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Thoracoscopic thymectomy for myasthenia gravis: a case report.

Total thymectomy combined with medical therapy is currently the most effective therapeutic strategy for patients with myasthenia gravis. The standard approach for total thymectomy is that of a median sternotomy. Other approaches include the cervical approach and partial sternotomy. We report a patient who underwent video-assisted thoracoscopic thymectomy at our institution. There was no postoperative complications and the patient was discharged on the fifth postoperative day. Video-assisted thoracoscopic thymectomy has proved to be an effective surgical therapy for the treatment of myasthenia gravis. The long-term outcome awaits close follow-up of the patients operated using this technique.

Adult↗

Thymectomy in the integrated management of myasthenia gravis.

Since the early days of Sauerbruch and Blalock, thymectomy has been used with increasing success in the management of myasthenia gravis. Several principles of management have emerged from this experience: the patient clearly benefits from care by a coordinated team, including a neurologist, intensivist, anesthesiologist, and surgeon in an institution familiar with the routine care of the myasthenic patient. Thymectomy is indicated early in the routine management of most patients with generalized myasthenia gravis, as well as those with purely ocular involvement uncontrolled by anticholinesterase medication. Patients should not undergo thymectomy while in crisis, but their medical condition should be optimally controlled prior to surgery, even if this requires the use of immunosuppressive agents. Because of the proven benefit in patient pain management and postoperative respiratory function, epidural adjuvant analgesia should be administered, unless contraindicated. Furthermore, the data from multiple series indicate that some form of "maximal" thymectomy should be used to try to remove all thymic tissue and induce patient clinical improvement or remission. Finally, long-term patient follow-up using an objective grading system should be maintained to optimize maximal functional status with as few medications as possible. When it is possible, there is little question that patients do better without long-term immunosuppression with steroids or other agents.

Animals↗

Thymectomy: its role in the management of myasthenia gravis.

The management and clinical course of patients with myasthenia gravis admitted to a neurological intensive therapy unit (ITU) for thymectomy over a 66 month period were reviewed. There were 53 patients, 20 male and 33 female, mean age 35.2 years (18-74) and median ITU stay of 5 days (2-30). Indications for thymectomy were thymic enlargement on computed tomography (34%), persistence of generalized symptoms (38%), a combination of both (20%), steroid side effects or dependency (4%) and progressive bulbar symptoms (4%). Following thymectomy, thymic histology revealed thymic follicular hyperplasia (26/53; 49%), atrophy (11/53; 21%), thymoma (12/53; 23%) and normal thymus (4/53; 8%). Post-operatively 23% required prolonged intubation (> 48 hrs); two patients required a tracheostomy 10 and 13 days post-operatively. Plasma exchange was required for two patients (3.8%) due to persistent severe myasthenic weakness. Three patients (6%) developed a post-operative chest infection and one pseudomembranous colitis. There were no post-operative mortalities during the study period. After 2 years, 35% of patients were in remission and 46% had ocular or mild generalized symptoms only. Thymectomy for myasthenia gravis is followed by sustained clinical improvement in the majority of patients. The appropriate post-operative management of these patients is best undertaken in a specialized neuro-intensive care setting. Copyright Rapid Science Ltd

Journal Article↗

Thymic function and impaired maintenance of peripheral T cell populations in children with congenital heart disease and surgical thymectomy.

The thymus begins involution in childhood and historically it was thought to be nonfunctional by adulthood, thus presenting no contraindication to the routine practice of thymectomy during cardiothoracic surgery. More recent data suggest, however, that the thymus remains active into adulthood and is responsible for the low-level production of normal T cells. We hypothesize, therefore, that incidental thymectomy during cardiothoracic surgery in infancy causes long-term changes in the cellular immune system. To investigate this hypothesis, we quantified peripheral T-cell subsets and T-cell recombination excision circles in children with congenital heart disease to measure the impact of cardiothoracic surgical procedures and thymectomy performed during a period of immunologic development. We found that cardiothoracic surgical procedures, especially if they include thymectomy, impair T-cell production and produce long-term decreases in total lymphocyte count and CD4(+) and CD8(+) T-cell subsets, suggesting that long-term maintenance of lymphocyte populations is disturbed.

