Thoracoscopic Thymectomy for Myasthenia Gravis: An early experience in Yemen

Thoracoscopic Thymectomy for Myasthenia Gravis: An early experience in Yemen | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Thoracoscopic Thymectomy for Myasthenia Gravis: An early experience in Yemen Yasser Abdurabo Obadiel, Mohammed Mohammed Al-Shehari, Ali Al-Shawesh, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3954654/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Thymectomy is an option for the treatment of myasthenia gravis MG. While the open technique was most frequently performed in the past, nowadays the endoscopic approach has gained wide acceptance. Here we assessed our early experience in thoracoscopic thymectomy (TT). Methods This case series was retrospectively conducted at Al-Thawra Modern General Hospital and included patients diagnosed with MG who underwent TT from January 2018 to January 2024. Results Our case series consisted of 13 predominantly female patients (61.5%), with a median age of 39.5 years. The most common presenting symptoms were generalized weakness and ptosis. Surgeries typically lasted 50 ± 10.41 minutes, with the majority performed using a left-sided thoracoscopic approach (n = 10, 77%). Immediate extubation was achieved in 10 patients (76%). Four patients experienced early postoperative complications (31%), including dyspnea, prolonged intubation, chest infection, confusion, tracheostomy, and re-tracheostomy. There were 2 recorded deaths due to complications. Eleven patients were followed up for an average of 16.5 months, revealing that 54.5% achieved complete stable remission, 18% showed improvement with reduced symptoms and medications, and 27% remained unchanged. Conclusions Thoracoscopic thymectomy is a safe and effective procedure for the management of MG in Yemeni patients. The observed remission and improvement rates are promising and align with global experiences. It is recommended that with proper resources and expertise, similar minimally invasive surgical approaches can be implemented in resource-limited regions. Cardiothoracic Surgery Indications early complications thoracoscopic thymectomy Yemen Plain language summary This research paper discusses the use of thoracoscopic thymectomy (TT) as a treatment option for myasthenia gravis (MG). MG is a condition that causes muscle weakness, and thymectomy involves removing the thymus gland to alleviate symptoms. The study was conducted at Al-Thawra Modern General Hospital in Yemen and included patients who underwent TT between January 2018 and January 2024. The case series consisted of 13 patients, mostly females, with a median age of 39.5 years. The most common symptoms observed were generalized weakness and ptosis (drooping eyelids). The surgeries took around 50 minutes on average, with a majority performed using a left-sided thoracoscopic approach. Immediate extubation (removal of the breathing tube) was successful in most cases. However, the study also reported some complications, including dyspnea (difficulty breathing), prolonged intubation (extended use of the breathing tube), chest infection, confusion, tracheostomy (surgical opening in the windpipe), and re-tracheostomy. Sadly, there were two recorded deaths due to complications. Follow-up was conducted on 11 patients for an average of 16.5 months. The results showed that 54.5% achieved complete stable remission, 18% experienced improvement with reduced symptoms and medications, and 27% had no significant changes in their condition. This early experience with TT for MG in Yemen provides valuable insights into the procedure's effectiveness and associated complications. Further research and evaluation are necessary to better understand the long-term outcomes and refine the approach for optimal patient care. Introduction Myasthenia gravis (MG) is a chronic autoimmune neuromuscular disease characterized by varying degrees of weakness of the voluntary muscles of the body. This condition is caused by a breakdown in the normal communication between nerves and muscles due to antibodies that block or alter the function of acetylcholine receptors at the neuromuscular junction. 1 – 3 The hallmarks of MG include muscle weakness, drooping eyelids, and difficulties with vision, speaking, swallowing, and breathing. 4 The thymus gland is implicated in the pathogenesis of MG, particularly in patients with thymomas or thymic hyperplasia. Thymectomy, the surgical removal of the thymus gland, is performed to improve the weakness caused by MG. It is a well-established treatment modality that has been shown to improve symptoms and reduce the need for immunosuppressive medications. 5 , 6 Thoracoscopic thymectomy (TT) or video-assisted thoracoscopic surgery (VATS) offers several advantages over open surgery. These include shorter hospital stays, less postoperative pain, reduced blood loss, lower rates of blood transfusion, and quicker recovery times. 7 , 8 In addition, the minimally invasive nature of VATS leads to better cosmetic outcomes and possibly lower overall healthcare costs. Although MG is a known health concern globally, the prevalence and management of the disease in Yemen are not well documented. This study aimed to shed light on the early experience of TT for MG patients in Yemen, where healthcare resources may be limited. Understanding the outcomes of this minimally invasive procedure in a resource-constrained setting is crucial for developing tailored treatment strategies and improving patient care for patients suffering from MG in Yemen and similar contexts. Patients and Methods Study Design: This case series study was conducted retrospectively and assessed our experience in TT in Yemen by assessing surgical approach, early management outcomes, and complications for patients diagnosed with myasthenia gravis (MG). Study Setting: The study was conducted at TMGH Sana'a city, Yemen, which served as the primary location for patient care and data collection. Participants: Patients diagnosed with MG who underwent TT at TMGH between January 2018 and January 2024 were included in the study. Patients were selected on the basis of the availability of medical records and meeting the inclusion criteria. Data Collection: Retrospective data collection was performed using a structure questionnaire based on previous studies 8 – 10 , by reviewing patients’ medical records, including preoperative characteristics, surgical details, and postoperative outcomes. Surgical Approach Thoracoscopic thymectomy was performed using single lung ventilation with 3 ports. The side of work was determined on the basis of the presence of a thymic mass on either side of the anterior mediastinum. The dissection began anterior to the ipsilateral phrenic nerve and involved the complete removal of the thymus, including the mass, and the dissection of the pericardial fat pad with careful attention to avoid injury to the contralateral phrenic nerve. A chest tube was inserted at the end of the procedure, and early extubation of the patient was the primary goal. Follow-up: With an average of 16.5 months, follow-up of 11 patients was conducted by taking patients’ contact information from their records and contacting them using a telephone. They were asked to confirm their preoperative symptoms and to describe their improvement after surgery and the time during which these symptoms improved. Those with partial or no improvement were also asked about the final improvement of their MG symptoms and if there was any reduction in their medication dosage. For measuring patient improvement, we categorize them based on the definitions provided by the Myasthenia Gravis Foundation of America (MGFA) Post-Intervention Status 11 , into three categories: Complete Stable Remission (CSR), representing those with no symptoms or signs of MG for at least 1 year and no therapy during that time; Change in Status (I), indicating patients with a substantial decrease in pre-treatment clinical manifestations or a sustained substantial reduction in MG medications; and Unchanged Status (U), comprising patients with no substantial change in pre-treatment clinical manifestations or reduction in MG medications as defined in the protocol. Outcome Measures: The primary outcome measures in this study included the surgical approach (left or right side) for TT, the occurrence and type of postoperative complications, particularly respiratory complications, and other adverse events. Patient outcomes such as time of