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Khawaja I. Effect of Thymectomy on Outcomes of Myasthenia Gravis Patients: A Case-Control Study at a Tertiary Care Hospital. Cureus 2023; 15:e37584. [PMID: 37193448 PMCID: PMC10183232 DOI: 10.7759/cureus.37584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/13/2023] [Indexed: 05/18/2023] Open
Abstract
Background and objective Myasthenia gravis (MG) is an acquired autoimmune disease mediated by antibodies affecting the neuro-muscular junction on the postsynaptic membrane, resulting in neuromuscular transmission obstruction and, consequently, muscle weakening. It is believed that the thymus gland plays a critical role in the production of these antibodies. Screening patients for thymoma and surgical excision of the thymus gland is a crucial part of the treatment. To compare the odds of good outcomes in Myasthenia Gravis patients with or without thymectomy. Material and methods A retrospective case-control study was conducted at the Department of Medicine and Neurology, Ayub Teaching Hospital, Abbottabad, Pakistan, from October 2020 to September 2021. A purposive sampling technique was employed. Thirty-two MG patients with thymectomy and 64 MG patients without thymectomy were selected for investigation. Controls and cases were matched on the basis of sex and age (1:2). A positive EMG study, acetylcholine receptor antibodies, and a pyridostigmine test were used to make the diagnosis of MG. Patients were called to the outpatient department for assessment of treatment outcomes. Primary outcome evaluation was done using the Myasthenia Gravis Foundation of America Post-Intervention Status (MGFA-PIS) tool at the last follow-up after one year. Results A sample of 96 patients was evaluated, of which 63 (65%) were females and 33 (34%) were males. The mean age for Group 1 (cases) was 35 years ±8.9 and for Group 2 (controls) was 37± 11.1. Age and Osserman stages were shown to be the two most crucial prognostic factors in our study. However, there are several other factors in our study that are linked to a poor response, such as a greater BMI, dysphagia, thymoma, older age, and a longer duration of disease. Conclusions Our findings indicate that none of the analysed groups had significantly worse outcomes as a result of the current clinical practice of thymectomy patient selection.
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Affiliation(s)
- Imran Khawaja
- Department of Internal Medicine, Ayub Teaching Hospital, Abbottabad, PAK
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Baram A, Salih KAH, Saqat BH. Thymectomy for non-thymomatous myasthenia gravis: Short and long term outcomes, a single-center 10 years' experience. INTERNATIONAL JOURNAL OF SURGERY OPEN 2021. [DOI: 10.1016/j.ijso.2021.100381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Shreedhara AS, Nair SS, Unnikrishnan M, Sandhyamani S, Sarma PS, Nair M, Sarada C. Determinants of Suboptimal Outcome Following Thymectomy in Myasthenia Gravis. Neurol India 2021; 69:419-425. [PMID: 33904466 DOI: 10.4103/0028-3886.314565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Background Response to thymectomy in myasthenia gravis (MG) is influenced by various patient-, disease-, and therapy-related factors. Methods Retrospective analysis of 128 patients with MG who underwent maximal thymectomy over 15 years was done to identify the determinants of suboptimal clinical outcome. Results Among the 128 patients, 62 (48.4%) were females with a mean age of 38.97 (12.29) years. Thymomatous MG occurred in 66 (51.6%). Overall improvement from preoperative status was noted in 88 (68.8%) patients after mean follow-up of 51.68 (33.21) months. The presence of thymoma was the major predictor of suboptimal clinical outcome (P = 0.001), whereas age, gender, preoperative disease severity, and seropositive status did not attain significance. Patients with better outcome had received higher steroid dose preoperatively (P = 0.035). Conclusions Suboptimal response after thymectomy occurred in one-third of MG patients, more commonly with thymomatous MG. Relationship of preoperative steroid therapy to remission merits evaluation.
