| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
Ann Thorac Surg 2000;70:1661
© 2000 The Society of Thoracic Surgeons
Discussion
DR SHAFIQUE H. KESHAVJEE (Toronto, Ontario, Canada): I would like to congratulate Dr Ruckert and his colleagues on the performance of a very nice study with an excellent, clear presentation. I also appreciated the opportunity to review their manuscript well in advance.
It is well accepted that thymectomy provides benefit to the vast majority of patients with myasthenia gravis, and the literature reveals that the results with respect to symptomatic improvement and remission of the disease are equivalent regardless of the route of surgery performed.
Myasthenic patients, by virtue of their disease, are high-risk surgical candidates and, indeed, the primary complications after thymectomy are respiratory, that is, respiratory failure or pneumonia. The surgical and anesthetic management of these patients must take this into account. Ideally, the thymectomy should add minimal respiratory insult. Most importantly, Dr Ruckert’s study has demonstrated that surgical technique can impact on the respiratory function and that a less invasive approach has a potential benefit in this setting.
Currently, there are three major areas where the management of these patients might differ: first, with the timing of referral for surgery; second, the technique or route of operation; and third, in the management of the myasthenic patient with a thymoma.
With these issues in mind, I have three questions for you.
First, are your patients referred for surgery after the diagnosis is made or after initial failure of medical management?
Second, you describe your procedure as minimally invasive—although it is less invasive than a sternotomy, it is not truly minimally invasive—a video-assisted transcervical thymectomy is the truly minimally invasive approach for this procedure. There is no need for a double-lumen endotracheal tube, no need to enter the pleural space with risk of pneumothorax or pleural effusion, no need for a pleural drainage tube, and no need for intravenous analgesia. In fact, in Toronto, our patients are discharged home the morning after their transcervical thymectomy. This approach has given our neurologists and our patients the confidence to come to surgery at the time of diagnosis. Have you considered this surgical route as a logical extension of your concept of minimal respiratory insult?
Second, do you routinely dissect the thymus gland up to the upper poles adjacent to the thyroid gland in the neck through the chest?
Finally, we routinely recommend the performance of a CT scan of the chest from the neck to the diaphragm to rule out a thymoma. If one is found, a sternotomy or partial sternotomy is performed. Thymomas are tumors with good biology and survival is often measured in decades, but these tumors are well known to present with local recurrence or droplet metastases, particularly if spillage occurs at surgery, and these recurrences are more difficult to manage. Are you advocating that thoracoscopic surgeons resect thymomas through the chest?
I enjoyed your paper and the presentation, and I would like to thank the Society for the privilege of being an invited discussant. Thank you.
DR RÜCKERT: Thank you, Dr Keshavjee, for your questions.
Concerning your first question, our patients are referred to the surgical clinic mainly from the neurological department. That is an advantage of the university clinic, but it is demonstrated in other centers, too. I think you have the same policy, and Johns Hopkins and many other centers are doing it in that way. That is what we would recommend. Most of the patients are referred for thymectomy as soon as possible after initial diagnosis of myasthenia gravis. In every case, the patients should be in the best, stable clinical situation that could be obtained preoperatively. Therefore, they are not only referred after initial treatment failure.
The second question concerning the transcervical approach refers to a really big discussion over the years. This discussion, let us say, has not been decided yet. With our study, we tried to have the same degree of radicality between both methods compared. Therefore, we chose the extended median sternotomy just as this conventional approach was recommended also by Bulkley, Masaoka, Jaretzki, and many others. The minimally invasive method, which removes the same amount of tissue with opening of both pleural cavities, should be our thoracoscopic approach. If we would feel it to be necessary, in case the upper thymic poles were not removable radically enough by the thoracoscopic approach, we would combine it with an additional cervical access. However, this was not necessary in any of the cases included in the study.
Concerning the thymomas, both of these tumors shown here in the median sternotomy group were of very small size, estimated 5 mm and 8 mm, and they were, of course, unknown before. All of our patients had preoperatively a CT from the neck to the diaphragm. If we find a suspected thymoma preoperatively, meanwhile we would not include these patients in a study with thoracoscopic thymectomy. We would open the mediastinum by median sternotomy.
| ||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
| ANN THORAC SURG | ASIAN CARDIOVASC THORAC ANN | EUR J CARDIOTHORAC SURG |
| J THORAC CARDIOVASC SURG | ICVTS | ALL CTSNet JOURNALS |
