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Descriptive analysis of therapeutic outcomes between thoracoscopic and transsternal thymectomy in myasthenia gravis patients from 2011 to 2021

Journal of Cardiothoracic Surgery volume 19, Article number: 510 (2024) Cite this article

Abstract

Background

Myasthenia gravis is an autoimmune disease with high prevalence of thymus disorders, in which, thymectomy is considered one of the therapeutic approaches in improving the patients’ clinical outcomes. Today, thoracoscopic thymectomy has received significant attention than the classic transsternal approach due to fewer complication. Therefore, this study was designed with the aim of investigating the therapeutic outcomes of thymectomy in patients with myasthenia gravis in the Afzalipour Hospital of Kerman between 2011 and 2021.

Methods

The current study is a descriptive analytical study on patients with myasthenia gravis who underwent surgical thymectomy within 2011–2021. Demographic and clinical characteristics of patients from the time of operation to three years of follow-up were extracted and recorded from clinical records or by phone calls. Data were analyzed using SPSS software.

Results

The data of 70 patients who underwent surgical thymectomy were analyzed. Thymectomy caused a significant reduction in the severity of the disease according to the Osserman classification (P = 0.001). It also significantly reduced the use of corticosteroids (P = 0.001) and IVIG (P = 0.015) compared to the time before the surgery. Sixty-two patients (88.57%) needed to take less medicine than before surgery. Left VATS was associated with less post-operative severity of the disease (P = 0.023). There were only two deaths during the follow-up period.

Conclusion

Overall, the findings of the present study demonstrated that thoracoscopic thymectomy is a useful surgical approach that leads to faster recovery, reducing the severity of the disease, need for medication, and complications in patients with myasthenia gravis, In comparison with the transsternal approach.

Peer Review reports

Introduction

Myasthenia gravis is an autoimmune disease of the neuromuscular junction (NMJ), characterized by weakness and fatigue of skeletal muscles [1]. The main cause of this disease is antibodies targeting acetylcholine receptor in the neuromuscular synapse, which leads to impaired signal transduction between the nervous and musculoskeletal system [2].

Myasthenia gravis is a relatively uncommon disease with the estimated prevalence rate between 70 and 163 people per million, which mostly occurs in women in the third and fourth decades of life [3,4,5].

Myasthenia gravis has the potential to affect any skeletal muscle, but it mostly presents with significant disruptions in the muscles involved in eye movement, swallowing, blinking, and facial expressions [6, 7]. Hence, ptosis, changes in facial expression, double vision, swallowing dysfunction, fluctuating fatigable weakness, speech impairments, respiratory issues, and paralysis are expected signs and symptoms in the patients [8, 9].

The most important feature is the history of fluctuating fatigable weakness which leads to the clinical diagnosis of the disease [10].

The ice pack test, the Mestinon test, the Tensilon test and measurement of anti-acetylcholine receptor antibodies (Anti-AChRAbs) and Muscle-specific receptor kinase tyrosine-specific (MuSK) antibodies in the serum are additional tests that can provide considerable assistance in diagnosing this condition [11].Approximately 90% of patients suffered from myasthenia gravis are seropositive for anti-acetylcholine receptor antibodies (Anti-AChRAbs) [12].

Thymoma and thymic carcinoma are the most prevalent tumors of thymus gland which usually occur between fourth and sixth decades of life and account for approximately 20% of mediastinal neoplasms [13, 14].

Anterior mediastinal masses have a higher Risk of being malignant compared to middle and posterior mediastinal masses. Malignant anterior mediastinal masses predominantly including thymoma, lymphoma, germ cell tumors, and tumors of the thyroid and parathyroid glands [15, 16]. Different symptoms are associated with the presence of malignant masses, including chest pain, dyspnea, cough, phrenic nerve paralysis, superior vena cava syndrome, and other symptoms such as night sweats, weight loss, and fever. Thymic carcinomas prognosis are worse than thymomas, and necrotic and calcification regions with irregular borders are visible in imaging [14, 17]. The most common paraneoplastic syndrome associated with thymoma, is myasthenia gravis which is found in at least 50% of the patients [18].