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Affiliation(s)
- A S Shreedhara
- Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| | - Sruthi S Nair
- Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| | - Madathipat Unnikrishnan
- Department of Cardiovascular and Thoracic Surgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| | - S Sandhyamani
- Department of Pathology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| | - P S Sarma
- Department of Pathology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| | - Muralidharan Nair
- Department of Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| | - C Sarada
- Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
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Zhang J, Chen Y, Zhang H, Yang Z, Zhang P. Effects of thymectomy on late-onset non-thymomatous myasthenia gravis: systematic review and meta-analysis. Orphanet J Rare Dis 2021; 16:232. [PMID: 34016126 PMCID: PMC8139042 DOI: 10.1186/s13023-021-01860-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 05/07/2021] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND The effects of thymectomy on late-onset non-thymomatous myasthenia gravis (NTMG) remain controversial. The objective of this study was to conduct a systematic review in order to answer two questions pertinent to late-onset NTMG: (1) do patients with late-onset NTMG experience the same effects from thymectomy as their early-onset counterparts? (2) Compared with conservative treatment, does thymectomy have any benefits for late-onset NTMG patients? METHODS We searched the PubMed, EMBASE, and Cochrane Library databases for studies published from January 1, 1950 to March 10, 2021. Outcomes were measured via clinical stable remission/pharmacological remission (CSR/PR) and improvement rates. We used Stata software to analyze the data. RESULTS We ultimately included a total of 12 observational articles representing the best evidence answering the questions of our study objective. Of these, nine studies, which included 896 patients overall (766 early-onset and 230 late-onset), compared postoperative outcomes between early- and late-onset NTMG. The remaining three articles, which included 216 patients (75 in the thymectomy group and 141 in the conservative-treatment group), compared thymectomy with conservative treatment for late-onset NTMG. The early- versus late-onset NTMG studies demonstrated that patients in the former category were 1.95× likelier than their late-onset counterparts to achieve clinical remission (odds ratio [OR] 1.95; 95% confidence interval [CI] 1.39-2.73; I2 = 0%). No difference was seen in improvement or remission + improvement rates between these two groups. When comparing thymectomy with conservative treatments in late-onset NTMG patients, neither did we observe any difference in CSR/PR. CONCLUSION We found that late-onset NTMG patients had a lower chance of achieving CSR after thymectomy than early-onset patients. Thymectomy in late-onset NTMG also yielded no benefit to CSR or PR compared with conservative treatments. In late-onset NTMG patients, thymectomy should therefore be performed with caution, and the appropriate cutoff between early- and late-onset MG should be further explored in order to tailor and execute the proper therapeutic strategies.
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Affiliation(s)
- Jinwei Zhang
- Department of Cardiothoracic Surgery, Tianjin Medical University General Hospital, No.154, Anshan Road, Tianjin, China
| | - Yuan Chen
- Department of Cardiothoracic Surgery, Tianjin Medical University General Hospital, No.154, Anshan Road, Tianjin, China
| | - Hui Zhang
- Department of Cardiothoracic Surgery, Tianjin Medical University General Hospital, No.154, Anshan Road, Tianjin, China
| | - Zhaoyu Yang
- Department of Cardiothoracic Surgery, Tianjin Medical University General Hospital, No.154, Anshan Road, Tianjin, China
| | - Peng Zhang
- Department of Cardiothoracic Surgery, Tianjin Medical University General Hospital, No.154, Anshan Road, Tianjin, China.
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Alqarni F, Almalki D, Aljohani Z, Ali A, AlSaleem A, Alotaibi N, Odeh S, Dalbhi SA. Prevalence and risk factors of myasthenia gravis recurrence post-thymectomy. ACTA ACUST UNITED AC 2021; 26:4-14. [PMID: 33530037 PMCID: PMC8015504 DOI: 10.17712/nsj.2021.1.20190041] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 08/30/2020] [Indexed: 12/13/2022]
Abstract
Objectives: To evaluate the prevalence and the factors associated with recurrence of myasthenia gravis following thymectomy. Methods: Six electronic databases which reported on recurrence of myasthenia gravis following thymectomy and/or its risk factors from 1985 to 2018 were searched. Summary prevalence and risk values obtained based on the random effect models were reported. Results: Seventy (70) papers containing 7,287 individuals with myasthenia gravis who received thymectomy as part of their management were retrieved. The patients had a mean follow-up of 4.65 years post-thymectomy. The prevalence of myasthenia gravis recurrence post-thymectomy was 18.0% (95% CI 14.7–22.0%; 1865/7287). Evident heterogeneity was observed (I2=93.6%; p<0.001). Recurrence rate was insignificantly higher in male compared with female patients (31.3 vs. 23.8%; p=0.104). Pooled recurrence rates for thymomatous (33.3%) was higher than the rate among non-thymomatous (20.8%) myasthenia gravis patients (Q=4.19, p=0.041). Risk factors for recurrence include older age, male sex, disease severity, having thymomatous myasthenia gravis, longer duration of the myasthenia gravis before surgery, and having an ectopic thymic tissue. Conclusion: A fifth of individuals with myasthenia gravis experience recurrence after thymectomy. Closer monitoring should be given to at-risk patients and further studies are needed to understand interventions to address these risks.
