Perioperative management - VATS Thymectomy

Thymoma

Thymomas are epithelial tumors with generally slow growth of the thymic remnant. In principle, thymomas are classified as malignant, but in 75% of cases, they grow slowly and do not metastasize. In contrast, the much more aggressive thymic carcinoma should be distinguished. Surgery with R0 resection is the standard therapy with a good prognosis. For large tumors or preoperative evidence of thymic carcinoma, neoadjuvant therapy or definitive radiochemotherapy should be considered.

Myasthenia Gravis

Due to their ability to mature T-cells, thymomas are associated with a variety of autoimmune diseases and paraneoplastic syndromes. The most common paraneoplasia in this context is myasthenia gravis. A thymectomy often results in a significant improvement in symptoms. Seronegative patients with myasthenia without detectable antibodies do not seem to benefit from surgery.

• Lack of cardiopulmonary reserve
• General anesthesia intolerance
• Coagulation disorder or use of anticoagulants
  • The permanent use of ASA 100mg does not constitute a contraindication.
  • In cases of higher-grade anticoagulation such as platelet aggregation inhibitors (e.g., Clopidogrel), NOACs (e.g., Xarelto), or Vitamin K antagonists (e.g., Falithrom or Marcumar), an interdisciplinary consultation should develop a therapeutic concept regarding the indication for anticoagulation, the possibility of bridging with heparin, and the surgical bleeding risk.

Thymomas are often found incidentally in X-ray examinations. Computed tomography of the thorax is the standard examination for mediastinal tumors. For assessing operability, magnetic resonance imaging, despite motion artifacts caused by cardiac action, is superior to computed tomography in depicting vascular and myocardial invasion and is therefore a valuable addition when such questions arise.

Nuclear Medicine Examination

Conventional diagnostics cannot always differentiate between thymic hyperplasia and thymoma or between scar and tumor tissue. Thymic tumors can be visualized through the expression of somatostatin receptors using somatostatin receptor scintigraphy (DOTATOC-PET/CT). The use of this examination also improves the accuracy of staging by significantly more reliable detection of metastases.

• Shaving of the left thoracic wall and in the area of the sternum, if necessary
• SingleShot antibiotic with Cefuroxime 1.5g intravenously approximately 30 minutes before the skin incision.

In addition to the general surgical risks such as thrombosis, embolism, allergy, infection, bleeding, and wound healing disorders, specific risks must be explained:

• Injury to major vessels, particularly the brachiocephalic vein (= Vena brachiocephalica)
• Injury to nerves, particularly the phrenic nerve and recurrent laryngeal nerve
• Postoperative lymphatic fistula with chylothorax
• Postoperative hemorrhage with potentially necessary reoperation
• Conversion to sternotomy and possibly extension of resection, approach depending on intraoperative findings
• Injury to adjacent structures, particularly the trachea and main bronchi, major vessels, and the esophagus, necessitating corresponding extension of the procedure
• Positioning injuries
• Cardiac arrhythmias
• Local recurrences

Treatment alternative: Depending on the context, fine needle biopsy, radio-/chemotherapy.