MYASTHENIA GRAVIS 2010

8/8/2019 MYASTHENIA GRAVIS 2010

1/44

Iskender Algithmi, MDRagab Shehata, MCs

Cardiothoracic SurgeryUnit - KAUH

2010

1st experience with roboticThymectomy in KAUH


2/44

Introduction

7 case underwent robotic Thymectomy in

KAUH between January 2009 to march2010.

Patients characteristics, preoperativepreparation, operative data, postoperativeresults will reviewed.


3/44

Preoperative Characteristics of Patients

Gender Female 7 (100%)

Mean age (range) 25 years (1745 years)Mean duration of symptoms 18 (6 64) (months)Osserman stage

I ocular myasthenia 6 (85%) IIa mild weakness 2 (28%) IIb moderate weakness 3 (44%) III acute sever weakness 1 (14%) IV late sever weakness 1( 14%)


4/44

Preoperative medication therapy:

Anticholinesterase 7 (100%) Steroid 7(100%) Azatioprine 2(28%) Cyclosporine 1(14%)


5/44


6/44

Complete labs:

CBC, U&E, LFT, INR,PTT, TFT

Pulmonary function test to asses

respiratory function


7/44

Radiology

Chest x ray PA & Lat. And CT chest.To evaluate any Mediastinal massesReveal enlarged thymus in 3 patient


8/44


9/44

Plasmapheresis

For all patient 3 sessions to:

- decrease Ab level- improve symptoms- decrease incidence of Myasthenic crises

Anesthesia assessmentICU referral


10/44

Surgical technique

Under general anesthesia

double lumen endotracheal tube for selectivesingle lung ventilation during the time of operation

One patient required bronchial blocker.


11/44

patient is positioned left side up at a 30-degree angle


12/44

Surgical technique

A camera port for the three-dimensional 0-degree

stereo endoscope is introduced through a 15 mmincision in the fifth intercostal space on themidaxillary lineTwo additional thoracic ports are inserted; one inthe third intercostal space on the midaxillaryregion and another in the fifth intercostal spaceon the midclavicular space


13/44


14/44

Surgical technique

Two arms of the da V inci system are then

attached to the two access points and another arm is attached to the port-inserted endoscope.During surgery the hemithorax was inflatedthrough the camera port with CO2 ranging inpressure from 6 to 10 mm Hg


15/44

Surgical technique


16/44

All anterior mediastinal tissue, including fat

between the phrenic nerves, and from innominatetvein to diaphragm dissected and removed


17/44

Surgical technique

After the hemostasis, a 28F drainage tube is

inserted through the port of the fifth intercostalspace, the lung is reinflated, and the other wounds are closed.


18/44

Thymus specimen


19/44

At the end of procedure

5 patient is extubated in the operating

room and, after an adequate period of observation, returns to the floor of thesurgical thoracic ward.2 patient need ICU admission


20/44

Operative Data

Robotic time:118 minutes

(range 95 to 240 minutes)Total operative time: 258 minutes

range (148 - 303 min)

No major Intraopertaive complications


21/44

Post operative

2 patients requires post op. ventilation for

6, 48 hours and ICU stays 1, 4 days.

Chest tube drainage: mean 240 mlPots op analgesia: tramadol 50mg po q6hHospital stay: 4 days (3-10)


22/44

Complications

One patient developed post operative

dyspnoa, wheeze and haemoptysis,Reintubated, ventilated , bronchoscopydone showing bronchial injury,

? Bronchial blocker frequent suction patient stabilized andextubated after 2 days


23/44

Histopathology

Thymic hyperplasia: 3 patient

Atrophic thymus: 2 patient

Normal thymic tissue 2 patient


24/44

Follow up

Follow up for 3 to 18 (mean 6)months shows:

Significant improvement and decreasemedication in 3 patient .Mid to moderate improvement in 2 caseNo improvement in 2 cases


