CASE REPORTCASE REPORT
CASE REPORT
CASE REPORT
Subxyphoid Uniportal VATS Extended Thymectomy in Non-Thymomatous Myasthenia Gravis: First Experience in Middle and East Indonesian Region
1Vasan, 2Ivan Joalsen.
1Departemen Bedah Toraks, Kardiak & Vaskular, RSUD Dr. Soetomo, Surabaya
2Divisi Bedah Toraks, Kardiak & Vaskular RSUD Abdul Wahab Sjahranie – Samarinda Kalimantan Timur
Abstract
Background:
Myasthenia gravis (MG) is an autoimmune disorder that places patients in debilitating condition. It currently affects 14 to 20 per 100,000 population, with 85% as Thymic hyperplasia while 15% are Thymic tumors. Extended thymectomy via subxiphoid uniportal VATS (SUVATS) offer several advantages, including the ability to access both sides of chest with single incision and reduced post-operative pain.[1,2,3]
Objective: To report a case of MG's patient with thymic hyperplasia who undergone extended Thymectomy via SUVATS in Abdul Wahab Sjahranie general Hospital, Samarinda-East Borneo.
Methods: A Case report of 24 years old female with ptosis; fatique and muscles weakness during activity; and had an history of taking mestinon for 6 years. Repetitive Nerve Stimulation Test (RNS) showed functional decrement in neuromuscular junction, and Computed Tomograph(CT) scan showed there was a 4.1x1.7 cm mass in anterior mediastinal area, encapsulated and inhomogen.
Result: Patient undergone extended thymectomy via SUVATS. Length of stay (LOS) in Intensive Care Unit (ICU) was 3 days and mestinon administered post operatively.
Conclusion: SUVATS approach gave a good outcome and less complication. This approach was the first which is done in Middle and East Indonesia
Keywords : Thymoma, Myastenia Gravis, Video-assisted thoracic surgery (VATS)
Introduction
MG is known as an autoimmune disease mainly mediated by auto antibodies against the acetylcholine receptors (AChR) between the synaptic space of the skeletal muscles. Myasthenia Gravis is characterized by weakness and fatigability of skeletal muscles, usually associated with Thyroid disease, Hodgkin's Lymphoma & Thymic gland abnormalities, with 85% as Thymic hyperplasia while 15% are Thymic tumors.[1,2]
Over the past decade, video-assisted thoracic surgery (VATS) has started to replace median sternotomy for the resection of non-invasive anterior mediastinal masses. The superiority of VATS thymectomy over sternotomy approach had been demonstrated by several studies, due to the smaller wound away from the midline which would provide better cosmoses, faster and better healing, decreased the postoperative length of ICU and hospital stays, and earlier return to work and daily activities without a difference in outcome when compared with sternotomy approach.[3,4]
Currently, a further evolution of VATS surgery is being developed—the SUVATS approach., a single vertical muscle-sparing incision is made in the subxiphoid space permitting thoracic surgery to be performed without requiring intercostal incisions.[5]
We report a case of MG's patient with thymic hyperplasia who undergone extended Thymectomy via SUVATS in Abdul Wahab Sjahranie general Hospital, Samarinda-East Borneo, first experience in midlle and east region of Indonesia.
Case Presentation
A Case report of 24 years old female was reffered from neurologtist with ptosis; fatique and muscles weakness during activity; and had an history of taking mestinon for 6 years. Repetitive Nerve Stimulation Test (RNS) showed functional decrement in neuromuscular junction, and Computed Tomograph(CT) scan showed there was a 4.1x1.7 cm mass in anterior mediastinal area, encapsulated and inhomogen (Fiugure. 1)
Fig 1. Chest CT Scan of the 24 y.o patient showed a mass in the anterior mediastinal segment
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Fig. 2. Incision of subxyphoid UVATS
Surgical technique
Under general anaesthesia, patients were placed in a supine position with a roll beneath the scapulae (for maximal chest extension). A 4-cm-long longitudinal subxiphoid incision was made. The xiphoid process was then resected/divided and the 4 cm-diameter wound retractor was inserted to provide a widened operative view. (Figure.2)ProximalProximalDistalDistalProximalProximalDistalDistalProximalProximalDistalDistalProximalProximal
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Blunt finger dissection created a retrosternal tunnel between the incision and the thoracic cavity and a wound protector was placed to further optimize the view. Any obstructing anterior mediastinal adipose tissue was removed by using harmonic cauter. A 10 mm 30o angle thoracoscope (Karl Storz, Tuttlingen, Germany) was used.