Adolescent↗

[Thymectomy in myasthenia gravis: long-term evolution and predictive factors].

INTRODUCTION: Thymectomy is a surgical procedure which is generally accepted for treatment of myasthenia gravis. OBJECTIVE: To describe the long-term evolution of 217 myasthenic patients who had had thymectomies in the Hospital Clinico Quirurgico Hermanos Ameijeiras in La Habana, Cuba. PATIENTS AND METHODS: We determined the stage of evolution of 217 patients, followed-up periodically, with an average observation time of 83.4 months and an interval of between 5 and 155 months. We also studied the frequency of remission and the influence of a group of variables on this, as well as the mortality and its causes. RESULTS: The clinical state of the patients was: remission 77 (35.4%); pharmacological remission 45 (20.7%); significant improvement 70 (32.2%); the same or worse 5 (2.3%); deaths 11 (5%), and unknown 9 (4.1%). The cases with thymomas had a more unsatisfactory course than the other patients, with fewer remissions and greater mortality. Over the first five years of the evolution of the disease, there was a 30% rate of remission; after five years this rose to 35-40% and after ten years reached 47%. The age of the patient, duration of symptoms, histology of the thymus, age of onset of the disease and duration of follow-up did not have any significant effect (p < 0.05) on the long-term evolution of the thymectomy, in contrast to the gravity of the condition according to Osserman's scale. CONCLUSION: The results of thymectomy, in our study were good and similar to the results reported in the international literature.

Adult↗

[Thymectomy in juvenile myasthenia gravis].

INTRODUCTION: Juvenile myasthenia gravis (JMG) is an infrequent autoimmune disease, the symptoms and therapeutic handling of which do not differ from those of the adult forms. Chronic treatment with corticoids very often causes side effects in childhood, which is why patients are being submitted to thymectomies at younger ages with better results. AIMS. To analyse the clinical and evolutionary profile of JMG treated by thymectomy in our centre. PATIENTS AND METHODS: We report the case of four girls aged between 5 and 13 who were diagnosed as suffering from generalised myasthenia gravis (MG) with bulbar affectation. One of them started with a myasthenic crisis. The four of them were submitted to Tensilon s test, an electrophysiological study, determination of AChR, thoracic CT, and study of autoimmunity and thyroid functioning. After surgery the thymus was analysed histologically. RESULTS: They all gave positive in Tensilon s test and were seropositive for AChR. They were treated with anticholinesterases, up to the maximum tolerated dose, and corticoids, without complete remission being accomplished and so they were submitted to a thymectomy in the first year of evolution. In three cases surgical approach was transsternal and in the other by means of a videothoracoscope. All the thymuses showed lymphoid hyperplasia. After a variable follow up the girls are at present asymptomatic, although none of them has been able to completely give up the pharmacological treatment. CONCLUSIONS: Thymectomy is one of the mainstays of treatment for JMG. The ever more frequent use of videothoracoscopic techniques achieves results that are similar to those obtained by conventional surgery but with fewer post operative and aesthetic problems

Adolescent↗

[Analysis of long-term results of thymectomy in control of myasthenia gravis].

OBJECTIVE AND METHODS: We studied 77 patients with myasthenia gravis (MG) in whom thymectomy had been done between 1968 and 1992. The mean follow-up period was 7.3 years. Our aim was to analyze their clinical courses with regard to various parameters: demographic, clinical and the anatomo-pathology of the thymus. We classified the patients according to three possible situations: in remission without treatment, in remission with some type of treatment and not in remission. RESULTS: We did not find any data which significantly affected the subsequent course of MG. However, there was a statistically significant improvement (p = 0.008) when the pre-thymectomy and post-thymectomy conditions of the patients were compared. CONCLUSIONS: Overall, our series of cases is comparable to the majority of those presented. It should be remembered that although thymectomy has a place in the treatment of MG, and the technique is of low morbidity, precise indication for it has not yet been established. There are a considerable number of patients in whom no improvement is seen after this operation, although in 30% improvement may be expected.