extubation, duration of chest tube placement, duration of ICU stay, ward stay, and overall hospital stay were assessed, along with the measurement of improvement in myasthenia gravis (MG) symptoms. Data Analysis: Data were analyzed using IBM SPSS statistics, v. 28.0 (IBM Corp., Armonk, NY, USA), through which the required tests were used. Descriptive statistics are presented as frequencies and percentages. Multiple response analysis was used to determine the patients’ presenting symptoms and early complications. The significance level was set at < 0.05. Ethical Considerations: Approval from the research committee of TMGH was obtained before conducting the study. Patient privacy and confidentiality were ensured during data collection and analysis in adherence to ethical guidelines and principles. Informed consent was obtained from the patients for participation in the study and phone follow-up. Results Demographic characteristics and clinical presentation The data analyzed involved 13 patients, with a majority of them being female (61.5%) and with an average age of 39.5 years. Among the patients, 2 (15.4%) had hypertension (HTN), 1 (7.7%) had diabetes mellitus (DM), and 1 (7.7%) had rheumatoid arthritis. The most common symptoms reported were generalized weakness and dropping of the eyelids, each observed in 76.9% of the patients (Table 1 ). Table 1 Demographic characteristics and clinical presentation of patients (n = 13) Variable N % Age (Mean) 39.5 ± 13.3 Gender Female 8 61.5% Male 5 38.5% Comorbidities No Comorbidity 9 69% hypertension 2 15% diabetes mellitus 1 7.7% rheumatoid arthritis 1 7.7% Clinical presentations Generalized weakness 10 76.9% Dropping of the eyelids 10 76.9% Dysphagia 8 61.5% Diplopia 8 61.5% Dyspnea 6 46.2% Blurring of the vision 3 23.1% Dysphonia 3 23.1% Dizziness (syncope) 3 23.1% Dysarthria 3 23.1% Tingling (paresthesia) 3 23.1% Headache 3 23.1% Limb weakness (arms/legs) 3 23.1% Difficulty in speech 2 15.4% Difficulty in mastication 2 15.4% Chest pain 2 15.4% Regurgitation 1 7.7% Chocking 1 7.7% On average, our patients had been living with MG for 56 months and experienced exacerbation periods lasting around 5 months. Prior to surgical treatment, 85% were on medication, predominantly pyridostigmine bromide. The preoperative regimen primarily included immunoglobulins, with neostigmine and hydrocortisone also commonly administered ( Table 2 ) . Table 2 Preoperative duration, exacerbation, and medical treatment for myasthenia gravis Preoperative variables N % Duration of myasthenia gravis (Mean ± SD) (n = 13) 55.83 ± 93.93 Exacerbation (Mean ± SD) 4.92 ± 3.32 Medical treatment (n = 11) Pyridostigmine bromide 9 81.8% Prednisolone 4 36.4% immunoglobulin 1 9.1% Redazol 1 9.1% Azathioprine 2 18.2% Others 2 18.2% Preoperative Medication immunoglobulin 61.5% Neostigmine 53.8% Hydrocortisone 23.1% Pyridostigmine 7.7% Atropine 7.7% Surgical Outcomes The average operation time was 50 ± 10.41 minutes, with most surgeries lasting between 40 and 80 minutes ( Table 3 ) . The majority of surgical approaches were left-sided (92.3%), with only one case involving a right-sided approach. Thymus gland invasion occurred in 23.1% of patients, while 76.9% exhibited non-invasive characteristics. Most of the patients (61.5%) had masses averaging 3.99 cm by 3.44 cm in length and width, respectively, whereas 30.8% displayed hyperplasia with average dimensions of 8.93 cm by 7.35 cm. Only one individual showed normal tissue characteristics. Unilateral chest tube insertion was prevalent, with most patients (76.9%) receiving a tube on one side and the remaining requiring bilateral insertion (23%). Table 3 Surgical Outcomes of Thoracoscopic Thymectomy (n = 13) Variable N % Approach side Right 1 7.7% Left 12 92.3% Intraoperative invasion Yes 3 23.1% No 10 76.9% Intraoperative finding Mass 8 61.5% Hyperplasia 4 30.8% Normal 1 7.7% Chest tube placement Unilateral chest tube Right 1 7.7% Left 9 69.2% Bilateral Right left 3 23.1% Operation time (Mean ± SD) 50 ± 10.41 min 13 - Early complications and outcomes Of the 13 patients, four suffered complications such as prolonged intubation and mechanical ventilation, dyspnea, and chest infection (each at 31%), confusion and tracheostomy (both 23%), with a re-tracheostomy (8%) and mortality rate of 15%. Most were extubated either immediately post-surgery or by the first day post-op (76.9%). The average Intensive Care Unit (ICU) stay was 7.3 days, during which two patients passed away. Eleven patients progressed to the general ward, staying for an average of 3.64 days. Chest tubes remained for an average of 5.57 days. Overall, the mean hospital stay was 9.46 days, with most patients (61.5%) discharged by day six ( Table 4 ) . Table 4 Early postoperative complications and outcomes Postoperative Outcomes N % Time for extubation (n = 13) Immediately postoperative 10 76.9% First post-operative day 3 23.1 ICU stay (n = 13) 7.30 ± 10.1 - Ward stay (n = 11) 3.64 ± 3.26 - Keeping chest tube (n = 13) 5.57 ± 5.73 - Hospital stay (n = 13) 9.46 ± 9.2 - Postoperative complication Yes 4 30.8 No 9 69.2% Frequency of complications (n = 9) Chest infection 3 23.1% Confusion (disturbance level of cons.) 3 23.1% Intubation and mechanical ventilation 3 23.1% Dyspnea 4 30.8% Tracheostomy 3 23.1% Re-tracheostomy 1 7.7% Mortality 2 15.3% MG Post-Intervention Status (n = 11) Complete stable remission (CSR) 6 54.5% Unchanged Status (U) 3 27% Change in Status (I) 2 18% Follow-up: We conducted a follow-up on 11 patients over an average of 16.5 months. Of these, 54.5% achieved complete stable remission, 18% showed reduced symptoms and lessened medication use, while 27% saw no change in their condition or treatment ( Table 4 ) . Discussion Our study of 13 patients with MG revealed that 61.5% were female, with an average age of 39.5 years, aligning with research that MG predominantly affects women under 40 and men over 50. 12 Additionally, prevalent comorbidities such as hypertension, diabetes mellitus, and rheumatoid arthritis were observed, reflecting MG's association with common conditions in an aging population. 13 The clinical presentation in our study, which included generalized weakness, ptosis, dysphagia, and diplopia, aligned with known MG symptoms such as fluctuating muscle weakness that worsened with activity and improved with rest. Ocular and bulbar symptoms, such as visual problems and difficulty swallowing, are often reported as the first signs. 4 , 14 Regarding treatment and medication use before thymectomy, patients with low respiratory reserves or bulbar symptomatology are frequently treated with intravenous immunoglobulin (IVIG) or plasma exchange (PLEX) before the procedure, as noted in our study, with immunoglobulin as the most used medication. This is consistent with the current recommendations. 15 Pyridostigmine bromide is commonly used as a first-line treatment to improve muscle weakness. 16 The thoracoscopic approach used in this study aligns with the literature suggesting that patients undergoing video-assisted thoracoscopic surgery (VATS) thymectomy achieve better surgical outcomes and fewer complications than those who opt for open thymectomy (OT). 17 Our results, showing a predominantly left-sided approach and an average operation duration of 50 ± 10.41 minutes, indicate a less invasive and more efficient procedure. Studies have also highlighted benefits such as shorter hospital stays and less intraoperative blood loss associated with thoracoscopic methods. 18 , 19 The complications observed in our cohort, including intubation/mechanical ventilation and re-tracheostomy, reflect the inherent risks associated with thymectomy. However, the overall complication rate for thoracoscopic thymectomy is reported to be approximately 12.2%, which is relatively low. 20 Catastrophic complications are very rare, but intraoperative complications such as bleeding require immediate attention. 21 , 22 Two patients died postoperatively with a mortality rate of 15.4%, which is higher than that reported by several previous studies, where the mortality rate of thoracoscopic thymectomy was 0–3.8%. 