Surgical treatment of myasthenia gravis: evident benefits and insidious pitfalls of mini-invasive techniques.

When surgery is indicated in the treatment of myasthenia gravis (MG), a total thymectomy is mandatory; this should be accomplished to achieve complete remission from symptoms. The embryology and anatomy of the mediastinal region and the thymus gland make the removal of all the thymic tissue—a prerequisite for symptom control given the autoimmune nature of the MG—a difficult surgical task that is usually performed in the vast majority of cases via an open-access transsternal approach. However, this approach significantly affects the postoperative morbidity, pain, and cosmesis; in recent years, many efforts have been undertaken to develop and validate less invasive techniques [1, 2]. All these approaches invariably use innovative video-assisted thoracic surgery technologies. Jurado and coworkers [3] performed a comprehensive comparative analysis of minimally invasive thymectomy performed via video-assisted thoracic surgery versus open thymectomy in a large series of patients affected mostly by MG [3]. Based on the results of this analysis, the authors conclude that, to control the effects of surgery itself on frail patients with MG (by decreasing the postoperative morbidity), the less-aggressive techniques should be preferred. We would support a cautionary attitude with this recommendation. In fact, Jaretzky and colleagues [4] clearly showed that transsternal approaches provide worse results in terms of long-term remission rate from MG if compared with less invasive approaches, given that the operation executed at the level of the mediastinum is the same. Moreover, ectopic thymic foci are found in more than half of cases [5] in which an extended thymectomy is performed (a type of operation virtually unfeasible through a non-trans-sternotomic or bilateral transthoracic access). One point of caution is that the feasibility and efficacy of all mini-invasive surgical techniques in the treatment ofMGshould be evaluated, accounting for the postoperative surgical outcomes and long-term neurologic outcomes. Insufficient data about the neurologic outcome in the MG subgroup of patients [3] makes it difficult to interpret the results, substantially weakening the conclusion that less invasive approaches should be preferred. We would welcome a comment from the authors on this point, in light of the firm principle that the completeness of the operation as defined by the extended thymectomy approach is the goal of any approach. In addition, we would welcome additional reasoning on the relative weight of the postoperative and cosmetic outcome patterns versus the long-term neurologic and quality-of-life outcome in patients with MG and what factors a surgeon should prioritize in the clinical decision-making process at the moment of the surgical indication. Thus, any attempt at ameliorating morbidity and cosmetic patterns in the postoperative setting is, in our opinion, to be carefully matched with the fact that long-term substantial benefit in such patients can be provided only if the thymic tissue resection is complete