Some characteristics of technique and early result of video-assisted thoracoscopic surgery for thymoma with myasthenia gravis at 103 Military Hospital

To review some characteristics of technique and evaluate the early-result of video-assisted thoracoscopic surgery for thymoma with myasthenia gravis at 103 Military Hospital. Subjects and methods: 61 thymoma patients with myasthenia gravis who underwent video-assisted thoracoscopic surgery thymectomy at 103 Military Hospital, from 10 - 2013 to 5 - 2019 were included. Results: There were no in-hospital mortality or major postoperative complications. The mean of operation time was 91.80 ± 49.94 mins, the mean of blood loss was 37.38 ± 31.58 mL, most of the patients resuscitated within 24 hours (93.5%), thoracic drainage duration was 57.84 ± 30.71 hours, and length of hospital stay was 9.8 ± 5.9 days. Conclusion: Video-assisted thoracoscopic surgery thymectomy for thymoma had few complications, and was safe for myasthenia gravis patients.

Journal of military pharmaco-medicine no7-2019 SOME CHARACTERISTICS OF TECHNIQUE AND EARLY RESULT OF VIDEO-ASSISTED THORACOSCOPIC SURGERY FOR THYMOMA WITH MYASTHENIA GRAVIS AT 103 MILITARY HOSPITAL Le Viet Anh1; Nguyen Van Nam1; Nguyen Truong Giang2 SUMMARY Objectives: To review some characteristics of technique and evaluate the early-result of video-assisted thoracoscopic surgery for thymoma with myasthenia gravis at 103 Military Hospital Subjects and methods: 61 thymoma patients with myasthenia gravis who underwent video-assisted thoracoscopic surgery thymectomy at 103 Military Hospital, from 10 - 2013 to 2019 were included Results: There were no in-hospital mortality or major postoperative complications The mean of operation time was 91.80 ± 49.94 mins, the mean of blood loss was 37.38 ± 31.58 mL, most of the patients resuscitated within 24 hours (93.5%), thoracic drainage duration was 57.84 ± 30.71 hours, and length of hospital stay was 9.8 ± 5.9 days Conclusion: Video-assisted thoracoscopic surgery thymectomy for thymoma had few complications, and was safe for myasthenia gravis patients * Keywords: Thymoma; Video-assisted thoracoscopic surgery; Myasthenia gravis INTRODUCTION Thymoma is a primary tumor in the upper and anterior mediastinum (90%), accounting for - 21.7% of all mediastinal tumors and 47% of all anterior mediastinal masses, about 0.2 - 1.5% of all malignant tumor Many authors had affirmed that when a thymoma with myasthenia gravis (MG) was diagnosed, thymectomy is a first-choice treatment and most effective Surgical removal of thymoma can be carried out via a trans-sternal or transcervical approach Recently, thymectomy via video-assisted thoracoscopic surgery (VATS) has become a preferred method for thymoma with MG at 103 Military Hospital Therefore, we carried out this research: To review some characteristics of technique and evaluate the early result of video-assisted thoracoscopic surgery (VATS) for thymoma with MG at 103 Military Hospital 103 Military Hospital Vietnam Military Medical University Correspoding author: Le Viet Anh (drlevietanh@gmail.com) Date received: 11/07/2019 Date accepted: 23/08/2019 134 Journal of military pharmaco-medicine no7-2019 SUBJECTS AND METHODS In the indispensable cases need a more trocar to hold the tumor Subjects Sixty-one thymoma patients with MG, as confirmed by postoperative histology, who underwent VATS thymectomy at 103 Military Hospital from 10 - 2013 to - 2019, were included * Techniques of VATS thymectomy: - Anaesthetization: With a double-lumen endotracheal tube for one-lung ventilation - Position: A 30 - 45 degree lateral position - Surgical approach: The left or right VATS was determined according to the position of the tumor presented in the preoperative chest CT-scan - Trocars: VATS was usually carried out with trocars: + Trocar 1: At the 3rd intercostal space (ICS) (or the 4th intercostal space) in the anterior axillary (AAL) or mid axillary (MAL) line for instruments th + Trocar 2: At the intercostal space (or the 6th intercostal space) in the anterior axillary (or mid-axillary) line for the camera + Trocar 3: At the 6th intercostal space (or the 7th intercostal space) in the anterior axillary (or mid-clavicular (MCL)) line for instruments - Determination of mediastinal pleura and anatomical landmarks, removing tumor and thymus gland Take the specimen with a specimen endo-bag under the camera's observation Check the surgical area and put the chest drainage