Keijzers Marlies, de Baets Marc, Hochstenbag Monique, Abdul-Hamid Myrurgia, Zur Hausen Axel, van der Linden Marcel, Kuks Jan, Verschuuren Jan, Kessels Fons, Dingemans Anne-Marie C, Maessen Jos
Department of Cardiothoracic Surgery, Maastricht University Medical Centre, Maastricht and GROW Research Institute for Oncology and Developmental Biology, Maastricht University, Maastricht, Netherlands Department of Pulmonology, Maastricht University Medical Centre, Maastricht and GROW Research Institute for Oncology and Developmental Biology, Maastricht University, Maastricht, Netherlands.
Department of Neuroscience, The School for Mental Health and Neuroscience, Maastricht University, Netherlands.
Eur J Cardiothorac Surg. 2015 Jul;48(1):40-5. doi: 10.1093/ejcts/ezu352. Epub 2014 Sep 18.
Thymectomy is frequently used in the treatment of myasthenia gravis (MG). But indication, timing or surgical approach remain controversial. This study reports our experiences with robotic thymectomy and surgical and neurological outcomes in a large cohort of patients with MG.
We retrospectively analysed the outcome of 125 patients with MG who underwent a robotic thymectomy using the da Vinci Surgical System (Intuitive Surgical, Inc., Sunnyvale, CA, USA) between 2004 and 2012. The Myasthenia Gravis Foundation of America (MGFA) Classification was used to determine preoperative and postintervention status.
Ninety-five women and 30 men underwent a robotic thymectomy. One hundred patients had a neurological follow-up of more than 12 months. Preoperative most severe MGFA classification was Stage I in 11 patients (8.8%), Stage IIA in 18 patients (14.4%), Stage IIB in 18 patients (14.4%), Stage IIIA in 7 patients (5.6%), Stage IIIB in 29 patients (23.2%), Stage IVA in 10 patients (8.0%), Stage IVB in 29 patients (23.2%) and Stage V in 3 patients (2.4%). Median surgical procedure time was 123 min (range 45-353 min). There were no major perioperative complications or deaths. The median postoperative hospital stay was 3 days (range 2-24 days). Histological analysis showed thymic remnant tissue in 41 patients (32.8%), follicular hyperplasia in 52 patients (41.6%), thymoma in 31 patients (24%), lipoma in 1 patient (0.8%) and a cyst in 1 patient (0.8%). Patients with thymic remnant tissue were significantly more preoperative steroid users compared with the follicular hyperplasia group (P = 0.02). With a median follow-up of 33 months (range 12-104 months), 77% of the patients showed neurological improvement. Three-year probability remission rate [complete stable remission (CSR) and pharmacological remission] is 28.2%. Patients who were not treated with prednisolone preoperatively showed a significant higher CSR than patients who did take prednisolone (P = 0.014). No significant difference was observed regarding timing of surgery (P = 0.37).
Robotic thymectomy in patients with MG is safe and feasible. A neurological benefit and decreased use of steroids can be obtained in the majority of patients. No significant difference in neurological outcome was observed as the result of timing of robot thymectomy after the onset of MG.
胸腺切除术常用于治疗重症肌无力（MG）。但其适应证、手术时机或手术方式仍存在争议。本研究报告了我们在一大群重症肌无力患者中开展机器人辅助胸腺切除术的经验以及手术和神经学方面的结果。
我们回顾性分析了2004年至2012年间使用达芬奇手术系统（直观外科公司，美国加利福尼亚州森尼韦尔市）接受机器人辅助胸腺切除术的125例重症肌无力患者的结果。采用美国重症肌无力基金会（MGFA）分类法来确定术前和干预后的状态。
95名女性和30名男性接受了机器人辅助胸腺切除术。100例患者接受了超过12个月的神经学随访。术前最严重的MGFA分类为：I期11例（8.8%），IIA期18例（14.4%），IIB期18例（14.4%），IIIA期7例（5.6%），IIIB期29例（23.2%），IVA期10例（8.0%），IVB期29例（23.2%），V期3例（2.4%）。手术中位时间为123分钟（范围45 - 353分钟）。围手术期无重大并发症或死亡。术后中位住院时间为3天（范围2 - 24天）。组织学分析显示，41例（32.8%）有胸腺残留组织，52例（41.6%）有滤泡增生，31例（24%）有胸腺瘤，1例（0.8%）有脂肪瘤，1例（0.8%）有囊肿。与滤泡增生组相比，有胸腺残留组织的患者术前使用类固醇的比例显著更高（P = 0.02）。中位随访33个月（范围12 - 104个月），77%的患者神经功能有改善。三年缓解概率[完全稳定缓解（CSR）和药物缓解]为28.2%。术前未接受泼尼松龙治疗的患者的CSR显著高于接受泼尼松龙治疗的患者（P = 0.014）。手术时机方面未观察到显著差异（P = 0.37）。
重症肌无力患者的机器人辅助胸腺切除术安全可行。大多数患者可获得神经学益处并减少类固醇的使用。重症肌无力发病后机器人辅助胸腺切除术的时机对神经学结果无显著差异。
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