| Background and ObjectiveMyasthenia gravis(MG) is an autoimmune disease, which is mainly mediated by the effect of the acetylcholine receptor antibody(AchRAb) against acetylcholine receptor(AchR) on the postsynaptic membrane of the neuromuscular junction(NMJ). Many studies have demonstrated that MG is associated with pathological alterations of the thymus in 80%-90% of cases, and which include the thymus hyperplasia or thymoma. The clinical symptoms are relieved in most of postoperative patients with MG, and the remission rate is 90% in the five years after thymectomy. Therefore, thymectomy along with anterior mediastinal fat dissection is recognized as the preferred method of treatment of MG. Postoperative myasthenic crisis is the most severe complication and one of the key causes of mortality after surgery. Once the postoperative myasthenic crisis occurs, it will affect the rehabilitation, increase the hospital stay, and increase the pain of patients. So predicting and reducing the occurrence of perioperative myasthenic crisis, reducing the morbidity and mortality of postoperative complications, shorting the hospital stay, and promoting the rapid recovery of the patients are particularly important in the perioperative management of MG.The emergence of the concept of fast trcck surgery(FTS) has opened up a new research idea for the rehabilitation of postoperative patients. The study of the concept of FTS began in 1990 s, and it was first proposed by Kehlet in Copenhagen Denmark in 2001. FTS is a new concept by using evidence-based medicine method to study the perioperative management measures, and optimizing the processing of operative techniques and methods by the integration of the latest study of the surgical, anesthesia, nursing. The purpose is to reduce the stress response in postoperative patients, promote rapid rehabilitation of postoperative patients, reduce the incidence of complications, shorten the hospitalization time. The concept of FTS is an important complement and improvement to the traditional surgery, and abandoned some old ideas in the traditional surgery, so it changed the mode of clinical treatment of many diseases. This concept has been widely used in Europe countries and the United States, the effect is very good. But a variety of measures of FTS has not been applied in domestic, the implementation of the old tradition is still applied in the most of the domestic medical center. In recent years, with the gradually development of FTS theory, the popularity of minimally invasive concept, the widespread application of video-assisted thoracoscopic surgery and the building of evidence-base medicine, it provides the possibility and feasibility of clinical application for FTS. There are also some reports on the rapid recovery, but the application and understanding are not unified in various domestic medical center, it was difficult for the development of FTS in China. So far the application of FTS in the perioperative management of MG has not been reported, it is necessary to evaluate the application of FTS in the perioperative management of MG.This study was designed to set up a mode of perioperative management of MG by the application of the concept of FTS, which was compared with a mode of perioperative management of MG by the application of traditional surgery, and combined the new method of clinical typing and staging for MG to guide the selection of surgical opportunity, the risk and benefit of FTS was evaluated, and the feasibility and safety of FTS was also discussed. This work will provide theoretical basis and clinical experience for the application of FTS in the perioperative management of MG, thus a new model of treatment was provided in the perioperative management of MG, Materials and MethodsRespectively using single port thoracoscopy approach combine with FTS plan of thymectomy in the treatment of 48 cases as experience group and the transverse incision at the second intercostal level pathway combined with traditional surgery plan of thymectomy in the treatment of 142 cases of the patients with MG as control group, the selection of surgical opportunity was respectively guided by the new method of clinical typing and staging for MG and Osserman classification before the operation, the two groups were compared in operative time, intra-operative blood loss, post-operative thoracic drainage volume and time, post-operative chest pain, post-operative hospital stay, postoperative incidence of myasthenic crisis, concentration of C-reative protein, such as clinical indicators. The improvement of clinical symptom was followed up after thymectomy. The statistical analysis was performed using SPSS17.0 software. The α value less than 0.05 was considered significant. Results1. The incidence of preoperative thirsty, hungry feeling in the experimental group was significantly lower than that in the control group(P﹤0.05).2. The volume of intra-operative blood loss, length of incision, postoperative hospitalization time, postoperative time placing a urinary catheter, the score and the duration of postoperative chest pain, postoperative eating and activity time of the experimental group, the incidence of postoperative myasthenic crisis of the experimental group were significantly lower than these of the control group(P﹤0.05). There was no significant difference in the operative time between the two groups(P>0.05). The pleural drainage tube was not indwelled in the experimental group after thymectomy. In the control group, the post-operative thoracic drainage volume was less than 100 ml(84.9±21.2 ml), and the mean time of removal of chest drainage tube was 1.6 d(1.6±0.4 d). According to the chest CT to assess the amount of pleural effusion or gas, all the patients were checked by the chest CT in the third day after operation, it showed: the lung inflation was good in the two groups; in the experimental group, there were 48 cases with a small amount of pleural effusion(<150 ml), 2 cases with a small amount of pleural effusion(<10%), which did not require pleural drainage or exhaust; in the control group, there were 142 cases with a small amount of pleural effusion(<50 ml), and no pneumatosis. All the patients were checked by the chest CT in the first month after operation, it showed that had no obvious pleural effusion volume(<30 ml) and no pneumatosis, which did not require pleural drainage or exhaust. There were no patients with incision infection in the experimental group, and 3 patients with incision infection in the control group.3. There were not myasthenic crisis in the experimental group, but 11 cases in the control group. According to the Osserman type, the 11 cases with myasthenic crisis were repectively grouped to Type Ⅱa(8 cases) and Type Ⅱb(3 cases), but according to the new method of clinical typing and staging for MG, the 11 cases with myasthenic crisis were repectively grouped to Type Ⅲb(2 cases), Type Ⅳ(7 cases) and Type Ⅴ(2 cases), 9 cases were at onset/advanced stage and 3 cases at the stable/remission stage.4. The concentration of C-reative protein in the experimental group was significantly lower than that in the control group in first day and forth day after operation(P﹤0.05).5. There was no statistical difference in the rate of remission in the 3-,6- and 12-month after operation between the two groups(P>0.05). Conclusion1. The pathway is safe, effective and feasible through uniport thoracoscopy approach without chest drainage tube in the process of thymectomy for the patients with MG.2. By the new method of clinical typing and staging for MG to guide the selection of surgical opportunity, it is helpful to predict the occurrence of postoperative myasthenic crisis, and the incidence of postoperative myasthenic crisis can be reduced by paying more attention to the perioperative management.3. Fast track surgery in thymectomy for the patients with MG is safe and effective. The use of fast track surgery plan and conservative treatment surgery plan compared: reduce the incidence of postoperative complications, shorten postoperative hospital stay, reduce the trauma and stress of the perioparative patients, relieve the pain of the patients, promote the rapid recovery of the patients with MG. This evaluation provides the basic theory and clinical experience for the application of FTS in the perioperative management of MG, and provides a new treatment model. |
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