23 , 24 The increased rate of mortality and morbidity in our study could be attributed to the intraoperative concomitant surgical invasion because one of the two patients with intraoperative invasion died after surgery. Another possible reason is the coincidence of surgeries during the outbreak of the COVID-19 pandemic. The follow-up outcomes in our study showed that 54.5% of patients achieved complete stable remission (CSR), 18% experienced a change in status with reduced symptoms and medications, and 27% remained unchanged after an average period of 16.5 months post-thymectomy. These findings agree with published research indicating that thymectomy can lead to persistent improvement in symptoms and remission in patients with MG. 25 A long-term follow-up study of thymectomy for patients with MG showed that the rate of CSR was around 19%, with an additional 16% of patients symptomatically improving and requiring less medication after thymectomy. 26 Another study reported that CSR could be achieved in approximately 40% of ocular MG patients 5 years after thymectomy, especially if the onset age was 40 years or younger. 27 Although spontaneous remission is uncommon, guidelines suggest that thymectomy is valuable as a form of treatment for MG, with better outcomes when performed within a short time from the onset of symptoms. 28 Furthermore, after a median follow-up of 2.9 years, a significant proportion of patients may discontinue prednisone, and some achieve complete stable remission. 29 Overall, these findings highlight the potential benefits of thymectomy in the management of MG and support the outcomes observed in our study. Our study is limited by its small sample size and the lack of long-term follow-up, which are critical for assessing the full impact of thoracoscopic thymectomy on patient outcomes. These limitations are significant when considering the variability of myasthenic symptoms and the progression of MG over time. Future studies should include larger cohorts with longer follow-up periods to better understand the long-term benefits and potential complications of thoracoscopic thymectomy. Research should also explore the efficacy of minimally invasive techniques compared to traditional open procedures and their impact on the quality of life of patients with MG. 30 Conclusion Our study shows that thoracoscopic thymectomy is a safe and effective treatment for myasthenia gravis in Yemen, yielding favorable early outcomes with many patients achieving complete stable remission. These results could encourage wider use of the procedure, enhancing MG management in areas with limited resources. Future research should focus on standardizing surgical methods, evaluating long-term effects, and developing optimal postoperative care protocols and complication management strategies. Declarations Ethics approval and informed consent All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Informed consent was obtained from all individual participants included in the study. Acknowledgments Not applicable. Disclosure The authors report no conflicts of interest. Competing of interest Non-financial competing interests Funding disclosure This study did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Data availability Not applicable. Declaration on generative AI and AI-assisted technologies in the writing process During the preparation of this work, the authors used [HyperWrite / summarization and improve text tools] to [summarize different long sections of the manuscript and improve text readability]. After using this tool/service, the authors reviewed and edited the content as needed and take full responsibility for the content of the publication. References Carr AS, Cardwell CR, McCarron PO, McConville J. A systematic review of population based epidemiological studies in Myasthenia Gravis. BMC Neurol . 2010;10(1):46. doi:10.1186/1471-2377-10-46 Gilhus NE, Skeie GO, Romi F, Lazaridis K, Zisimopoulou P, Tzartos S. Myasthenia gravis — autoantibody characteristics and their implications for therapy. Nat Rev Neurol . 2016;12(5):259-268. doi:10.1038/nrneurol.2016.44 Myasthenia Gravis [Internet]. National Institute of Neurological Disorders and Stroke. [cited 2024 Feb 8]. 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Liu X, Zhou W, Hu J, et al. Prognostic predictors of remission in ocular myasthenia after thymectomy. J Thorac Dis . 2020;12(3):422-430. doi:10.21037/jtd.2020.01.17 Mineo TC, Ambrogi V. Outcomes after thymectomy in class I myasthenia gravis. J Thorac Cardiovasc Surg . 2013;145(5):1319-1324. doi:10.1016/j.jtcvs.2012.12.053 Bi Z, Cao Y, Liu C, et al. Remission and relapses of myasthenia gravis on long-term tacrolimus: a retrospective cross-sectional study of a Chinese cohort. Ther Adv Chronic Dis . 2022;13:204062232211225. doi:10.1177/20406223221122538 Wilshire CL, Blitz SL, Fuller CC, et al. Minimally invasive thymectomy for myasthenia gravis favours left-sided approach and low severity class. European Journal of Cardio-Thoracic Surgery . 2021;60(4):898-905. doi:10.1093/ejcts/ezab014 Additional Declarations The authors declare no competing interests. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3954654","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":272731422,"identity":"d321264f-57c8-4f70-8fa1-caceaaf18dda","order_by":0,"name":"Yasser Abdurabo Obadiel","email":"","orcid":"https://orcid.org/0000-0002-3566-7281","institution":"Department of Surgery, Al-Thawra Modern General Hospital, Sana’a University, Sana’a City, Yemen","correspondingAuthor":false,"prefix":"","firstName":"Yasser","middleName":"Abdurabo","lastName":"Obadiel","suffix":""},{"id":272731423,"identity":"9f0b2829-cca8-47a8-9e82-cfa0e5d0d374","order_by":1,"name":"Mohammed Mohammed Al-Shehari","email":"","orcid":"https://orcid.org/0000-0003-1295-0620","institution":"Department of Surgery, Al-Thawra Modern General Hospital, Sana’a University, Sana’a City, Yemen","correspondingAuthor":false,"prefix":"","firstName":"Mohammed","middleName":"Mohammed","lastName":"Al-Shehari","suffix":""},{"id":272731424,"identity":"3a6f2b50-1178-43f4-a301-bc71928eb1bd","order_by":2,"name":"Ali Al-Shawesh","email":"","orcid":"","institution":"Department of Surgery, Al-Thawra Modern General Hospital, Sana’a City, Yemen","correspondingAuthor":false,"prefix":"","firstName":"Ali","middleName":"","lastName":"Al-Shawesh","suffix":""},{"id":272731425,"identity":"ea5fcabd-e63f-4086-aba2-a8bd6232c464","order_by":3,"name":"Basma Abdulaleem Al-Huribi","email":"","orcid":"","institution":"Department of Surgery, Al-Thawra Modern General Hospital, Sana’a City, Yemen","correspondingAuthor":false,"prefix":"","firstName":"Basma","middleName":"Abdulaleem","lastName":"Al-Huribi","suffix":""},{"id":272731426,"identity":"8d51fcfd-b1b5-45ba-9e11-188a7185f00b","order_by":4,"name":"Haitham Mohammed Jowah","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAzUlEQVRIiWNgGAWjYBACAwaGBCB1QA7M4yFFizFJWkDgQGID0VrMGRgePuapuZM+f0YC44O3bQyJ/YS0WDYwJBvzHHuWu+FGArPhXKCWmQ2EHHaAIU06h+1w7gaJBDZpXqCWDQeI0vLvcLr8jAT23yAt+4nSktt2OIHhRgIbM9gWQn4xOAz0y9++w4YbzjxslpxzTsJ4BkFbjvckPpzx7bC8fHvywQ9vymxk+xsIWcPMkwBlMYLUSjgS1MHAwI7qEHvCOkbBKBgFo2CkAQCEAUMIrb03fgAAAABJRU5ErkJggg==","orcid":"https://orcid.org/0009-0008-3815-3017","institution":"Department of Surgery, Faculty of Medicine, Sana’a University, Sana’a City, Yemen","correspondingAuthor":true,"prefix":"","firstName":"Haitham","middleName":"Mohammed","lastName":"Jowah","suffix":""}],"badges":[],"createdAt":"2024-02-13 23:19:02","currentVersionCode":1,"declarations":{"humanSubjects":true,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":true,"humanSubjectConsent":true,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-3954654/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3954654/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":51133491,"identity":"29b4d794-4939-460d-9f9a-bea7bd1432d1","added_by":"auto","created_at":"2024-02-14 18:06:21","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":364746,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3954654/v1/cd605f59-6515-4491-a7c4-bdb8a5035cba.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003e\u003cstrong\u003eThoracoscopic Thymectomy for Myasthenia Gravis: An early experience in Yemen\u003c/strong\u003e\u003c/p\u003e","fulltext":[{"header":"Plain language summary","content":"\u003cp\u003eThis research paper discusses the use of thoracoscopic thymectomy (TT) as a treatment option for myasthenia gravis (MG). MG is a condition that causes muscle weakness, and thymectomy involves removing the thymus gland to alleviate symptoms. The study was conducted at Al-Thawra Modern General Hospital in Yemen and included patients who underwent TT between January 2018 and January 2024.