Descriptive Analysis of Therapeutic Outcomes between Thoracoscopic and Transsternal Thymectomy in Myasthenia Gravis Patients from 2011 to 2021

doi:10.21203/rs.3.rs-4336798/v1

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Research Article

Descriptive Analysis of Therapeutic Outcomes between Thoracoscopic and Transsternal Thymectomy in Myasthenia Gravis Patients from 2011 to 2021

https://doi.org/10.21203/rs.3.rs-4336798/v1

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published 03 Sep, 2024

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Background

Myasthenia gravis is an autoimmune disease with high prevalence of thymus disorders, in which, thymectomy is considered one of the therapeutic approaches in improving the patients’ clinical outcomes. Today, thoracoscopic thymectomy has received significant attention than the classic transsternal approach due to fewer complication. Therefore, this study was designed with the aim of investigating the therapeutic outcomes of thymectomy in patients with myasthenia gravis in the Afzalipour Hospital of Kerman between 2011–2021.

Methods

The current study is a descriptive analytical study on patients with myasthenia gravis who underwent surgical thymectomy within 2011–2021. Demographic and clinical characteristics of patients from the time of operation to three years of follow-up were extracted and recorded from clinical records or by phone calls. Data were analyzed using SPSS software.

Results

The data of 70 patients who underwent surgical thymectomy were analyzed. Thymectomy caused a significant reduction in the severity of the disease according to the Osserman classification (P = 0.001). It also significantly reduced the use of corticosteroids (P = 0.001) and IVIG (P = 0.015) compared to the time before the surgery. 78.57% of patients needed to take less medicine than before surgery. Left VATS was associated with less post-operative severity of the disease (P = 0.023). There were only two deaths during the follow-up period.

Conclusion

Overall, the findings of the present study demonstrated that thoracoscopic thymectomy is a useful surgical approach that leads to faster recovery, reducing the severity of the disease, need for medication, and complications in patients with myasthenia gravis, In comparison with the transsternal approach.

Myasthenia Gravis

Thymectomy

Thoracoscopy

Mid-sternotomy

Myasthenia gravis is an autoimmune disease of the neuromuscular junction (NMJ), characterized by weakness and fatigue of skeletal muscles (1). The main cause of this disease is antibodies targeting acetylcholine receptor in the neuromuscular synapse, which leads to impaired signal transduction between the nervous and musculoskeletal system (2).

Myasthenia gravis is a relatively uncommon disease with the estimated prevalence rate between 70 and 163 people per million, which mostly occurs in women in the third and fourth decades of life (3–5).

Myasthenia gravis has the potential to affect any skeletal muscle, but it mostly presents with significant disruptions in the muscles involved in eye movement, swallowing, blinking, and facial expressions (6, 7). Hence, ptosis, changes in facial expression, double vision, swallowing dysfunction, fluctuating fatigable weakness, speech impairments, respiratory issues, and paralysis are expected signs and symptoms in the patients (8, 9).

The most important feature is the history of fluctuating fatigable weakness which leads to the clinical diagnosis of the disease (10).

The ice pack test, the Mestinon test, the Tensilon test and measurement of anti-acetylcholine receptor antibodies (Anti-AChRAbs) and Muscle-specific receptor kinase tyrosine-specific (MuSK) antibodies in the serum are additional tests that can provide considerable assistance in diagnosing this condition (11).Approximately 90% of patients suffered from myasthenia gravis are seropositive for anti-acetylcholine receptor antibodies (Anti-AChRAbs) (12).

Thymoma and thymic carcinoma are the most prevalent tumors of thymus gland which usually occur between fourth and sixth decades of life and account for approximately 20% of mediastinal neoplasms (13, 14).

Anterior mediastinal masses have a higher Risk of being malignant compared to middle and posterior mediastinal masses. Malignant anterior mediastinal masses predominantly including thymoma, lymphoma, germ cell tumors, and tumors of the thyroid and parathyroid glands (15, 16). Different symptoms are associated with the presence of malignant masses, including chest pain, dyspnea, cough, phrenic nerve paralysis, superior vena cava syndrome, and other symptoms such as night sweats, weight loss, and fever. Thymic carcinomas prognosis are worse than thymomas, and necrotic and calcification regions with irregular borders are visible in imaging (14, 17). The most common paraneoplastic syndrome associated with thymoma, is myasthenia gravis which is found in at least 50% of the patients (18).

