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Robotic Thymectomy in Patients with Myasthenia Gravis: Neurological and Surgical Outcome
Marlies Keijzers, Marc de Baets, Monique Hochstenbag, Marcel van der Linden, Anne-Marie C. Dingemans, Jos G. Maessen.
Maastricht University Medical Center, Maastricht, Netherlands.

Thymectomy is accepted in the treatment of Myasthenia Gravis (MG). Indication, timing and surgical approach remains controversial. Our study reports our surgical and neurologic experiences with robotic thymectomy in a large group of patients with MG.
We retrospectively analyzed 125 patients with MG who underwent a robotic thymectomy using the da Vinci Robotic system (Intuitive Surgical, Inc, Sunnyvale, Calif) between 2004 and 2012. 90 patients had a neurological follow up of more than 12 months. The Myasthenia Gravis Foundation Classification was used to determine pre-operative and postintervention status. MGFA preoperative classification were stage I in 14.4%, stage II 20%, Stage III 28.8%, Stage IV 31.2%, Stage V 2.4%.
110 women and 15 men underwent a robotic thymectomy. Median procedure time was 123 minutes (range, 45-353 minutes). There were no peri-operative complications or deaths. Postoperatively 2 patients suffered from a myasthenic crisis requiring prolonged ventilation. The median postoperative hospital stay was 3 days (range, 2-24 days). Histological analysis showed a thymic rest in 41 patients (32,8%), follicular hyperplasia in 52 patients (41.6%), thymoma in 31 patients (24%), lipoma in 1 patient (0,8%) and a cyste in 1 patient (0,8%). Steroid use was significantly increased in patients with a thymic rest (P=0.01). With a median follow-up of 33 months (range, 12-101 months) 76,7% of the patients improved neurologically according to MGFA. Follow-up showed a 5-year probability remission rate (complete stable remission and pharmalogical remission) of 37% (figure 1). In 90% of the patients steroid treatment was decreased or interrupted. There was no significant difference in neurological outcome regarding the timing of surgery (<12 months versus > 12 months after onset MG).
Robotic thymectomy in patients with MG is safe and feasible. A neurological benefit and decreased use of steroids can be obtained in the majority of patients. No significant difference in neurological outcome was observed as the result of timing of robot thymectomy after the onset of MG.

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