胸腔镜手术切除胸腺瘤治疗重症肌无力

Resection of Thymoma by Video-assisted Thoracoscopy for Myasthenia Gravis

目的探讨胸腔镜手术治疗胸腺瘤伴重症肌无力的可行性。方法2005年7月～2006年2月,采用电视胸腔镜在双腔气管插管静脉复合麻醉下行胸腺、胸腺瘤切除术10例,胸腺瘤最大6cm×4cm×3cm。于腋中线第5肋间做1cm胸腔镜口,腋前线与锁骨中线中点第4肋间做3cm主操作孔,腋前线第6肋间做1.5cm辅助操作孔。术中沿胸廓内动脉与锁骨下动脉分叉下方、胸廓内动脉内侧,剪开纵隔胸膜暴露同侧胸腺及部分对侧胸腺;沿上腔静脉或膈神经前方剪开胸膜,暴露同侧胸腺下极,自下而上游离同侧胸腺,沿头臂干静脉前方解剖、结扎胸腺静脉,同法游离对侧并切除。术后全部进行4000cGy放疗。结果手术时间70～130min,平均110min。术中出血<100ml。术后Masaoka分期Ⅰ期7例,Ⅱ期3例。术后无死亡,未出现心肺并发症和重症肌无力危象。术后1周重症肌无力症状缓解。10例随访8～15个月,平均13.0月,均无复发、转移,重症肌无力症状无明显加重。结论采用胸腔镜手术切除Ⅰ期或部分Ⅱ期胸腺瘤技术上是可行的,创伤小,术后并发症少,且不影响美观。

Objective To evaluate the feasibility of video-assisted thoracoscopic resection of thymoma for myasthenia gravis. Methods Between July 2005 and February 2006, 10 patients with thymoma were enrolled in this study. After double lumen intubation, video-assisted thoracoscopic resection of the thymus and thymoma was performed on the patients under total intravenous anesthesia. The largest tumor in this series was 6 cm × 4 cm × 3 cm. For a three-trocar technique, three incisions with a length of 1, 3, or 1.5 cm were made respectively at the fifth intercostal space on the midaxillary line, fourth intercostal space on the middle between the anterior axillary line and midclavicular line, and sixth intercostal space on the anterior axillary line. During the operation, to expose the ipsilateral thymus and part of the contralateral thymus, the mediastinal pleura was cut along the internal thoracic artery, and superior vena cava or phrenic nerve. The thymus was then separated, and the thymic vein was dissected along the brachiocephalic vein and ligated. All the patients received radiotherapy after the operation with a dose of 4000 cGy. Results The operation time ranged from 70 to 130 minutes （mean, 110 minutes） and the blood loss was less than 100 ml in all the cases. After the operation, 7 patients presented Masaoka stage Ⅰand 3 were at stage Ⅱ. No patient died or had cardiopulmonary complications or myasthenia crisis. The symptoms of myasthenia gravis were relieved in 1 week. The patients were followed up for 8 to 15 months （ mean 13.0 months）. During the period, none of them developed recurrence, metastasis, or aggravation of the myasthenia gravis. Conclusions It is feasible to resect stage I to II thymoma by video-assisted thoracoscopy. The procedure is minimal invasive with a few postoperative complications and good cosmetic outcomes.