\u003c/p\u003e\n\u003cp\u003eThe case series consisted of 13 patients, mostly females, with a median age of 39.5 years. The most common symptoms observed were generalized weakness and ptosis (drooping eyelids). The surgeries took around 50 minutes on average, with a majority performed using a left-sided thoracoscopic approach. Immediate extubation (removal of the breathing tube) was successful in most cases.\u003c/p\u003e\n\u003cp\u003eHowever, the study also reported some complications, including dyspnea (difficulty breathing), prolonged intubation (extended use of the breathing tube), chest infection, confusion, tracheostomy (surgical opening in the windpipe), and re-tracheostomy. Sadly, there were two recorded deaths due to complications.\u003c/p\u003e\n\u003cp\u003eFollow-up was conducted on 11 patients for an average of 16.5 months. The results showed that 54.5% achieved complete stable remission, 18% experienced improvement with reduced symptoms and medications, and 27% had no significant changes in their condition.\u003c/p\u003e\n\u003cp\u003eThis early experience with TT for MG in Yemen provides valuable insights into the procedure\u0026apos;s effectiveness and associated complications. Further research and evaluation are necessary to better understand the long-term outcomes and refine the approach for optimal patient care.\u003c/p\u003e"},{"header":"Introduction","content":"\u003cp\u003eMyasthenia gravis (MG) is a chronic autoimmune neuromuscular disease characterized by varying degrees of weakness of the voluntary muscles of the body. This condition is caused by a breakdown in the normal communication between nerves and muscles due to antibodies that block or alter the function of acetylcholine receptors at the neuromuscular junction. \u003csup\u003e\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e The hallmarks of MG include muscle weakness, drooping eyelids, and difficulties with vision, speaking, swallowing, and breathing. \u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe thymus gland is implicated in the pathogenesis of MG, particularly in patients with thymomas or thymic hyperplasia. Thymectomy, the surgical removal of the thymus gland, is performed to improve the weakness caused by MG. It is a well-established treatment modality that has been shown to improve symptoms and reduce the need for immunosuppressive medications. \u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e,\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThoracoscopic thymectomy (TT) or video-assisted thoracoscopic surgery (VATS) offers several advantages over open surgery. These include shorter hospital stays, less postoperative pain, reduced blood loss, lower rates of blood transfusion, and quicker recovery times. \u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e,\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e In addition, the minimally invasive nature of VATS leads to better cosmetic outcomes and possibly lower overall healthcare costs.\u003c/p\u003e \u003cp\u003eAlthough MG is a known health concern globally, the prevalence and management of the disease in Yemen are not well documented. This study aimed to shed light on the early experience of TT for MG patients in Yemen, where healthcare resources may be limited. Understanding the outcomes of this minimally invasive procedure in a resource-constrained setting is crucial for developing tailored treatment strategies and improving patient care for patients suffering from MG in Yemen and similar contexts.\u003c/p\u003e"},{"header":"Patients and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\n\u003ch2\u003eStudy Design:\u003c/h2\u003e\n\u003cp\u003eThis case series study was conducted retrospectively and assessed our experience in TT in Yemen by assessing surgical approach, early management outcomes, and complications for patients diagnosed with myasthenia gravis (MG).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\n\u003ch2\u003eStudy Setting:\u003c/h2\u003e\n\u003cp\u003eThe study was conducted at TMGH Sana'a city, Yemen, which served as the primary location for patient care and data collection.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\n\u003ch2\u003eParticipants:\u003c/h2\u003e\n\u003cp\u003ePatients diagnosed with MG who underwent TT at TMGH between January 2018 and January 2024 were included in the study. Patients were selected on the basis of the availability of medical records and meeting the inclusion criteria.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\n\u003ch2\u003eData Collection:\u003c/h2\u003e\n\u003cp\u003eRetrospective data collection was performed using a structure questionnaire based on previous studies \u003csup\u003e\u003cspan class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e, by reviewing patients\u0026rsquo; medical records, including preoperative characteristics, surgical details, and postoperative outcomes.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\n\u003ch2\u003eSurgical Approach\u003c/h2\u003e\n\u003cp\u003eThoracoscopic thymectomy was performed using single lung ventilation with 3 ports. The side of work was determined on the basis of the presence of a thymic mass on either side of the anterior mediastinum. The dissection began anterior to the ipsilateral phrenic nerve and involved the complete removal of the thymus, including the mass, and the dissection of the pericardial fat pad with careful attention to avoid injury to the contralateral phrenic nerve. A chest tube was inserted at the end of the procedure, and early extubation of the patient was the primary goal.\u003c/p\u003e\n\u003c/div\u003e\n\u003ch2\u003eFollow-up:\u003c/h2\u003e\n\u003cp\u003eWith an average of 16.5 months, follow-up of 11 patients was conducted by taking patients\u0026rsquo; contact information from their records and contacting them using a telephone. They were asked to confirm their preoperative symptoms and to describe their improvement after surgery and the time during which these symptoms improved. Those with partial or no improvement were also asked about the final improvement of their MG symptoms and if there was any reduction in their medication dosage.\u003c/p\u003e\n\u003cp\u003eFor measuring patient improvement, we categorize them based on the definitions provided by the Myasthenia Gravis Foundation of America (MGFA) Post-Intervention Status \u003csup\u003e\u003cspan class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e, into three categories: Complete Stable Remission (CSR), representing those with no symptoms or signs of MG for at least 1 year and no therapy during that time; Change in Status (I), indicating patients with a substantial decrease in pre-treatment clinical manifestations or a sustained substantial reduction in MG medications; and Unchanged Status (U), comprising patients with no substantial change in pre-treatment clinical manifestations or reduction in MG medications as defined in the protocol.\u003c/p\u003e\n\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\n\u003ch2\u003eOutcome Measures:\u003c/h2\u003e\n\u003cp\u003eThe primary outcome measures in this study included the surgical approach (left or right side) for TT, the occurrence and type of postoperative complications, particularly respiratory complications, and other adverse events. Patient outcomes such as time of extubation, duration of chest tube placement, duration of ICU stay, ward stay, and overall hospital stay were assessed, along with the measurement of improvement in myasthenia gravis (MG) symptoms.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\n\u003ch2\u003eData Analysis:\u003c/h2\u003e\n\u003cp\u003eData were analyzed using IBM SPSS statistics, v. 28.0 (IBM Corp., Armonk, NY, USA), through which the required tests were used. Descriptive statistics are presented as frequencies and percentages. Multiple response analysis was used to determine the patients\u0026rsquo; presenting symptoms and early complications. The significance level was set at \u0026lt;\u0026thinsp;0.05.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\n\u003ch2\u003eEthical Considerations:\u003c/h2\u003e\n\u003cp\u003eApproval from the research committee of TMGH was obtained before conducting the study. Patient privacy and confidentiality were ensured during data collection and analysis in adherence to ethical guidelines and principles. Informed consent was obtained from the patients for participation in the study and phone follow-up.