Adolescent↗

Neuromyelitis optica in patients with myasthenia gravis who underwent thymectomy.

BACKGROUND: Myasthenia gravis (MG) and neuromyelitis optica (NMO, also known as Devic disease) are rare autoimmune disorders, with upper-limit prevalence estimates in the general population of 15 per 100,000 and 5 per 100,000, respectively. To our knowledge, an association between these diseases has not been previously reported. OBJECTIVES: To describe 4 patients with MG who developed NMO after thymectomy and to analyze possible causes of apparent increased prevalence of NMO among patients with MG. DESIGN: Case series. PATIENTS: Four patients with MG who underwent thymectomy. INTERVENTIONS: None. RESULTS: The prevalence of MG within the published cohort of patients with NMO is more than 150 times higher than that in the general population. CONCLUSION: Dysregulation of B-cell autoimmunity in myasthenia, possibly exacerbated by loss of control over autoreactive cells as a result of thymectomy, may predispose patients to the development of NMO.

Adolescent↗

Effect of thymectomy on blood T-cell subsets in myasthenia gravis.

We studied peripheral blood mononuclear T-cell subsets in 23 patients with myasthenia gravis who had undergone thymectomy at least one year before study. An increase in the T4+/T8+ (helper-inducer/suppressor-cytotoxic cell) ratio was seen, similar to that previously reported in nonthymectomized patients with myasthenia gravis. Six patients were studied before and after thymectomy and no consistent alteration in the pattern of T-cell subsets was detected. We were not able to demonstrate a quantitative effect of thymectomy on peripheral blood mononuclear T-cell subsets in patients with myasthenia gravis.

Adult↗

A pair of monozygotic twins who are concordant for myasthenia gravis but became discordant for systemic lupus erythematosus post-thymectomy.

We describe a pair of monozygotic twins who are concordant for myasthenia gravis but discordant for systemic lupus erythematosus (SLE). SLE developed in twin 1 18 years post-thymectomy and has been characterized by recurrent transverse myelitis and optic neuritis. Twin 2 remains well post-thymectomy, except for a skin rash and persistent leukopenia. Both twins have developed autoimmune thyroid disease. We review genetic and environmental factors of importance in the pathogenesis of SLE and discuss the possible role of thymectomy in the etiology of the disease.

Adult↗

Regulation of the immune response by subclasses of T lymphocytes. II. The effect of adult thymectomy upon humoral and cellular responses in mice.

The immunologic consequences resulting from thymectomy in adult life were investigated. Primary humoral responses were not diminished shortly after adult thymectomy, as judged by responses of intact thymectomized mice as well as by the ability of spleen cells from such mice to transfer primary responses. However, secondary humoral responses were substantially reduced in irradiated recipients of spleen cells from primed adult-thymectomized mice, suggesting that the thymus is required in adult life to maintain a population of cells important in the generation of immunologic helper memory. By contrast, small doses of anti-thymocyte serum, which primarily affect recirulating T cells, abrogated the primary humoral response, but allowed the subsequent development of immune memory. Using a technique permitting in vitro sensitization of purified T cells to alloantigens, it was shown that adult thymectomy increases the ability of T cells to generate primary cytotoxic responses, but had little effect upon the development of cytotoxic T memory activity. These experiments suggest that in adult life the thymus maintains a regulatory population of T cells in peripheral tissues which suppress early T cell differentiation to cytotoxic effector cells and potentiates the development of immune memory.

Age Factors↗

Organ-specific autoimmunity induced by adult thymectomy and cyclophosphamide-induced lymphopenia.