Thymectomy leads to improvement in approximately 75% of patients with myasthenia gravis, with complete remission in 30% of cases. While thymectomy may have greater benefits in younger patients, optimal outcomes have been reported in both younger and older age groups (19–22). Thymectomy is performed in patients with myasthenia gravis due to thymic abnormalities, with most cases having thymic hyperplasia (85%) or thymoma (15%). The procedure is safe and effective, even in pediatric patients, and studies demonstrate that some factors such as age under 35, Presence of symptoms less than 24 months before the operation and no prior history of steroid treatment to be associated with better outcomes in patients(21, 23, 24).

Generally, thymectomy can be performed in four main methods: trans-cervical thymectomy, video-assisted thoracoscopic surgery (VATS), trans-sternal thymectomy, and a combination of trans-cervical and trans-sternal thymectomy (25). In all these methods, the thymic tissue is resected, but the resection of extra-capsular mediastinal tissue and cervical fat tissue varies. Some surgeons prefer the trans-sternal approach due to extensive approach for thorough exploration of the mediastinum up to the neck and enables complete removal of thymic tissue and fat (25, 26).

On the other hand, one of the best surgical approaches for thymectomy is video-assisted thoracoscopic surgery (VATS), which is considered a less invasive method and suitable for patients with a diagnosis of myasthenia gravis. Some studies have shown that using minimally invasive techniques such as video-assisted and robot-assisted approaches are associated with fewer complications and mortality compared to trans-sternal techniques, while achieving similar therapeutic outcomes(27).

However, considering the inconsistent results of various studies, it seems that more extensive research is still needed to investigate the outcomes of different surgical techniques in patients with myasthenia gravis. Therefore, in the present study, we focused on evaluating patients with myasthenia gravis who underwent thoracoscopic thymectomy and examined the long-term results.

Study design

This is a single center, analytical and descriptive cross-sectional study, conducted on patients suffered from myasthenia gravis who underwent surgical thymectomy at Afzalipour Hospital in Kerman between 2011 and 2021. In this study, the medical records of all patients who underwent surgical thymectomy as a management for myasthenia gravis and were admitted to the thoracic surgery department of Afzalipour Hospital in Kerman were examined using the census approach.

The inclusion criteria were as follows: confirmed diagnosis of myasthenia gravis based on clinical history, physical examination, and documented findings from the Tensilon test and electromyography; undergoing a spiral chest CT scan with a specific focus on the mediastinum; confirmation of thymoma indicating eligibility for surgical intervention by a neurologist; and performance of thoracoscopic or trans-sternal thymectomy with complete excision of thymic tissue.

The exclusion criteria were previous diagnosis of connective tissue disease and missing more than 70% of the research variables in the patients' medical records and inability to follow up via phone for completing research data.

Ethical rules

The present study was approved by the ethics committee of Kerman university of medical sciences (the approval number: IR.KMU.AH.REC.1401.064). Necessary administrative arrangements and permissions were obtained to access patients' clinical records. Confidentiality of collected data was maintained, and results were published without disclosing any patient identities. Participants were informed about the study objectives and their voluntary participation, ensuring data was used solely for research purposes.

Participants and data collection

The study was conducted according to the CONSORT statement and Helsinki declarations and was approved by ethics committee of Kerman university of medical sciences. After conducting the necessary administrative coordination, the study variables in this research included thymus cytopathological findings, patients' personal information, duration of disease remission and recurrence, any previous symptoms, severity of the disease before surgery (according to the myasthenia gravis foundation of America classification), duration of disease until surgery, surgical complications, and disease progression after surgery for a period of 3 years of follow-up (in terms of the need for readmission, medication use, and patient outcome). All mentioned data were extracted from the patients' clinical records. In case of missing information, the necessary data were collected and completed using the telephone number recorded during the patient's hospitalization.

