After the operation, a patient may wake up with a breathing tube. Recovery is not painful, and patients are usually discharged within a few days after surgery. Although it varies from person to person, patients are generally expected to be able to return to normal daily activities in three to six weeks.
Thymectomy is a long-term treatment strategy; it does not have acute effects on the symptoms of myasthenia gravis. Although doctors may slightly adjust medications, patients will need to continue their regular treatment. A significant improvement in symptoms due to thymectomy can be expected within one year after surgery. It is possible symptoms will disappear permanently.
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Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. I would say that most of the patients that showed functional improvement, had it within 12 months after the operation. De Leyn Leuven, Belgium : Did you do any reoperations for myasthenia, and can you tell us anything about it?
Dr Venuta : We did only two reoperations for myasthenia, and these patients were not included in this study. One patient was operated by us 11 years before and another patient was operated at another institution through a lateral thoracotomy 20 years before. We performed a median sternotomy in both patients with a radical extended thymectomy according to Jaretzky, since we wanted to be radical.
One patient is alive and his condition is improved, and the other one died in the postoperative course. Dr De Leyn : At this moment, what are your indications for reoperation for myasthenia?
Dr Venuta : We usually discuss this with the neurologist, we consider an indication to reoperation if there is an improvement and then there is a decline after the operation, or the patient is not happy with his condition and has to take steroids again after the operation, or needs plasmapheresis; there are very serious cases, even 5, 6 years after the first operation and these patients should be considered for reoperation. Van Schil Edegem, Belgium : Do you use a special preoperative preparation, like plasmapheresis in the severe cases of myasthenia?
Did you encounter some respiratory insufficiency after thymectomy? Dr Venuta : We have used plasmapheresis in 22 cases before the operation, and it's mainly been used to improve preoperative functional status. If we can treat these serious patients before the operation, we try to do plasmapheresis also to lower the dose of steroids before surgery.
We had only three patients with respiratory failure after the operation and two died. Ninety-seven percent of the patients have been extubated inside the operating room, and I would say that the postoperative course has been without major problems in most of them.
You did 46 patients through a cervicotomy. Was there any difference between the median sternotomy and the cervicotomy group? Dr Venuta : The 46 patients operated through the transcervical approach were the first group in our series and the transcervical approach was the standard one for thymectomy in patients with myasthenia gravis.
Then the papers from Masaoka and other Japanese authors came out, and we switched to what we thought was a more suitable approach to reach the lower part of the mediastinum, without performing a median sternotomy. We have used the Jaretzky approach in the two patients who required reoperation. Now, in terms of results, we are a little disappointed because there was a difference between patients operated through a partial median sternotomy and the previous series.
They did better. However, the statistical analysis showed that there was no significant difference between the two groups. So this is one of the cases where we must trust the statistics; however, we think that these patients should be considered for the more extended approach to completely clean the mediastinum. We have recently undertaken operating on such patients.
Was your experience with that small group of patients different from the remainder of the series? Dr Venuta : They did well. They had an extremely favorable outcome. They had better results if compared with the other groups. Dr Benfield : That has been our experience as well. The second question pertains to our dialogue with the neurologists as to the postoperative management of these patients. We have noted that a certain number of these patients benefit from thymectomy immediately, right in the recovery room.
Such patients don't need the medications postoperatively and therefore I prefer not to give medications until the indications for medication becomes clear. Our neurologists generally wish to continue the medications postoperatively more or less as a given and then to embark on a gradual decrease in dosage as a titration of clinical evidence of myasthenia..
What is your policy regarding the postoperative management of these patients? Dr Venuta : I'm glad you have such a good relationship with your neurologist.
Our situation is a little more difficult. We try to keep these patients without medications for the first 48 h, unless they do need something. Our patients go routinely to the intensive care unit for at least 24 h, even if they are extubated in the operating room and medications are given by the intensivists, after that period most of our patients take the same medications that they took before the operation, and then they lower them when they go back to the neurologic clinic after the operation.
Google Scholar. Oxford University Press is a department of the University of Oxford. It furthers the University's objective of excellence in research, scholarship, and education by publishing worldwide. Sign In or Create an Account. Sign In. Advanced Search. Search Menu. Article Navigation. Close mobile search navigation Article Navigation. Volume Article Contents Abstract.
Patients and methods. Appendix A. Conference discussion. Thymectomy for myasthenia gravis: a year experience 1. Oxford Academic. Erino A. Tiziano De Giacomo. Giorgio Della Rocca. Minimally invasive surgery can be done through a cervicotomy, a transcervical-subxyphoid approach or unilateral or bilateral video-assisted or robotic assisted thoracic surgery VATS. Considering the benefit of a minimally invasive approach and the comparable results obtained by open and minimally invasive surgery 9 - 13 , it is unlikely that a randomized trial between open and minimally invasive surgery will take place in the future and minimally invasive approach will increasingly be preferred The extent of thymectomy remains a controversial topic.
Although the presence of extra-capsular thymic tissue is frequent and well described 15 , the accessibility of these ectopic thymic foci as well as their function and impact on outcome have been unclear. Ectopic thymic foci are found more frequently in patients with an atrophic thymus and their presence carries a poor outcome even after maximal thymectomy with resection of all potential sites of ectopic thymic foci in the neck and mediastinum 16 , Since ectopic thymic foci are usually isolated to one or two sites and are most frequently found in the anterior mediastinal fat, an extended thymectomy involving the fat located between the pericardium, both pleura and the diaphragm can be safely accessible and should be routinely resected regardless of the type of surgical approach.
Extending the surgery to resect tissues in the pericardiophrenic angles, aorto-pulmonary window, aorto-caval groove and along the thyroid gland carry a risk of phrenic or recurrent nerve injury and there is currently limited evidence to suggest that it should be done routinely. A randomized clinical trial would be needed to answer this question. Interestingly, positron emission tomography PET has shown a correlation between parathymic standardized uptake value and presence of ectopic thymic tissue, but future research is needed to determine the clinical utility of this test for patients with MG In the future, refinements in our understanding of the disease and its relations to the thymus will certainly help refine the selection of patients for thymectomy.
The extent of thymectomy remains an open question that may lead to the next surgical trial in MG. Cite this article as: de Perrot M, Donahoe L.
J Thorac Dis ;9 2
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