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Affiliation(s)
- Fatmah Alqarni
- From the Department of Medicine (Alqarni, AlSaleem, Odeh), Princess Nourah Bin Abdulrahman University, Department of Neurology (Ali), King Fahad Medical City, Riyadh, College of Nursing (Alotaibi), King Saud Bin Abdulaziz University for Health Sciences, Department of Nephrology (Al Dalbhi), Prince Sultan Military Medical City, Riyadh, Department of Internal Medicine (Almalki), Prince Sattam Bin Abdulaziz University, Al-Kharj, Department of Neurology (Aljohani), King Abdullah Medical City, Makkah, Kingdom of Saudi Arabia
| | - Daifallah Almalki
- From the Department of Medicine (Alqarni, AlSaleem, Odeh), Princess Nourah Bin Abdulrahman University, Department of Neurology (Ali), King Fahad Medical City, Riyadh, College of Nursing (Alotaibi), King Saud Bin Abdulaziz University for Health Sciences, Department of Nephrology (Al Dalbhi), Prince Sultan Military Medical City, Riyadh, Department of Internal Medicine (Almalki), Prince Sattam Bin Abdulaziz University, Al-Kharj, Department of Neurology (Aljohani), King Abdullah Medical City, Makkah, Kingdom of Saudi Arabia
| | - Ziyad Aljohani
- From the Department of Medicine (Alqarni, AlSaleem, Odeh), Princess Nourah Bin Abdulrahman University, Department of Neurology (Ali), King Fahad Medical City, Riyadh, College of Nursing (Alotaibi), King Saud Bin Abdulaziz University for Health Sciences, Department of Nephrology (Al Dalbhi), Prince Sultan Military Medical City, Riyadh, Department of Internal Medicine (Almalki), Prince Sattam Bin Abdulaziz University, Al-Kharj, Department of Neurology (Aljohani), King Abdullah Medical City, Makkah, Kingdom of Saudi Arabia
| | - Abdulrahman Ali
- From the Department of Medicine (Alqarni, AlSaleem, Odeh), Princess Nourah Bin Abdulrahman University, Department of Neurology (Ali), King Fahad Medical City, Riyadh, College of Nursing (Alotaibi), King Saud Bin Abdulaziz University for Health Sciences, Department of Nephrology (Al Dalbhi), Prince Sultan Military Medical City, Riyadh, Department of Internal Medicine (Almalki), Prince Sattam Bin Abdulaziz University, Al-Kharj, Department of Neurology (Aljohani), King Abdullah Medical City, Makkah, Kingdom of Saudi Arabia
| | - Alanood AlSaleem
- From the Department of Medicine (Alqarni, AlSaleem, Odeh), Princess Nourah Bin Abdulrahman University, Department of Neurology (Ali), King Fahad Medical City, Riyadh, College of Nursing (Alotaibi), King Saud Bin Abdulaziz University for Health Sciences, Department of Nephrology (Al Dalbhi), Prince Sultan Military Medical City, Riyadh, Department of Internal Medicine (Almalki), Prince Sattam Bin Abdulaziz University, Al-Kharj, Department of Neurology (Aljohani), King Abdullah Medical City, Makkah, Kingdom of Saudi Arabia
| | - Noura Alotaibi