tube - Conversion to open surgery when there were complications which cannot be treated by VATS, invasive tumors that VATS could not remove safely After surgery, if respiratory is guaranteed, withdraw the endotracheal tube and transfer to the Department of Thoracic Surgery or to the intensive care unit (ICU) * Index: - Sites: Sides, number and position of ports - Surgery: VATS or conversion to open surgery - Operating: Status of invasion, accidents, surgery time, blood loss - Postoperative: ICU stay, chest tube removal time, complications, post-operative hospital stay * Data: with the SPSS software, version 23.0 (SPSS Inc., Chicago, IL, USA) RESULTS Some characteristics of the technique of VATS for thymoma with MG Table 1: Sides, number and position of ports Criteria Patients Rate (%) Right 35 57.4 Left 26 42.6 59 96.7 3.3 Sites Number of ports 135 Journal of military pharmaco-medicine no7-2019 rd 37 60.7 rd 6.6 th 16 26.2 th 6.6 th 21 34.4 th 34 55.7 th 4.9 th 4.9 th 9.8 th 52 85.2 th 1.6 th 3.3 3.3 ICS - AAL ICS - MAL Trocar ICS - AAL ICS - MAL ICS - AAL ICS - MAL Position ports Trocar of ICS - AAL ICS - MAL ICS - AAL ICS - MAL Trocar ICS - AAL ICS - MCL Trocar nd ICS - MCL (ICS: Intercostal space) There were 35 cases (57.4%) approaching through the right pleural, the remaining 26 cases (42.6%) were approached via left pleural, most patients used trocars (96.7%) and there were locations commonly used: 3rd ICS AAL (60.7%), 5th ICS MAL (55.7%) and 6th ICS MCL 85.2% Table 2: Relationship between surgery method and tumor size Tumor size Total Surgery method < cm - cm ≥ cm n 15 31 53 % 24.6 50.8 11.5 86.9 n p VATS Conversion to open surgery 0.68 % 3.3 6.6 3.3 13.1 n 17 35 61 % 27.9 57.4 14.8 100 b Total (b: Chi - Square test) Conversion to open surgery was available in all size groups, higher in group ≥ cm This difference was not statistically significant 136 Journal of military pharmaco-medicine no7-2019 Table 3: Masaoka stage and surgery method Masaoka stage Surgery method I VATS Conversion surgery to open Total II III Total IVa p IVb n 34 11 53 % 64.2 20.8 13.2 1.9 100 n 1 % 12.5 12.5 75.0 100 n 41 12 10 61 % 57.4 18.0 13.1 11.5 100 < 0,001 b (b: Chi - Square test) cases had to conversion to open surgery, the most were in the group Masaoka Iva stage, one case in Masaoka I stage, this was the case with operative accident Table 4: Characteristics of VATS for thymoma with MG Criteria Patients Rate (%) 3.3 ≤ 60 23 37.7 > 60 - 120 27 44.3 > 120 11 18.0 Accidents Surgical time (minutes) Mean of surgical time (min) ( Mean of blood loss (mL) ( 91.80 ± 49.94 ± SD) 37.38 ± 31.58 ± SD) There were 3.3% of complications, the average time of surgery was 91.80 minutes 23/61 patients (37.7%) within 60 minutes The average blood loss during surgery: 37.38 mL (at least 10 mL, maximum of 200 mL) The early-result of VATS for thymoma with MG Table 5: Early-result of VATS for thymoma with MG Criteria Length of ICU stay (hours) Chest tube (hours) removal time Patients Rate (%) None 42 68.9 ≤ 24 15 24.6 > 24 - 48 3.3 > 48 3.3 ≤ 24 3.3 > 24 - 48 40 65.6 > 48 19 31.1 137 Journal of military pharmaco-medicine no7-2019 Mean of chest tube removal time (hous) ( 57.84 ± 30.71 ± SD) Complications Postoperative hospital stay (days) Mean of postoperative hospital stay (days) ( 13.1 ≤7 28 45.9 - 10 21 34.4 > 10 12 19.7 ± SD) 9.8 ± 5.9 After surgery, most patients (42/61 = 68.9%) were removed the endotracheal tube and transferred directly to the Thoracic Department, in ICU within 24 hours (24.6%) and had time to withdraw drainage after surgery within 48 hours ( 68.9%) The duration of postoperative treatment was less than days (45.9%) and - 10 days (34.4%) and the average treatment day was 9.8 ± 5.9 days (the shortest was days, the longest was 37 days) DISCUSSION Some characteristics of the technique of VATS for thymoma with MG The choice of left or right VATS depends on the surgeon’s experience and the anatomy of the tumor, which was normally studied in preoperative chest CT-scan While Yim et al (1995) prefered to approach the tumor via right VATS, most European surgeons prefer the leftsided approach [1] In our study, the right approach was mainly (57.4%) In fact, right VATS offered better visualization and control of the superior vena cava, aorta and right atrium, thereby reducing the potential risk of injury to these structures However, with a non-small amount of access to the left side of the road (42.6%), we also had safe operation with no