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Ann Thorac Surg 2004;78:404-409
© 2004 The Society of Thoracic Surgeons

Original article: general thoracic

Transcervical-subxiphoid-videothoracoscopic "maximal" thymectomy—operative technique and early results

Marcin Zielinski, MD, PhDa*, Jaroslaw Kuzdzal, MD, PhDa, Artur Szlubowski, MDa, Jerzy Soja, MD, PhDb

a Department of Thoracic Surgery, Pulmonary Hospital, Zakopane, Poland
b Department of Interventional Pulmonology, Jagiellonian University, Kraków, Poland

Accepted for publication February 6, 2004.

* Address reprint requests to Dr Zieliski, ul. Gladkie 1, 34-500 Zakopane, Poland
e-mail: marcinz{at}mp.pl


   Abstract
Top
 Abstract
Introduction
 Material and methods
 Results
 Comment
 References
 
BACKGROUND: The operative technique of a transcervical-subxiphoid-videothoracoscopic "maximal" thymectomy without sternotomy is described and the early results of the follow-up of patients operated on are analyzed.

METHODS: One-hundred "maximal" transcervical-subxiphoid-videothoracoscopic thymectomies were performed for nonthymomatous myasthenia gravis during a recent 32-month period (from September 1, 2000 to May 8, 2003). Patient characteristics, complications, pathologic findings, and the results of follow-up were analyzed.

RESULTS: The study group included 83 women and 17 men. The mean age was 29.8 years (range, 10–69 years). The mean preoperative duration of myasthenia was 2.73 years (range, 3 months to 17 years). The preoperative Osserman score was I–III, 27 patients were taking steroids preoperatively. Eleven operations were performed by two teams working simultaneously and 89 operations were performed by one surgeon including four combined thymectomy-thyroid operations in patients with myasthenia and thyroid nodules. The mean operative time for two-team approach thymectomies was 159.09 minutes (range, 140–170 minutes) and the mean operative time for the thymectomy performed by one surgeon was 199.41 minutes (range, 150–270 minutes) (p = 0.0004). There was a 15.0% (15 out of 100) postoperative morbidity and no mortality. Foci of ectopic thymic tissue were found in 71.0% of the patients and were most prevalent in the perithymic fat (37.0%) and in the aorta-pulmonary window (33.0%). The mean weight of the specimen was 78.4 g (range, 14.5–253.0 g). In 48 patients followed-up for 12 months, the improvement rate was 83.3%, the no improvement rate was 14.6%, and 1 patient died during the follow-up period. Complete remission rates were 18.8% and 32.0% after 1 and 2 years of follow-up, respectively.

CONCLUSIONS: We conclude that the "maximal" transcervical-subxiphoid-videothoracoscopic thymectomy is a safe operative technique, avoiding a sternotomy, performed partly in an open fashion with the extensiveness comparable with the transsternal extended and "maximal" thymectomies. The two-team approach helps to reduce the operative time. However, because of the limited time of follow-up it is too early for the final assessment of the long-term results of this method in the treatment of myasthenia gravis.


   Introduction
Top
 Abstract
 Introduction
Material and methods
 Results
 Comment
 References
 
Myasthenia gravis is a rare autoimmune disorder occurring predominantly in young women. The thymus gland plays a central role in the pathogenesis of myasthenia gravis and thymectomy is recognized as an effective surgical therapy in myasthenia gravis complementing medical therapy with anticholinesterase inhibitors and immunosuppressive drugs. The aim of the thymectomy in the treatment of myasthenia gravis is the complete removal of all the thymic tissue, because it is well established that residual thymic tissue left after an incomplete thymectomy often leads to persistence or aggravation of the disease. It was found by Wêgllowski in 1912 [1] and afterwards by Masaoka and associates and Jaretzki and associates that the gross and microscopic foci of thymic tissue are widely distributed in cervical and mediastinal fat outside the thymic gland and can be found in 39.5%–98.0% of patients undergoing thymectomy [2–4]. There were 784 thymectomies in myasthenia gravis performed in the period 1967–2003 at the Department of Thoracic Surgery in The Pulmonary Hospital in Zakopane. All operations performed during 1967–1997 were basic thymectomies executed through the superior partial longitudinal sternotomy. Afterwards 74 extended transsternal thymectomies were performed for nonthymomatous myasthenia gravis in the period from January 1, 1998 to June 30, 2000. This technique includes a wide opening of both pleural cavities and the complete exenteration of the fatty tissue of the lower-anterior part of the neck and anterior and middle mediastinum from the level of the lower poles of the thyroid gland to the diaphragm; laterally both phrenic nerves are the margins of resection. In 56.9% of the patients, ectopic foci of thymic tissue in the fat of the neck or mediastinum were found [5]. Although the extended thymectomy is a major procedure, there were few postoperative complications similar to those noted after a basic thymectomy [5]. The total sternotomy is an obvious drawback of that procedure, therefore since July 2000 we have started to use a less invasive technique described by Novellino and associates [6] and subsequently we have developed an original technique called a "maximal" transcervical-subxiphoid-videothoracoscopic thymectomy [7] which we describe in this report.


