Subxiphoid completion thymectomy for refractory non-thymomatous myasthenia gravis

Thymectomy is an effective surgical procedure complementing medical therapy of patients with myasthenia gravis (MG) (1,2). Extended thymectomy entailing complete removal of thymic and perithymic tissue has been advocated as the desired target for a fast and durable remission of MG symptoms (3). However, response to procedure is not often prompt and effective, ranging from 23.1% to 46% (4-6) in terms of complete remission rate at 5-year follow up. The presence of residual thymic tissue (7) or ectopic thymic tissue within the mediastinal fat tissue (8-11) still producing antibodies against the receptor for acetylcholine (anti-AChRAb) has been suggested as the main reason for post-thymectomy refractory MG. Indeed, despite the intent of radical thymectomy, residual thymic tissue can be present in 64–70% of thymectomized patients (7,11). In this regard, completion thymectomy has been advocated after unsuccessful thymectomy (12) with quite effective results by using extended either maximal trans-sternal (13,14) or, more recently, video-assisted transthoracic (VATS) approaches (15)