complications According to many opinions of other authors, it is agreed that the pleural approach to the left or right side is not different 138 VATS thymectomy could be accomplished with ports: A 10 mm port for a telescope, two ports for instruments, while the fourth or the fifth trocar could be used when necessary Some surgeons prefered to use four trocars or single-port In our study, we managed to completely remove the thymoma with ports, except for only two patients (3.3%) with a large tumor that required another port to hold the tumor The authors' comments that in addition to patient posture, the position of trocar plays a very important role in the surgery Authors used different trocar position Nguyen Cong Minh used trocars at 7th ICS PAL, AAL and 3rd ICS MAL Anthony P.Yim (1999): the 3rd ICS MAL, the 5th ICS PAL and the 6th ICS AAL Mineo T.C (1996) used trocars at the 4th ICS MCL, the 5th ICS AAL for the camera, the 4th ICS AAL, the 6th ICS MCL and AAL [2] In our study (table 1), we often used trocars: the 3rd ICS AAL (60,7%), the 5th Journal of military pharmaco-medicine no7-2019 ICS MAL (55.7%) and the 6th ICS MCL (85.2%) In case of necessity, we used another trocar at the 2nd ICS MCL So far, there is still no agreement on how big the thymoma’s size is, so it is possible to work with it, how much should it not be? The statistics according to table showed that the rate of open surgery was available in all size groups: size less than cm with two cases, greater than cm with two cases and from - cm with cases But this difference was not statistical significance Therefore, it can be seen that the size of the tumor is relative because it depends on many other factors, especially the invasion of the tumor It is better when VATS used for thymoma at early stage (according to Masaoka) Research was conducted by Chung et al (2012) on 25 thymoma patients without myasthenia indicated that there were no patients in Masaoka stage III, and only one case in Masaoka stage IV [3] Similarly, our data indicated that there were patients in the Masaoka stage III (13.1%) and patients in the Masaoka stage IVa (11.5%), the rest were in Masaoka stage I, II Agasthian (2011) had suggested that thymoma at an early stage can be safely removed with VATS [4] However, the author has reported that there were 13 patients with invasive thymoma which could be performed the surgery successfully Table showed in fact that in cases had conversion to open surgery, most of all in Masaoka IVa stage, there was only case in Masaoka I stage due to operation accident One point to note was that there was a difference between the assessment of the invasive status of thymoma and surrounding organizations between images on the CT-scan and in operating So that the surgeon had to consider carefully the characteristics and properties of tumors on CT-scan before surgery, the direct assessment of tumors in operating is extremely important, to be able to predict the operation and make decisions immediately to operate with VATS or conversion to open surgery The mean surgical time was 91.80 minutes, we experienced shorter time surgery in the latter part of the study, in which 23/61 operations (37.7%) were completed within 60 mins The majority of surgery time was from 60 minutes to 120 minutes (44.3%) This result was similar to other studies by Yim [1], Ashleigh Xie [5], Mineo T.C [2] (from 80 minutes to 160 minutes) The amount of blood loss by the authors was also different, from 40 mL to 183.1 mL Blood loss in our study was 37.38 ± 31.58 mL (10 - 200 mL), patients with high amounts of blood loss were usually suffered from complications or conversion to open surgery, while patients with completely and conveniently VATS, the amount of blood loss was lower The early result of VATS for thymoma with MG The results of our study showed that the time stay at ICU after thymectomy was reduced with the VATS approach, as shown by either a smaller number of patients requiring ICU or shorter length of 139 Journal of military pharmaco-medicine no7-2019 ICU stay In our study, non-ICU: 68.9%; ≤ 24 hours: 24.6%; > 24 - 48 hours: 3.3%; > 48 hours 3.3% Reduced resuscitation time and ventilation time will reduce the risk of respiratory failure compared to a longer time In comparison with previous research, it is clear that thymectomy by VATS had significantly reduced the duration of postoperative resuscitation treatment compared to open surgery Especially during the later period