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Ann Thorac Surg 2004;78:409-410
© 2004 The Society of Thoracic Surgeons

Invited commentary

M. Blair Marshall, MD

Department of Surgery, Thoracic Section, Hospital of the University of Pennsylvania, 3400 Spruce St, Philadelphia, PA 19104, USA

e-mail: blair.marshall{at}uphs.upenn.edu

Thoracic surgeons agree that thymectomy is part of the standard treatment for nonthymomatous myasthenia gravis (MG). Beyond this, there remains controversy surrounding the necessary extent of thymectomy and the analysis of the data. The literature is replete with retrospective reviews of varying techniques that cannot be adequately analyzed owing to lack of uniform definitions and variables. The patient cohorts are not the same, the techniques are not the same, and there are few defined objective preoperative and postoperative evaluations [1].

In light of this, Zieliski and colleagues describe their experience with a transcervical-subxiphoid-videothorascopic "maximal" thymectomy. This technique is most accurately represented as a combination of previously described techniques. The authors' approach incorporates most of the more minimally invasive thymectomy techniques: the excellent exposure of the cervical portion of the gland obtained with the transcervical technique [2], the distal exposure of the gland and ectopic tissue with the subxiphoid technique [3], and the bilateral intrathoracic views obtained with the video thorascope placed on either side of the chest [4]. In doing this, their exposure is maximized, and the relative shortcomings of each of the less invasive techniques are minimized. The distinct disadvantage with this approach is the increased operative time, which is offset by the use of two operative teams. The entire gland and most of the extralobar thymic tissue distributed in the cervical and mediastinal fat are removed with this technique. From the description, it is unclear if the pretracheal fat is removed as part of the procedure. Also, the lateral boundaries for the mediastinal dissection are defined by the phrenic nerves, thus leaving behind any possible additional thymic tissue that may be lateral to these structures. Because of this, one could argue that this technique does not quite represent a "maximal" thymectomy as described by Jaretzki and Wolff [5]. The follow-up in the patient population is short, but their initial results are comparable with other techniques including the transcervical-transsternal "maximal" thymectomy. Unfortunately, without performing a prospective trial, where the data are uniform and the definitions universal, the comparative analysis of these data will continue to be flawed. If we are able to conclusively show that a maximal thymectomy is the procedure of choice for patients with nonthymomatous myasthenia gravis, this procedure will certainly play a role in the management of these patients.

References

  1. Jaretzki A. Thymectomy for myasthenia gravis: analysis of the controversies regarding technique and results. Neurology 1997;48(Suppl 5):52-63.
  2. Cooper J.D., AL-Jalaihawa A.N., Pearson F.G., Humphrey J.G., Humphrey H.E. An inproved technique to facilitate transcervical thymectomy for myasthenia gravis. Ann Thorac Surg 1988;45:242-247.[Abstract]
  3. Uchiyama A., Shimizu S., Murai H., Kuroki S., Okido M., Tanaka M. Infrasternal mediastinoscopic thymectomy in myasthenia gravis: surgical results in 23 patients. Ann Thorac Surg 2001;72:1902-1905.[Abstract/Free Full Text]
  4. Yim A.P.C., Kay R.L.C., Ho J.K.S. Video-assisted thorascopic thymectomy for myasthenia gravis. Chest 1995;108:1140-1143.[Free Full Text]
  5. Jaretzki A., III, Wolff M. Maximal thymectomy for myasthenia gravis. Surgical anatomy and operative technique. J Thorac Cardiovasc Surg 1988;96:711-716.[Abstract]




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