Hybrid endoscopic thymectomy: combined transesophageal and transthoracic approach in a survival porcine model with cadaver assessment.
BACKGROUND
Video-assisted thoracoscopic surgery thymectomy has been used in the treatment of Myastenia Gravis and thymomas (coexisting or not). In natural orifice transluminal endoscopic surgery, new approaches to the thorax are emerging as alternatives to the classic transthoracic endoscopic surgery. The aim of this study was to assess the feasibility and reliability of hybrid endoscopic thymectomy (HET) using a combined transthoracic and transesophageal approach.


METHODS
Twelve consecutive in vivo experiments were undertaken in the porcine model (4 acute and 8 survival). The same procedure was assessed in a human cadaver afterward. For HET, an 11-mm trocar was inserted in the 2nd intercostal space in the left anterior axillary line. A 0° 10-mm thoracoscope with a 5-mm working channel was introduced. Transesophageal access was created through a submucosal tunnel using a flexible gastroscope with a single working channel introduced through the mouth. Using both flexible (gastroscope) and rigid (thoracoscope) instruments, the mediastinum was opened; the thymus was dissected, and the vessels were ligated using electrocautery alone.


RESULTS
Submucosal tunnel creation and esophagotomy were performed safely without incidents in all animals. Complete thymectomy was achieved in all experiments. All animals in the survival group lived for 14 days. Thoracoscopic and postmortem examination revealed pleural adhesions on site of the surgical procedure with no signs of infection. Histological analysis of the proximal third of the esophagus revealed complete cicatrization of both mucosal defect and myotomy site. In the human cadaver, we were able to replicate all the procedure even though we were not able to identify the thymus.


CONCLUSIONS
Hybrid endoscopic thymectomy is feasible and reliable. HET could be regarded as a possible alternative to classic thoracoscopic approach for patients requiring thymectomy.
Life and Health Sciences Research Institute (ICVS), School of Health Sciences, University of Minho, Campus de Gualtar, 4709-057, Braga, Portugal, moreirapinto@gmail.com.
João
J
Moreira-Pinto
Aníbal
A
Ferreira
Alice
A
Miranda
Carla
C
Rolanda
Jorge
J
Correia-Pinto
D000368:Aged; D000818:Animals; D002102:Cadaver; D004947:Esophagus / Q000601:surgery; D005260:Female; D020699:Gastroscopes; D006801:Humans; D008026:Ligation; D057605:Natural Orifice Endoscopic Surgery / Q000379:methods*; D015203:Reproducibility of Results; D013525:Surgical Instruments; D013552:Swine; D020775:Thoracic Surgery, Video-Assisted / Q000379:methods*; D013934:Thymectomy / Q000379:methods*; D013945:Thymoma / Q000601:surgery*