Video-assisted thoracoscopic thymectomy for non-thymomatous myasthenia gravis: a right-sided or left-sided approach?

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was in [patients undergoing video-assisted thoracoscopic thymectomy for myasthenia gravis (MG)] is a [left-sided approach] superior to a [right-sided approach] in terms of [clinical outcome]? Two hundred and fifty-nine papers were found using the reported search. In looking at both procedures, we selected studies with a sizeable number of patients performing or studying both procedures and comparing their outcome. Hence, only 4 studies represented the best evidence to answer the clinical question. The authors, journal, date, country, study type, patient group, relevant outcomes and results of these papers are tabulated. Two studies compared their clinical experience with a right-sided versus a left-sided video assisted thoracoscopic surgery thymectomy approach, while 1 study compared using a bilateral versus a unilateral right-sided approach in patients with non-thymomatous MG. The number of patients studied included 31, 107 and 103 patients, respectively. All 3 studies demonstrated no difference regarding surgical time, intraoperative blood loss, postoperative hospital stay, postoperative complications and therapeutic effects (the last study compared the 5-year complete stable remission rate). All 3 studies concluded that both approaches are feasible, effective and comparable in operative and long-term results for the treatment of non-thymomatous MG. One anatomical study compared both approaches in 10 cadavers, 5 in each group. They studied the size of the specimen resected and visualization of different anatomic sites via each approach. Visualization was superior using the left-sided approach, while a right-sided approach resulted in slightly higher chances of an incomplete resection. The study concluded that a left-sided approach achieves a better chance of radical thoracoscopic thymectomy due to anatomic considerations. In conclusion, despite 1 cadaveric study suggesting that a left-sided approach may achieve more complete resection, possibly due to anatomical considerations, there are no differences in outcomes with either unilateral approach in terms of complications, hospital stay or long-term symptom relief.

Combined Vascular and Orthopaedic Approach for a Pseudotumor Causing Deep Vein Thrombosis after Metal-on-Metal Hip Resurfacing Arthroplasty.

Introduction. Metal-on-metal (MoM) hip resurfacings have been associated with a variety of complications resulting from adverse reaction to metal debris. Pseudotumors have rarely been reported to cause deep venous thrombosis (DVT). Study Design. A case report and a review of the literature. Case Presentation. A 75-year-old female who had left metal-on-metal hip resurfacing 6 years ago presented with left groin pain associated with unilateral lower limb edema and swelling. By duplex and MRI studies, our patient had an extensive soft tissue necrosis associated with a large pelvic mass causing extensive DVT of the lower limb secondary to mechanical compression of the left iliac vein. Results. Our case was initially treated for DVT followed by dual surgical approach. The pseudotumor was excised through a separate iliofemoral approach and revision of the hip implant was undertaken through a posterior approach in the same setting. An inferior vena cava (IVC) filter was inserted to minimise the perioperative risks of handling the iliac veins. Conclusion. A combined approach with vascular surgeons is required. Combined resection of the pseudotumor and revision of the metal bearing surfaces is essential, in order to achieve a good surgical outcome in this rare complication.