Seminars in thoracic and cardiovascular surgery | 2019
The Jury Is in on the Great Debate: Small Numbers, Powerful Results.
Abstract
See Editorial Commentary on pages 561-568. The international trial of myasthenia gravis (MGTX) was recently completed after many years of enrollment and patient follow-up and conclusively defined the role of thymectomy in the treatment of non-thymomatous myasthenia gravis (MG). Through the visionary tireless surgical leadership of Alfred Jaretzki, the persistence and medical leadership of John Newsom-Davis, and an extremely committed and diligent international group of investigators, 126 patients were enrolled in a prospective blinded fashion to definitively prove the benefit of extended thymectomy in myasthenia gravis. Prospectively randomized patients who underwent an extended thymectomy via median sternotomy had significantly improved MG course and medication needs compared to patients who received prednisone-based medical therapy alone. Beyond the effect of the trial results alone, we should be reminded and heartened as a surgical community of the enormity and power of a well-constructed prospective randomized study to help define our practice. In the era of data conveniently accessible in large clinical databases, we must not succumb to the siren call of large retrospective series in lieu of achievable prospective studies designed to appropriately answer specific relevant debates. The evolution of surgical techniques has made the debate about the surgical approach to thymectomy almost moot. In the MGTX trial, the approach was via a sternotomy, but more importantly, the trial explicity demanded and trained surgeons to perform a maximal extended thymectomy; prescribed and mandated in the study as a standardized resection encompassing the entire neck and mediastinum. Thus, the study conclusively proved the positive role of complete maximial thymecotmy in myasthenia gravis, the role of lesser resections are yet to proven. However, any operative approach