25/44

Brief review of Thymectomy in

myasthenia gravis


26/44

MYASTHEN IA

Autoimmune disease

Affects neuromuscular junction receptorsCharacterized by:

Localized or generalized weakness that improveswith rest

Inability to sustain or repeat muscle contractions


27/44


28/44

CLASS IF ICAT IONS

Osserman Group I ocular disease Group IIA mild, general symptoms Group IIB mod, general symptoms Group III acute, severe; lasts weeks-

months; severe bulbar S. Group IV late; severe, marked bulbar S.

and general severe weakness


29/44

MYASTHEN IA

BULBAR WEAKNESS Oropharyngeal weakness, dysphagia Difficulty breathing Difficulty clearing secretions


30/44

MYASTHEN IA

85% have antibodies to ACh receptors in skeletalmuscleAntibody binds close to receptor sitesdestruction of sitesThymus thought to be involved:

30-50% pts with thymoma have MG After Thymectomy

25% remission70-80% improve over weeks to months


31/44

DIAGNOS IS

Clinical symptoms

EMGImprovement after EdrophoniumBulbar symptoms = poor prognostic sign


32/44

TREATMENT

GOAL:

Improving neuromuscular function


33/44

TREATMENT (medical)

Cholinesterase inhibitors Inhibit hydrolysis ACh increase its concentration Successful in mild disease Pyridostigmine (longer duration, less side effects)

60 mg po Q6h


34/44

TREATMENT (medical)

Corticosteroids Dec AChR antibodies

80% remissionLimited by long term Side Effect

G I bleed HTN, hyperglycemia Osteoporosis susceptibility to infection


35/44

TREATMENT (medical)

Immunosuppressive Interferes with formation AChR antibodies Side effects

Bone marrow suppressionSusceptibility to infectionsmalignancy

Cyclophosphamide, azathioprine,cyclosporine


36/44

TREATMENT

Plasmapheresis

Short term improvement significant decease postop. complications

IV Immunoglobulin Short term May be given pre op


37/44

TREATMENT (surgical)

Thymectomy:Major source antibody productionArrests/reverses diseaseIndicated in:

Adults with generalized disease Thymoma Thymic hyperplasia Drug resistant MG


38/44

Thymectomy (approach)

The transsternal approach:w idespread surgical technique for Thymectomy.The main advantages are: an optimal exposition anddissection of the thymus and perithymic fat tissueLow er risks of vascular and nervous injuries.

Disadvantages include invasiveness of the approachand a longer hospitalization.


39/44

Thymectomy

The transcervical thymectomy:

minimally invasive technique that is easily acceptedby young patients and neurologists.The advantages are a short hospitalization, fe w er complications and lo w er costs.

Disadvantage: small space of access makingsurgical manoeuvres difficultImpossible to perform a thymectomy that extends tothe perithymic fat tissue.


40/44

Thymectomy

V ATS thymectomy:

minimally invasive techniquethrough the left- or right-sided approachgood visualization of the anterior mediastinum,achieving an extended thymectomy.

The disadvantages are the 2-dimensional vie w of theoperative field and the limited manipulation of theendoscopic instruments.


41/44

Thymectomy

The robotic Thymectomy:

Combines the advantages of minimally invasivetechniques (fewer complications, minimalthoracic trauma, decreased postoperative pain,early improved pulmonary function, shorter recovery period and optimal cosmetic resultsthe specific advantages is 3-dimensional vision, ascale motion w ith tremor filtering and articulatedmovements.


42/44

Results


43/44

Conclusion

In patients with MG, robot-assisted thymectomy canbe performed safely and efficiently.The improved visualization and instrument and itsadvanced technology may facilitate the minimallyinvasive approach to the thymus.We prefer to use the left-sided approach because it

provides an enhanced visualization of the aorticwindow and it reduces the probability of phrenicnerves injury.A longer follow-up is necessary to verify long-term

clinical results.


44/44

Thank you

Documents

MYASTHENIA GRAVIS 2010