Do we even need to relax? Evolution of non-intubated video assisted thoracic surgery thymectomy for myasthenia gravis—a narrative review

Abstract

Objective: Traditional approaches to thymectomy for myasthenia gravis (MG) formerly included open sternotomy and later video-assisted-(VATS) and robot-assisted thoracic surgery (RATS) through traditional double-lumen intubation anaesthesia. The aim of the review was to describe current role of non-intubated (NI) minimally invasive techniques in thoracic surgery with emphasis on NI-VATS thymectomy and point out advantages and disadvantages of the method from both the surgical-and anaesthesiological point of view.Background: With the introduction of non-intubated thoracic surgery (NITS) pioneer surgeons and anaesthesiologists have managed to carry out various thoracic surgery procedures from major lung resections to thymectomy without having to deal with the disadvantages of traditional intratracheal tube placement and reduce adverse effects of intubation, such as tracheal injury, lung infections, or hoarseness. Without the need of muscle relaxants, faster overall recovery can be achieved, granting improved postoperative patient outcomes, especially in cases of MG.Methods: Evolution of the NI technique and important results are presented through literature data and references. Only published manuscripts written in English language were considered including case reports, retrospective-, and prospective cohorts, meta-analysis, systematic reviews and randomized controlled trials.Conclusions: Although NI-VATS thymectomy remains a promising novel approach with numerous apparent benefits, further data evaluation and larger scale of patient outcome analysis is needed to determine exact indications and feasibility of the technique.

Pathophysiological background and perioperative outcome of thymus removal with spontaneous ventilation by intubation

“…Liu et al found a 5.88-fold higher incidence of postoperative myasthenic crisis when surgery was performed from thoracotomy versus VATS [139,140]. In addition to the use of thoracic epidural anaesthesia [137], the use of the NITS technique is not associated with the administration of muscle relaxants [141,142]. The use of the NITS technique is limited by several previously published criteria [125][126][127]143].…”