- From the Department of Medicine (Alqarni, AlSaleem, Odeh), Princess Nourah Bin Abdulrahman University, Department of Neurology (Ali), King Fahad Medical City, Riyadh, College of Nursing (Alotaibi), King Saud Bin Abdulaziz University for Health Sciences, Department of Nephrology (Al Dalbhi), Prince Sultan Military Medical City, Riyadh, Department of Internal Medicine (Almalki), Prince Sattam Bin Abdulaziz University, Al-Kharj, Department of Neurology (Aljohani), King Abdullah Medical City, Makkah, Kingdom of Saudi Arabia
| | - Shahla Odeh
- From the Department of Medicine (Alqarni, AlSaleem, Odeh), Princess Nourah Bin Abdulrahman University, Department of Neurology (Ali), King Fahad Medical City, Riyadh, College of Nursing (Alotaibi), King Saud Bin Abdulaziz University for Health Sciences, Department of Nephrology (Al Dalbhi), Prince Sultan Military Medical City, Riyadh, Department of Internal Medicine (Almalki), Prince Sattam Bin Abdulaziz University, Al-Kharj, Department of Neurology (Aljohani), King Abdullah Medical City, Makkah, Kingdom of Saudi Arabia
| | - Sultan Al Dalbhi
- From the Department of Medicine (Alqarni, AlSaleem, Odeh), Princess Nourah Bin Abdulrahman University, Department of Neurology (Ali), King Fahad Medical City, Riyadh, College of Nursing (Alotaibi), King Saud Bin Abdulaziz University for Health Sciences, Department of Nephrology (Al Dalbhi), Prince Sultan Military Medical City, Riyadh, Department of Internal Medicine (Almalki), Prince Sattam Bin Abdulaziz University, Al-Kharj, Department of Neurology (Aljohani), King Abdullah Medical City, Makkah, Kingdom of Saudi Arabia
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Mavroudis C. History of the Southern Thoracic Surgical Association President’s Award for Best Scientific Paper. Ann Thorac Surg 2018; 105:1568-1574. [DOI: 10.1016/j.athoracsur.2018.01.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2017] [Revised: 12/25/2017] [Accepted: 01/03/2018] [Indexed: 10/18/2022]
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Amore D, Scaramuzzi R, Di Natale D, Curcio C. Hemorrhagic complication during robotic surgery in patient with thymomatous myasthenia gravis. J Vis Surg 2018; 4:41. [PMID: 29552523 DOI: 10.21037/jovs.2018.01.10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Accepted: 01/11/2018] [Indexed: 11/06/2022]
Abstract
The advantages of thymectomy as part of the treatment of myasthenia gravis has been demonstrated repeatedly in the literature. Both single-institution and multi-institution trials have shown robotic thymectomy to be safe, feasible and associated with better early clinical outcomes than the trans-sternal approach. Most reports have also documented the superiority of robotic technology in the dissection of the superior mediastinum over conventional thoracoscopy, thanks to instruments with more degrees of movement and freedom. However, in case of a vascular injury in the superior mediastinum, after an initial management with minimally invasive approach, one should not hesitate to convert to sternotomy if the bleeding control hasn't been definitely established. In this way it is possible to avoid catastrophic injuries, also in relation to the limitations that, in our opinion, the robotic surgery has once a major vascular injury occurs in the mediastinum.