The right pleural cavity was opened initially, with the left lung being selectively ventilated. Dissection of pericardial and epiphrenic fat pads was performed by using Harmonic cauter and then the right lobe of the thymus was identified and dissected from the pericardium and ascending aorta. Care was taken to visualize fully the innominate vein and superior vena cava junction prior to dissection of the thymic horn from the underlying innominate vein. The thymic veins were identified prior to draining into the innominate vein and divided using a Harmonic Cauter.
The left pleural cavity was then opened with the right lung selectively ventilated. The left pericardial and aortopulmonary window adipose tissue was dissected prior to completing dissection of the left thymic horn. The freed thymus and any attached mediastinal fat was then removed via the subxiphoid incision .
A 24 Ch chest drain was placed in each pleural cavity and the subxiphoid incision closed around the drains. The mean operative duration was 1.5 up to 3 hours. The mean operative blood loss was 50 mL approximately.
Results
Post Operatively, the patient was transferred to the ICU for observation. Mestinon was administered post-operatively. There were no incidence of phrenic nerve palsy on patient. Histopathologic findings showed that the mass was thymic hyperplasia (Figure.3).
The LOS in ICU was 3 days and dispatched on the fourth day.
Fig. 3. Thymic Hyperplasia (Hassal Corpuscle)
Discussion
This case report demonstrates the subxiphoid-VATS approach to be a safe and feasible approach to performing extended thymectomy in selected patients.
Many studies confirmed that, compared to standard sternotomy, VATS thymectomy results in less post-operative pain, better preserved pulmonary function, improved cosmesis (which can be particularly important to many young female myasthenia gravis patients) According to Meyer's, patients in VATS group had longer operation time, but shorter postoperative hospital LOS, less quantity of drainage, and shorter duration of drainage than that of patients via thoracotomy. [3,6]
The subxiphoid-VATS approach represents a further development of minimally invasive thoracic surgery. The potential benefits of this approach include reduced postoperative pain and the absence of chest wall paraesthesia due to preservation of the intercostal innervation and the absence of chest drains impinging on the intercostal neurovascular bundles. The main limitation of the technique is reduced instrument manoeuvrability; however, this can be overcome with specially modified instruments and an angled thoracoscope.[5]
This case report adds further to the evidence that the SUVATS approach is a safe and feasible approach to performing extended thymectomy.
References
Samuel O, Otohinoyi David et al. Myasthenia Gravis, Thymoma, and Thymectomy : The Clinical Interplay. International Journal of Clinical and Biomedical Research, 2018. . Accessed at 22 September 2018
Yadav Subash, Ricardo Salonga, Jose Edzel Tamayo et al. Thymic Carcinoma Presenting as Myasthenia Gravis. Chest AAnnual Meeting, 2016. Accessed at 22 September 2018
Bedetti Benedetta, Pierfiorgio Solli, David Lawrence et al. Single Port Video Assisted Thoracoscopic Thymectomy. J Vis Surg, 2016; 2:149. Accessed at 22 September 2018
Salim Ehab F. Role of VATS in Thymectomy for Non-Thymomatous Myasthenia Gravis. The Egyptian Society of Cardio-Thoracic Surgery.2018. Accessed at 22 September 2018
Weaver D, Ali JM, Jiang L, Yang C, Wu L, Jiang G, Aresu G. Uniportal subxiphoid video-assisted thoracoscopic approach for thymectomy: a case series. J Vis Surg 2017;3:169. Accessed at 22 September 2018
Yuan Zu-Yuang, Gui-Yu Cheng, Ke-Lin Sun et al. Comparative Study of Video-Assisted Thoracic Surgery Versus Open Thymectomy for Thymoma in One Single Center. J Thorax Dis. 2014;6(6):726-733. Accessed at 22 september 2018
