Original article: general thoracic
Transcervical thymectomy for myasthenia gravis achieves results comparable to thymectomy by sternotomy

Presented at the Thirty-eighth Annual Meeting of The Society of Thoracic Surgeons, Fort Lauderdale, FL, Jan 28–30, 2002.
https://doi.org/10.1016/S0003-4975(02)03722-0Get rights and content

Abstract

Background. It remains controversial whether transcervical thymectomy offers results equivalent to thymectomy by way of a median sternotomy in the treatment of myasthenia gravis. Furthermore, preoperative prognostic factors have not been clearly defined.

Methods. This study is a retrospective chart review and interview of 78 patients completing transcervical thymectomy for myasthenia gravis between 1992 and 1999.

Results. There were 24 men and 54 women. Mean age was 40 years (range, 13 to 78 years). Twelve patients were in Osserman class 1, 25 in class 2, 30 in class 3, and 11 in class 4 (mean, 2.5). There was no perioperative mortality and 6 (7.7%) morbidities. Mean length of stay was 1.5 days and mean follow-up, 54.6 months. The crude cumulative complete remission (asymptomatic off medications for 6 months) rate was 39.7% (n = 31). Only 8 patients (10.3%) failed to improve after transcervical thymectomy. Kaplan-Meier estimates of complete remission were 31% and 43% at 2 and 5 years, respectively. Eight patients with thymoma had a 5-year estimated complete remission rate of 75% in contrast to 43% in 38 patients with thymic hyperplasia and 36% in 32 patients with neither thymoma nor hyperplasia (p = 0.01). Twelve patients with ocular myasthenia had a 5-year estimated complete remission rate of 57%, whereas patients with mild-to-moderate (n = 55) or severe (n = 11) generalized symptoms had 5-year complete remission rates of 43% and 30%, respectively (p = 0.21).

Conclusions. Overall, extended transcervical thymectomy offers results that are comparable to those published for the transsternal procedure. Patients with milder disease (including isolated ocular disease) and taking no preoperative immunosuppressive agents appear to experience higher remission rates. In contrast to previous studies, we also find that small thymomas predict better responses to thymectomy.

Section snippets

Patients and methods

We conducted a retrospective review of 121 consecutive patients who underwent attempted transcervical thymectomy between January 1992 and September 1999. The medical records, operative notes, and pathology reports were reviewed. Of the 98 patients with MG, 92 patients (93.8%) were available for follow-up evaluation by either telephone contact or communication with their neurologist. Eight patients who required extension of the cervical incision were excluded from the analysis (two underwent

Patient characteristics

Of the 78 patients with MG, there were 24 men and 54 women, mean age 40 years (range, 13 to 78 years). By the modified Osserman classification, 12 patients had a maximum preoperative severity of illness placing them in class 1, 25 in class 2, 30 in class 3, and 11 in class 4, with a mean preoperative Osserman classification of 2.5 (Table 1). Preoperative treatments are listed in Table 2.

Operative morbidity

Mean operative time was 96.8 minutes (range, 40 to 180 minutes). There was no perioperative mortality. There

Comment

Transcervical thymectomy, although it offers advantages in terms of morbidity, patient comfort, and length of stay, has been criticized based on the belief that total thymectomy cannot be performed by this approach and the presumption that therefore, TCT must result in lower rates of MG remission. However, complete resection of all thymic tissue may not be achieved even by the radical approach of “transcervical transsternal maximal thymectomy” advocated by Jaretski and Wolff [3]. When this more

References (40)

  • R Kay et al.

    Response to thymectomy in Chinese patients with myasthenia gravis

    J Neurol Sci

    (1994)
  • P.F Roberts et al.

    Thymectomy in the treatment of ocular myasthenia gravis

    J Thorac Cardiovasc Surg

    (2001)
  • D.G Mulder et al.

    Thymectomy for myasthenia gravisrecent observations and comparison with past experience

    Ann Thorac Surg

    (1989)
  • L.E Stern et al.

    Long-term evaluation of extended thymectomy with anterior mediastinal dissection for myasthenia gravis

    Surgery

    (2001)
  • A Blalock et al.

    The treatment of myasthenia gravis by removal of the thymus gland

    JAMA

    (1941)
  • E.D Schumacher et al.

    Thymectomie bei einem fall von morbus basedowi mit myasthenie

    Mitteilg Grenzgebiete Med Chir

    (1912)
  • A Jaretzki

    Thymectomy for myasthenia gravisanalysis of the controversies regarding techniques and results

    Neurology

    (1997)
  • A Jaretski et al.

    Myasthenia gravisrecommendations for clinical research standards

    Ann Thorac Surg

    (2000)
  • E.L Kaplan et al.

    Nonparametric estimation from incomplete observations

    J Am Stat Assoc

    (1958)
  • N Mantel

    Evaluation of survival data and two new rank order statistics arising in its consideration

    Cancer Chemother Rep

    (1966)

    • Cited by (103)

    • Thoracoscopic thymectomy – The method of choise in surgical treatment of non-invasive thymomas

      2019, Annals of Medicine and Surgery

    • Eyelid and Facial Nerve Disorders

      2018, Liu, Volpe, and Galetta's Neuro-Ophthalmology: Diagnosis and Management

    • Myasthenia Gravis with Toxic Goiter: Challenges with Management in a Low-Resource Setting in Africa; Review of Literature and Case Report

      2024, Nigerian Journal of Clinical Practice

    • The impact of thymectomy in subgroups of Myasthenia gravis patients: a single center longitudinal observation

      2023, Neurological Research and Practice

    • Point Counter-Point: Thymectomy in Ocular Myasthenia Gravis

      2022, Journal of Neuro-Ophthalmology

    • The value of thymectomy in the treatment of non-thymomatous myasthenia gravis

      2022, Chirurg
    View all citing articles on Scopus
    View full text
    Copyright © 2002 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.