
Jurado and coworkers [3] performed a comprehensive
comparative analysis of minimally invasive thymectomy
performed via video-assisted thoracic surgery versus open thymectomy
in a large series of patients affected mostly by MG [3].
Based on the results of this analysis, the authors conclude that,
to control the effects of surgery itself on frail patients with MG
(by decreasing the postoperative morbidity), the less-aggressive
techniques should be preferred. We would support a cautionary
attitude with this recommendation. In fact, Jaretzky and colleagues
[4] clearly showed that transsternal approaches provide
worse results in terms of long-term remission rate from MG if
compared with less invasive approaches, given that the operation
executed at the level of the mediastinum is the same. Moreover,
ectopic thymic foci are found in more than half of cases [5] in which
an extended thymectomy is performed (a type of operation
virtually unfeasible through a non-trans-sternotomic or bilateral
transthoracic access). One point of caution is that the feasibility
and efficacy of all mini-invasive surgical techniques in the treatment
ofMGshould be evaluated, accounting for the postoperative
surgical outcomes and long-term neurologic outcomes.
Insufficient data about the neurologic outcome in the
MG subgroup of patients [3] makes it difficult to interpret the
results, substantially weakening the conclusion that less invasive
approaches should be preferred. We would welcome a comment
from the authors on this point, in light of the firm principle that
the completeness of the operation as defined by the extended
thymectomy approach is the goal of any approach. In addition,
we would welcome additional reasoning on the relative weight
of the postoperative and cosmetic outcome patterns versus
the long-term neurologic and quality-of-life outcome in patients
with MG and what factors a surgeon should prioritize in the clinical
decision-making process at the moment of the surgical
indication.
Thus, any attempt at ameliorating morbidity and cosmetic patterns
in the postoperative setting is, in our opinion, to be carefully
matched with the fact that long-term substantial benefit in such patients
can be provided only if the thymic tissue resection is complete
AB - When surgery is indicated in the treatment of myasthenia gravis
(MG), a total thymectomy is mandatory; this should be accomplished
to achieve complete remission from symptoms.
The embryology and anatomy of the mediastinal region and
the thymus gland make the removal of all the thymic tissue—a
prerequisite for symptom control given the autoimmune nature
of the MG—a difficult surgical task that is usually performed
in the vast majority of cases via an open-access transsternal
approach. However, this approach significantly affects the postoperative
morbidity, pain, and cosmesis; in recent years, many
efforts have been undertaken to develop and validate less invasive
techniques [1, 2]. All these approaches invariably use innovative
video-assisted thoracic surgery technologies.
Jurado and coworkers [3] performed a comprehensive
comparative analysis of minimally invasive thymectomy
performed via video-assisted thoracic surgery versus open thymectomy
in a large series of patients affected mostly by MG [3].
Based on the results of this analysis, the authors conclude that,
to control the effects of surgery itself on frail patients with MG
(by decreasing the postoperative morbidity), the less-aggressive
techniques should be preferred. We would support a cautionary
attitude with this recommendation. In fact, Jaretzky and colleagues
[4] clearly showed that transsternal approaches provide
worse results in terms of long-term remission rate from MG if
compared with less invasive approaches, given that the operation
executed at the level of the mediastinum is the same. Moreover,
ectopic thymic foci are found in more than half of cases [5] in which
an extended thymectomy is performed (a type of operation
virtually unfeasible through a non-trans-sternotomic or bilateral
transthoracic access). One point of caution is that the feasibility
and efficacy of all mini-invasive surgical techniques in the treatment
ofMGshould be evaluated, accounting for the postoperative
surgical outcomes and long-term neurologic outcomes.
Insufficient data about the neurologic outcome in the
MG subgroup of patients [3] makes it difficult to interpret the
results, substantially weakening the conclusion that less invasive
approaches should be preferred. We would welcome a comment
from the authors on this point, in light of the firm principle that
the completeness of the operation as defined by the extended
thymectomy approach is the goal of any approach. In addition,
we would welcome additional reasoning on the relative weight
of the postoperative and cosmetic outcome patterns versus
the long-term neurologic and quality-of-life outcome in patients
with MG and what factors a surgeon should prioritize in the clinical
decision-making process at the moment of the surgical
indication.
Thus, any attempt at ameliorating morbidity and cosmetic patterns
in the postoperative setting is, in our opinion, to be carefully
matched with the fact that long-term substantial benefit in such patients
can be provided only if the thymic tissue resection is complete
KW - 13
KW - 13
UR - http://hdl.handle.net/10807/52975
U2 - 10.1016/j.athoracsur.2013.03.103
DO - 10.1016/j.athoracsur.2013.03.103
M3 - Article
SN - 0003-4975
VL - 2013
SP - 1525
EP - 1525
JO - Annals of Thoracic Surgery
JF - Annals of Thoracic Surgery
ER -