of the study, most of our patients were transfered straightly to the Department of Thoracic after surgery It is further demonstrated that patients had received many advantages from VATS when performing thymectomy According to table 5, the majority of patients in our study were removed chest tube after surgery within 48 hours (68.9%) However, compared with the authors, there were many different results, the withdrawal chest tube time was from 1.8 to 4.2 days Except for patients (11.5%) with postoperative respiratory failure and one patient (1.6%) with a little pleural effusion, non-hospital mortality or major postoperative complication was observed in our study, these results were similar to the study by Chao (2015), Cheng (2008) [6], Chung (2012) [3], Liu T.J (2014) [7], Manoly (2014) [8], Sakamaki (2014) [9] and Ye B (2014) [10] No case of diaphragmatic paralysis as reported by Manoly’s study (2014) (11.8%) [8], it was 6.7% in Ashleigh Xie’,s study [5] and pneumothorax in Ashleigh Xie’s study was 1.9% [5], Ye.B: 0.8% [10] Most patients had a postoperative treatment period of fewer than days 140 (45.9%) and - 10 days (34.4%) The length of postoperative treatment was 9.8 ± 5.9 days (5 - 37 days) The result of our study was so higher than the other authors, like Nguyen Cong Minh: 6.5 days (5 days - 22 days), Anthony P.Yim (1995) [1]: days, Mineo T.C: days, Mack M.J (1996): days [12], Popescu I (2002) [13]: 2.28 days However, in comparison with previous open surgery (transternal surgery), the average postoperative hospital stay was shortened remarkably CONCLUSION Video-assisted thoracoscopic surgery thymectomy for thymoma is safe surgery It can be widely applied even for MG with no death, fewer accidents and complications, good outcomes REFERENCES Sim A.P, Kay R.L, Ho J.K Videoassisted thoracoscopic thymectomy for myasthenia gravis Chest 1995, 108 (5), pp.1440-1443 Mineo T.C et al Adjuvant pneumomediastinum in thoracoscopic thymectomy for myasthenia gravis Ann Thorac Surg 1996, 62 (4), pp.1210-1212 Chung J.W et al Long-term results of thoracoscopic thymectomy for thymoma without myasthenia gravis J Int Med Res 2012, 40 (5), pp.1973-1981 Agasthian T, Lin S.J Clinical outcome of video-assisted thymectomy for myasthenia gravis and thymoma Asian Cardiovasc Thorac Ann 2010, 18 (3), pp.234-239 Xie A et al Video-assisted thoracoscopic surgery versus open thymectomy for thymoma: A systematic review Ann Cardiothorac Surg 2015, (6), pp.495-508 Journal of military pharmaco-medicine no7-2019 Cheng, Yu-Jen Video-thoracoscopic resection of encapsulated thymic carcinoma: Retrospective comparison of the results between thoracoscopy and open methods Annals of Surgical Oncology 2008, 15 (8), pp.2235-2238 Liu,T.J et al Video-assisted thoracoscopic surgical thymectomy to treat early thymoma: A comparison with the conventional transsternal approach Ann Surg Oncol 2014, 21 (1), pp.322-328 thymoma J Thorac Cardiovasc Surg 2014, 148 (4), pp.1230-1237 e1 10 Ye B et al Surgical techniques for early stage thymoma: Video-assisted thoracoscopic thymectomy versus transsternal thymectomy J Thorac Cardiovasc Surg 2014, 147 (5), pp.1599-1603 11 Loscertales J et al The treatment of myasthenia gravis by video-thoracoscopic thymectomy The technic and the initial results Arch Bronconeumol 1999, 35 (1), pp.9-14 Manoly I et al Early and mid-term outcomes of trans-sternal and video-assisted thoracoscopic surgery for thymoma Eur J Cardiothorac Surg 2014, 45 (6), pp.e187-193 12 Mack M.J et al Results of videoassisted thymectomy in patients with myasthenia gravis J Thorac Cardiovasc Surg 112 (5), pp.1352-1359; discussion 1359-60 Sakamaki Y et al Intermediate-term oncologic outcomes after video-assisted thoracoscopic thymectomy for early stage 13 Popescu I et al Thymectomy by thoracoscopic approach in myasthenia gravis Surg Endosc 2002, 16 (4), pp.674-684 141 ... 200 mL) The early- result of VATS for thymoma with MG Table 5: Early- result of VATS for thymoma with MG Criteria Length of ICU stay (hours) Chest tube (hours) removal time Patients Rate (%) None... post-operative hospital stay * Data: with the SPSS software, version 23.0 (SPSS Inc., Chicago, IL, USA) RESULTS Some characteristics of the technique of VATS for thymoma with MG Table 1: Sides, number and. .. 37 days) DISCUSSION Some characteristics of the technique of VATS for thymoma with MG The choice of left or right VATS depends on the surgeon’s experience and the anatomy of the tumor, which