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\n\u003ch2\u003eDemographic characteristics and clinical presentation\u003c/h2\u003e\n\u003cp\u003eThe data analyzed involved 13 patients, with a majority of them being female (61.5%) and with an average age of 39.5 years. Among the patients, 2 (15.4%) had hypertension (HTN), 1 (7.7%) had diabetes mellitus (DM), and 1 (7.7%) had rheumatoid arthritis. The most common symptoms reported were generalized weakness and dropping of the eyelids, each observed in 76.9% of the patients (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tab1\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eDemographic characteristics and clinical presentation of patients (n\u0026thinsp;=\u0026thinsp;13)\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eVariable\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e\u003cem\u003eN\u003c/em\u003e\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e\u003cem\u003e%\u003c/em\u003e\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eAge (Mean)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e39.5\u0026thinsp;\u0026plusmn;\u0026thinsp;13.3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eFemale\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e8\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e61.5%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMale\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e38.5%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eComorbidities\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNo Comorbidity\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e9\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e69%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ehypertension\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e15%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ediabetes mellitus\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e7.7%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003erheumatoid arthritis\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e7.7%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eClinical presentations\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eGeneralized weakness\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e10\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e76.9%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDropping of the eyelids\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e10\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e76.9%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDysphagia\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e8\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e61.5%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDiplopia\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e8\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e61.5%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDyspnea\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e6\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e46.2%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eBlurring of the vision\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e23.1%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDysphonia\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e23.1%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDizziness (syncope)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e23.1%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDysarthria\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e23.1%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eTingling (paresthesia)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e23.1%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eHeadache\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e23.1%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eLimb weakness (arms/legs)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e23.1%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDifficulty in speech\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e15.4%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDifficulty in mastication\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e15.4%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eChest pain\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e15.4%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eRegurgitation\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e7.7%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eChocking\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e7.7%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eOn average, our patients had been living with MG for 56 months and experienced exacerbation periods lasting around 5 months. Prior to surgical treatment, 85% were on medication, predominantly pyridostigmine bromide. The preoperative regimen primarily included immunoglobulins, with neostigmine and hydrocortisone also commonly administered \u003cstrong\u003e(\u003c/strong\u003eTable\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e\u003cstrong\u003e)\u003c/strong\u003e.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tab2\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003ePreoperative duration, exacerbation, and medical treatment for myasthenia gravis\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003ePreoperative variables\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eN\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e%\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDuration of myasthenia gravis (Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD) (n\u0026thinsp;=\u0026thinsp;13)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e55.83\u0026thinsp;\u0026plusmn;\u0026thinsp;93.93\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eExacerbation (Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4.92\u0026thinsp;\u0026plusmn;\u0026thinsp;3.32\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMedical treatment (n\u0026thinsp;=\u0026thinsp;11)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePyridostigmine bromide\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e9\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e81.8%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePrednisolone\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e36.4%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eimmunoglobulin\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e9.1%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eRedazol\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e9.1%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAzathioprine\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e18.2%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eOthers\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e18.2%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePreoperative Medication\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eimmunoglobulin\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e61.5%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNeostigmine\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e53.8%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eHydrocortisone\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e23.1%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePyridostigmine\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e7.7%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAtropine\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e7.7%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\n\u003ch2\u003eSurgical Outcomes\u003c/h2\u003e\n\u003cp\u003eThe average operation time was 50\u0026thinsp;\u0026plusmn;\u0026thinsp;10.41 minutes, with most surgeries lasting between 40 and 80 minutes \u003cstrong\u003e(\u003c/strong\u003eTable\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e\u003cstrong\u003e)\u003c/strong\u003e. The majority of surgical approaches were left-sided (92.3%), with only one case involving a right-sided approach. Thymus gland invasion occurred in 23.1% of patients, while 76.9% exhibited non-invasive characteristics. Most of the patients (61.5%) had masses averaging 3.99 cm by 3.44 cm in length and width, respectively, whereas 30.8% displayed hyperplasia with average dimensions of 8.93 cm by 7.35 cm. Only one individual showed normal tissue characteristics. Unilateral chest tube insertion was prevalent, with most patients (76.9%) receiving a tube on one side and the remaining requiring bilateral insertion (23%).