胸腺切除术治疗重症肌无力的围手术期和长期疗效：手术入路比较和预后分析。
Perioperative and long-term outcome of thymectomy for myasthenia gravis: comparison of surgical approaches and prognostic analysis.
机构信息
Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China.
出版信息
Chin Med J (Engl). 2013 Jan;126(1):34-40.
BACKGROUND
Thymectomy is an established treatment for myasthenia gravis (MG), and video-assisted thoracoscopic surgery (VATS) thymectomy has become an acceptable surgical procedure. This study aimed to compare the results of VATS thymectomy and open thymectomy and to identify the prognostic factors after thymectomy.
METHODS
The clinical data of 187 consecutive thymectomies performed between July 2000 and December 2009 were retrospectively reviewed; 75 open thymectomies and 112 VATS thymectomies. Clinical efficacy and variables influencing outcome were assessed by Kaplan-Meier survival curves and Cox proportional hazards regression analysis.
RESULTS
The operative blood loss in the VATS group was significantly less than that in the open group ((62.14 ± 55.43) ml vs. (137.87 ± 165.25) ml, P < 0.05). The postoperative crisis rate increased with the severity of preoperative MG and the prescription dose of anticholinesterase. Complete follow-up information of patients more than 12 months after the thymectomy was obtained on 151 cases, 89 cases from the VATS group and 62 cases from the open group, with a mean follow-up period of 59.3 months, range from 12 to 117 months. Complete stable remission (CSR) was the end point for evaluation of the treatment results. The overall five-year CSR rate was 57.5%. Two good prognostic factors were identified; preoperative prescription of anticholinesterase alone (P = 0.035) and non-thymomatous MG (P = 0.003). The five-year CSR rate of the ocular type of MG reached a high level of 67.4%.
CONCLUSIONS
Thymectomy can achieve good long-term CSR in MG, and VATS is an ideal alternative method. High-dose prescription of anticholinesterase and the advanced stage by Myasthenia Gravis Foundation of America (MGFA) classification have higher risks of postoperative crisis. Preoperative prescription of anticholinesterase alone and non-thymomatous MG are good prognostic factors. Thymectomy should also be considered for the ocular type of MG.
背景
胸腺切除术是重症肌无力（MG）的一种既定治疗方法，而电视辅助胸腔镜手术（VATS）胸腺切除术已成为一种可接受的手术程序。本研究旨在比较 VATS 胸腺切除术和开放胸腺切除术的结果，并确定胸腺切除术后的预后因素。
方法
回顾性分析 2000 年 7 月至 2009 年 12 月期间连续进行的 187 例胸腺切除术的临床资料；其中 75 例为开放胸腺切除术，112 例为 VATS 胸腺切除术。通过 Kaplan-Meier 生存曲线和 Cox 比例风险回归分析评估临床疗效和影响结果的变量。
结果
VATS 组的手术出血量明显少于开放组（（62.14±55.43）ml 比（137.87±165.25）ml，P<0.05）。术后危象发生率随术前 MG 的严重程度和抗胆碱酯酶药物的处方剂量增加而增加。对 151 例患者进行了超过 12 个月的胸腺切除术后的完整随访信息，其中 VATS 组 89 例，开放组 62 例，平均随访时间为 59.3 个月，范围为 12-117 个月。完全稳定缓解（CSR）是评估治疗结果的终点。总体五年 CSR 率为 57.5%。确定了两个良好的预后因素；术前单独使用抗胆碱酯酶（P=0.035）和非胸腺瘤型 MG（P=0.003）。眼肌型 MG 的五年 CSR 率达到了较高水平的 67.4%。
结论
胸腺切除术可使 MG 获得良好的长期 CSR，VATS 是一种理想的替代方法。高剂量的抗胆碱酯酶处方和 MGFA 分类的晚期有更高的术后危象风险。术前单独使用抗胆碱酯酶和非胸腺瘤型 MG 是良好的预后因素。对于眼肌型 MG，也应考虑进行胸腺切除术。
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