Autoimmune gastritis, a CD4+ T cell-mediated organ-specific autoimmune disease, can be induced by thymectomy of neonatal, but not of older, BALB/c mice. Here we have shown that autoimmune gastritis can also be induced in 6-8-week-old BALB/c mice by thymectomy combined with a single dose of cyclophosphamide (300 mg/kg). This treatment reduced the numbers of splenic T and B cells approximately 25-fold. However, by 8 days after treatment, the number of splenic lymphocytes had returned to normal adult levels. Approximately 50% of treated mice developed autoimmune gastritis after 10-12 weeks. These mice had mononuclear cellular infiltrates within the gastric mucosa and serum autoantibodies to the alpha and beta subunits of the gastric H+/K+ ATPase. Transgenic mice, expressing the gastric H+/K+ ATPase beta-subunit in the thymus (Alderuccio, F., Toh, B. H., Tan, S. S., Gleeson, P. A. and van Driel, I. R., J. Exp. Med. 1993. 178: 419), did not develop autoimmune gastritis after the adult thymectomy/cyclophosphamide treatment. Thus a T cell response to the H+/K+ ATPase beta-subunit is likely to be required for the onset of gastritis. These observations suggest that pathogenic autoreactive T cells exist in the periphery of normal adult mice and that autoimmunity can be induced by the activation of these autoreactive T cells following transient lymphopenia. Cyclophosphamide-treatment of adult mice without thymectomy did not induce autoimmune gastritis, suggesting thymic regulation of these pathogenic T cells.

Aging↗

Expression of a gastric autoantigen in pancreatic islets results in non-destructive insulitis after neonatal thymectomy.

Autoimmune gastritis, induced by day-3 thymectomy of BALB/c mice, is a destructive CD4+ T cell-mediated disease characterized by leukocyte infiltrates in the gastric mucosa, loss of parietal and chief cells and anti-gastric H/K ATPase autoantibodies. Our previous studies have indicated that a T cell response to the H/K ATPase beta subunit is required for the onset of autoimmune gastritis (Alderuccio, F., Toh, B. H., Tan, S. S., Gleeson, P. A. and van Driel, I. R., J. Exp. Med. 1993. 178: 419). To determine whether a response to the beta subunit autoantigen is alone sufficient to induce autoimmunity, or whether other tissue-specific factors are required, we have generated transgenic mice expressing the gastric H/K ATPase beta subunit in beta islet cells of the pancreas (RIP-H/K beta). RIP-H/K beta mice developed autoimmune gastritis and insulitis after day-3 thymectomy. Significantly, insulitis, observed as a peri-islet infiltrate, was only detected in thymectomized mice with autoimmune gastritis. There was no apparent immune destruction of the pancreas as insulitis did not progress to invasion of the islets or diabetes. Double transgenic mice, expressing the gastric H/K ATPase beta subunit in the thymus and in the pancreas, were protected from both gastritis and insulitis after day-3 thymectomy. Therefore, insulitis in the RIP-H/K beta mice appears to be dependent on a T cell response to the H/K ATPase beta subunit. This is the first example where an organ-specific initiating autoantigen has been expressed in another peripheral tissue. Autoimmune destruction in the stomach, but not the pancreas, indicates that tissue-specific factors play a fundamental role in the development of organ-specific autoimmunity.

Animals↗

Changes in human T lymphocytes after thymectomy and during senescence.

Peripheral lymphocytes from individuals who had been thymectomized in adult life for myasthenia gravis (MG) or for other, nonimmunological reasons showed a moderate decrease in proliferative response capacity to several T-cell mitogens as compared to lymphocytes from normal individuals. The decrease of the response to mitogens and allogeneic lymphocytes was 20-30% within 5 years after thymectomy and about 50% more than 15 years after thymectomy. A comparable decrease in lymphocyte proliferative response capacity was found in healthy aged humans (68-97 years old). Analysis of T lymphocytes from both aged and thymectomized individuals with monoclonal (OKT) antibodies showed a similar pattern: the proportion of T lymphocytes binding OKT6, OKT10, or OKI1 were found. A biochemical parameter for human T-cell differentiation, the lactate dehydrogenase (LDH) isoenzyme pattern, showed a significantly lower H/M ratio in the group of elderly people compared to young individuals. Furthermore, among patients thymectomized for MG, a significant correlation was observed between the LDH isoenzyme pattern of the T lymphocytes and the proliferative response to mitogens of these cells. In contrast, in healthy thymectomized individuals the LDH isoenzyme pattern appeared to be normal. These findings indicate that, after thymectomy or involution of the thymus, at least part of the peripheral blood T lymphocytes have properties different from those of the cells of young individuals. These cells might represent immature and/or not fully differentiated lymphocytes.