\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tab3\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eSurgical Outcomes of Thoracoscopic Thymectomy (n\u0026thinsp;=\u0026thinsp;13)\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eVariable\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eN\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e%\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eApproach side\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eRight\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e7.7%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eLeft\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e12\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e92.3%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eIntraoperative invasion\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e23.1%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e10\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e76.9%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"3\" align=\"left\"\u003e\n\u003cp\u003eIntraoperative finding\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMass\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e8\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e61.5%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eHyperplasia\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e30.8%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNormal\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e7.7%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eChest tube placement\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eUnilateral chest tube\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eRight\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e7.7%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eLeft\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e9\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e69.2%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eBilateral\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eRight left\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e23.1%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eOperation time (Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e50\u0026thinsp;\u0026plusmn;\u0026thinsp;10.41 min\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e13\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\n\u003ch2\u003eEarly complications and outcomes\u003c/h2\u003e\n\u003cp\u003eOf the 13 patients, four suffered complications such as prolonged intubation and mechanical ventilation, dyspnea, and chest infection (each at 31%), confusion and tracheostomy (both 23%), with a re-tracheostomy (8%) and mortality rate of 15%. Most were extubated either immediately post-surgery or by the first day post-op (76.9%). The average Intensive Care Unit (ICU) stay was 7.3 days, during which two patients passed away. Eleven patients progressed to the general ward, staying for an average of 3.64 days. Chest tubes remained for an average of 5.57 days. Overall, the mean hospital stay was 9.46 days, with most patients (61.5%) discharged by day six \u003cstrong\u003e(\u003c/strong\u003eTable\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e\u003cstrong\u003e)\u003c/strong\u003e.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tab4\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eEarly postoperative complications and outcomes\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003ePostoperative Outcomes\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eN\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e%\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eTime for extubation (n\u0026thinsp;=\u0026thinsp;13)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eImmediately postoperative\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e10\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e76.9%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eFirst post-operative day\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e23.1\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eICU stay (n\u0026thinsp;=\u0026thinsp;13)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e7.30\u0026thinsp;\u0026plusmn;\u0026thinsp;10.1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eWard stay (n\u0026thinsp;=\u0026thinsp;11)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3.64\u0026thinsp;\u0026plusmn;\u0026thinsp;3.26\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eKeeping chest tube (n\u0026thinsp;=\u0026thinsp;13)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e5.57\u0026thinsp;\u0026plusmn;\u0026thinsp;5.73\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eHospital stay (n\u0026thinsp;=\u0026thinsp;13)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e9.46\u0026thinsp;\u0026plusmn;\u0026thinsp;9.2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePostoperative complication\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e30.8\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e9\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e69.2%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eFrequency of complications (n\u0026thinsp;=\u0026thinsp;9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eChest infection\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e23.1%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eConfusion (disturbance level of cons.)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e23.1%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eIntubation and mechanical ventilation\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e23.1%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDyspnea\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e30.8%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eTracheostomy\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e23.1%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eRe-tracheostomy\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e7.7%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMortality\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e15.3%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMG Post-Intervention Status (n\u0026thinsp;=\u0026thinsp;11)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eComplete stable remission (CSR)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e6\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e54.5%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eUnchanged Status (U)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e27%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eChange in Status (I)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e18%\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\n\u003ch2\u003eFollow-up:\u003c/h2\u003e\n\u003cp\u003eWe conducted a follow-up on 11 patients over an average of 16.5 months. Of these, 54.5% achieved complete stable remission, 18% showed reduced symptoms and lessened medication use, while 27% saw no change in their condition or treatment \u003cstrong\u003e(\u003c/strong\u003eTable\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e\u003cstrong\u003e)\u003c/strong\u003e.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eOur study of 13 patients with MG revealed that 61.5% were female, with an average age of 39.5 years, aligning with research that MG predominantly affects women under 40 and men over 50. \u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e Additionally, prevalent comorbidities such as hypertension, diabetes mellitus, and rheumatoid arthritis were observed, reflecting MG's association with common conditions in an aging population. \u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe clinical presentation in our study, which included generalized weakness, ptosis, dysphagia, and diplopia, aligned with known MG symptoms such as fluctuating muscle weakness that worsened with activity and improved with rest. Ocular and bulbar symptoms, such as visual problems and difficulty swallowing, are often reported as the first signs. \u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e,\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eRegarding treatment and medication use before thymectomy, patients with low respiratory reserves or bulbar symptomatology are frequently treated with intravenous immunoglobulin (IVIG) or plasma exchange (PLEX) before the procedure, as noted in our study, with immunoglobulin as the most used medication. This is consistent with the current