LA TIMECTOMIA ROBOTICA

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1 LA TIMECTOMIA ROBOTICA Prof. Giuseppe Marulli UOC Chirurgia Toracica Università di Padova

2 . The thymus presents a challenge to the surgeon not only as a structure that may be origin of benign and malignant neoplasms, but also as a organ that is involved in fundamental aspects of cellular immunity and neuromuscolar conduction... In Shields TW: General Thoracic Surgery, 1994, p.1770

3 RATIONALE FOR THYMECTOMY IN MG The thymus may play a role in pathogenesis of myasthenia (possible source of antigen to drive this autoimmune disease) Most patients with MG and autoantibodies directed against the acetylcholine receptor (AChR) have thymic abnormalities: hyperplasia is found in 60 to 70% and thymoma in 10 to 15% The disease often improves or disappears after thymectomy (Blalock 1936)

4 First thymectomy: Sauerbruch, Trans-cervical approach in patient with myasthenia gravis (MG). Thymectomy for thymoma: Blalock, Trans-sternal approach in 19 year old woman with MG and thymoma. Clagett (1949).. Keynes (1955).. Viets and Schwab (1960)...

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6 SOME OF THE DIFFICULTIES IN STUDYING MG MG IS AN UNCOMMON DISEASE THE NATURAL HISTORY IS UNPREDICTABLE THERE ARE SEVERAL VERSIONS OF CLINICAL CLASSIFICATION THE OUTCOMES ARE INFLUENCED BY: AGE, GENDER, TIMING OF THYMECTOMY, UNDERLYING PATHOLOGY, Ab STATUS. THERE ARE DIFFERENCES IN THE NEUROLOGIST S PRACTICE. THERE IS LACK OF UNIFORM STANDARDS IN REPORTING (THYMOMATOUS AND NON THYMOMATOUS MG). LACK OF RCT

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9 INDICATIONS FOR THYMECTOMY AND SELECTION OF CANDIDATES AGE (15-50 yrs recommended) Ab STATUS (AntiAChR+ and antimusk - preferred) MG CLASS (Generalized MG Ocular MG???) CLINICAL STATUS (Stable disease, no recent crisis) ONSET OF DISEASE (Early onset before months -associated with better results) VINCENT A, 2010 EFNS GUIDELINES, 2010

10 EXPECTED BENEFITS OF THYMECTOMY IN MG - CLINICAL BENEFITS (REMISSION-IMPROVEMENT OF SYMPTOMS) - REDUCTION OF MEDICATIONS (ADVERSE EFFECTS COSTS) - MINIMAL INVASIVENESS AND LOW COMPLICATIONS (RISK-BENEFIT BALANCE)

11 MG patients undergoing thymectomy were more likely to achieve medication-free remission, become asymptomatic, and improve than MG patients not undergoing thymectomy. MG patients undergoing thymectomy were twice as likely to attain medication-free remission, 1.6 times as likely to become asymptomatic, and 1.7 times as likely to improve.

12 NONRANDOMIZED STUDIES

13 2 BAROHN RJ 2008

14 The time-weighted average Quantitative Myasthenia Gravis score over a three-year period was significantly lower for the thymectomy group compared with the prednisone-alone group (6.15 versus 8.99, estimated difference 2.85, 95% CI ). The average requirement for alternate-day prednisone over three years was significantly lower for the thymectomy group (44 versus 60 mg, estimated difference 16 mg, 95% CI 7-25). The proportion of subjects requiring immunosuppression with azathioprine was significantly lower for the thymectomy group (17 versus 48 percent, estimated difference 31 percent, 95% CI 16-47). The proportion of subjects hospitalized for MG exacerbations was significantly lower for the thymectomy group (9 versus 37 percent, estimated difference 28 percent, 95% CI 14-42). The proportion of subjects who achieved minimal manifestation status was significantly greater in the thymectomy group at 12 months (67 versus 37 percent) and at 36 months (67 versus 47 percent).

15 EXPECTED BENEFITS OF THYMECTOMY IN MG - CLINICAL BENEFITS (REMISSION-IMPROVEMENT OF SYMPTOMS) - REDUCTION OF MEDICATIONS (ADVERSE EFFECTS COSTS) - MINIMAL INVASIVENESS AND LOW COMPLICATIONS (RISK-BENEFIT BALANCE)

16 REDUCTION OF MEDICATIONS

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18 EXPECTED BENEFITS OF THYMECTOMY IN MG - CLINICAL BENEFITS (REMISSION-IMPROVEMENT OF SYMPTOMS) - REDUCTION OF MEDICATIONS (ADVERSE EFFECTS COSTS) - MINIMAL INVASIVENESS AND LOW COMPLICATIONS (RISK-BENEFIT BALANCE)

19 MORTALITY 5-15% BEFORE 1970 < 1% AFTER 1970 WOUND HEALING DISORDERS STERNUM INSTABILITY HAEMORRAGE PHRENIC NERVE DAMAGE (2-3%) PNEUMONIA (8-10%) VENTILATORY SUPPORT (2-5%) TRACHEOSTOMY MORBIDITY (5-20%)

20 Sonett JR, Jaretzki III A. Thymectomy for nonthymomatous myasthenia gravis: a critical analysis. Ann N Y Acad Sci 2008;1132:315 28

21 EXTIMATED RESECTIONAL EXTENT OF THYMECTOMY TECHNIQUES Basic cervical Extended cervical VATS (40-50%) (75-80%) (80-85%)??? Standard Sternal Extended Sternal Cervical & Sternal (70-80%) (85-95%) (98-100%)

