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Ann Thorac Surg 1996;62:245
© 1996 The Society of Thoracic Surgeons

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Discussion

Discussion

See also page 242.

DR JOEL D. COOPER (St. Louis, MO): This is a great paper. I would say the main message, as I think all of us who have been involved in these cases are convinced, is that if you have myasthenia gravis you ought to have your thymus gland out and you ought to have it out as soon as possible, except perhaps for the group with ocular symptoms only, who are controversial. That goes for patients up to the age of 50 years. I think it is interesting to see the results in the older age group.

Some years ago we reported on our transcervical approach, which I understand is controversial, and gives similar results. I noticed that 85% of our group were free of generalized weakness after a median follow-up of 3 years, 95% had improved by at least one grade, and 86% had improved by two or more grades. Sixty percent of our group had moderate or severe weakness beforehand.

I have done about 200 of these operations. Since I have moved to the States, the pressures of the economic system here have led to early discharge. Half the patients go home the day after the operation and the balance go home on the next day. I have not pushed this procedure for fear that it might push surgeons, by making them fear competition from a transcervical approach, into trying this approach. Frankly, it does take a lot of experience and willingness to make it a special interest. I think it does not matter by which procedure you have your thymus gland out these days; there is nothing wrong with a sternotomy.

The reason I even mention the transcervical approach is because recently I have heard of endoscopic or thoracoscopic removal of the thymic gland for myasthenia. I would argue that if you do not want to do a sternotomy, and there is no reason not to, then the transcervical approach, not the thoracoscopic one, makes more sense. It involves a little incision, no double-lumen tube, no collapse of either lung, no chest tubes, and most patients go home the next day. Therefore, the transcervical approach fulfills anything that you would want to fulfill with a minimally invasive procedure. So I think whether you favor a sternotomy or not, a thymectomy should be done in these patients. I would caution, however, that the thoracoscopic approach, at least in my book, does not have anything to offer in this particular disease. Thank you very much for this opportunity.

DR SCOTT: One thing I did not mention is that our mean follow-up in these cases was 5.5 years, with variable lengths from 1 month to more than 16 years. So we had a reasonable follow-up. I think Dr Cooper's results using the transcervical approach are similar to the outcomes that we have presented using the median sternotomy and extensive thymectomy.

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