Transcervical thymectomy for myasthenia gravis achieves results comparable to thymectomy by sternotomy

Thymectomy is more effective than conservative treatment for myasthenia gravis regarding outcome and clinical improvement

BACKGROUND

Myasthenia gravis (MG) is an autoimmune disease with a tremendous impact on the quality of life. Controversies over which patients should be operated on because they may benefit most from thymectomy are still ongoing. The aim of this study was to report our long-term results of patients with MG with comparison of thymectomy and conservative treatment.

METHODS

We report a series of 252 patients with MG. Survival data were generated. Patients were seen in the outpatient clinic, where a modified Osserman score and quality of life score were evaluated at the end of the follow-up period for all surviving patients.

RESULTS

A total of 172 patients with MG were followed after thymectomy or with conservative treatment for a median time of 9.8 years. Patients who underwent thymectomy had significantly greater rates of remission and improvement compared with conservative treatment. Furthermore, they had a significantly greater survival.

CONCLUSION

Currently, different effective modalities of treatment are available in patients with MG. In our long-term follow-up, thymectomy was superior to conservative treatment regarding overall survival, clinical improvement, and remission rate. Therefore, thymectomy should be considered strongly for all patients with generalized MG.

Partial upper sternotomy for anterosuperior mediastinal surgery: an institutional experience

BACKGROUND

Median sternotomy is the traditional approach used to resect anterior mediastinal masses or access the anterosuperior compartment of the mediastinum. A partial upper sternotomy is an alternative, less invasive technique. Our goal in this study is to analyze the circumstances under which partial upper sternotomy is appropriate and to determine the outcomes of these patients.

METHODS

From January 1994 to July 2008, 35 patients underwent partial upper sternotomy, solely or as part of a larger procedure. We analyzed these patients to determine the utility of this approach, the ability to achieve complete resection, and outcomes.

RESULTS

Of the 35 patients, 13 patients underwent resection for thymoma (9 stage I, 4 stage II), 5 for cervical node dissection, 7 for thymic hyperplasia, 3 for thyroid resection, 3 for esophagectomy, 2 for thymic cyst, 1 for bronchogenic cyst, and 1 for thymic cholesterol granuloma. Median age of patients was 51 (range 28-79) years with 54% (n = 19) males. There were no intraoperative complications or deaths within 30 days. Median length of stay was 3 days. Complete resection was possible for all patients who underwent resection for thymic masses, hyperplasia, or cystic mediastinal structures (n = 24). There were no recurrences on long-term follow-up for those with thymomas.

CONCLUSIONS

Partial upper median sternotomy is a safe and effective means of accessing the anterosuperior mediastinum. It is an alternative to full sternotomy and provides a less invasive means of resecting small anterior mediastinal masses as well as accessing the thoracic inlet.

Extended transcervical thymectomy in the treatment of myasthenia gravis

The ideal operative technique for thymectomy in myasthenia gravis remains controversial. Most surgeons perform thymectomy via median sternotomy, some supplementing this with an even more extensive mediastinal and cervical dissection designed to remove all areas of possible ectopic thymic tissue. We and others have advocated a transcervical approach that is less morbid and costly than sternotomy approaches. The transcervical approach allows a complete extracapsular thymic resection, but it does not address all areas of potential ectopic thymic tissue. We have published our experience with 151 extended transcervical thymectomies (TCT). At mean follow-up of 53 months (complete follow-up in 97%), Kaplan-Meier estimates of complete stable remission were 33% and 35% at 3 and 6 years. If one includes patients who became asymptomatic but remained on low dose, single-drug immunosuppression as complete remissions (CRs), then the CR rates were 43% and 45% at 3 and 6 years. Longer term (mean 83 months) follow-up of the earliest 84 patients in the series showed preserved CR rates. On multivariate analysis, only preoperative Osserman Class (group mean 2.3) was significantly associated with improved CR rate. These results were obtained with a major operative complication rate of 0.7% and minor complication rate of 6.6%, and nearly every operation was performed without the need for overnight hospital admission. We believe that these response rates following TCT are sufficiently similar to those following transsternal techniques of thymectomy to allow us to recommend this less morbid and less costly operation as an eminently reasonable choice in the surgical treatment of myasthenia gravis.

Video-Assisted Extended Transcervical Thymectomy

Objective

The objective of this study was to demonstrate extended thymectomy via the transcervical route.

