横断胸骨扩大胸腺切除治疗全身型重症肌无力

doi:10.3877/cma.j.issn.2095-8773.2014.01.005

目的

探讨经横断胸骨入路行扩大胸腺切除治疗重症肌无力的临床疗效。了解该入路的特点及临床疗效有助于该领域胸外科医师在临床实践中进行更好的临床决策。

方法

对1998至2008年在复旦大学附属华山医院胸心外科行横断胸骨治疗全身型重症肌无力的211例患者的临床资料进行回顾性研究，分析患者术中和术后基本情况。并对术后5年进行随访的患者根据是否合并胸腺瘤进行分组，采用χ²检验比较两组间的疗效。

结果

经横断胸骨入路能满足对合并Masaoka-Koga Ⅰ期及Ⅱ期胸腺瘤患者及无瘤患者实施扩大胸腺切除的需要，手术并发症较低，便于围术期护理，恢复迅速。对173例患者进行术后5年随访，总缓解率达到79.8%(138/173)，无肿瘤复发。合并胸腺瘤组的总缓解率为81.9%(59/72)，未合并胸腺瘤组的总缓解率为78.2%(79/101)，两组间比较差异无统计学意义(χ²＝0.362，P＝0.548)。

结论

与其他常用手术入路相比，横断胸骨入路的特点值得该领域胸外科医师关注。

关键词: 重症肌无力, 胸腺切除术, 手术入路

Objective

To investigate the clinical outcomes of transverse sternotomy extended thymectomy for myasthenia gravis. Further understanding about the merits and incompetence of this approach may help to make clinical decisions.

Methods

The clinical data of 211 patients undergoing transverse sternotomy for generalized myasthenia gravis between 1998 and 2008 in Department of Cardiothoracic Surgery, Huashan Hospital affiliated to Fudan University were retrospectively studied, and the basic conditions during and after operation were analysed. The clinical outcomes were compared by χ² test between patients with thymoma and those without thymoma after follow-up for 5 years.

Results

Transverse sternotomy was an effective approach for nonthymomatous and Masaoka-Koga stage Ⅰ or stage Ⅱ thymomatous patients, with less complications. It was convenient for intraoperative manipulation and perioperative management. Patients had a quick recovery with minimum discomfort. After follow-up for 5 years in 173 patients, the overall remission rate for myasthenia gravis was 79.8%(138/173), with no recurrence. The overall remission rates of patients with thymoma and those without thymoma were 81.9%(59/72) and 78.2%(79/101), respectively, and there was no significant differences between them (χ²=0.362, P=0.548).

Conclusion

Transverse sternotomy approach can be considered in the treatment of myasthenia gravis when other options are less preferred.

Key words: Myasthenia gravis, Thymectomy, Surgical approach

表1 211例横断胸骨扩大胸腺切除患者临床特征

患者特征		例数(%)
改良Osserman分型		?
?	Ⅱa	61(28.9)
?	Ⅱb	104(49.3)
?	Ⅲ	46(21.8)
既往危象发作史		27(12.8)
接受激素或其他免疫抑制剂治疗		107(50.7)
影像学(CT或MRI)显示胸腺占位性病变		86(40.8)
并发症		96(45.5)

表1 211例横断胸骨扩大胸腺切除患者临床特征

患者特征		例数(%)
改良Osserman分型		?
?	Ⅱa	61(28.9)
?	Ⅱb	104(49.3)
?	Ⅲ	46(21.8)
既往危象发作史		27(12.8)
接受激素或其他免疫抑制剂治疗		107(50.7)
影像学(CT或MRI)显示胸腺占位性病变		86(40.8)
并发症		96(45.5)

图1 横断胸骨入路手术切口

图2 行胸腺切除术的重症肌无力患者一期愈合的横断胸骨入路手术切口

表2 胸腺切除术后5年重症肌无力患者的随访结果[例(%)]

组别	例数	CR	PR	SD	PD
未合并胸腺瘤组	101	18(17.82)	61(60.40)	19(18.81)	3(2.97)
合并胸腺瘤组	72	15(20.83)	44(61.11)^a	8(11.11)	5(6.94)^b
χ²值	0.247	0.009	1.893	0.739	?
P值	0.619	0.924	0.168	0.390	?

表2 胸腺切除术后5年重症肌无力患者的随访结果[例(%)]

组别	例数	CR	PR	SD	PD
未合并胸腺瘤组	101	18(17.82)	61(60.40)	19(18.81)	3(2.97)
合并胸腺瘤组	72	15(20.83)	44(61.11)^a	8(11.11)	5(6.94)^b
χ²值	0.247	0.009	1.893	0.739	?
P值	0.619	0.924	0.168	0.390	?

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Transverse sternotomy extended thymectomy for generalized myasthenia gravis

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Transverse sternotomy extended thymectomy for generalized myasthenia gravis