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Affiliation(s)
- Dario Amore
- Division of Thoracic Surgery, Monaldi Hospital, Naples, Italy
| | | | | | - Carlo Curcio
- Division of Thoracic Surgery, Monaldi Hospital, Naples, Italy
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Alipour-Faz A, Shojaei M, Peyvandi H, Ramzi D, Oroei M, Ghadiri F, Peyvandi M. A comparison between IVIG and plasma exchange as preparations before thymectomy in myasthenia gravis patients. Acta Neurol Belg 2017; 117:245-249. [PMID: 27530310 DOI: 10.1007/s13760-016-0689-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Accepted: 08/05/2016] [Indexed: 10/21/2022]
Abstract
Myasthenia gravis (MG) is one of the curable neurologic disorders. Various pharmacological therapies are administered for these patients and a thymectomy plays an important role in the therapy of myasthenia gravis, which develops a permanent or relative remission. We investigated the efficacy of intravenous immunoglobulin (IVIG) and plasma exchange (PLEX) as a preparation before thymectomy in patients with MG. This randomized clinical trial was conducted on 24 patients with MG referred for thymectomy, which were randomized to two groups of IVIG and PLEX. The IVIG group received IVIG 1 g/kg/day for two consecutive days and the PLEX group underwent 1-L plasma exchange five times with 5 % albumin replacement fluid, every other day, 10-30 days before the procedure. The duration of hospitalization (day), length of intensive care unit (ICU) stay after surgery (day), length of intubation period (h), duration of surgery (h) and dose of steroid administered were compared between the two groups. Analysis was performed via SPSS version 20. In the PLEX group, post-operative outcomes (duration of hospitalization, ICU length of stay after surgery, intubation period and duration of surgery) were longer than those in the IVIG group. There was significant difference in intubation period (p value = 0.01) and duration of surgery (p value = 0.05) between the PLEX and IVIG groups. The administration of IVIG in comparison to PLEX can be more effective in the preparation before thymectomy in myasthenia gravis patients.
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Kaufman AJ, Palatt J, Sivak M, Raimondi P, Lee DS, Wolf A, Lajam F, Bhora F, Flores RM. Thymectomy for Myasthenia Gravis: Complete Stable Remission and Associated Prognostic Factors in Over 1000 Cases. Semin Thorac Cardiovasc Surg 2016; 28:561-568. [DOI: 10.1053/j.semtcvs.2016.04.002] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/11/2016] [Indexed: 11/11/2022]
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Diaz A, Black E, Dunning J. Is thymectomy in non-thymomatous myasthenia gravis of any benefit? Interact Cardiovasc Thorac Surg 2013; 18:381-9. [PMID: 24351507 DOI: 10.1093/icvts/ivt510] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was if thymectomy in non-thymomatous myasthenia gravis was of any benefit? Overall, 137 papers were found using the reported search, of which 16 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. The outcome variables were similar in all of the papers, including complete stable remission (CSR), pharmacological remission, age at presentation, gender, duration of symptoms, preoperative classification (Oosterhius, Osserman or myasthenia gravis Foundation of America (MGFA)), thymic pathology, preoperative medications (steroids, immunosuppressants), mortality and morbidity. We conclude that evidence-based reviews have shown that relative rates of thymectomy patients compared with non-thymectomy patients attaining outcome indicate that the former group of patients is more likely to achieve medication-free remission, become asymptomatic and clinically improve (54%, P < 0.01), particularly patients with severe and generalized symptoms (P = 0.007). Patients with generalized myasthenia gravis showed 11% stronger association with favourable outcomes after thymectomy. Some studies show early remission rates (RRs), as early as 6 months post-thymectomy, of 44%. Overall, the reported remission rate for non-thymomatous myasthenia gravis is between 38 and 72% up to 10 years of follow-up. Among these patients, those with thymic hyperplasia show the best complete stable remission rates (42%, P < 0.04) in the majority of studies. Age showed variability across the studies and the cut-off was also different among them. Overall age < 45 years showed a higher probability of achieving complete stable remission during follow-up (81% benefit rate (BR), P < 0.02). Pharmacological improvement is reported between 6 and 42%. However, the certainty of these benefits has not been established due to factors such as the confounding differences between myasthenia gravis patients receiving and not receiving thymectomy, the non-randomized nature of class II studies and the lack of Class I evidence to support its use. There is currently a randomized trial ongoing looking at thymectomy by sternotomy vs controls and the results are eagerly awaited.