Methods

With the use of the Rultract retractor (Rultract, Cleveland, OH), videothoracoscopy and single-lung ventilation allowed complete thymectomy.

Results

This article demonstrates complete resection of all the thymus from the anterior and superior mediastinum.

Conclusions

In selected patients, the transcervical route can used to completely resect the thymus, avoiding the morbidity of sternotomy.

Outcomes after 151 extended transcervical thymectomies for myasthenia gravis

BACKGROUND

The ideal operative technique for thymectomy in myasthenia gravis (MG) remains controversial. We present the largest series of extended transcervical thymectomy to provide outcomes data to compare with transsternal procedures.

METHODS

A retrospective chart review/interview was made of 164 patients operated upon from 1992 to 2004. Complete remission (CR) was defined as asymptomatic off medication for 6 months or asymptomatic on low-dose single-drug therapy (< or = 10 mg/d prednisone or < or = 150 mg/d azathioprine). A modified Osserman classification based upon the Myasthenia Gravis Foundation of America quantitative disease severity score was employed.

RESULTS

The overall complication rate was 7.3%, and nearly all procedures were outpatient. Mean age at surgery was 43 years, and mean preoperative Osserman class was 2.3 (21% class 1; 39% class 2; 28% class 3; 12% class 4). Mean length of follow-up was 53 months. Mean postoperative Osserman class was 1.0. Nineteen percent of patients failed to improve. The crude cumulative CR rate was 37% (n = 58). Kaplan-Meier estimates of CR were 43% and 45% at 3 and 6 years, respectively. On multivariate analysis, only preoperative disease severity was significantly (inversely) associated with Kaplan-Meier CR rates. Longer-term follow-up (83 months) of only the earlier patients shows preserved CR rates (46%).

CONCLUSIONS

This largest series of extended transcervical thymectomy for MG confirms that the 5-year Kaplan-Meier CR rate is comparable with that obtained after transsternal procedures. Patients with less severe disease have higher CR rates. Complete responses are durable, as the CR rate remains stable with extended follow-up.

Thoracoscopic Thymectomy Mid-Term Results

BACKGROUND

Results of thymectomy in patients with myasthenia gravis need to be reported in a standardized way to allow accurate comparison.

METHODS

A retrospective study was conducted of 107 patients with myasthenia gravis without thymoma. Patients were followed-up for more than 12 months after thoracoscopic thymectomy and analyzed according to Myasthenia Gravis Foundation of America Recommendations for Clinical Research Standards.

RESULTS

The study population was aged 8 to 60 years old and included 15 men (14%) and 92 women (86%). A right-side approach was used in 36 patients, and the remaining 71 patients had a left-side approach. Mortality was 0% and morbidity was 9.34%. The mean operative time was 90 +/- 45 minutes. The histologic diagnosis of the resected thymus was hyperplasia (78.5%), atrophy (15%), and normal status (6.5%). The mean length of hospitalization was 2.3 days (range, 2 to 6 days). The mean follow-up was 36.4 months (range, 12 to 74 months). The rate of complete stable remission was 59.5% by the end of postoperative year 6. An earlier onset age and early operation were significantly associated with complete stable remission and pharmacologic remission. A comparison of right side versus left side approach showed similarities in mean operative time, mean length of hospitalization, histopathologic results, and remission rates.

CONCLUSIONS

Outcomes of the thoracoscopic approach in myasthenia gravis without thymoma were similar to those provided by open surgery, with the acknowledged benefits of minimally invasive surgery and good patient acceptance.

Experience with starting tacrolimus postoperatively after transsternal extended thymectomy in patients with myasthenia gravis

BACKGROUND

Thymectomy is a standard treatment of myasthenia gravis (MG). Immunomodulating agents are frequently given during the post-thymectomy latency period until complete remission is fully consolidated, but serious side effects is a relevant clinical problem for patients on long-term immunomodulating treatment.

OBJECTIVE

To assess the effectiveness of starting tacrolimus in the immediate postoperative period in MG patients undergoing transsternal extended thymectomy, with complete stable remission (CSR) as the primary outcome of the study.

