Right Side Approach for Video-Assisted Thoracoscopic Thymectomy in Treating Myasthenia Gravis

從右側胸腔利用胸腔鏡施行胸腺摘除手術治療重症肌無力症

林同森(Torng-Sen Lin) ； 陳大成(Ta-Cheng Chen) ； 吳金燕(Chin-Yen Wu) ； 鄭清源(Ching-Yuan Cheng) ； 徐彥勳(Yen-Shing Shu) ； 葉坤土(Kun-Tu Yeh) ； 陳淑真(Shu-Chen Chen) ； 周明智(Ming-Chih Chou)

《The Changhua Journal of Medicine》 8卷3期 (2003/07) Pp. 149-154

摘要

胸腺摘除手術已經確定為改善重症肌無力症的有效辦法，從西元一九九七年一月到西元二零零二年八月，我們收集了五十一個重症肌無力症的病患經右側胸腔利用胸腔鏡施行胸腺切除手術來治療重症肌無力症，其中三十三位是女性，十八位是男性，平均年齡是37.9歲。疾病嚴重度依Osserman氏分類法為Class Ⅰ（十一位）、Ⅱa（十八位）、Ⅱb（十八位）、Ⅲ（二位）、Ⅳ（二位）。手術前不需作例行性血漿置換術，手術時病患在雙管氣管插管麻醉下採左側半躺姿勢。施行胸腺及前縱膈腔脂肪組織切除手術。手術過程僅需要三個壹公分刀口，平均手術時間一百五十分鐘（一百二十到二百六十分鐘），大多數患者能在手術房或是麻醉恢復室拔除氣管插管，有兩例患者手術後需要使用呼吸器時間較長。手術取出的標本平均重量為49.4公克，以胸腺增生為主，有三例合併有良性胸腺腫瘤，四十五例胸腺增生，三例胸腺萎縮。併發症包括一例胸腔出血及一例肺塌陷，沒有死亡病例發生。手術後平均住院時間為六天。經過平均三十六點一個月的追蹤，四十七(92.1%)例患者獲得明顯症狀改善。根據DeFiLiPPi的預後分類方法，其中十四(27.5%)例患者手術後沒有任何症狀也不需要再服用任何藥物，十四(27.5%)例患者屬於第二類，二十一(41.4%)例患者屬於第三類，二(3.9%)例患者屬於第四類，但是沒有屬於第五類的患者。我們建議經由右側胸腔鏡的幫忙，施行胸腺切除手術治療重症肌無力症是一個安全而且可行的方法。

關鍵字

重症肌無力症 ； 電視輔助胸腔鏡手術 ； 電視輔助胸腔鏡胸腺切除手術 ； 胸腔鏡胸腺切除手術

並列摘要

Background: Thymectomy is an effective method of improving myasthenia gravis. Video-assisted thoracoscopic surgery provides a new approach to thymectomy, for the treatment of myasthenia gravis. We present our experience using video-assisted thoracoscopic thymectomy to treat Taiwanese patients with myasthenia gravis.
Method: From January 1997 to August 2002, 51 patients with myasthenia gravis were enrolled: 18 males and 33 females, ranging in age from 11 to 64 years (average, 37.9 years). Preoperative Osserman's classifications were: class Ⅰ, 11 patients; class ⅡA, 18 patients; class ⅡB, 18 patients; class Ⅲ, 2 patients; and class Ⅳ, 2 patients. Only 2 patients received preoperative plasmapheresis; during surgery, all except 2, were placed supine position in the 45-degree left-lateral decubitus position under double-lumen iritubated anesthesia. Both the thymic gland and anterior mediastinal adipose tissue can be harvested using the right-side approach for video-assisted thoracoscopic surgery.
Results: All procedures were performed using a right-side approach without conversion. The average operating time was 150 minutes (range, 120 to 260 minutes). The harvested thymus gland weighed an average of 49.4 grams (range, 21.4 to 90 grams). Two patients required prolonged postoperative ventilator support. Final pathologic results were: 3 encapsulated stage I thymomas, 45 hyperplastic thymus glands, and 3 atrophic thymus glands. Complications included 1 segmental atelatasis of the lung and 1 hemothorax; no surgical mortalities occurred. Mean postoperative hospital stay was 6 days (range, 4-20 days). After a mean follow-up of 36.1 months (range, 6-60 months), 47 (92.1%) patients experienced improvement or resolution of symptoms: 14 (27.5%) patients obtained complete remission without any medication, 14 (27.5%) patients were categorized as class 2, 21(41.1%) patients were class 3, 2 (3.9%) patients were class 4, and none were class 5, according to DeFilippi postoperative classification.
Conclusion: Complete thymectomy can be achieved by video-assisted thoracoscopic thymectomy, and this procedure is technically feasible and associated with favorable outcomes.

並列關鍵字

myasthenia gravis ； video-assisted thoracoscopic surgery ； video-assisted thoracoscopic thymectomy ； thoracoscopic thymectomy