   Material and methods
Top
 Abstract
 Introduction
 Material and methods
Results
 Comment
 References
 
One-hundred consecutive patients were operated on for nonthymomatous myasthenia gravis with a "maximal" transcervical-subxiphoid-videothoracoscopic thymectomy between September 1, 2000 and May 8, 2003. Our method of thymectomy was approved by the local Bioethical Committee and by the Institutional Review Board. Informed consent was obtained from all patients. No patient was excluded because of any other previous surgery, obesity, or for any other reason. Over the same period the patients undergoing a rethymectomy due to refractory myasthenia after previous thymectomy were operated on using the complete sternotomy approach.

The operative technique of this procedure is as follows: a patient is positioned supine on the operating table with a roll placed beneath the thoracic spine to elevate the chest and to hyperextend the patient's neck. Under general anesthesia an endobronchial tube is inserted to conduct selective lung ventilation during the latter part of the procedure. The skin is prepared from the chin to the umbilicus and bilaterally past the posterior axillary line. To shorten the operative time, the procedure may be performed by two teams—one called the "cervical team" working from above and the other called "the subxiphoid team" working from below the sternum. Alternatively, the whole operation is performed by one surgeon.

The cervical part of the operation: a transverse 5–8 cm incision is made in the neck above the sternal notch. The platysma and superficial cervical fascia are divided and the anterior jugular veins are divided and suture-ligated. The strap muscles are split along their median raphe and retracted laterally. The whole thyroid gland is visualized and all the adipose tissue is removed downward from the level of the upper poles of the thyroid gland. The parathyroid glands and both laryngeal recurrent nerves are visualized and carefully preserved. The fatty tissue containing the superior poles of the thymus is separated from the lower poles of the thyroid gland with one to four inferior thyroid veins ligated and divided. The thymus with the surrounding fat is then separated from the sternohyoid and sternothyroid muscles, the trachea, the internal surface of the sternum, the carotid arteries, the innominate artery, the aorta, and the right innominate vein. At this point a sternal retractor connected to the firm frame with a traction mechanism is inserted under the manubrium of the sternum to elevate it several centimeters to provide access to the anterior mediastinum. The inferior thyroid veins [1–4] and the thymic veins [1–4] are dissected, clipped, and divided close to the left innominate vein. The fatty tissue from the area called "the aorta-caval groove" is removed. The boundaries of this space are the division of the innominate artery and the aorta (medially), the trachea (posteriorly), the right innominate vein and the right mediastinal pleura (laterally), and the right main bronchus, azygos vein, and superior vena cava (inferiorly). The dissection proceeds caudally below the left innominate vein and the specimen is separated from the pericardium at a distance of several centimeters (Fig 1). The most difficult but very important part of this operation is the dissection of the adipose tissue from the aorta-pulmonary window. Further dissection of two other branches of the left innominate vein, namely the left internal thoracic vein and the accessory hemiazygos vein, is mandatory. These two veins are subsequently divided and their ends are secured with clips or suture-ligatures (preferably). The division of these veins provides much better access to the aorta-pulmonary window above the left innominate vein that is retracted toward the aorta. The next step is the visualization of the left phrenic nerve that runs very close to the left internal thoracic vein and the left vagus nerve that runs laterally to the left common carotid artery. With blunt dissection using a peanut sponge, the fatty tissue of the aorta-pulmonary window is dissected from these nerves, the aorta, and the left mediastinal pleura. At the bottom of the aorta-pulmonary window the left pulmonary artery is visualized. In difficult patient cases the dissection of the aorta-pulmonary window is completed at a later stage of the operation with a videothoracoscopic camera inserted inside the chest.



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  		Fig 1. Schematic view of the transcervical operative field.