Thymectomy leads to improvement in approximately 75% of patients with myasthenia gravis, with complete remission in 30% of cases. While thymectomy may have greater benefits in younger patients, optimal outcomes have been reported in both younger and older age groups [19,20,21,22]. Thymectomy is performed in patients with myasthenia gravis due to thymic abnormalities, with most cases having thymic hyperplasia (85%) or thymoma (15%). The procedure is safe and effective, even in pediatric patients, and studies demonstrate that some factors such as age under 35, Presence of symptoms less than 24 months before the operation and no prior history of steroid treatment to be associated with better outcomes in patients [21, 23, 24].

Generally, thymectomy can be performed in four main methods: trans-cervical thymectomy, video-assisted thoracoscopic surgery (VATS), trans-sternal thymectomy, and a combination of trans-cervical and trans-sternal thymectomy [25]. In all these methods, the thymic tissue is resected, but the resection of extra-capsular mediastinal tissue and cervical fat tissue varies. Some surgeons prefer the trans-sternal approach due to extensive approach for thorough exploration of the mediastinum up to the neck and enables complete removal of thymic tissue and fat [25, 26].

On the other hand, one of the best surgical approaches for thymectomy is video-assisted thoracoscopic surgery (VATS), which is considered a less invasive method and suitable for patients with a diagnosis of myasthenia gravis. Some studies have shown that using minimally invasive techniques such as video-assisted and robot-assisted approaches are associated with fewer complications and mortality compared to trans-sternal techniques, while achieving similar therapeutic outcomes [27].

However, considering the inconsistent results of various studies, it seems that more extensive research is still needed to investigate the outcomes of different surgical techniques in patients with myasthenia gravis. Therefore, in the present study, we focused on evaluating patients with myasthenia gravis who underwent thoracoscopic thymectomy and examined the long-term results.

Methods

Study design

This is a retrospective, single center, analytical and descriptive cross-sectional study, conducted on patients suffered from myasthenia gravis who underwent surgical thymectomy at Afzalipour Hospital in Kerman between 2011 and 2021. In this study, the medical records of all patients who underwent surgical thymectomy as a management for myasthenia gravis and were admitted to the thoracic surgery department of Afzalipour Hospital in Kerman were examined using the census approach.

The inclusion criteria were as follows: confirmed diagnosis of myasthenia gravis based on clinical history, physical examination, and documented findings from the Tensilon test and electromyography; undergoing a spiral chest CT scan with a specific focus on the mediastinum; confirmation of thymoma indicating eligibility for surgical intervention by a neurologist; and performance of thoracoscopic or trans-sternal thymectomy with complete excision of thymic tissue.

The exclusion criteria were previous diagnosis of connective tissue disease and missing more than 70% of the research variables in the patients’ medical records and inability to follow up via phone for completing research data.

Ethical rules

The present study was approved by the ethics committee of Kerman university of medical sciences (the approval number: IR.KMU.AH.REC.1401.064). Necessary administrative arrangements and permissions were obtained to access patients’ clinical records. Confidentiality of collected data was maintained, and results were published without disclosing any patient identities. Participants were informed about the study objectives and their voluntary participation, ensuring data was used solely for research purposes.

Participants and data collection

The study was conducted according to the CONSORT statement and Helsinki declarations and was approved by ethics committee of Kerman university of medical sciences. After conducting the necessary administrative coordination, the study variables in this research included thymus cytopathological findings, patients’ personal information, duration of disease remission and recurrence, any previous symptoms, severity of the disease before surgery (according to the myasthenia gravis foundation of America classification), duration of disease until surgery, surgical complications, and disease progression after surgery for a period of 3 years of follow-up (in terms of the medication use, and patient outcome). All mentioned data were extracted from the patients’ clinical records. In case of missing information, the necessary data were collected and completed using the telephone number recorded during the patient’s hospitalization.