Adolescent↗

Role of thymectomy in the surgical treatment of myasthenia gravis.

Of the 26 patients with myasthenia gravis undergone thymectomy, 11 cases had either benign or malignant thymoma as judged not only by hitological examination but also by their clinical and operative findings. Age of initial onset ranged from 13 to 64 years old. Fifteen out of 26 (58 per cent) benefited from thymectomy. Duration of the symptom from the onset to the operation and the presence or absence of the thymoma are not related to their outcome. Benign or malignant nature of thymoma should not be determined by histological examination alone but by combined evaluation of clinical and operative findings. Serial studies of serum immunoglobulin levels before and after thymectomy suggested that this disorder could be associated with humoral antibody (IgG). HLA typing of the patients with myasthenia gravis did not indicate the presence of any specific antigens.

Adolescent↗

The influence of thymectomy on germ-cells of the testis in mice.

We performed thymectomy on the immature and mature male mice and made a quantitative assay of various germ cells of the seminiferous epithelium in the testis with Image Analyser System 35 days following thymectomy. The results indicated that as compared with the control group, all germ cells of the spermatogenesis lineage decreased in the immature group and in the mature group after thymectomy. The present study showed that thymus and its hormone stimulated not only the mitotic division, but also the meiotic division of germ cells during spermatogenesis, suggesting that thymus-sexual axis may play an important role in the process of spermatogenesis in the testis.

Animals↗

Perioperative medical management and outcome following thymectomy for myasthenia gravis.

PURPOSE: To describe the evolution of the perioperative management of myasthenia gravis (MG) patients undergoing thymectomy and to question the need for systematic postoperative ventilation. CLINICAL FEATURES: We collected data retrospectively from 36 consecutive MG patients who underwent thymectomy over a 21-yr period, via transthoracic, -cervical or -sternal incisions (n=5, n=7, n=24, respectively). From 1980 to 1993, a balanced anesthetic technique (n=24) included various inhalational agents with opiates and myorelaxants (in eight cases); 22 patients were admitted to the intensive care unit (ICU). Since 1994, i.v. propofol was combined with epidural bupivacaine and sufentanil (n=12); all patients were admitted to the postanesthesia care unit. Short-term postoperative ventilation (median time four hours, range from three to 48 hr) was required in eight patients who had longer hospital stay (median stay=12 days, range (8-28) vs five days (4-15) for patients with early extubation, P <0.05) but similar clinical improvement six months after thymectomy. Postoperative ventilatory support was required more frequently when a balanced anesthetic technique was used (odds ratio=4.2 (1.1-9.7), P=0.03) and particularly when myorelaxants were given (odds ratio=13.9 (2.1-89.8), P=0.009). Leventhal's scoring system had low sensitivity (22.2%) and positive predictive values (25%). CONCLUSIONS: Our data show that the severity of MG failed to predict the need for postoperative ventilation. A combined anesthetic technique was a safe and cost-effective alternative to balanced anesthesia as it provided optimal operating conditions and resulted in fewer admissions in ICU and shorter hospital stays.

Adolescent↗

Subxiphoid approach for thoracoscopic thymectomy.

Avoiding sternotomy, cumulative experience has demonstrated the efficacy and safety of minimally invasive thoracoscopic thymectomy. Previous reports describing the transcervical, left or right thoracic approach, although demonstrating promising results, involve some compromise of the surgical exposure. We designed a new approach through the subxiphoid route to perform extended thymectomy using the standard thoracoscopic technique. We used this approach on two consecutive patients. Additional port sites were created on both sides of the anterior chest wall for introducing instruments. This approach provides an excellent view of the bilateral pleural cavities, which is essential for adequate mediastinal fatty tissue dissection, especially because the surgical plan calls for removal of all the bilateral pericardiophrenic fat pads and the mediastinal fat tissue between the bilateral phrenic nerves. This approach omits the sternotomy while making extended thymectomy possible through the bilateral access. All the possible thymic-bearing mediastinal fat tissues can be removed under direct thoracoscopic view, which may subsequently translate into better results.

Adult↗