Notably mentioned, the verbal consent, to contact the patients, was obtained from the patients during hospitalization, and during the telephone calls, the research objectives, study design, and voluntary nature of answering the questions were explained to the participants. Additionally, assurance was given that this information would only be used for research purposes and that the presentation of results would be done without disclosing the patient's name and surname. All collected data were recorded in the data collection form and used for statistical analysis.

Statistical analysis

SPSS version 26 was used to perform statistical analysis. Paired test was used to examine the disease severity, type of treatment before and after the surgery. Moreover, chi square and Kruskal wallis tests were used to examine other study variables. Descriptive statistics indices were used to describe the collected data. Frequency and percentage were used for qualitative variables, while mean and standard deviation were used for quantitative variables.

Based on the inclusion and exclusion criteria, a total number of 70 patients entered the trial of which 71.4% were female. The mean age of the participants at enrollment was 35.02 \(\pm\) 11.76 years (16 to 58 years) and the mean age of the participants at the time of surgical intervention was 36.41 \(\pm\) 11.56 years. The average time between diagnosis and surgery was 13.79 ± 14.84 months, with a range of one month to 70 months.

Generalized involvements were seen in 84.1% and ocular involvements were seen in 15.9% of patients. Pathological assessments showed that in 73% of participants, the thymus pathology was hyperplasia, while in 27% it was thymoma. Additionally, in 90.5% of cases, the antibody detection test was positive, while in 9.5% it was negative (Fig. 1).

Moreover, the investigations on the type of medical treatment before surgical intervention revealed that 80% of them were using pyridostigmine, 94.29% were using corticosteroids, 61.43% were using IVIg, and 18.57% of cases underwent plasmapheresis (Table 1).

Table 1

the type of medical treatment before surgical intervention.
Prevalence	Number	Type of treatment
80%	56	Pyridostigmine
94.29%	66	Corticosteroids
61.43%	43	IVIg
18.57%	13	Plasmapheresis

The dose of consumed prednisolone by the patients prior to the surgery was 27.22 ± 10.73 mg per day, and the average duration of medication usage before surgery was 12.19 ± 10.68 months.

70% of the patients underwent the left VATS approach surgery, 20% underwent the right VATS approach and 10% underwent mid-sternotomy. The average duration of the operation was 165 \(\pm\) 18 minutes and the average of the patient’s hospitalization lasted for 3.56 \(\pm\) 0.76 days. The evaluation on the post thoracoscopic surgical thymectomy complications revealed that infection occurred in 17.14% of patients, and bleeding in 1.42% of patients. 35.71% of patients were admitted In ICU after surgery and one patient died during the postoperative hospitalization. Furthermore, during follow up, another patient, apart from the previously mentioned mortality, passed away (Table 2).

Table 2

post-surgical thymectomy complications and outcomes.
Prevalence	Number	Post surgical complications
17.14%	12	Infection
1.42%	1	Bleeding
35.71%	25	ICU admission
34.28%	24	Readmission
1.42%	1	Mortality
2.85%	2	Death	Outcomes
97.14%	68	Live	Outcomes

Based on Osseman classification, most of the patients categorized in class III (48.57%) and class II (27.1%) preoperative, while after surgical intervention, most of the patients categorized in class I (80%). The observed changes in disease severity before and after surgery were statistically significant (P = 0.001) (Table 3).

Table 3

Disease severity before and after surgery based on Osserman classification.
P value	Post operative		Preoperative
0.001	Prevalence	Number	Prevalence	Number
	80%	56	11.42%	8	I	Osserman classification
	15.71%	11	27.1%	19	II
	2.85%	2	48.57%	34	III
	1.42%	1	12.85%	9	IV
	0	0	0	0	V

The comparison of the type of used medication before and after surgery revealed a significant decrease in corticosteroids consumption from 94.29–60% (P = 0.001). Moreover, similar changes observed in IVIg consumption, and it decreased from 61.43–40% which was statistically significant (P = 0.015) (Table 4).

Table 4

Comparison of treatment before and after thymectomy surgery.
P value	Post operative		Preoperative		Treatment
P value	Prevalence	Number	Prevalence	Number	Treatment
0.495	84%	59	80%	56	Pyridostigmine
0.001	60%	42	94.29%	66	Corticosteroids
0.015	40%	28	61.43%	43	IVIg
0.027	6%	4	18.57%	13	Plasmapheresis

Generally, medications consumption was reduced in 88.57% of patients and was increased in 1.42% after surgical intervention. 10% had similar medication consumption before and after surgery.