Notably mentioned, the verbal consent, to contact the patients, was obtained from the patients during hospitalization, and during the telephone calls, the research objectives, study design, and voluntary nature of answering the questions were explained to the participants. Additionally, assurance was given that this information would only be used for research purposes and that the presentation of results would be done without disclosing the patient’s name and surname. All collected data were recorded in the data collection form and used for statistical analysis.

Surgical techniques

Midsternotomy thymectomy

This approach involved a vertical incision through the sternum, providing direct access to the anterior mediastinum. The sternum was divided in the midline, allowing for a wide exposure of the thymus gland and surrounding tissue. This technique enabled complete removal of the thymus gland, along with the adjacent mediastinal fat tissue. The sternotomy approach was considered the gold standard for thymectomy due to its excellent visualization and ability to achieve extensive resection.

Left VATS thymectomy

In this minimally invasive approach, the patient was positioned in a right lateral decubitus position. Three to four small incisions were made in the left chest wall, allowing for the insertion of a thoracoscope and surgical instruments. The left-sided approach provided excellent exposure of the left pericardiophrenic region, aortocaval groove, and aortopulmonary window, facilitating the removal of the thymus gland and surrounding fat tissue. The left VATS approach was associated with less postoperative pain, shorter hospital stays, and faster recovery compared to the midsternotomy approach.

Right VATS thymectomy

This approach was similar to the left VATS thymectomy, but the patient was positioned in a left lateral decubitus position, and the incisions were made in the right chest wall. The right-sided approach offered good visualization of the right pericardiophrenic region and the superior vena cava. However, some surgeons prefer the left VATS approach due to the natural inclination of the thymus gland towards the left side and better exposure of the aortopulmonary window.

The choice of surgical approach (VATS or midsternotomy) for thymectomy was primarily based on the surgeon’s preference and experience, as well as the patient’s individual characteristics and clinical presentation. During the study period, our institution had surgeons who were proficient in both thoracoscopic and transsternal thymectomy techniques. The decision to perform a specific approach was made after careful consideration of several factors, including tumor size and location, patient’s body habitus, presence of comorbidities, and patient preference. Patients with larger tumors or tumors located in the anterior mediastinum were more likely to undergo transsternal thymectomy, as this approach provides better exposure and facilitates complete resection of the tumor and surrounding thymic tissue. In patients with a higher body mass index or a barrel-shaped chest, the transsternal approach was often preferred due to the increased difficulty in achieving adequate exposure through the thoracoscopic approach. Patients with significant comorbidities, such as severe cardiopulmonary disease, were more likely to be selected for the transsternal approach to minimize the risk of perioperative complications associated with prolonged single-lung ventilation during thoracoscopic procedures. After a thorough discussion of the potential benefits and risks associated with each surgical approach, patient preference was also considered when deciding between VATS and transsternal thymectomy. Ultimately, the final decision regarding the surgical approach was made on a case-by-case basis, considering the individual patient’s clinical presentation and the surgeon’s assessment of the most appropriate technique to ensure optimal outcomes.

Definition of variables

Infection

Infection was defined as any clinically diagnosed postoperative infection, including surgical site infection, pneumonia, or sepsis, that required treatment within 30 days of the thymectomy procedure.

Bleeding

Bleeding was defined as any postoperative hemorrhage or hematoma formation that required surgical intervention, transfusion, or resulted in a significant drop in hemoglobin levels (> 2 g/dL) within 30 days of the thymectomy procedure.

ICU admission

ICU admission was defined as any postoperative admission to the intensive care unit for monitoring or management of complications, regardless of the length of stay, within 30 days of the thymectomy procedure.

Readmission

Readmission was defined as any hospital admission related to myasthenia gravis, thymectomy complications and other reasons within 30 days of the initial discharge following the thymectomy procedure.

Mortality

Mortality was defined as any death occurring within 30 days of the thymectomy procedure or during the postoperative hospital stay.

