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Eur J Cardiothorac Surg 2005;28:504-505
© 2005 Elsevier Science NL
Letter to the Editor |
Thoracic Surgery Department, Evangelisches Krankenhaus Duisburg-Nord, Fahrner Str. 133, 47169 Duisburg, Germany
Received 14 June 2005; accepted 15 June 2005.
* Tel.: +49 203 508 5996; fax: +49 203 508 1913. (Email: boseila{at}gmx.de).
Key Words: Manubriotomy • Sternotomy • Myasthenia gravis • Pulmonary function • Thymectomy • Postoperative morbidity
We have read with interest Dr Zielinskis letter and we thank him for his comments.
Different authors stated that partial sternotomy permits excellent visualization of the thymus gland, its vascular attachments, and all peripheral tissues in the mediastinal region limited by the thyroid gland superiorly, between the phrenic nerves laterally, and pericardial sac and mediastinal pleura inferiorly [1–3]. In our study, we took separate margins for frozen section analysis to make sure no thymic tissue is left behind, and to support our belief that the manubriotomy approach is equal to the sternal approach in the extent of dissection, with the advantage of being less invasive.
Postoperative morbidity was encountered in the sternotomy approach group of our study in six patients out of the 26 patients (23%). We did not differentiate the morbidity in major and minor; we mentioned all abnormal deviations encountered disregarding severity. In a literature review, the operative morbidity in transsternal thymectomy was found to be between 4 and 33% [4].
In our study, six patients who were operated upon through the transsternal approach had radiological evidence of pneumonitis; in four patients (15.4%) with clinical evidence of chest infection, and in two patients without clinical correlate. This is not surprising because patients with myasthenia gravis face major pulmonary problems as part of their disease process; as the myasthenic forced vital capacities are significantly lower than those for normal subjects. Due to expiratory weakness, cough efficacy is reduced and may lead to postoperative pulmonary complications [5]. The preoperative data of the patients in the sternotomy group of our study have demonstrated those findings in the form of a FVC of 67.2% and a FEV1 of 67% of predicted values.
According to the literature, in transsternal thymectomy the incidence of retention of respiratory secretions is 10%; of atelectasis is 7%. Pneumonia develops in 1–14% of patients, whereas upper airway infections afflict 1.5–35% of surgical patients [4].
As regards the non-pulmonary complications in our transsternal thymectomy group, they comprised wound infection in two patients with mediastinitis (7.7%), and one patient with phrenic palsy (3.8%). The following incidences of surgical complications are quoted in the literature for transsternal thymectomy: wound infection 1–7%, sternal disruption 1–4%, and injury to the phrenic nerve 0–4.5% [4].
In conclusion, we would like to emphasize that this comparative study is not trying to discredit the procedure of transsternal thymectomy, but is claiming that there are postoperative advantages of the manubriotomy approach with the same extent of resection which a sternotomy allows.
References
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