recommendations. \u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e Pyridostigmine bromide is commonly used as a first-line treatment to improve muscle weakness. \u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe thoracoscopic approach used in this study aligns with the literature suggesting that patients undergoing video-assisted thoracoscopic surgery (VATS) thymectomy achieve better surgical outcomes and fewer complications than those who opt for open thymectomy (OT). \u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e Our results, showing a predominantly left-sided approach and an average operation duration of 50\u0026thinsp;\u0026plusmn;\u0026thinsp;10.41 minutes, indicate a less invasive and more efficient procedure. Studies have also highlighted benefits such as shorter hospital stays and less intraoperative blood loss associated with thoracoscopic methods. \u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e,\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe complications observed in our cohort, including intubation/mechanical ventilation and re-tracheostomy, reflect the inherent risks associated with thymectomy. However, the overall complication rate for thoracoscopic thymectomy is reported to be approximately 12.2%, which is relatively low. \u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e Catastrophic complications are very rare, but intraoperative complications such as bleeding require immediate attention. \u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e,\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eTwo patients died postoperatively with a mortality rate of 15.4%, which is higher than that reported by several previous studies, where the mortality rate of thoracoscopic thymectomy was 0\u0026ndash;3.8%. \u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e,\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e The increased rate of mortality and morbidity in our study could be attributed to the intraoperative concomitant surgical invasion because one of the two patients with intraoperative invasion died after surgery. Another possible reason is the coincidence of surgeries during the outbreak of the COVID-19 pandemic.\u003c/p\u003e \u003cp\u003eThe follow-up outcomes in our study showed that 54.5% of patients achieved complete stable remission (CSR), 18% experienced a change in status with reduced symptoms and medications, and 27% remained unchanged after an average period of 16.5 months post-thymectomy. These findings agree with published research indicating that thymectomy can lead to persistent improvement in symptoms and remission in patients with MG. \u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eA long-term follow-up study of thymectomy for patients with MG showed that the rate of CSR was around 19%, with an additional 16% of patients symptomatically improving and requiring less medication after thymectomy. \u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e Another study reported that CSR could be achieved in approximately 40% of ocular MG patients 5 years after thymectomy, especially if the onset age was 40 years or younger. \u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003e Although spontaneous remission is uncommon, guidelines suggest that thymectomy is valuable as a form of treatment for MG, with better outcomes when performed within a short time from the onset of symptoms. \u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e Furthermore, after a median follow-up of 2.9 years, a significant proportion of patients may discontinue prednisone, and some achieve complete stable remission. \u003csup\u003e\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e Overall, these findings highlight the potential benefits of thymectomy in the management of MG and support the outcomes observed in our study.\u003c/p\u003e \u003cp\u003eOur study is limited by its small sample size and the lack of long-term follow-up, which are critical for assessing the full impact of thoracoscopic thymectomy on patient outcomes. These limitations are significant when considering the variability of myasthenic symptoms and the progression of MG over time.\u003c/p\u003e \u003cp\u003eFuture studies should include larger cohorts with longer follow-up periods to better understand the long-term benefits and potential complications of thoracoscopic thymectomy. Research should also explore the efficacy of minimally invasive techniques compared to traditional open procedures and their impact on the quality of life of patients with MG. \u003csup\u003e\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e"},{"header":"Conclusion","content":" \u003cp\u003eOur study shows that thoracoscopic thymectomy is a safe and effective treatment for myasthenia gravis in Yemen, yielding favorable early outcomes with many patients achieving complete stable remission. These results could encourage wider use of the procedure, enhancing MG management in areas with limited resources. Future research should focus on standardizing surgical methods, evaluating long-term effects, and developing optimal postoperative care protocols and complication management strategies.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and informed consent\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Informed consent was obtained from all individual participants included in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDisclosure\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors report no conflicts of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting of interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNon-financial competing interests\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding disclosure\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclaration on generative AI and AI-assisted technologies in the writing process\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDuring the preparation of this work, the authors used [HyperWrite / summarization and improve text tools] to [summarize different long sections of the manuscript and improve text readability]. After using this tool/service, the authors reviewed and edited the content as needed and take full responsibility for the content of the publication.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eCarr AS, Cardwell CR, McCarron PO, McConville J. A systematic review of population based epidemiological studies in Myasthenia Gravis. \u003cem\u003eBMC Neurol\u003c/em\u003e. 2010;10(1):46. doi:10.1186/1471-2377-10-46\u003c/li\u003e\n\u003cli\u003eGilhus NE, Skeie GO, Romi F, Lazaridis K, Zisimopoulou P, Tzartos S. Myasthenia gravis \u0026mdash; autoantibody characteristics and their implications for therapy. \u003cem\u003eNat Rev Neurol\u003c/em\u003e. 2016;12(5):259-268. doi:10.1038/nrneurol.2016.44\u003c/li\u003e\n\u003cli\u003eMyasthenia Gravis [Internet]. National Institute of Neurological Disorders and Stroke. [cited 2024 Feb 8]. Available from: https://www.ninds.nih.gov/health-information/disorders/myasthenia-gravis \u003c/li\u003e\n\u003cli\u003eMyasthenia gravis - Symptoms and causes - Mayo Clinic [Internet]. Mayo Clinic. 2023 [cited 2024 Feb 8]. Available from: https://www.mayoclinic.org/diseases-conditions/myasthenia-gravis/symptoms-causes/syc-20352036 \u003c/li\u003e\n\u003cli\u003eAljaafari D, Ishaque N. Thymectomy in myasthenia gravis: A narrative review. \u003cem\u003eSaudi J Med Med Sci\u003c/em\u003e. 2022;10(2):97. doi:10.4103/sjmms.sjmms_80_22\u003c/li\u003e\n\u003cli\u003eThymectomy [Internet]. Myasthenia Gravis Foundation of America. [cited 2024 Feb 8]. Available from: https://myasthenia.org/MG-Education/Learn-More-About-MG-Treatments/MG-Brochures/thymectomy .