Statistical analysis

SPSS version 26 was used to perform statistical analysis. Paired test was used to examine the disease severity, type of treatment before and after the surgery. Moreover, chi square and Kruskal Wallis tests were used to examine other study variables. Descriptive statistics indices were used to describe the collected data. Frequency and percentage were used for qualitative variables, while mean and standard deviation were used for quantitative variables.

Results

Based on the inclusion and exclusion criteria, a total number of 70 patients entered the trial of which 50 patients (71.4%) were female. The mean age of the participants at diagnosis was 35.02 \(\:\pm\:\) 11.76 years (16 to 58 years) and the mean age of the participants at the time of surgical intervention was 36.41 \(\:\pm\:\) 11.56 years. The average time between diagnosis and surgery was 13.79 ± 14.84 months, with a range of one month to 70 months.

Generalized involvements were seen in 59 patients (84.1%) and ocular involvements were seen in 11 patients (15.9%). Pathological assessments showed that in 51 patients (73%), the thymus pathology was hyperplasia, while in 19 patients (27%) it was thymoma. Additionally, in 63 (90.5%) of cases, the antibody detection test was positive, while in 7 patients (9.5%) it was negative (Fig. 1).

Fig. 1
figure 1

The prevalence of pathology and antibody results in participants

Full size image

Based on the pathological findings, the distribution of thymoma and hyperplasia among the different surgical approach groups was as follows: in the mid-sternotomy group, 2 patients had thymoma, and 5 patients had hyperplasia; in the left VATS group, 13 patients had thymoma, and 36 patients had hyperplasia; and in the right VATS group, 4 patients had thymoma, and 10 patients had hyperplasia. The prevalence of thymoma and hyperplasia was comparable across the three surgical approach groups, with no significant differences observed.

Moreover, the investigations on the type of medical treatment before surgical intervention revealed that 56 (80%) of them were using pyridostigmine, 66 patients (94.29%) were using corticosteroids, 43 patients (61.43%) were using IVIg, and 13 (18.57%) of cases underwent plasmapheresis. The 14% of patients on steroids without pyridostigmine were likely those who could not tolerate pyridostigmine due to side effects or had a contraindication to its use. (Table 1).

Table 1 The type of medical treatment before surgical intervention
Full size table

The dose of consumed prednisolone by the patients prior to the surgery was 27.22 ± 10.73 mg per day, and the average duration of medication usage before surgery was 12.19 ± 10.68 months.

Forty-nine (70%) patients underwent the left VATS approach surgery, 14 (20%) underwent the right VATS approach and seven (10%) underwent mid-sternotomy. The average duration of the operation was 165 \(\:\pm\:\) 18 min and the average of the patient’s hospitalization lasted for 3.56 \(\:\pm\:\) 0.76 days. The evaluation on the post-surgical thymectomy complications revealed that infection occurred in 12 (17.14%) patients, and bleeding in one (1.42%) patient. Twenty-five (35.71%) patients were admitted In ICU after surgery and one (1.42%) patient died during the postoperative hospitalization. Twenty-four (34.28%) patients readmitted to the hospital within 30 days after the surgery. Furthermore, during follow up, another patient, apart from the previously mentioned mortality, passed away (Table 2).

Table 2 Post-surgical thymectomy complications and outcomes
Full size table

Based on Osseman classification, most of the patients categorized in class III (48.57%) and class II (27.1%) preoperative, while after surgical intervention, most of the patients categorized in class I (80%). The observed changes in disease severity before and after surgery were statistically significant (P = 0.001) (Table 3).

Table 3 Disease severity before and after surgery based on Osserman classification
Full size table

The comparison of the type of used medication before and after surgery revealed a significant decrease in corticosteroids consumption from 94.29 to 60% (P = 0.001). Moreover, similar changes observed in IVIg consumption, and it decreased from 61.43 to 40% which was statistically significant (P = 0.015) (Table 4).