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24 IT IS DIFFICULT TO COMPARE THE OUTCOMES OF THE DIFFERENT OPERATIVE TECHNIQUES (CONFOUNDING FACTORS INFLUENCED BOTH THE CONTROLLED AND THE UNCONTROLLED STUDIES) BUT OUTCOMES ARE PROBABLY SIMILAR (CLASS III EVIDENCE). (Meyer et al., 2009)

25 IDEALLY, THE LESS INVASIVE SURGICAL TECHNIQUES ARE DESIRABLE, ASSUMING THE RESULTS ARE EQUIVALENT

26 TRANS-STERNAL PLUS TRANS-CERVICAL THYMECTOMY "Maximal" thymectomy for myasthenia gravis. Surgical anatomy and operative technique. Jaretzki A 3rd, Wolff M. Department of Surgery, Columbia-Presbyterian Medical Center, New York, N.Y. J Thorac Cardiovasc Surg Nov;96(5):711-6.

27 ADVANTAGES Optimal exposition of the operative field Thymectomy easier and extended to the perithymic tissue Low probability of nervous and vascular injuries DISADVANTAGES Invasive technique Longer hospitalization than minimally invasive techniques More complications Lesser acceptability by young patients

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29 ADVANTAGES Minimally invasive technique Short hospitalization and low costs Optimal cosmetic results Easily accepted by young patients Minimal thoracic trauma and early improved lung function 2-D view of the operative field DISADVANTAGES Arms do not articulate making difficult the dissection of the neck and the access to the contralateral mediastinum Needs in some cases, of a cervical incision Impossibility to perform an extended thymectomy (thymus plus perithymic tissues)

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33 WHY ROBOTIC ASSISTANCE FOR THORACOSCOPIC SURGERY? ENHANCED VISUALIZATION (INTUITIVE 3-D VIEW) HIGH DEXTERITY OF SURGICAL INSTRUMENTS (360 OF ROTATION AND 7 DEGREES OF FREEDOM IN THE ARTICULATED MOVEMENTS) TREMOR FILTERING SAFE AND COMFORTABLE DISSECTION OF VASCULAR AND NERVOUS STRUCTURES BETTER DISSECTION IN REMOTE, FIXED AND DIFFICULT TO REACH AREAS OF THE NECK AND MEDIASTINUM

34 DISADVANTAGES OF ROBOTIC THORACOSCOPIC THYMECTOMY Initial high costs Early increased operative time (learning curve) Absence of tactile feedback

35 POSITION Double lumen tube Left side approach 30 degrees up on bean bag Arms at side

36 PORT PLACEMENT Left arm - 5th intercostal space - midclavicular line Camera - 5th intercostal space - anterior portion of midaxillary region Right arm - 3rd intercostal space - anterior portion of midaxillary region

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39 OPTICS 0 degree scope 30 degree scope 6-10 mmhg CO2 insufflation

40 COSMETIC RESULT

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42 APRIL 2002 APRIL 2017 OUR EXPERIENCE: 186 PATIENTS WITH MG TREATED WITH DA VINCI ROBOTIC SYSTEM THE MAJORITY OF THESE UNDERWENT LEFT-SIDED THORACOSCOPIC THYMECTOMY, SOME PATIENTS WITH RIGHT-SIDED THYMOMA WHERE APPROACHED FROM THE RIGHT SIDE 133 PATIENTS WERE FEMALE AND THE MEAN AGE WAS 38 YEARS OLD MOST PATIENTS TAKING COMBINED THERAPY FOR MG IN PARTICULAR ANTICHOLINESTERASE AND STEROID

43 Preoperative patients characteristics GENDER Male Female 53 (28,4%) 133 (71,5%) MEAN AGE (range) 38 years (11-76) MEAN DURATION OF PREOPERATIVE SYMPTOMS (range) ACETYLCHOLINE RECEPTOR ANTIBODIES Positive Negative MGFA CLASS I IIa IIb IIIa IIIb IVa IVb PREOPERATIVE THERAPY Anticholinesterase Steroid Azatioprine Cyclosporine Plasmapheresis Immunoglobulin 11 months (0-216) 130 (69,8%) 48 (25,8%) 34 (18,27%) 52 (27,95%) 26 (13,97%) 32 (17,20%) 17 (9,13%) 8 (4,3%) 8 (4,3%) 168 (90,32%) 121 (65,05%) 39(20,96%) 9 (4,83%) 20 (10,75%) 29 (15,59%)

44 SURGICAL RESULTS - MEAN OPERATIVE TIME: 150 MINUTES ( MINUTES) - MEAN TIME OF HOSPITAL STAY: 3 DAYS (2-33 DAYS) - MEDIAN TIME TO CHEST TUBE REMOVAL: 2 DAYS (1-32 DAYS) - NO DEATHS, NO INTRAOPERATIVE COMPLICATIONS, NO RECURRENT LARYNGEAL OR PHRENIC NERVE INJURIES - POSTOPERATIVE COMPLICATIONS: 2 PT WITH CHYLOTHORAX, 2 PTS WITH HAEMOTHORAX

45 PATHOLOGIC RESULTS 130 (69,89%) thymic hyperplasia 13 (6,98%) atrophic thymus 12 (6,45%) residual normal thymus 31 (16,66%) thymoma

46 SUMMARY Thymectomy has an important role in myasthenia gravis patients. Lack of randomized trials investigating different surgical approaches for thymectomy Increasing use of minimally invasive approaches in non-thymomatous MG Robotic approach has several advantages: safety, low complications, short hospital stay, optimal cosmetic results, good neurological results.

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