\u003c/li\u003e\n\u003cli\u003eYang Y, Dong J, Huang Y. Thoracoscopic thymectomy versus open thymectomy for the treatment of thymoma: A meta-analysis. \u003cem\u003eEuropean Journal of Surgical Oncology (EJSO)\u003c/em\u003e. 2016;42(11):1720-1728. doi:10.1016/j.ejso.2016.03.029\u003c/li\u003e\n\u003cli\u003eErşen E, Kılı\u0026ccedil; B, Kara HV, et al. Comparative study of video-assisted thoracoscopic surgery versus open thymectomy for thymoma and myasthenia gravis. \u003cem\u003eVideosurgery and Other Miniinvasive Techniques\u003c/em\u003e. 2018;13(3):376-382. doi:10.5114/wiitm.2018.75835\u003c/li\u003e\n\u003cli\u003eSobhy E, Al Kindi A, Al Jabri N, Salem A. Thoracoscopic versus classic trans-sternal thymectomy for myasthenia gravis: single-center experience. \u003cem\u003eZagazig University Medical Journal\u003c/em\u003e. 2020;0(0):0-0. doi:10.21608/zumj.2020.44192.1963\u003c/li\u003e\n\u003cli\u003eToker A, \u0026Ouml;zkan B. Videothoracoscopic thymectomy for myasthenia gravis: an overview of complications on 387 VATS thymectomies for myasthenia gravis. \u003cem\u003eVideo Assist Thorac Surg\u003c/em\u003e. 2017;2:19-19. doi:10.21037/vats.2017.03.07\u003c/li\u003e\n\u003cli\u003eSanders DB, Wolfe GI, Benatar M, et al. International consensus guidance for management of myasthenia gravis. \u003cem\u003eNeurology\u003c/em\u003e. 2016;87(4):419-425. doi:10.1212/WNL.0000000000002790\u003c/li\u003e\n\u003cli\u003eDong D, Chong MK chun, Wu Y, et al. Gender differences in quality of life among patients with myasthenia gravis in China. \u003cem\u003eHealth Qual Life Outcomes\u003c/em\u003e. 2020;18(1):296. doi:10.1186/s12955-020-01549-z\u003c/li\u003e\n\u003cli\u003eLaakso SM, Myllynen C, Strbian D, Atula S. Comorbidities worsen the prognosis of generalized myasthenia gravis post-thymectomy. \u003cem\u003eJ Neurol Sci\u003c/em\u003e. 2021;427:117549. doi:10.1016/j.jns.2021.117549\u003c/li\u003e\n\u003cli\u003eShawn J Bird, MD. Clinical manifestations of myasthenia gravis [Internet]. UpToDate. 2024 [cited 2024 Feb 8]. Available from: https://www.uptodate.com/contents/clinical-manifestations-of-myasthenia-gravis. \u003c/li\u003e\n\u003cli\u003eAlhaidar MK, Abumurad S, Soliven B, Rezania K. Current Treatment of Myasthenia Gravis. \u003cem\u003eJ Clin Med\u003c/em\u003e. 2022;11(6):1597. doi:10.3390/jcm11061597\u003c/li\u003e\n\u003cli\u003eWebsite N. Myasthenia gravis Treatment [Internet]. nhs.uk. 2023 [cited 2024 Feb 8]. Available from: https://www.nhs.uk/conditions/myasthenia-gravis/treatment/ .\u003c/li\u003e\n\u003cli\u003eQi K, Wang B, Wang B, Zhang LB, Chu XY. Video-assisted thoracoscopic surgery thymectomy versus open thymectomy in patients with myasthenia gravis: a meta-analysis. \u003cem\u003eActa Chir Belg\u003c/em\u003e. 2016;116(5):282-288. doi:10.1080/00015458.2016.1176419\u003c/li\u003e\n\u003cli\u003eErşen E, Kılı\u0026ccedil; B, Kara HV, et al. Comparative study of video-assisted thoracoscopic surgery versus open thymectomy for thymoma and myasthenia gravis. \u003cem\u003eVideosurgery and Other Miniinvasive Techniques\u003c/em\u003e. 2018;13(3):376-382. doi:10.5114/wiitm.2018.75835\u003c/li\u003e\n\u003cli\u003eYang Y, Dong J, Huang Y. Thoracoscopic thymectomy versus open thymectomy for the treatment of thymoma: A meta-analysis. \u003cem\u003eEuropean Journal of Surgical Oncology (EJSO)\u003c/em\u003e. 2016;42(11):1720-1728. doi:10.1016/j.ejso.2016.03.029\u003c/li\u003e\n\u003cli\u003eXu J, Qian K, Deng Y, et al. Complications of robot‐assisted thymectomy: A single‐arm meta‐analysis and systematic review. \u003cem\u003eThe International Journal of Medical Robotics and Computer Assisted Surgery\u003c/em\u003e. 2021;17(6). doi:10.1002/rcs.2333\u003c/li\u003e\n\u003cli\u003eBennett B, Rentea RM. Thymectomy [Internet]. StatPearls - NCBI Bookshelf. 2023 [cited 2024 Feb 8]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK564302/ \u003c/li\u003e\n\u003cli\u003eYano M, Numanami H, Yamaji M, Taguchi R, Furuta C, Haniuda M. A pitfall of thoracoscopic thymectomy: a case with intraoperative and postoperative complications. \u003cem\u003eSurg Case Rep\u003c/em\u003e. 2017;3(1):99. doi:10.1186/s40792-017-0374-3\u003c/li\u003e\n\u003cli\u003eTomulescu V, Ion V, Kosa A, Sgarbura O, Popescu I. Thoracoscopic Thymectomy Mid-Term Results. \u003cem\u003eAnn Thorac Surg\u003c/em\u003e. 2006;82(3):1003-1007. doi:10.1016/j.athoracsur.2006.04.092\u003c/li\u003e\n\u003cli\u003eSiwachat S, Tantraworasin A, Lapisatepun W, Ruengorn C, Taioli E, Saeteng S. Comparative clinical outcomes after thymectomy for myasthenia gravis: Thoracoscopic versus trans-sternal approach. \u003cem\u003eAsian J Surg\u003c/em\u003e. 2018;41(1):77-85. doi:10.1016/j.asjsur.2016.09.006\u003c/li\u003e\n\u003cli\u003eKhawaja I. Effect of Thymectomy on Outcomes of Myasthenia Gravis Patients: A Case-Control Study at a Tertiary Care Hospital. \u003cem\u003eCureus\u003c/em\u003e. Published online April 14, 2023. doi:10.7759/cureus.37584\u003c/li\u003e\n\u003cli\u003eKaufman AJ, Palatt J, Sivak M, et al. Thymectomy for Myasthenia Gravis: Complete Stable Remission and Associated Prognostic Factors in Over 1000 Cases. \u003cem\u003eSemin Thorac Cardiovasc Surg\u003c/em\u003e. 2016;28(2):561-568.\u003c/li\u003e\n\u003cli\u003eLiu X, Zhou W, Hu J, et al. Prognostic predictors of remission in ocular myasthenia after thymectomy. \u003cem\u003eJ Thorac Dis\u003c/em\u003e. 2020;12(3):422-430. doi:10.21037/jtd.2020.01.17\u003c/li\u003e\n\u003cli\u003eMineo TC, Ambrogi V. Outcomes after thymectomy in class I myasthenia gravis. \u003cem\u003eJ Thorac Cardiovasc Surg\u003c/em\u003e. 2013;145(5):1319-1324. doi:10.1016/j.jtcvs.2012.12.053\u003c/li\u003e\n\u003cli\u003eBi Z, Cao Y, Liu C, et al. Remission and relapses of myasthenia gravis on long-term tacrolimus: a retrospective cross-sectional study of a Chinese cohort. \u003cem\u003eTher Adv Chronic Dis\u003c/em\u003e. 2022;13:204062232211225. doi:10.1177/20406223221122538\u003c/li\u003e\n\u003cli\u003eWilshire CL, Blitz SL, Fuller CC, et al. Minimally invasive thymectomy for myasthenia gravis favours left-sided approach and low severity class. \u003cem\u003eEuropean Journal of Cardio-Thoracic Surgery\u003c/em\u003e. 2021;60(4):898-905. doi:10.1093/ejcts/ezab014\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Sana'a University","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Indications, early complications, thoracoscopic thymectomy, Yemen","lastPublishedDoi":"10.21203/rs.3.rs-3954654/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3954654/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eBackground\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThymectomy is an option for the treatment of myasthenia gravis MG. While the open technique was most frequently performed in the past, nowadays the endoscopic approach has gained wide acceptance. Here we assessed our early experience in thoracoscopic thymectomy (TT).\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThis case series was retrospectively conducted at Al-Thawra Modern General Hospital and included patients diagnosed with MG who underwent TT from January 2018 to January 2024.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e\u003c/p\u003e \u003cp\u003eOur case series consisted of 13 predominantly female patients (61.5%), with a median age of 39.5 years. The most common presenting symptoms were generalized weakness and ptosis. Surgeries typically lasted 50\u0026thinsp;\u0026plusmn;\u0026thinsp;10.41 minutes, with the majority performed using a left-sided thoracoscopic approach (n\u0026thinsp;=\u0026thinsp;10, 77%). Immediate extubation was achieved in 10 patients (76%). Four patients experienced early postoperative complications (31%), including dyspnea, prolonged intubation, chest infection, confusion, tracheostomy, and re-tracheostomy. There were 2 recorded deaths due to complications. Eleven patients were followed up for an average of 16.5 months, revealing that 54.5% achieved complete stable remission, 18% showed improvement with reduced symptoms and medications, and 27% remained unchanged.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusions\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThoracoscopic thymectomy is a safe and effective procedure for the management of MG in Yemeni patients. The observed remission and improvement rates are promising and align with global experiences. It is recommended that with proper resources and expertise, similar minimally invasive surgical approaches can be implemented in resource-limited regions.\u003c/p\u003e","manuscriptTitle":"Thoracoscopic Thymectomy for Myasthenia Gravis: An early experience in Yemen","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-02-14 17:58:14","doi":"10.21203/rs.3.rs-3954654/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"05b1dc45-21cd-4e82-9c5d-7a0ba1efc3b1","owner":[],"postedDate":"February 14th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":28747546,"name":"Cardiothoracic Surgery"}],"tags":[],"updatedAt":"2024-02-14T17:58:14+00:00","versionOfRecord":[],"versionCreatedAt":"2024-02-14 17:58:14","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3954654","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3954654","identity":"rs-3954654","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}