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Affiliation(s)
- Andres Diaz
- Department of Cardiothoracic Surgery, John Radcliffe Hospital, Oxford, UK
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Su C, Su Y, Chou CW, Liu W, Zou J, Luo H, Chen Z. Intravenous flurbiprofen for post-thymectomy pain relief in patients with myasthenia gravis. J Cardiothorac Surg 2012; 7:98. [PMID: 23020939 PMCID: PMC3493291 DOI: 10.1186/1749-8090-7-98] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2012] [Accepted: 09/23/2012] [Indexed: 12/24/2022] Open
Abstract
Background Post-thymectomy pain in myasthenia gravis (MG) patients can inhibit breathing and coughing. Inappropriate usage of analgesics may exacerbate respiratory inhibition and even cause myasthenic crisis. Flurbiprofen is a non-steroidal anti-inflammatory drug (NSAID) that is commonly used to control moderate postoperative pain and is not associated with respiratory inhibition. We hypothesized that flurbiprofen may provide post-thymectomy pain relief without increasing the risk of complications in MG patients. Methods Two hundred MG patients underwent extended thymectomy from March 2006 to December 2010 and were randomly allocated to a flurbiprofen group (110 patients, 50 mg intravenous flurbiprofen axetil) or a control group (90 patients, 100 mg intramuscular tramadol) as postoperative analgesia. Visual analog scale (VAS) pain score, heart rate, blood pressure, respiratory rate, pulse oximetry (SpO2), and adverse effects were recorded before and up to 24 h after drug administration. Results There were no significant differences in the preoperative clinical characteristics of the flurbiprofen and control (tramadol) groups. Both flurbiprofen and tramadol significantly alleviated post-thymectomy pain (p < 0.05 for both), but patients in flurbiprofen group had significantly lower VAS pain scores at 0.5 h, 2 h, 4 h, and 8 h after surgery (p < 0.05 for all times). There were no significant post-thymectomy changes of heart rate, respiratory rate, mean arterial blood pressure, or SpO2 in either group at all time points. Conclusions Post-thymectomy intravenous administration of flurbiprofen axetil provides safe and effective analgesia for MG patients.
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Affiliation(s)
- Chunhua Su
- Department of Thoracic Surgery Lung Cancer Research Center, The First Affiliated Hospital, Sun Yat-sen University, No, 58, Zhongshan Road 2, Guangzhou, Guangdong, 510080, People's Republic of China.
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Wang Q, Xu Z, Lin B, Lu F, Cui Y. Simultaneous operation for multiple valvular disease and myasthenia in a woman. Heart Lung Circ 2010; 20:130-1. [PMID: 20810314 DOI: 10.1016/j.hlc.2010.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2009] [Revised: 03/02/2010] [Accepted: 07/08/2010] [Indexed: 11/15/2022]
Abstract
Myasthenia gravis is a neuromuscular disorder, and the severe complication of myasthenic crisis is a life-threatening condition, usually induced by stress such as fever, trauma or a surgical procedure. Simultaneous heart surgery and thymectomy in a patient with concomitant heart disease and myasthenia gravis has been previously reported. We report a female patient with rheumatic valvular disease and myasthenia gravis who received triple heart valve surgery and thymectomy simultaneously. In her early recovery, two episodes of myasthenic crisis occurred which were treated promptly with a successful surgical outcome.
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Affiliation(s)
- Qiang Wang
- Department of Cardiothoracic Surgery, Changhai Hospital, 168 Changhai Road, Shanghai 200433, China.
