Thymectomy

Thymectomy refers to the surgical removal of the thymus gland. The thymus is a small gland that lies behind your sternum (breastbone). Up until early childhood, this gland helps in the development of the defence (immune) system. The thymus gland remains enlarged and active until puberty, after which, it starts to shrink, leaving only fatty tissue. This gland does not play an essential role in the body after puberty.

Thymectomy is performed to treat conditions that affect the thymus gland for example thymoma or myasthenia gravis. Thymoma is the cancer of the thymus gland while myasthenia gravis is a neuromuscular disease caused by an immune system disorder, in which an individual experiences muscle weakness. Most individuals with myasthenia gravis have abnormalities or diseases of the thymus gland such as thymoma or an enlarged thymus gland.

A doctor may recommend thymectomy in:

• People with myasthenia gravis who are below 60 years of age
• People diagnosed with thymoma
• People with myasthenia gravis who have acetylcholine (neurotransmitter) receptor antibodies in their blood. Individuals with myasthenia gravis have muscle weakness as a peculiar symptom, which is caused by auto-antibodies such as acetylcholine receptors, MuSK and LRP4 targeted against the neuromuscular junction.

Common symptoms of thymoma and myasthenia gravis are listed below:

• Cough that lasts longer or does not go away
• Muscle weakness
• Double vision
• Shortness of breath
• Drooping eyelids
• Difficulty in swallowing
• Chest pain or pressure
• Swelling on the face or arms

Thymectomy seems to be effective only when it is carried out within six to 12 months of the onset of symptoms. This procedure is generally not recommended in the following cases:

• People with myasthenia gravis that affects only eyes (ocular myasthenia)
• During pregnancy due to the possible risks linked with the surgery
• People with antibodies to muscle-specific kinase (MuSk-MG)

Before going for thymectomy, your doctor will ask you to get the following tests:

• Blood tests
• Electrocardiogram (ECG)
• MRSA test: It is a nasal swab test for methicillin-resistant Staphylococcus aureus, a bacterial infection that is resistant to antibiotics.
• Urine test
• You doctor will do a physical exam and take your medical history.
• Biopsy, to examine the cells or tissues under a microscope. It may be performed in various ways like fine needle aspiration (FNA), core needle (removes a larger core or tissue sample than FNA technique), incisional (removal of a part of tissue) and excisional biopsy (removal of the entire abnormal skin).

Imaging tests including:

• Chest X-ray
• Computed tomography (CT) scan: A CT scan gives a series of images of the internal body parts with higher resolution than X-rays.
• Magnetic resonance imaging (MRI) scan: An MRI gives detailed pictures of the body’s internal tissues and organs using radio waves, a magnetic field and a computer.
• Positron emission tomography (PET) scan: PET helps in detecting malignancy (spread of cancer) by injecting radioactive glucose. Cancer cells tend to consume a higher amount of glucose as compared to normal cells.
• Pulmonary function tests (PFTs) may be done to assess the strength and function of the lungs.

The following preparations are done before the surgery:

• You will need to arrange for a trusted friend who can bring you to the hospital and also take you back home.
• You must avoid smoking as it impairs wound healing.
• Your doctor will ask you to stop taking some medicines, especially anticoagulants (to prevent blood clots) such as warfarin, dabigatran, rivaroxaban, and apixaban before surgery.
• You need to be well-nourished for better recovery from the operation. So, your doctor will ask you to eat regularly and take nutritious drinks to maintain weight. Eat small meals consisting of soft or moist foods to help ease the dryness of the mouth.
• Your doctor will also explain the procedure to you along with its risks and benefits.
• You will be asked to sign a consent form, which will give your approval for the procedure.

Once you arrive at the hospital for a thymectomy, you will be guided in the following manner:

• You will be asked to wear surgical stockings to prevent deep vein thrombosis (formation of a blood clot). You will have to keep using them until your discharge.
• A nurse will check your temperature, blood pressure, and pulse.
• He/she will also give you a heparin injection to prevent blood clots.
• You will be given general anaesthesia, which will make you sleep throughout the procedure.