 
The subxiphoid part of the operation: a transverse 4–6 cm incision is made above the xiphoid process. The subcutaneous tissue and the medial parts of the rectus muscles are cut near the insertions to the costal arches. The xiphoid process is divided transversely and left without removal. The selective left lung ventilation is started resulting in the collapse of the right lung. The anterior mediastinum is opened from below the sternum. A second sternal retractor connected to the traction frame (the same one which is used for traction of the manubrium) is placed under the sternum which is elevated to facilitate access to the anterior mediastinum from below (Fig 2). A 10 mm thoracoscopic port is inserted into the right pleural cavity in the sixth intercostal space in the anterior axillary line. The right mediastinal pleura is cut near the sternal surface up to the level of the right internal thoracic vein which is left intact. The prepericardial fat and right and left epiphrenic fat pads are dissected from the pericardium and diaphragm with blunt dissection using a peanut sponge and a sharp dissection using scissors. Dissection of the prepericardial fat containing the thymus gland proceeds upwards under the control of the videothoracoscopic camera with en bloc fashion without any attempt to dissect the thymus gland separately (Fig 3). The right phrenic nerve is a margin of dissection. At this moment the thymus is attached to the pericardium only with its left lower pole. Ventilation of the right lung is resumed and the left lung is collapsed. A 10 mm thoracoscopic port is inserted into the left pleural cavity as on the right side. The operating table is rotated on the right side with elevation of the left side which lowers the mediastinum improving access to the left pleural cavity. Under the control of the videothoracoscopic camera the left mediastinal pleura is divided along the sternum and the left prepericardial fat is dissected from the pericardium above the level of the previously divided left internal thoracic vein. The left lower pole of the thymus is separated from the pericardium and the specimen is removed. Dissection of the aorta-pulmonary window is completed, if necessary, at this stage of the operation. Hemostasis is checked, the thoracoscopic ports are removed, and the chest tubes are inserted into both pleural cavities through the incisions made for insertion of the ports. Ventilation of both lungs is resumed. The cervical and subxiphoid incisions are closed in the standard manner. Generally, a patient is extubated immediately after the operation.



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  		Fig 2. Double-hook traction device used for the operation.

 


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  		Fig 3. Simultaneous dissection of the thymus through the transcervical and subxiphoid incisions.

 
The thymus gland and the fatty tissue from regions of the neck, the aorta-caval groove, the aorta-pulmonary window, the right and the left periocardio-phrenic areas and the perithymic region were examined separately by the same two pathologists and multiple biopsies were taken from each area and stained with hematoxylin/eosin. In pathologic studies the histologic types of the thymus were described as hyperplastic, involuted or normal and fatty tissue was examined for ectopic thymic foci. The foci were considered proven if the Hassall's corpuscles were found and were considered suspected when the Hassall's corpuscles were absent but the typical histologic architecture of the thymic tissue was discovered. To all patients questionnaires were sent every year with questions about symptoms (or lack of symptoms), medications (anticholinergic, corticosteroids or immunosuppressive drugs and the doses of drugs), improvement, stabilization or worsening and (in women) the effect of pregnancy on the myasthenia.


   Results
Top
 Abstract
 Introduction
 Material and methods
 Results
Comment
 References
 
There were 83 women and 17 men. The mean age was 29.8 years (range, 10–69 years). The mean duration of the symptoms of myasthenia gravis before an operation was 2.73 years (range, 3 months to 17 years). There were 3 patients in stage I, 33 patients in stage IIa, 54 patients in stage IIb, 10 patients in stage III, and none in stage IV according to Osserman classification. Twenty-seven patients were taking steroids preoperatively. Eleven operations were performed by two teams working simultaneously and 89 operations were performed by one surgeon including four combined thymectomy-thyroid operations for patients with myasthenia and thyroid nodules. The mean operative time for two-team approach thymectomies was 159.09 minutes (range, 140–170 minutes) and the mean operative time for a thymectomy performed by one surgeon was 199.41 minutes (range 150–270 minutes) (p = 0.0004). For 4 patients in whom the thymectomy and the thyroid resection was performed during the same procedure the mean operative time was 256.25 minutes (range, 220–285 minutes).