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Ko SF, Huang CC, Hsieh MJ, Ng SH, Lee CC, Lee CC, Lin TK, Chen MC, Lee L. 31P MR spectroscopic assessment of muscle in patients with myasthenia gravis before and after thymectomy: initial experience. Radiology 2008; 247:162-9. [PMID: 18270377 DOI: 10.1148/radiol.2471070591] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To prospectively assess muscle metabolism in myasthenia gravis (MG) patients before and after thymectomy by using phosphorus 31 (31P) magnetic resonance (MR) spectroscopy. MATERIALS AND METHODS With institutional review board approval and informed consent, resting and dynamic (31)P MR spectroscopy were performed in 14 healthy volunteers (five men, nine women; mean age, 33 years; range, 23-48 years) and 16 MG patients (six men, 10 women; mean age, 37 years; range 18-50 years) before and after thymectomy. Patients were stratified into groups according to the modified Osserman classification: mild-MG group (classes I-IIA) and moderate-to-severe-MG group (classes IIB-IV). Variables compared among the three groups (Kruskal-Wallis test) included the inorganic phosphate (P(i))-adenosine triphosphate (ATP) (P(i)/ATP) ratio, phosphocreatine (PCr)-ATP (PCr/ATP) ratio, P(i)/PCr ratio, muscle pH at resting and at end-exercise ( 31)P MR spectroscopy, rate constant for PCr recovery (k(PCr)), and maximum oxidative capacity (V(max)). These variables were also compared in MG patients before and after thymectomy (Wilcoxon signed rank test). RESULTS There were no significant differences in resting P(i)/ATP, PCr/ATP, and P(i)/PCr ratios and resting muscle pH among the three groups (control group, 14; mild-MG group, nine; moderate-to-severe-MG group, seven). Comparison of the control group with the mild-MG group and comparison of the mild-MG group before thymectomy with the mild-MG group after thymectomy showed no significant differences in end-exercise P(i)/ATP, PCr/ATP, and P(i)/PCr ratios; end-exercise muscle pH; k(PCr); and V(max). Compared with the control and mild-MG groups, the moderate-to-severe-MG group had significantly higher end-exercise P(i)/ATP and P(i)/PCr ratios and significantly lower end-exercise muscle pH, k(PCr), and V(max) before thymectomy (P < or = .001), but these values showed significant restoration to normal after thymectomy (P = .018). CONCLUSION Mild-MG group patients have muscle oxidative metabolism similar to that of healthy control subjects, whereas moderate-to-severe-MG group patients have impaired V(max) during exercise and a noticeable shift to glycolytic metabolism, but these abnormalities are reversible after thymectomy.
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Affiliation(s)
- Sheung-Fat Ko
- Department of Radiology, Chang Gung University, College of Medicine, Chang Gung Memorial Hospital-Kaohsiung Medical Center, Kaohsiung, Taiwan.
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Mediastinum. Surgery 2008. [DOI: 10.1007/978-0-387-68113-9_76] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Chan KH, Cheung RTF, Mak W, Ho SL. Nonthymoma early-onset- and late-onset-generalized myasthenia gravis—A retrospective hospital-based study. Clin Neurol Neurosurg 2007; 109:686-91. [PMID: 17644246 DOI: 10.1016/j.clineuro.2007.05.023] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2007] [Revised: 05/28/2007] [Accepted: 05/30/2007] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Acquired myasthenia gravis (MG) is predominantly due to nicotinic acetylcholine receptor (AChR) autoantibodies (Ab). Differences between nonthymoma early-onset and late-onset MG were reported. We studied the clinical and serological characteristics of nonthymoma AChR Ab-positive-generalized MG patients. PATIENTS AND METHODS Chinese AChR Ab-positive-generalized MG patients who had generalized disease for 3 years or longer were studied. RESULTS Among 41 such patients, 25 (61%) were female. The mean onset age was 43.5 years (range 9-78 years) and the mean follow-up duration was 7.8 years (range 3-20 years). Sixteen (39%) patients had late-onset disease (onset age >or=50 years). Compared to early-onset patients (onset age <50 years), late-onset patients were characterized by male predominance (p=0.002), absence of thymic lymphofollicular hyperplasia (p=0.036), and a higher striated muscle Ab seropositivity rate (94% versus 4%, p<0.001). Although there was no statistically significant difference in clinical severity and outcome or response to treatment between late-onset and early-onset patients, 50% and 75% of late-onset patients had moderate or severe disease at onset and worst status, respectively, compared to 28% and 52% for early-onset patients at onset and worst status, respectively. Also 63% of late-onset patients had disease progressed within first 3 years compared to only 40% of early-onset patients did. CONCLUSION Nonthymoma late-onset-generalized MG patients were common among Hong Kong Chinese, with a statistically non-significant trend that it was clinically more severe than early-onset MG but with similar clinical outcome or response to treatment; >90% of these patients were seropositive for striated muscle Ab.
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Affiliation(s)
- K H Chan
- Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China.
