Diaz Andres, Black Edward, Dunning Joel
Department of Cardiothoracic Surgery, John Radcliffe Hospital, Oxford, UK.
Interact Cardiovasc Thorac Surg. 2014 Mar;18(3):381-9. doi: 10.1093/icvts/ivt510. Epub 2013 Dec 18.
A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was if thymectomy in non-thymomatous myasthenia gravis was of any benefit? Overall, 137 papers were found using the reported search, of which 16 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. The outcome variables were similar in all of the papers, including complete stable remission (CSR), pharmacological remission, age at presentation, gender, duration of symptoms, preoperative classification (Oosterhius, Osserman or myasthenia gravis Foundation of America (MGFA)), thymic pathology, preoperative medications (steroids, immunosuppressants), mortality and morbidity. We conclude that evidence-based reviews have shown that relative rates of thymectomy patients compared with non-thymectomy patients attaining outcome indicate that the former group of patients is more likely to achieve medication-free remission, become asymptomatic and clinically improve (54%, P < 0.01), particularly patients with severe and generalized symptoms (P = 0.007). Patients with generalized myasthenia gravis showed 11% stronger association with favourable outcomes after thymectomy. Some studies show early remission rates (RRs), as early as 6 months post-thymectomy, of 44%. Overall, the reported remission rate for non-thymomatous myasthenia gravis is between 38 and 72% up to 10 years of follow-up. Among these patients, those with thymic hyperplasia show the best complete stable remission rates (42%, P < 0.04) in the majority of studies. Age showed variability across the studies and the cut-off was also different among them. Overall age < 45 years showed a higher probability of achieving complete stable remission during follow-up (81% benefit rate (BR), P < 0.02). Pharmacological improvement is reported between 6 and 42%. However, the certainty of these benefits has not been established due to factors such as the confounding differences between myasthenia gravis patients receiving and not receiving thymectomy, the non-randomized nature of class II studies and the lack of Class I evidence to support its use. There is currently a randomized trial ongoing looking at thymectomy by sternotomy vs controls and the results are eagerly awaited.
根据结构化方案撰写了一篇胸外科最佳证据主题文章。所探讨的问题是，非胸腺瘤性重症肌无力患者行胸腺切除术是否有益？通过报告的检索方式，共找到137篇论文，其中16篇代表回答该临床问题的最佳证据。现将这些论文的作者、期刊、发表日期、国家、研究的患者群体、研究类型、相关结局及结果制成表格。所有论文中的结局变量相似，包括完全稳定缓解（CSR）、药物缓解、发病年龄、性别、症状持续时间、术前分类（奥斯特休斯、奥斯erman或美国重症肌无力基金会（MGFA））、胸腺病理、术前用药（类固醇、免疫抑制剂）、死亡率和发病率。我们得出结论，循证综述表明，与未行胸腺切除术的患者相比，行胸腺切除术患者达到相关结局的相对比例表明，前一组患者更有可能实现停药缓解、无症状并在临床上得到改善（54%，P<0.01），尤其是症状严重且广泛的患者（P = 0.007）。全身型重症肌无力患者行胸腺切除术后与良好结局的关联更强，为11%。一些研究显示，胸腺切除术后6个月时的早期缓解率（RRs）高达44%。总体而言，非胸腺瘤性重症肌无力患者随访长达10年的报告缓解率在38%至72%之间。在这些患者中，大多数研究表明胸腺增生患者的完全稳定缓解率最高（42%，P<0.04）。各研究中年龄存在差异，其临界值也各不相同。总体而言，年龄<45岁的患者在随访期间实现完全稳定缓解的可能性更高（受益率（BR）为81%，P<0.02）。药物改善率报告为6%至42%。然而，由于接受和未接受胸腺切除术的重症肌无力患者之间存在混杂差异、II类研究的非随机性质以及缺乏I类证据支持其使用等因素，这些益处的确定性尚未确立。目前正在进行一项关于胸骨切开术行胸腺切除术与对照组的随机试验，人们急切期待结果。