There was a 15.0% postoperative morbidity and no mortality in the whole group. The intraoperative and postoperative complications are listed in Table 1. The complications included a small laceration of the vena cava in 1 patient which was repaired using vascular clips without sternotomy. Two patients required revision (without sternotomy) for postoperative bleeding (one from the left internal thoracic vein and the other from the anterior jugular vein). One pleural hematoma necessitated needle aspiration and in the other patient unilateral chest redrainage and a subsequent videothoracoscopy for removal of the residual blood clots on the eleventh day after the first procedure was necessary; there was one transient paresis of the left laryngeal recurrent nerve which subsided after 3 months. Five patients (5%) needed ventilator support for respiratory insufficiency for 3–5 days. In 1 patient a subarachnoid hemorrhage occurred on the fourth postoperative day; the patient was transferred to the neurosurgical department and operated on successfully. Pneumonia without respiratory insufficiency developed in 1 patient and 2 patients had minor problems with the subxiphoid wound. There were no conversions to sternotomy and no need for tracheostomy in any patient. In the pathologic studies, ectopic foci of the thymic tissue containing the Hassall's corpuscles were found in 48 patients and highly probable foci but without Hassall's corpuscles were found in 28 patients. Overall, proven or highly suspected foci of thymic tissue were discovered in 71 patients (in some patients, both proven and suspected foci were found). In 13 patients ectopic foci were found in two areas, in 7 patients in three areas, and in 1 patient in four areas. Table 2 presents the incidence of the proven and suspected ectopic foci by localization. The incidence of foci was highest in the perithymic region (37.0%) and in the aorta-pulmonary window (33.0%). The mean weight of the specimen was 78.4 g (range, 14.5–253.0 g) which is comparable with the mean weight of the specimen in 58 patients operated on at our department by the transsternal extended thymectomy in the period 1998–1999 (mean weight, 73.7 g; range, 21.5–248.6 g). There were 48 patients after transcervical-subxiphoid-videothoracoscopic "maximal" thymectomy followed up for more than 12 months, therefore the results of the follow-up of this group can only be analyzed. No patients were lost from follow-up and all patients responded to the questionnaires. Forty out of 48 patients (83.3%) improved, 7 out of 48 patients (14.6%) showed no improvement, and 1 patient died 4 months after the operation from a hemorrhage of a gastric ulcer; the patient was taking high doses of steroids preoperatively and postoperatively. In none of the patients was deterioration of myasthenia reported. The 1-year complete remission rate (no myasthenic symptoms and no drugs needed) was 18.8% (9 out of 48) and the 2-year remission rate was 32% (8 out of 25). The relation between the Osserman score and complete remission rate in patients in whom the results of 1 and 2 years of follow-up are available is presented in Table 3.


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  		Table 1. Complications in 100 Consecutive Patients Operated on by a "Maximal" Transcervical-Subxiphoid-Videothoracoscopic Thymectomy

 

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  		Table 2. Occurrence and Localization of the Proven Ectopic Foci (Hc+) or the Suspected Ectopic Foci (Hc–) in Separate Areas of the Adipose Tissue of the Neck and the Mediastinum in 100 Consecutive Patients Operated on by a "Maximal" Transcervical-Subxiphoid-Videothoracoscopic Thymectomy

 

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  		Table 3. Relation Between Osserman Score and the Complete Remission Rate in Patients With Whom the Results of 1 and 2 Years of Follow-Up are Available

 

   Comment
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
References
 
The thymectomy has a proven valuable in the treatment of myasthenia, but the extent of the operation is a matter of debate. According to Jaretzki, operative approaches involve the simple transcervical thymectomy, the simple transthoracic thymectomy (through partial or complete median sternotomy or lateral thoracotomy), the extended transcervical thymectomy, the videothoracoscopic thymectomy performed unilaterally from the right or left side or the video-assisted extended thymectomy, the extended transsternal thymectomy, and—the most radical—transcervical-transsternal "maximal" thymectomy [8–12]. Recently, three other techniques were described—the transcervical-subxiphoid-videothoracoscopic "maximal" thymectomy, developed in our department [7], a similar method reported independently by Takeo and associates [13], and the infrasternal mediastinoscopic thymectomy reported by Kido and associates [14] and Uchiyama and associates [15]. The transcervical and the videothoracoscopic techniques of a thymectomy are less invasive procedures and are claimed to be equivalent to the extended and even "maximal" thymectomies in terms of late results of treatment of myasthenia [16, 17]. Controversies are raised, however, regarding the extensiveness (defined as the removal of the whole thymus with the surrounding fat of the neck and mediastinum) and completeness (defined as the removal of the whole thymus gland) of less invasive techniques. A detailed discussion of this issue is presented by Jaretzki [8]. Our procedure is more extensive in regard to the removal of fatty tissue from the aorta-caval groove (we remove the fatty tissue both anterior and posterior to the aorta and superior vena cava, almost reaching the spine) and fatty tissue anterior to the trachea, almost reaching the level of tracheal bifurcation when compared with the method of Jaretzki [3]. The use of a double sternal elevator is of great help during the whole operation. The two-team approach reduces the mean operative time up to 159.09 minutes (range, 220–250 minutes) which is comparable with the operative time of extended transsternal thymectomies [18]. In the one-surgeon approach the operative time is significantly longer (p = 0.0004). The mean time of the operation is 199.41 minutes (range, 150–270 minutes) depending mainly on the anatomy of the left innominate vein and its branches.

