Surgical and neurologic outcomes after robotic thymectomy in 100 consecutive patients with myasthenia gravis.

OBJECTIVE: Thymectomy is a well-defined therapeutic option for patients with myasthenia gravis; however, controversies still exist about the surgical approach, indication, and timing for surgery. We reviewed our experience reporting surgical and neurologic results after robotic thymectomy in patients with myasthenia gravis. METHODS: Between 2002 and 2010, 100 patients (74 female and 26 male; median age, 37 years) underwent left-sided robotic thymectomy using the da Vinci robotic system (Intuitive Surgical, Inc, Sunnyvale, Calif). The Myasthenia Gravis Foundation of America classification was adopted for pre- and postoperative evaluation. Preoperative Myasthenia Gravis Foundation of America class was I in 10% of patients, II in 35% of patients, III in 39% of patients, and IV in 16% of patients. RESULTS: Median operative time was 120 (60-300) minutes. No death or intraoperative complications occurred. Postoperative complications were observed in 6 patients (6%) (bleeding requiring blood transfusions in 3, chylothorax in 1, fever in 1, and myasthenic crisis in 1). Median hospital stay was 3 days (range, 2-14 days). Histologic analysis revealed 76 patients (76%) with hyperplasia, 7 patients (7%) with atrophy, 8 patients (8%) with small thymomas, and 9 patients (9%) with normal thymus; ectopic thymic tissue was found in 26 patients (26%). Clinical follow-up showed a 5-year probability of complete stable remission and overall improvement of 28.5% and 87.5%. Remission was significantly associated with preoperative I to II Myasthenia Gravis Foundation of America class (P = .02). A significant improvement rate was found in Myasthenia Gravis Foundation of America class I to II (P = .03) and AbAchR+ (P = .04). A high percentage of patients interrupted or reduced their medications. CONCLUSIONS: Robotic thymectomy is a safe and effective procedure. We observed a neurologic benefit in a great number of patients. A better clinical outcome was obtained in patients with early Myasthenia Gravis Foundation of America class.

An Unusual Complication of Surgery for Type A Dissection Treated by Thoracic Endovascular Aortic Repair.

A 58-year-old man was admitted to our hospital for massive swelling in an anterior cervical location. Nine years earlier, he underwent surgical repair of a complex type A aortic dissection. This procedure was complicated by a fistula between the anastomosis of the graft and the descending aorta, resulting in massive presternal swelling. Therefore, we performed thoracic endovascular repair with successful sealing of the prosthetic leak, achieving progressive reduction in the collection of fluid. We propose thoracic endovascular aortic repair as an alternative to open surgical repair for the treatment of complicated cases.

Emergency Thoracic Endovascular Aneurysm Repair in Acute Type B Dissection with Visceral Malperfusion.

A 46-year-old female patient was admitted to the emergency room with the sudden onset of abdominal pain, back pain, and paresthesia in the right leg. An emergent chest computed tomography (CT) showed an acute Type B aortic dissection. An emergency thoracic endovascular aneurysm repair (TEVAR) procedure was subsequently performed, for an evolving visceral malperfusion syndrome. We performed the procedure using an axillary approach because the small diameter of the true lumen precluded transfemoral endovascular access. This case illustrates that TEVAR permits the treatment of complicated acute Type B aortic dissection; specifically, technical variations can expand the applicability of endovascular procedures.