Table 4 Comparison of treatment before and after thymectomy surgery
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Generally, medications consumption was reduced in 62 (88.57%) patients and was increased in one patient (1.42%) after surgical intervention. Seven (10%) patients had similar medication consumption before and after surgery.

The comparison of post-surgical thymectomy complications between mid-sternotomy, left and right VATS indicated that there were no significant differences found in terms of bleeding, ICU admission, readmission rates, medication consumption, and disease severity before and after surgery. However, there was a significant difference in disease severity and class I classification, according to the Osserman classification, had a higher prevalence in the left VATS group (P = 0.023). moreover, there was a significant difference in infection rates which was due to the differences between right VATS approach and mid sternotomy (Table 5).

Table 5 Comparison of post-surgical thymectomy complications between mid-sternotomy, left and right VATS
Full size table

Moreover, there were no significant differences in the operation time and hospitalization between right and left VATS. On average, the duration of hospitalization for patients undergoing mid-sternotomy was approximately three days longer than patients undergoing thoracoscopy. However, this difference was not statistically significant (p = 0.086).

Discussion

Thoracoscopic thymectomy is a surgical approach with minimal invasion, that was done in 1992 for the first time [28].

Considering the available evidence regarding the complications of sternotomy, such as increase in surgical site infection, hospitalization, post operative pain and, bleeding, many surgeons and patients now prefer less invasive techniques, including thoracoscopic approaches [29, 30].

Our study results showed that 50 (71.4%) of patients who were candidates for thymectomy were female, with a female-to-male ratio of approximately 2.5. In a study by Alshekhlee et al., women made up 61.6% of myasthenia gravis cases [31]. Similarly, in a study by Lashkari Zadeh et al., 68% of patients with myasthenia gravis who were candidates for surgery were women [28]. Many studies have demonstrated that the prevalence of myasthenia gravis is higher in women compared to men at younger ages, while it becomes almost equal in both genders in older ages [32].

The high readmission rate of 34.28% observed in this study warrants further investigation to identify the underlying causes and implement strategies to reduce readmissions. Potential reasons for this finding could include postoperative complications, disease exacerbations, or inadequately managed comorbidities during the initial hospital stay [33, 34]. Infection (17.14%) and bleeding (1.42%) were identified as postoperative complications that might have necessitated readmission for further treatment [35]. Additionally, despite overall improvement in disease severity and medication requirements following thymectomy, some patients may have experienced temporary worsening of symptoms or required adjustments in their treatment regimen, leading to readmissions [36]. Comorbidities, such as cardiovascular disease, diabetes, or respiratory disorders, may also influence readmission rates if not properly managed during the initial hospital stay or after discharge [37].

We regret to report that two mortalities occurred during the study period. One patient from the mid-sternotomy thymectomy group passed away during the postoperative hospitalization due to severe dyspnea caused by pulmonary thromboembolism. This complication highlights the potential risks associated with the more invasive mid-sternotomy approach, which may lead to prolonged immobilization and an increased likelihood of venous thromboembolism [38, 39].

The second mortality occurred in the left VATS group, with the patient passing away one year after the surgery due to complications related to the progression of myasthenia gravis. Despite the overall favorable outcomes associated with thoracoscopic thymectomy, it is important to acknowledge that the procedure may not always halt the progression of the disease, particularly in cases with advanced or refractory myasthenia gravis [40, 41].

The present study showed a significant difference in the distribution of disease severity before and after surgical thymectomy. Before surgery only 11.42% of patients were classified as class I according to the Osserman classification, whereas after surgery, this percentage increased to 80%. Therefore, surgical thymectomy resulted in a reduction in disease severity and improvement in symptoms.

Additionally, the study population had a significantly lower corticosteroid and IVIg consumption. Consistent with our study, Rabiou et al. demonstrated that thymectomy resulted in positive clinical outcomes in patients with myasthenia gravis [42]. Similarly, Wolfe et al. found that patients required less prednisolone or immunosuppressive medication after thymectomy surgery, indicating improved clinical outcomes [19]. Lashkari Zadeh et al. also reported improvement in patients’ clinical outcomes, after undergoing thoracoscopic thymectomy [28].

