| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
Ann Thorac Surg 2001;72:1441-1442
© 2001 The Society of Thoracic Surgeons
a Department of Surgical Sciences, Division of General Thoracic Surgery, Catholic University, Largo Agostino Gemelli, 8, 00168 Rome, Italy
e-mail: alfcesario{at}yahoo.com
To the Editor
Surgery of the thymus in the myasthenic patient has long represented a field of interest to our institution. Recently, we described a cosmetic approach to a trans-sternal radical thymectomy performed with the aid of video-assisted thoracic surgery equipment [1]. The publication of Grandjean and colleagues’ experience [2] compels us to make this comment to the Editor.
The role of thymectomy in the management of myasthenia remains uncertain "because a definitive study of the effectiveness of thymectomy has never been done" [3]; "it has not been demonstrated unequivocally that this is necessary...total thymectomy is considered to be the goal of surgery" [4]; "it is not clear that all the described resectional techniques can achieve this goal"; and "the debate regarding which technique is preferable is not resolved" [4]. Actually, "the majority of the studies regarding thymectomy did not show significant benefit: (a) the methods were not optimum in all the reports; (b) none was randomized; (c) none used blinded outcome assessments; (d) none described either patient selection criteria or the pathologic status of the thymus gland." Moreover, "given these limitations and the fact that only modest improvement was seen and in only a minority of studies, it is surprising that thymectomy is such widely accepted treatment for Myasthenya Gravis: randomized trials are needed" [5]. Despite this evidence, we strongly believe that, at present, no thoracic surgeon would deny a thymectomy to a myasthenic patient in cases in which a neurologist has recommended this surgery. As thoracic surgeons, therefore, we must endeavor to perform the least invasive operation possible, while respecting criteria for a radical resection with attention to cosmetic appearance. In regards to completeness of surgery, we believe that radical "extended" thymectomy can only be performed through the approaches classified by Jaretzky and colleagues as T3 or T4 (trans-sternal bilateral) [4]. Validation of results obtained through unilateral techniques should be supported by clinical follow-ups which are longer term than those currently available within the literature addressing this issue. In fact, due to the extreme lack of homogeneity of the reported results, it is not possible to carry out a true comparison of the clinical outcome regarding the different surgical techniques. At present, we believe that only a broad and median approach to the mediastinal region can allow full extirpation of all thymic tissue and mediastinal fat, bilaterally to, and sometimes beyond, the pleural layers.
Having put forward these premises, we believe that cosmesis is a focal issue in the surgical approach to thymectomy. Grandjean and coworkers’ paper describes [2] a midline 8-cm to 10-cm incision starting 1 cm below the jugulum which is used to perform a median partial sternotomy ("up to the third intercostal space"). This access allows an "extended" radical thymectomy. While we agree with the authors that "this technique may improve operative results of extended thymectomy...in terms of pain control and hospital stay" (which, in fact, can be considered a T3—trans-sternal—technique), we do not agree that it may improve cosmetic results.
Moreover, if the authors had focused their comments on cosmetic improvement with respect to T3–T4 (trans-sternal) thymectomy techniques, citation of our technique which produces excellent cosmetic results, with good and comparable clinical results, (in terms of successful myasthenia gravis control) in a large number of patients, would have been greatly appreciated.
References
Related Article
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 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 |