The comparison of post-surgical thymectomy complications between mid-sternotomy, left and right VATS indicated that there were no significant differences found in terms of bleeding, ICU admission, readmission rates, medication consumption, and disease severity before and after surgery. However, there was a significant difference in disease severity and class I classification according to the Osserman classification had a higher prevalence in the left VATS group (P = 0.023). moreover, there was a significant difference in infection rates which was due to the differences between right VATS approach and mid sternotomy (Table 5).

Table 5

Comparison of post thoracoscopic surgical thymectomy complications between mid-sternotomy, left and right VATS.
P value	Mid sternotomy			Right VATS		Left VATS		Outcomes
P value	Prevalence		Number	Prevalence	Number	Prevalence	Number
0.001	71%	5		14%	2	10%	5	Infection
0.80	0%	0		0%	0	2%	1	Bleeding
0.32	57%	4		43%	6	31%	15	ICU admission
0.80	43%	3		29%	4	35%	17	Readmission
0.339	100%	7		0	0	2%	1	I	Osserman classification preoperative
	0%	0		21.4%	3	32.7%	16	II
	0%	0		50%	7	55.1%	27	III
	0%	0		28.6%	4	10.2%	5	IV
	0%	0		0	0	0	0	V
0.023	100%	7		57.1%	8	83.7%	41	I	Osserman classification postoperative
	0%	0		28.6%	4	14.3%	7	II
	0%	0		14.3%	2	0	0	III
	0%	0		0	0	2%	1	IV
	0%	0		0	0	0	0	V
0.739	100%	7		92.9%	13	85.7%	42	Decreased	Medication consumption
	0%	0		7.1%	1	12.2%	6	No change
	0%	0		0	0	2%	1	Increased

Moreover, there were no significant differences in the operation time and hospitalization between right and left VATS. On average, the duration of hospitalization for patients undergoing mid-sternotomy was approximately three days longer than patients undergoing thoracoscopy. However, this difference was not statistically significant (p = 0.086).

Thoracoscopic thymectomy is a surgical approach with minimal invasion, that was done in 1992 for the first time (28).

Considering the available evidence regarding the complications of sternotomy, such as increase in surgical site infection, hospitalization, post operative pain and, bleeding, many surgeons and patients now prefer less invasive techniques, including thoracoscopic approaches (29, 30).

Our study results showed that 71.4% of patients who were candidates for thymectomy were female, with a female-to-male ratio of approximately 2.5. In a study by Alshekhlee et al., women made up 61.6% of myasthenia gravis cases (31). Similarly, in a study by Lashkari Zadeh et al., 68% of patients with myasthenia gravis who were candidates for surgery were women (28). Many studies have demonstrated that the prevalence of myasthenia gravis is higher in women compared to men at younger ages, while it becomes almost equal in both genders in older ages (32).

The present study showed a significant difference in the distribution of disease severity before and after thoracoscopic thymectomy surgery. Before surgery only 11.42% of patients were classified as class I according to the Osserman classification, whereas after surgery, this percentage increased to 80%. Therefore, thoracoscopic thymectomy surgery resulted in a reduction in disease severity and improvement in symptoms.

Additionally, the study population had a significantly lower corticosteroid and IVIg consumption. Consistent with our study, Rabiou et al. demonstrated that thymectomy resulted in positive clinical outcomes in patients with myasthenia gravis (33). Similarly, Wolfe et al. found that patients required less prednisolone or immunosuppressive medication after thymectomy surgery, indicating improved clinical outcomes (19). Lashkari Zadeh et al. also reported improvement in patients’ clinical outcomes, after undergoing thoracoscopic thymectomy (28).

Previously mentioned, the comparison of complications between left and right VATS indicated that there were no significant differences found in terms of bleeding, ICU admission, readmission rates, medication consumption, and disease severity before and after surgery, while the postoperative severity of the disease was lower in the group that underwent left VATS. In accordance with our study findings, Xie et al. demonstrated that there were no significant differences in the duration of surgery, hospitalization period, bleeding and, postoperative complications between left and right VATS approaches (34).

