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Ann Thorac Surg 2006;82:1007-1008
© 2006 The Society of Thoracic Surgeons
22 River Reach Way, Charleston, SC 29407-3372
(Email: jrubin{at}knology.net).
The article by Tomulescu and colleagues [1] underlines the persistence in the controversy between those who promote "maximal" thymectomy during the course of treating myasthenia gravis and those who do not. The authors state that their procedure is equivalent to "standard extended" transsternal thymectomy, an operation which is said to remove about 85% of thymic tissue in the mediastinum.
A survey of the current literature further emphasizes the nub of the issue. Reproof being cast on those who do not espouse removal of as much thymus and ectopic thymus as possible is becoming more apparent. The focus is more and more on maximal thymectomy as the standard of care, even by thoracoscopic approaches, and parallels the attention to the maximal operation promoted by others [2, 3]. Maximal is generally defined as en bloc removal of thymus and all perithymic fat from the neck to the diaphragm and between the phrenic nerves.
The choice of video-assisted surgery is attractive to patients with nonthymomatous myasthenia gravis. The surgery is cosmetically acceptable and seems to have less morbidity than the open transsternal operation. Does that mean that we, as surgeons recommending the best available treatment for this disease, should promote leaving residual thymic rests to achieve general acceptance over a maximal transsternal operation that is expected to improve remission, diminish the incidence of reoperation, and lessen dependence on pharmacologic intervention in the long term? Somewhere, the two approaches should intersect in all clinical aspects.
Twenty years ago, Jareztki and colleagues [2] illustrated that there were adverse consequences to nonmaximal thymectomy. In the authors' reference to Jaretzki and colleagues, they choose to focus on thymic histology rather than the point that Jaretzki and colleagues were making, which is a lesson emphasizing as much removal of thymic tissue as possible. Other more contemporary studies that have used thoracoscopic procedures promote the notion of maximal thymectomy with results that are comparable with the transsternal maximal operation [4, 5].
For Tomulescu and colleagues, the devil is in the details. The remission rates with or without dependence on drugs may be similar in the intermediate term in the authors' study and the other studies promoting maximal thoracoscopic thymectomy as the approach of choice. Will the rates of crippling recurrent myasthenia gravis and reoperation be the same? With the quoted incidence of ectopic thymic rests in mediastinal fat of 70% or more, the current standard of care tilts very much in favor of en bloc maximal thymectomy, which strives to remove 95% or more of thymic tissue predictably, irrespective of the ways in which the procedure is accomplished.
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