METHODS

Forty-eight MG patients received tacrolimus, 0.1 mg/kg per day b.i.d. (started 24 h after thymectomy) and prednisone 1.5 mg/kg/day. Histologically, 34 patients had hyperplasia, 20 thymic involution, and 14 thymoma. Of the 48 patients, 40 completed 1 year of tacrolimus therapy, 38 completed 2 years, 27 completed 3 years, 21 completed 4 years, and 9 more than 5 years. Mean dose of tacrolimus was 4.9 mg/day (range 2-8 mg/day) with a mean plasma drug concentration of 7.6 ng/mL (range 7-9 ng/mL). Prednisone could be withdrawn after the first year in 93.7% of patients and at 2 years in 100%.

RESULTS

The mean follow-up was 24.4 months, SD 17.3 (range 6-60 months). Improvement of muscular strength and decrease of anti-AChR antibodies were statistically significant (p < 0.001) shortly after operation. CSR was obtained in 33.4% of patients, pharmacological remission in 62.6%; 4% of patients had minimal symptoms. None of the patients with thymoma achieved CSR. The estimated median follow-up to obtain a CSR was 37.9 months (95% confidence interval [CI] 26.4-49.5 months). The overall crude CSR rate was 33.4%, with 47% for non-thymoma patients. The probability to achieve CSR at 3 years was 67% for the non-thymomatous group.

CONCLUSIONS

Long-term immune-directed treatment with tacrolimus to improve the effectiveness of thymectomy in MG is feasible and was associated with a high rate of CSR in patients without thymoma.

Ocular motor dysfunction and ptosis in ocular myasthenia gravis: effects of treatment

AIM

The optimal treatment of ocular myasthenia gravis (OMG) remains unknown. The authors evaluated the efficacy of prednisone and pyridostigmine in reducing diplopia, ocular motor dysfunction, and ptosis in patients with OMG.

METHODS

Review of records from a clinical database from one neuro-ophthalmology service of patients presenting with OMG between 1990 and 2002, excluding those who developed generalised MG within the first month after diagnosis. Institutional review board approval was obtained for this study.

PARTICIPANTS/INTERVENTIONS

Non-randomised, unmasked, therapy was given. 55 patients with diplopia in primary or downward gaze and clinically demonstrable extraocular muscle dysfunction received prednisone. 34 patients who had contraindications to steroids or who refused treatment with prednisone received pyridostigmine only. Over 5 days the daily prednisone dose was increased to 50-60 mg and then gradually reduced to 10 mg, followed by further reduction as tolerated. The pyridostigmine dose was begun at 180 mg daily and increased as tolerated.

MAIN OUTCOME MEASURES

Follow up evaluations, performed at 1, 3-6, 12, and 24 months, detailed the frequency of ptosis and diplopia and the amount of ocular motor deviation in primary and downward gaze.

RESULTS

The prednisone and pyridostigmine groups were similar for age, sex, acetylcholine receptor antibody level, prism cover test results for primary and downward gaze, diplopia in primary and downward gaze, and unilateral ptosis. Bilateral ptosis was present in 32.4% of the pyridostigmine group and 10.9% of the prednisone group (p = 0.02). The prednisone group showed resolution in primary gaze diplopia, downgaze diplopia, unilateral ptosis, and bilateral ptosis in 73.5%, 75.5%, 85.7%, and 98%, respectively at 1 month. The benefit persisted at 3-6, 12, and 24 months except for the bilateral ptosis. The pyridostigmine group showed resolution in primary gaze diplopia, downgaze diplopia, unilateral ptosis, and bilateral ptosis in 6.9%, 17.2%, 50%, and 76.7% of patients after 1 month of treatment. The prism cover results improved (p = 0.003) in the prednisone group only. In the prednisone group, four patients had no response to therapy. Among the 51 prednisone responsive patients, there were 33 recurrences in 26 patients. 12 patients, all prednisone treated, had remissions. Except for three patients who developed diabetes, no patient developed a clinically significant systemic corticosteroid complication.

CONCLUSION

These results suggest that 50-60 mg daily prednisone followed by lower doses (10 mg or less) has the benefit of resolving ptosis and diplopia that lasts for at least 2 years in approximately 70% of patients.

Video-Assisted Thoracic Surgery Thymectomy for Nonthymomatous Myasthenia Gravis

STUDY OBJECTIVES

Minimal-access thymectomy has become increasingly popular as surgical treatment for patients with nonthymomatous myasthenia gravis (NTMG) because of its comparable efficacy, safety, and lesser degree of tissue trauma compared with conventional open surgery. We reviewed and analyzed our data on video-assisted thoracic surgery (VATS) thymectomy and present the clinical outcomes according to the Myasthenia Gravis Foundation of America classification.

