presentazione di powerpoint · via cervico-sternotomica secondo maggi • thoracoscopic extended...
TRANSCRIPT
Author disclosure
No conflicts of interest or financial ties to disclose
• Thymomatous MG • Non-thymomatous MG (anti-AChR antibody-positive)
– Early-onset MG: ocular typ with resistance to immunosuppressive therapy
– Early-onset MG: generalized type– Late-onset MG: in patients >60 years old only for
refractory cases– Juvenile MG: in patients >12 years old only for
severe MG
Thymomatous MG
• Thymomas are present in 10% of patients with myasthenia gravis
• Thymectomy is considered to be mandatory to prevent further spread
N Engl J Med 1994;330:1797-810
• MG remission and improvement rates in patients with thymoma have been reported to be similar or slightly worse than those without
Thymomatous MG
– Early-onset MG: ocular typ with resistance to immunosuppressive therapy
– Early-onset MG: generalized type– Late-onset MG: in patients >60 years old only for
refractory cases– Juvenile MG: in patients >12 years old only for
severe MG
Non-Thymomatous MG
• Up to 70% of the remaining patients with myasthenia gravis have hyperplastic thymicchanges
J Autoimmun 2014;52:90- 100.
extended transsternal thymectomy
• Some authors advocate extended-cervical thy-mectomy for minimizing postoperative painand so ventilator need
• It is the controversial part of this approachthat it may be inadequate to reveal thymusfully and that residual thymus tissue mayremain in the left posterior side.
J Cardiothorac Surg 2010; 37: 1137-43.
Eur J Cardiothorac Surg 2003;24:677-83Ann Thorac Surg 2002;74:320-6; discussion 326-7
Via transcervicale secondo Cooper
Via transcervicale secondo Levasseur
Timectomia sec. Novellino: 1 cervicotomia e 6 - 8 accessi toracici
Median sternotomy (extended transsternal thy-mectomy or combined transcervical-transste-rnal thymectomy) is preferred by many chestsurgeons and neurologists. This approachprovides a broad exploration area from medias-tinum to neck, allowing complete resection of allthymic and associated fat tissues.
Ann Cardiothorac Surg 2016; 5: 1-9
Semin Neurol 2004; 24: 49-62
Via sternotomica classica
Transternal maximal thymectomy (Jaretzky)
cervicotomia associata ad una sternotomia mediana totale
• Removal of all thymic tissue, all mediastinal tissue anterior to pericardium and great vessels
• Removal of the mediastinal pleura• Removal of the upper poles with the adjacent fatty tissue
Via cervico-sternotomica secondo Jaretzki
Via cervico-sternotomica secondo Maggi
• Thoracoscopic extended thymectomy has the results comparable to those by a mediansternotomy approach
VATS vs transsternal thymectomyfor MG
• Longer operative time (268±51 vs. 177±92 min, P<0.05),
• Equivalent perioperative morbidity and mortality
• Better cosmesis• Shorter length of stay• Reduces need for postoperative medication• Equivalent disease resolution outcomes
Interact Cardiovasc Thorac Surg. 2011 Jan;12(1):40-6
10-year remission rate: 50% overall response rate: about 90%utility collar minicervicotomy was added in 21
patients (66%) 6% median sternotomy
Incidence of MG
Technique n. pts.
mortality
Nerveinjury (%)
TMG/NTMG (%)
Partial/complete remission
(%)
Mean postop.Hospital.
days
Transstern. 34 0 1 (2.8) 7/27(20,6/79,4
)
24(70,6)
7,5
VATS 10 0 0 3/7(30/70)
8(80)
4,2
Conclusions
1. transsternal thymectomy represented the goldstandard technique
2. minimally invasive techniques may leave behindectopic thymic tissue in perithymic and pericardial fields
3. less-invasive thymectomy approaches seems to have similar effectiveness and shorterpostoperative recovery times and bettercosmesis
4. RCT to compare resectional techniques are needed
In patients with invasive thymoma, combinedresection of invaded organs is sometimesnecessary. In cases of pleural dissemination, extrapleural pneumonectomy may also be considered. Such cases need to be evaluated on an individual basis when planning surgery.