Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2020 May;12(5):2388-2394.
doi: 10.21037/jtd.2020.03.81.

Subxiphoid completion thymectomy for refractory non-thymomatous myasthenia gravis

Vincenzo Ambrogi  1 , Federico Tacconi  1 , Francesco Sellitri  1 , Alessandro Tamburrini  2 , Gianluca Perroni  3 , Federica Carlea  3 , Eleonora La Rocca  3 , Gianluca Vanni  1 , Orazio Schillaci  4 , Tommaso Claudio Mineo  1
Affiliations

Subxiphoid completion thymectomy for refractory non-thymomatous myasthenia gravis

Vincenzo Ambrogi et al. J Thorac Dis. 2020 May.

Abstract

Background: Completion thymectomy may be performed in patients with non-thymomatous refractory myasthenia gravis (MG) to allow a complete and definitive clearance from residual thymic tissue located in the mediastinum or in lower neck. Hereby we present our short- and long-term results of completion thymectomy using subxiphoid video-assisted thoracoscopy.

Methods: Between July 2010 and December 2017, 15 consecutive patients with refractory non-thymomatous myasthenia, 8 women and 7 men with a median age of 44 [interquartile range (IQR) 38.5-53.5] years, underwent video-thoracoscopic completion thymectomy through a subxiphoid approach.

Results: Positron emission tomography (PET) showed mildly avid areas [standardized uptake value (SUV) more than or equal to 1.8] in 11 instances. Median operative time was 106 (IQR, 77-141) minutes. No operative deaths nor major morbidity occurred. Mean 1-day postoperative Visual Analogue Scale value was 2.53±0.63. Median hospital stay was 2 (IQR, 1-3.5) days. A significant decrease of the anti-acetylcholine receptor antibodies was observed after 1 month [median percentage changes -67% (IQR, -39% to -83%)]. Median follow-up was 45 (IQR, 21-58) months. At the most recent follow-up complete stable remission was achieved in 5 patients. Another 9 patients had significant improvement in bulbar and limb function, requiring lower doses of corticosteroids and anticholinesterase drugs. Only one patient remained clinically stable albeit drug doses were reduced. One-month postoperative drop of anti-acetylcholine receptor antibodies was significantly correlated with complete stable remission (P=0.002).

Conclusions: This initial experience confirms that removal of ectopic and residual thymus through a subxiphoid approach can reduce anti-acetylcholine receptor antibody titer correlating to good outcome of refractory MG.

Keywords: Myasthenia gravis (MG); acetylcholine receptor antibodies; completion thymectomy; subxiphoid video-assisted thoracic surgery (subxiphoid VATS).

PubMed Disclaimer

Conflict of interest statement

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/jtd.2020.03.81). The authors have no conflicts of interest to declare.

Figures

Figure 1
Figure 1
Position of thymic residual and ectopic tissue removed. Incision line is dashed.
Figure 2
Figure 2
Intraoperative image of residual perithymic tissue removal.
Figure 3
Figure 3
PET imaging demonstrating hyperplastic residual thymic tissue in the aortocaval groove (circle).
Figure 4
Figure 4
Kaplan Meier curve of remission after subxiphoid completion thymectomy.
See this image and copyright information in PMC

References

    1. Wolfe GI, Kaminski HJ, Aban IB, et al. Randomized trial of thymectomy in myasthenia gravis. N Engl J Med 2016;375:511-22. 10.1056/NEJMoa1602489 - DOI - PMC - PubMed
    1. Yang J, Liu C, Li T, et al. Prognosis of thymectomy in myasthenia gravis patients with thymus hyperplasia. Int J Neurosci 2017;127:785-9. 10.1080/00207454.2016.1257993 - DOI - PubMed
    1. Jaretzki A, 3rd, Penn AS, Younger DS, et al. “Maximal” thymectomy for myasthenia gravis:results. J Thorac Cardiovasc Surg 1988;95:747-57. 10.1016/S0022-5223(19)35684-3 - DOI - PubMed
    1. Mack MJ, Landreneau RJ, Yim AP, et al. Results of video-assisted thymectomy in patients with myasthenia gravis. J Thorac Cardiovasc Surg 1996;112:1352-60. 10.1016/S0022-5223(96)70151-4 - DOI - PubMed
    1. Nakamura H, Taniguchi Y, Suzuki Y, et al. Delayed remission after thymectomy for myasthenia gravis of the purely ocular type. J Thorac Cardiovasc Surg 1996;112:371-5. 10.1016/S0022-5223(96)70264-7 - DOI - PubMed