DESIGN

A retrospective review of VATS thymectomy for NTMG in a university hospital over a 12-year period. Data were collected from the medical records and supplemented with telephone surveys. The impact of surgery and other variables potentially affecting complete stable remission (CSR) were calculated using Kaplan-Meier survival curves; comparisons between survival curves was performed using the log-rank test.

RESULTS

A total of 38 consecutive patients underwent VATS thymectomy for NTMG. Median postoperative stay was 3 days. Pathologic examination revealed thymic hyperplasia in 61.1% of cases, normal thymus in 22.2%, and thymic atrophy in 16.6%. There was no perioperative mortality; complications occurred in four patients. After a median follow-up of 69 months, 91.6% of patients experienced improvement, with crude CSR achieved in 22.2%. Kaplan-Meier survival curve demonstrated a 75% CSR rate at 10-year follow-up. On univariate analysis, only disease duration < or = 12 months (p = 0.03) was associated with a statistically significant improvement in CSR.

CONCLUSIONS

VATS thymectomy for NTMG results in symptomatic improvement in the vast majority of patients, with a high rate of CSR. The procedure is associated with low morbidity and no perioperative mortality. Future studies on thymectomy for myasthenia gravis should be reported in a standardized manner to allow accurate comparisons between results in the absence of randomized prospective trials.

Factors influencing the outcome of transsternal thymectomy for myasthenia gravis

BACKGROUND

Thymectomy is one of the current treatment strategies for patients with myasthenia gravis (MG); however, the selection criteria for surgery remain controversial.

METHODS

The demographic data and the surgical results of 168 patients with MG who underwent transsternal thymectomy from June 1986 to December 2000 were retrospectively reviewed. Follow-up information was obtained by review of the hospital records or telephone contact. The postoperative status of MG was assessed at the interval of 1, 3 and 6 months and then annually. The complete remission rate (CRR) between groups was compared.

RESULTS

A total of 168 patients, including 69 male patients and 99 female patients, with a mean age of 38.3 years (range 13-80 years), were analyzed. The symptom duration before operations was from 1 to 312 months with a mean of 33.8 months. Complete follow-up information was obtained on 154 patients (91.6%) with a mean follow-up duration of 98.9 months. Complete remission was achieved in 89 of 154 patients (57.8%) and marked clinical improvement in 47 patients (30.5%). Total improvement rate was 88.3%. Seventeen of 24 patients (70.8%) with ocular MG and 18 of 35 patients (51.4%) with thymoma had reached complete remission during the follow-up period. The CRR increased with each consecutive year and reached the plateau in the fourth postoperative year. There was no surgical mortality. The complication rate was 16.6%. Univariate analysis demonstrated that age <35 years old (P = 0.0001), symptom duration before operation <24 months (P = 0.01) and absence of preoperative steroid treatment (P = 0.04) were favorable prognostic factors. Multivariate Cox regression analysis revealed age <35 years old (odds ratio = 3.645, P = 0.001), symptom duration before operation <24 months (2.311, P = 0.041) were favorable prognostic factors for patients having transsternal thymectomy.

CONCLUSIONS

Transsternal thymectomy is feasible in the management of patients with MG at all stages with high improvement rate and low surgical morbidity. Those patients aged 35 years or less at operation, with symptoms developed <24 months before operation, may benefit more from thymectomy. MG patients with thymoma did as well as patients without thymoma, and 18 of 35 patients with thymoma had reached complete remission during the follow-up period. Thymectomy seems to be beneficial also for ocular MG.

Application of Robotic-Assisted Techniques to the Surgical Evaluation and Treatment of the Anterior Mediastinum

BACKGROUND

We report our initial experience with the application of robotic-assisted technologies to the treatment of diseases of the anterior mediastinum.

METHODS

Between October 2001 and December 2003, 18 consecutive patients with anterior mediastinal masses were referred for diagnosis and treatment. Fifteen patients underwent robotic-assisted surgery with the da Vinci robotic system. A single surgical team performed all operations. Resection was accomplished by either median sternotomy or robotic-assisted techniques.