Yim et al. mentioned that right VATS approach was associated with a better surgical field visualization (35). However, Mineo et al. demonstrated that left VATS approach should be preferred due to inclined thymus tissue towards the left pericardiophrenic region. This approach can provide better access to aortocaval groove, aortopulmonary window, and pericardiophrenic space (34, 36). Also, anatomical studies had shown that left VATS approach had lower residual thymus tissue after thymectomy (37). Probably, the decrease in disease severity was attributed to a lower residual thymus tissue after left VATS in our study.

The investigation of hospitalization duration in our study patients revealed an average duration of 3.56 days. In accordance with these findings, Lin et al. reported an average hospitalization period of 5.6 days for VATS thymectomy patients (38). Similarly, Wright et al. reported a 4-day average (39)and Manlulu et al. reported a 3-day average of hospitalization period, which are almost in line with the findings of our study (40).

The mortality rate for 3 years follow up was 2.85% which indicated that thoracoscopic approach is considered a safe approach for thymectomy. Furthermore, the hospitalization duration in patients undergoing surgery with a mid-sternotomy approach was 6.43 days, which was longer compared to the thoracoscopic approach. Supporting these findings, Sobhy et al. also demonstrated that the thoracoscopic thymectomy approach is associated with a shorter hospitalization duration compared to the transsternal approach (41). Zahid et al. also demonstrated that VATS thymectomy approach had an average hospitalization duration of 5.6 days, while this duration was 8.1 days for the mid-sternotomy approach (42). In the study by Ye et al., the hospitalization duration after surgery in the VATS approach was on average 5 days shorter than the transsternal approach (43). Therefore, it appears that the thoracoscopic technique is accompanied by a shorter hospitalization duration and, in this regard, has superiority over the mid-sternotomy technique.

In total, the present study findings showed that thoracoscopic thymectomy, is a beneficial surgical approach which leads to faster recovery, reducing the severity of the disease and reducing the medication consumption in patients suffers from myasthenia gravis. It also has some negligible postoperative complications which are lower than other surgical approaches known for thymectomy.

Consent to Participate

All human participants involved in this study provided informed consent for their participation. Prior to enrollment, each participant was provided with detailed information about the study objectives, procedures, potential risks, and benefits. They were informed about their right to withdraw from the study at any time without consequences. Written informed consent was obtained from each participant before their inclusion in the study. For participants unable to provide written consent due to medical conditions, verbal informed consent was obtained in the presence of a witness. The study protocol, including the consent procedures, was reviewed, and approved by the ethics committee of Kerman University of Medical Sciences (Approval number: IR.KMU.AH.REC.1401.064). Confidentiality of participants' information was strictly maintained throughout the study, and data were used solely for research purposes.

Consent for Publication

All authors listed in this manuscript provide their consent for publication. We confirm that the manuscript entitled "Descriptive Analysis of Therapeutic Outcomes between Thoracoscopic and Transsternal Thymectomy in Myasthenia Gravis Patients from 2011 to 2021" has not been published elsewhere and is not under consideration for publication in any other journal. We agree to the submission of this manuscript to your journal, and we authorize the journal to publish this article, including all text, tables, figures, and supplementary materials, if accepted for publication.

Availability of data and materials

The data that support the findings of this study are available from the corresponding author upon reasonable request.

Conflict of interests

The authors declare that they have no known conflict of financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Funding Statement

This research was conducted without external funding. All expenses associated with the research, including data collection, analysis, and publication, were covered by the authors personally. There was no financial support or sponsorship from any organization, institution, or funding agency for this study.

Acknowledgements

The authors are grateful to the physicians, and study participants for their valuable contributions and cooperation.

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No competing interests reported.

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Descriptive Analysis of Therapeutic Outcomes between Thoracoscopic and Transsternal Thymectomy in Myasthenia Gravis Patients from 2011 to 2021

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Journal Publication

Version 1

Abstract

Background

Methods

Results

Conclusion

Figures

Introduction

Methods

Study design

Ethical rules

Participants and data collection

Statistical analysis

Results

Discussion

Conclusion

Declarations

References

Additional Declarations

Status:

Journal Publication

Version 1