Despite the possibility of also using this technique in patients of thymoma, we continue to operate on such patients with the transsternal technique, similar to the one described by Bulkley and associates, to minimize the danger of violating the tumor's capsule with dissemination of the neoplasm [18]. We operated on 5 patients with the technique reported by Novellino and associates [6]. Unfortunately, the intrathoracic part of this operation is a pure videothoracoscopic procedure which is very tedious and very difficult when performing en block dissection of the whole specimen. For these reasons, we started to operate on myasthenic patients using our own technique which seems to be much simpler. Our technique is similar to the one described by Takeo and associates [13], however there are several differences between both methods. The procedure performed by Takao and associates is executed mainly thoracoscopically through three ports on each side and with the use of a harmonic scalpel. Our method is performed mainly in an open fashion with only one port on each side and with instruments used for open surgery. Additionally, a two-team approach proposed by our method helps to reduce the time of the operation. The extensiveness of the procedure of Takeo and associates was not described in detail. The "maximal" transcervical-subxiphoid-videothoracoscopic thymectomy is a relatively safe procedure with no mortality and a 15% morbidity rate plus only 5% of the patients needed the support of a ventilator. The postoperative respiratory insufficiency rate in patients operated on in our department using the transsternal extended thymectomy was 5.2% [5]. Although there were only a few complications related to the sternotomy wound in previous experiences in our department, with only two sternal dehiscences in 680 thymectomies (including thymomas and rethymectomies) [19], there is always the risk of such complications. Currently, we are comparing prospectively the pain intensity and the postoperative spirometric changes in patients operated on with the extended transsternal thymectomy for myasthenia with thymomas and patients operated on with the presented method for nonthymomatous myasthenia. The mean weights of the specimen in the "maximal" transcervical-subxiphoid-videothoracoscopic thymectomy and the transsternal extended thymectomy groups operated on at our department in 1998/1999 are comparable (78.4 g vs 73.7 g, respectively) which supports our presumption that the extensiveness of both methods is similar [5]. At present, it is possible to report the results of 1 and 2 years of follow-up only in a small part of the whole group (48 out of 100 and 19 out of 100 patients, respectively). The complete remission rates after 1 and 2 years of follow-up are 18.8% and 32.0%, respectively. The results are acceptable, however it is too early to asses the long-term effectiveness of this procedure. There was a trend toward better results regarding the complete remission rates in the lower Osserman stages (I, IIA, and II B) contrary to no remissions in stage III (Table 3). However, because of the small numbers of patients in this subgroups, a statistical analysis is not possible.

We conclude that the "maximal" transcervical-subxiphoid-videothoracoscopic thymectomy is a relatively safe technique, avoiding the use of the sternotomy, performed partly in an open fashion with the extensiveness comparable with the extended transsternal and transcervical-transsternal thymectomies. The two-team approach helps to reduce the operative time. The early results of the follow-up for part of the whole group are acceptable, but the final evaluation of this method in the treatment of myasthenia gravis will be possible in the future.