Previously mentioned, the comparison of complications between left and right VATS indicated that there were no significant differences found in terms of bleeding, ICU admission, readmission rates, medication consumption, and disease severity before and after surgery, while the postoperative severity of the disease was lower in the group that underwent left VATS. In accordance with our study findings, Xie et al. demonstrated that there were no significant differences in the duration of surgery, hospitalization period, bleeding and, postoperative complications between left and right VATS approaches [43].

Yim et al. mentioned that right VATS approach was associated with a better surgical field visualization [44]. However, Mineo et al. demonstrated that left VATS approach should be preferred due to inclined thymus tissue towards the left pericardiophrenic region. This approach can provide better access to aortocaval groove, aortopulmonary window, and pericardiophrenic space [43, 45]. Also, anatomical studies had shown that left VATS approach had lower residual thymus tissue after thymectomy [46]. Probably, the decrease in disease severity was attributed to a lower residual thymus tissue after left VATS in our study. Rückert et al. conducted an anatomical study comparing the radicality of thoracoscopic thymectomy approaches and found that the left-sided approach was associated with a lower amount of residual thymic tissue after the procedure [46]. This finding can be attributed to the natural inclination of the thymus gland towards the left side, as well as the better exposure of the aortopulmonary window and the left pericardiophrenic region provided by the left VATS approach [44, 45]. The more complete removal of thymic tissue with the left VATS approach may contribute to the observed lower postoperative disease severity in patients undergoing this technique compared to the right VATS approach in our study.

The investigation of hospitalization dur11111ation in our study patients revealed an average duration of 3.56 days. In accordance with these findings, Lin et al. reported an average hospitalization period of 5.6 days for VATS thymectomy patients [47]. Similarly, Wright et al. reported a 4-day average [48]and Manlulu et al. reported a 3-day average of hospitalization period, which are almost in line with the findings of our study [49].

The mortality rate for 3 years follow up was 2.85% which indicated that thoracoscopic approach is considered a safe approach for thymectomy. Furthermore, the hospitalization duration in patients undergoing surgery with a mid-sternotomy approach was 6.43 days, which was longer compared to the thoracoscopic approach. Supporting these findings, Sobhy et al. also demonstrated that the thoracoscopic thymectomy approach is associated with a shorter hospitalization duration compared to the transsternal approach [50]. Zahid et al. also demonstrated that VATS thymectomy approach had an average hospitalization duration of 5.6 days, while this duration was 8.1 days for the mid-sternotomy approach [51]. In the study by Ye et al., the hospitalization duration after surgery in the VATS approach was on average 5 days shorter than the transsternal approach [52]. Therefore, it appears that the thoracoscopic technique is accompanied by a shorter hospitalization duration and, in this regard, has superiority over the mid-sternotomy technique.

Conclusion

In total, the present study findings showed that thoracoscopic thymectomy, is a beneficial surgical approach which leads to faster recovery, reducing the severity of the disease and reducing the medication consumption in patients suffers from myasthenia gravis. It also has some negligible postoperative complications which are lower than other surgical approaches known for thymectomy.

Limitations

One limitation of the present study was the lack of a patient satisfaction survey, which could have provided valuable insights into patient-reported outcomes and experiences following thymectomy. While the objective measured of disease severity, medication requirements, and complications were thoroughly assessed, the subjective perspectives of patients regarding their quality of life, symptom improvement, and overall satisfaction with the surgical approach were not captured. The inclusion of a well-designed patient satisfaction survey would have offered a more comprehensive evaluation of the therapeutic outcomes, as it would have complemented the clinical data with patient-centered insights. Future studies investigating the comparative effectiveness of thoracoscopic and transsternal thymectomy should consider incorporating patient satisfaction assessments to gain a holistic understanding of the impact of these surgical approaches on the lives of individuals with myasthenia gravis.