RESULTS

Fourteen patients underwent successful robotic-assisted thymectomy. One patient underwent robotic-assisted biopsy of a mass that was later determined to be a poorly differentiated carcinoma, 3 patients underwent complete thymectomy by median sternotomy for biopsy-proven extracapsular thymoma, 7 patients had thymoma, and 3 had myasthenia gravis. There were 2 patients each with benign thymic cysts and thymic hyperplasia. Primary thymic carcinoid, thymolipoma, papillary thyroid cancer, and poorly differentiated carcinoma were present in 1 patient each. No conversions, intraoperative complications, or deaths occurred in the 15 patients who underwent robotic-assisted resection. The mean operative time was 96 minutes (range 62 to 132 minutes). The mean robotic time was 48 minutes (range 22 to 76). The median hospital stay was 2 days. All patients are doing well, with a median follow-up of 1 year.

CONCLUSIONS

Robotic-assisted surgery of the anterior mediastinum, and particularly thymectomy, can be performed safely and efficiently. The increased visualization and instrument dexterity afforded by this technology provides an optimal minimally invasive approach to the anterior mediastinum. From this experience we have formulated a comprehensive treatment algorithm for the surgical evaluation and treatment of patients with anterior mediastinal diseases.

Transcervical-subxiphoid-VATS "maximal" thymectomy for myasthenia gravis

A maximally extended thymectomy is performed through four incisions: a transverse 5-8 cm incision in the neck, a 4-6 cm subxiphoid incision and two 1 cm incisions for videothoracoscopic ports. The cervical part of the procedure is performed with an open technique, the intrathoracic part of the procedure is performed with the videothoracoscopy assisted (VATS) technique. The whole thymus with the surrounding fatty tissue containing possible ectopic foci of the thymic tissue is removed. The need for sternotomy is avoided while the completeness of the operation is retained.

Video-assisted transcervical thymectomy

BACKGROUND

The optimal surgical approach for complete removal of the thymus gland has long been debated. In this report, the excision of the entire gland through a transcervical incision using video-assisted techniques is described.

METHODS

Ten patients, including one with thymoma and myasthenia gravis, underwent surgery via the transcervical approach. After standard dissection up to the level of the innominate vein and ligation of the thymic vessels, a laparoscope was inserted into the mediastinum. In the patient with thymoma, the operation was completed by a small incision in the third intercostal space.

RESULTS

No perioperative mortality or long-term morbitity was observed. The mean hospital stay was 69.6 h. After a mean follow-up period of 63.8 months, eight patients displayed complete remission, whereas one continued to receive minimal medication. The patient with thymoma showed considerable improvement, but remained on same medical regimen No complications were seen throughout the study.

CONCLUSION

Video-assisted thymectomy improves effectiveness of the transcervical approach for thymectomy with a minimum of trauma and excellent results.

Transcervical-subxiphoid-videothoracoscopic “maximal” thymectomy—operative technique and early results

BACKGROUND

The operative technique of a transcervical-subxiphoid-videothoracoscopic "maximal" thymectomy without sternotomy is described and the early results of the follow-up of patients operated on are analyzed.

METHODS

One-hundred "maximal" transcervical-subxiphoid-videothoracoscopic thymectomies were performed for nonthymomatous myasthenia gravis during a recent 32-month period (from September 1, 2000 to May 8, 2003). Patient characteristics, complications, pathologic findings, and the results of follow-up were analyzed.

RESULTS

The study group included 83 women and 17 men. The mean age was 29.8 years (range, 10-69 years). The mean preoperative duration of myasthenia was 2.73 years (range, 3 months to 17 years). The preoperative Osserman score was I-III, 27 patients were taking steroids preoperatively. Eleven operations were performed by two teams working simultaneously and 89 operations were performed by one surgeon including four combined thymectomy-thyroid operations in patients with myasthenia and thyroid nodules. The mean operative time for two-team approach thymectomies was 159.09 minutes (range, 140-170 minutes) and the mean operative time for the thymectomy performed by one surgeon was 199.41 minutes (range, 150-270 minutes) (p = 0.0004). There was a 15.0% (15 out of 100) postoperative morbidity and no mortality. Foci of ectopic thymic tissue were found in 71.0% of the patients and were most prevalent in the perithymic fat (37.0%) and in the aorta-pulmonary window (33.0%). The mean weight of the specimen was 78.4 g (range, 14.5-253.0 g). In 48 patients followed-up for 12 months, the improvement rate was 83.3%, the no improvement rate was 14.6%, and 1 patient died during the follow-up period. Complete remission rates were 18.8% and 32.0% after 1 and 2 years of follow-up, respectively.