   References
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
 References
 

  1. Wêglowski R. Ueber die Halsfisteln und Cysten. Arch Klin Chirurgie 1912;98:151-201.
  2. Masaoka A., Nagaoka Y., Kotake Y. Distribution of thymic tissue at the anterior mediastinum. Current procedures in thymectomy. J Thorac Cardiovasc Surg 1975;70:747-754.[Abstract]
  3. Jaretzki A., III, Wolff M. "Maximal" thymectomy for myasthenia gravis. Surgical anatomy and operative technique. J Thorac Cardiovasc Surg 1988;96:711-716.[Abstract]
  4. Ashour M. Prevalence of ectopic thymic tissue in myasthenia gravis and its clinical significance. J Thorac Cardiovasc Surg 1995;109:632-635.[Abstract/Free Full Text]
  5. Zieliski M, Kzzal J, Szlubowski A, Soja J. Comparison of late results of basic transsternal and extended transsternal thymectomies in the treatment of myasthenia gravis. Ann Thorac Surg (Accepted for publication)
  6. Novellino L., Longoni M., Spinelli L., Andretta M., Cozzi M., Faillace G., et al. "Extended" thymectomy, without sternotomy performed by cervicotomy and thoracoscopic technique in the treatment of myasthenia gravis. Int Surg 1994;79:378-381.[Medline]
  7. Zieliski M. Technique of transcervical-subxiphoid-VATS "maximal" thymectomy in treatment of myasthenia gravis. Przegld Lekarski 2000;57(Suppl 5):64-65.
  8. Jaretzki A., III Thymectomy for myasthenia gravis: analysis of the controversies regarding technique and results. Neurology 1997;48(Suppl 5):S52-63.
  9. Cooper J.D., Al-Jalaihawa A.N., Pearson F.G., Humphrey J.G., Humphrey H.E. An improved technique to facilitate transcervical thymectomy for myasthenia gravis. Ann Thorac Surg 1988;45:242-247.[Abstract]
  10. Calhoun R.F., Ritter J.H., Guthrie T.J., Pestronk A., Meyers B.F., Patterson G.A., et al. Results of transcervical thymectomy for myasthenia gravis in 100 consecutive patients. Ann Surg 1999;230:555-561.[Medline]
  11. Yim A.P.C., Kay R.L.C., Ho J.K.S. Video-assisted thoracoscopic thymectomy for myasthenia gravis. Chest 1995;108:1440-1443.[Abstract/Free Full Text]
  12. Mack M.J., Scruggs G.R. Video-assisted thymectomy. In: Shields T.W., LoCicero J., Ponn R., eds. General Thoracic Surgery, 5th ed Philadelphia: Lippincott, Williams, & Wilkins, 2000:2243-2250.
  13. Takeo S., Sakada T., Yano T. Video-assisted extended thymectomy in patients with thymoma by lifting the sternum. Ann Thorac Surg 2001;71:1721-1723.[Abstract/Free Full Text]
  14. Kido T., Hazama K., Inoue Y., Tanaka Y., Takao T. Resection of anterior mediastinal masses through an infrasternal approach. Ann Thorac Surg 1999;67:263-265.[Abstract/Free Full Text]
  15. Uchiyama A., Shimizu S., Murai H., Kuroki S., Okido M., Tanaka M. Infrasternal mediastinoscopic thymectomy in myasthenia gravis: surgical results in 23 patients. Ann Thorac Surg 2001;72:1902-1905.[Abstract/Free Full Text]
  16. Mineo T.C., Pompeo E., Lerut T.E., Bernardi G., Coosemans W., Nofroni I. Thoracoscopic thymectomy in autoimmune myasthenia: results of left-sided approach. Ann Thorac Surg 2000;69:1537-1541.[Abstract/Free Full Text]
  17. Shrager J.B., Deeb M.E., Mick R., Brinster C.J., Childers H.E., Marshall B., et al. Transcervical thymectomy for myasthenia gravis achieves results comparable to thymectomy by sternotomy. Ann Thorac Surg 2002;74:320-327.[Abstract/Free Full Text]
  18. Bulkley G.B., Bass K.N., Stephenson G.R., Diener-West M., Simeon G., Reilly P.A., et al. Extended cervicomediastinal thymectomy in the integrated management of myasthenia gravis. Ann Surg 1997;226:324-335.[Medline]
  19. Zieliski M, Kudal J, Staniec B, Harazda M, Nabialek T, Pankowski J, et al. Safety of preoperative use of steroids for transsternal thymectomy in myasthenia gravis. Book of abstracts. 2nd EACTS/ESTS Joint Meeting, Vienna, Austria, 12–15 October 2003



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M. de Kraker, J. Kluin, N. Renken, A. P.W.M. Maat, and A. J.J.C. Bogers
CT and myasthenia gravis: correlation between mediastinal imaging and histopathological findings
Interactive CardioVascular and Thoracic Surgery, June 1, 2005; 4(3): 267 - 271.
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M. Zielinski, J. Kuzdzal, and T. Nabialek
Transcervical-subxiphoid-VATS "maximal" thymectomy for myasthenia gravis
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