Another limitation was the unequal distribution of patients among the surgical approach groups. Most patients (70%) underwent left VATS, while only 20% underwent right VATS and 10% underwent mid-sternotomy. This imbalance reflects the real-world clinical practice at our institution during the study period, where thoracoscopic thymectomy, particularly the left VATS approach, was more commonly performed due to its perceived advantages and surgeon preference. Although the study provides valuable insights into the outcomes of thymectomy in myasthenia gravis patients, the limited number of patients in the mid-sternotomy group may affect the generalizability of our findings and reduce the statistical power to detect significant differences between the surgical techniques.

Data availability

No datasets were generated or analysed during the current study.

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Acknowledgements

The authors are grateful to the physicians, and study participants for their valuable contributions and cooperation.

Funding

This research was conducted without external funding. All expenses associated with the research, including data collection, analysis, and publication, were covered by the authors personally. There was no financial support or sponsorship from any organization, institution, or funding agency for this study.

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Authors and Affiliations

  1. Pathology and Stem Cell Research Center, Department of Pathology, School of Medicine, Kerman University of Medical Sciences, Kerman, Iran

    Mahdiye Lashkarizadeh

  2. Department of General Surgery, School of Medicine, Kerman University of Medical Sciences, Kerman, Iran

    Vahid Haghollahi & Mohammadreza Lashkarizadeh

  3. Physiology Research Center, Institute of Neuropharmacology, Kerman University of Medical Sciences, Kerman, Iran

    Nazanin Zeinali Nezhad

  4. Gastrointestinal Research Center, Kerman University of Medical Sciences, Kerman, Iran

    Amirhossein Shahpar

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  1. Mahdiye Lashkarizadeh
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  2. Vahid Haghollahi
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  3. Nazanin Zeinali Nezhad
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  4. Mohammadreza Lashkarizadeh
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  5. Amirhossein Shahpar
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Contributions

Nazanin Zeinali Nezhad: Conceptualization, Data curation, Writing – original draft.Amirhossein Shahpar: Data curation, Investigation, Writing – review & editing.Vahid Haghollahi: Methodology, Supervision, Validation.Mohammadreza Lashkarizadeh: Writing – review & editing, Supervision.Mahdiye Lashkarizadeh: Project administration, Supervision, Validation.

Corresponding author

Correspondence to Mohammadreza Lashkarizadeh.

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Consent to participate

All human participants involved in this study provided informed consent for their participation. Prior to enrollment, each participant was provided with detailed information about the study objectives, procedures, potential risks, and benefits. They were informed about their right to withdraw from the study at any time without consequences. Written informed consent was obtained from each participant before their inclusion in the study. For participants unable to provide written consent due to medical conditions, verbal informed consent was obtained in the presence of a witness. The study protocol, including the consent procedures, was reviewed, and approved by the ethics committee of Kerman University of Medical Sciences (Approval number: IR.KMU.AH.REC.1401.064). Confidentiality of participants’ information was strictly maintained throughout the study, and data were used solely for research purposes.

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All authors listed in this manuscript provide their consent for publication. We confirm that the manuscript entitled “Descriptive Analysis of Therapeutic Outcomes between Thoracoscopic and Transsternal Thymectomy in Myasthenia Gravis Patients from 2011 to 2021” has not been published elsewhere and is not under consideration for publication in any other journal. We agree to the submission of this manuscript to your journal, and we authorize the journal to publish this article, including all text, tables, figures, and supplementary materials, if accepted for publication.

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Lashkarizadeh, M., Haghollahi, V., Nezhad, N.Z. et al. Descriptive analysis of therapeutic outcomes between thoracoscopic and transsternal thymectomy in myasthenia gravis patients from 2011 to 2021. J Cardiothorac Surg 19, 510 (2024). https://doi.org/10.1186/s13019-024-02983-6

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Keywords

Journal of Cardiothoracic Surgery

ISSN: 1749-8090

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