Thymectomy takes around one to three hours and can be done using any of the several approaches listed below:

• Transsternal thymectomy: In this procedure, a surgeon will make an incision on your skin right above your breastbone. He/she will drag aside your breastbone to reach your thymus gland. Once the thymus gland is removed, the surgeon will close the incision with stitches. You may have to stay in the hospital for up to a week after this surgery.
• Transcervical thymectomy: For this surgery, your surgeon will make a small cut above your breastbone, in the lower portion of your neck. 
• Video-assisted thoracoscopic surgery (VATS): VATS is also called keyhole surgery. In this, a surgeon will make multiple small cuts on the left or right side of your chest. Through these cuts, he/she will insert the surgical instruments and a small camera to look at the inside of your body and remove your thymus gland. As compared to the above two surgeries, this surgery requires a shorter hospital stay (one to three days).
• Robotic-assisted thoracoscopic surgery (RATS): This approach is even less invasive. For this surgery, the surgeon will make only five small cuts on your chest to insert surgical tools and a small camera, which will then be connected to the arms of a robotic machine. The surgeon will control the robotic arms and use a 3D screen to get a magnified view of the inside of your chest.

After the surgery, you will be in the recovery room for 24 hours or until you are stable and then moved to another ward.

When you wake up from the surgery:

• You may have an oxygen mask on to ensure you have an adequate supply of oxygen to help you recuperate from anaesthesia. 
• You will have an intravenous (IV) line inserted in your arm to give you fluids and medicines.
• You may have chest drains (one or two) depending on the type of surgery you underwent, to remove fluid, air or blood. When there is no air leakage and the fluid also stops draining, these drains will be removed. This is generally done two to three days after the surgery.
• Once the drains are removed, the stitch at each drain site will be removed after seven to 10 days. 
• You will be allowed to take sips of water after you wake up.
• You will be asked to move around the day after the operation to prevent chest infection and other complications.

You should take the following care for a quick recovery after thymectomy.

Wound care: 

• Keep the surgical wound dry and clean.
• It is normal to have some swelling around the wound. It will go down in a few weeks. 
• Generally, dissolvable stitches are used that need not be removed. However, the stitch near the drain will have to be removed. 
• Avoid wearing tight clothes as it can irritate or put pressure on the wound. 
• Do not soak in a bathtub for a long time for the first four to six weeks. After a bath, pat the wound dry.
• Avoid using soap or scented body wash on the wound.

Pain: 

• You will feel some soreness or stiffness around the wound, for which you will be given pain medicines.
• Your pain will decrease with time.

Diet:

• Eat small, frequent meals and snacks, and include nutritious drinks in your diet. 
• You may be asked to have soft and plain foods while you are getting better. Drink a lot of fluids to prevent dehydration.

Work and travelling: 

• The recovery depends on the type of surgery performed. Surgery with a transsternal approach requires three months off from work while minimally-invasive procedures require you to be off work for two to three weeks. 
• You should not drive for about four to six weeks after the operation; however, if you have undergone surgeries like VATS or RATS, you can drive after two weeks.
• You may fly after six weeks but check with your surgeon before air travel.

The benefits of thymectomy are as follows:

• Improvement in muscle weakness.
• In a few people, a thymectomy affords permanent remission, which means medications are no longer required. 
• Some people do not see a difference in their condition immediately. Thymectomy is not a quick fix solution but a long-term solution as the improvement is gradual.

When to see the doctor?

Visit or call your doctor immediately if you observe the following symptoms:

• Discharge from the wound
• Increased pain 
• Constipation persists despite taking a laxative
• The wound becomes reddish, warm and swollen
• The wound looks like it is coming apart
• Signs of infection such as fever and chills
• Difficulty in breathing, cough or chest pain
• Continuous nausea and vomiting
• Pain and/or swelling in the calves, feet or legs

Thymectomy is associated with the following risks or complications:

• Pain and discomfort
• Infection
• Bleeding
• Damage to other organs or to the nerves running in the chest (phrenic nerve palsy)
• Respiratory failure

Your follow-up appointment will be scheduled six weeks after the surgery.

Disclaimer: The above information is provided purely from an educational point of view and is in no way a substitute for medical advice by a qualified doctor.