CONCLUSIONS

We conclude that the "maximal" transcervical-subxiphoid-videothoracoscopic thymectomy is a safe operative technique, avoiding a sternotomy, performed partly in an open fashion with the extensiveness comparable with the transsternal extended and "maximal" thymectomies. The two-team approach helps to reduce the operative time. However, because of the limited time of follow-up it is too early for the final assessment of the long-term results of this method in the treatment of myasthenia gravis.

Prognostic factors for myasthenic crisis after transsternal thymectomy in patients with myasthenia gravis

OBJECTIVE

The purpose of this study was to assess which clinical features of patients with myasthenia gravis predict postoperative respiratory problems due to myasthenic crisis after transsternal thymectomy.

METHODS

One hundred twenty-two patients who underwent transsternal thymectomy in our institute were analyzed retrospectively. Fourteen of those experienced myasthenic crisis and required prolonged (48 hours or more) postoperative mechanical ventilation. The following factors were evaluated: sex, age, body mass index, grade of symptom, disease interval, existence of thymoma, history of preoperative crisis, doses of anticholinesterase drugs, steroid use, pulmonary function, serum anti-acetylcholine receptor antibody, history of pulmonary disease, presence of other disease, operation time, and blood loss.

RESULTS

Univariate analysis revealed preoperative bulbar symptoms (odds ratio = 14.246, P =.001), history of preoperative myasthenic crisis (7.091,.018), and preoperative serum level of anti-acetylcholine receptor antibody > 100 nmol/L (4.098,.044) were prognostic factors for postoperative myasthenic crisis. On the other hand, multivariate logistic regression analysis revealed preoperative bulbar symptoms (33.333,.004), preoperative serum level of anti-acetylcholine receptor antibody > 100 nmol/L (7.874,.020), and intraoperative blood loss > 1000 mL (18.519,.048) were prognostic factors for postoperative myasthenic crisis.

CONCLUSIONS

In this study, postoperative myasthenic crisis after transsternal thymectomy in 122 patients with myasthenia gravis was affected by the existence of preoperative bulbar symptoms, history of preoperative myasthenic crisis, preoperative serum level of anti-acetylcholine receptor antibody > 100 nmol/L, and intraoperative blood loss > 1000 mL. Meticulous preoperative and postoperative care should be carried out to prevent postoperative myasthenic crisis in patients with these prognostic factors.

Clinical evaluation and management of myasthenia gravis

Myasthenia gravis (MG) is a syndrome of fluctuating skeletal muscle weakness that worsens with use and improves with rest. Eye, facial, oropharyngeal, axial, and limb muscles may be involved in varying combinations and degrees of severity. Its etiology is heterogeneous, divided initially between those rare congenital myasthenic syndromes, which are genetic, and the bulk of MG, which is acquired and autoimmune. The autoimmune conditions are divided in turn between those that possess measurable serum acetylcholine receptor (AChR) antibodies and a smaller group that does not. The latter group includes those MG patients who have serum antibodies to muscle-specific tyrosine kinase (MuSK). Therapeutic considerations differ for early-onset MG, late-onset MG, and MG associated with the presence of a thymoma. Most MG patients can be treated effectively, but there is still a need for more specific immunological approaches.

Thymectomy for myasthenia gravis: analysis of controversies--patient management

BACKGROUND

Debate continues regarding the effectiveness of thymectomy in the treatment of nonthymomatous autoimmune myasthenia gravis primarily because there have been no controlled prospective studies. The debate is compounded by the lack of recognition that all thymectomies are not equal in extent or effectiveness and by the fact that all the studies are retrospective without common definitions of myasthenia gravis manifestations or response to therapy. In addition, the analysis of data is often inappropriate.

REVIEW SUMMARY

Evidence is presented demonstrating that the extent of the various thymic resectional techniques is very variable and often incomplete and that the more complete the thymic resection the better the results. The indications for thymectomy, the selection of the technique of the resection, the reoperations issue, the perioperative management of the myasthenia gravis patient, morbidity and mortality, and appropriate methods of outcome research are also reviewed.

CONCLUSION

In view of the impressive results associated with a complete thymic resection in the treatment of myasthenia gravis, patients should not be denied this operation because of lack of prospective proof to-date, and when a thymectomy is performed a total resection is indicated.