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Ann Thorac Surg 2002;74:634
© 2002 The Society of Thoracic Surgeons
a Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka 812-8582, Japan
e-mail: uchiyama{at}surg1.med.kyushu-u.ac.jp
To the Editor
We thank Dr Jaretzki for his comments on our article [1]. Dr Jaretzki states that our new thymectomy technique presents some problems, which include difficulty in removal of extra-lobar tissue in the neck, and potential phrenic nerve injury. He mentions that the postoperative improvement we observed cannot be attributed to the thymectomy alone because all our patients received steroid therapy postoperatively, and he refers the reader back to the conventional indications for wide local excision. We find Dr Jaretzki’s comments to be well taken; however, we would like to express the following reservations.
(1) According to Dr Jaretzki’s findings of thymic gland being widely distributed in the neck [2], the transsternal "maximal" thymectomy with neck dissection may be an appropriate approach for surgical treatment of patients with myasthenia gravis as far as maximal resection is concerned. It may be difficult to remove all the fatty tissue in the neck by an endoscopic approach alone. One option is the use of an additional neck incision, as was done in the first 18 patients in our series. According to our experience, however, dissection of extra-lobar tissue beneath the thyroid gland can also be performed without cervical incision under infrasternal mediastinoscopy in most cases.
(2) As we reported, phrenic nerve injury did occur in one of our patients during total dissection of large amounts of fatty tissue of the left upper mediastinum. The phrenic nerve was divided in this case, so much more attention should have been given to its orientation. However, the patient had no complaint or respiratory symptoms after surgery. Although we did experience this phrenic nerve injury in the first series of 23 patients, we emphasize that the risk of nerve injury is quite low during mediastinoscopic thymectomy because the phrenic nerves are clearly visualized during the procedure. Therefore, we believe that with more experience, the incidence of nerve injury can be decreased to that associated with sternotomy.
(3) It is possible that postoperative immunosuppression therapy influenced the short-term clinical improvements we observed. However, postoperative use of steroids is routine in our institution. A comparison of the therapeutic effects between transsternal and mediastinoscopic thymectomy will be carried out in the near future.
(4) All thymomas in our series were less than 5 cm in diameter, thus complete thymothymectomy was achieved with our technique. A study of the indications for this approach to the thymic neoplasm will also be carried out in the near future.
We thank Dr Jaretzki for his interest in our article and for his constructive criticism.
References
This article has been cited by other articles:
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H. Hirose Double criss-cross sternal wiring and chest wound infections: Reply Ann. Thorac. Surg., September 1, 2003; 76(3): 977 - 977. [Full Text] [PDF]
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