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16
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Kim HK, Park MS, Choi YS, Kim K, Shim YM, Han J, Kim BJ, Kim J. Neurologic outcomes of thymectomy in myasthenia gravis: Comparative analysis of the effect of thymoma. J Thorac Cardiovasc Surg 2007; 134:601-7. [PMID: 17723805 DOI: 10.1016/j.jtcvs.2007.05.015] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2007] [Revised: 05/01/2007] [Accepted: 05/11/2007] [Indexed: 11/18/2022]
Abstract
OBJECTIVES The objectives of this study were to compare the clinical features and the outcomes after thymectomy between patients with and without thymoma and to evaluate the influence of thymectomy on the subsequent clinical course of myasthenia gravis. METHODS Between 1995 and 2003, 64 consecutive patients underwent thymectomy, and of these, 60 patients were followed up for at least 12 months postoperatively. The study population was divided into 2 groups based on the presence of thymoma. We performed a retrospective analysis to compare the neurologic outcomes of thymectomy between patients with thymomatous myasthenia gravis and those with nonthymomatous myasthenia gravis. RESULTS Twenty-four patients had a thymoma. No significant differences were observed between the 2 groups regarding the preoperative severity of myasthenia gravis. There was no significant difference in the follow-up duration between the 2 groups. There was no significant difference in the overall remission rate between the 2 groups (P = .064). The mean time required to reach a remission was 10.6 months and 23.5 months in the thymoma and nonthymoma groups, respectively. The mean duration of remission was 43.1 months and 30.8 months in the thymoma and nonthymoma groups, respectively. In the early phase of follow-up, more patients reached remission in the thymoma group than those in the nonthymoma group (P = .040). CONCLUSIONS Neurologic outcomes of the thymoma group were no worse than those of the nonthymoma group. It is expected that earlier thymectomy is likely to result in a better prognosis by shortening the disease period, even for patients with nonthymomatous myasthenia gravis.
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Affiliation(s)
- Hong Kwan Kim
- Department of Thoracic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
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17
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Yuan HK, Huang BS, Kung SY, Kao KP. The effectiveness of thymectomy on seronegative generalized myasthenia gravis: comparing with seropositive cases. Acta Neurol Scand 2007; 115:181-4. [PMID: 17295713 DOI: 10.1111/j.1600-0404.2006.00733.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To investigate the efficacy of thymectomy between patients with seronegative myasthenia gravis (SNMG) and seropositive myasthenia gravis (SPMG). METHODS We present here the first Taiwanese retrospective paired cohort study comparing the effectiveness of thymectomy among 16 seronegative and 32 seropositive MG patients after matching for age-of-onset and time-to-thymectomy, and following up over a mean of 35 +/- 20 (7-86) months. Clinical characteristics and complete stable remission (CSR) rates were compared and analyzed between the groups. RESULTS There were no major clinical differences between the two groups except for our finding of a lower percentage of SNMG receiving preoperative plasmapheresis or human immunoglobulin than SPMG (31% for SNMG vs 72% for SPMG, P = 0.007). CSR rates calculated using the Kaplan-Meier method were similar in the two groups (38% for SNMG vs 50% for SPMG, P = 0.709). The median time for CSR was 47.4 months for SNMG and 48.2 months for SPMG. Thymic hyperplasia were the most common pathology (69% for SNMG vs 88% for SPMG, P = 0.24). During the follow-up period, we found no group difference on prednisolone or pyridostigmine dosages. Significant postoperative dosage reductions on pyridostigmine, but not on prednisolone, were found in both groups. CONCLUSIONS Thymectomy has a comparable response among SNMG and SPMG in our study. Thymic hyperplasia is prevalent in our SNMG patients and thymectomy may also be a therapeutic option to increase the probability of remission or improvement in SNMG. More prospective controlled trial will be helpful in the future.
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Affiliation(s)
- H K Yuan
- Neurological Institute, Taipei Veterans General Hospital, National Yang-Ming Univresity School of Medicine, Taipei, Taiwan
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19
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Kattach H, Anastasiadis K, Cleuziou J, Buckley C, Shine B, Pillai R, Ratnatunga C. Transsternal Thymectomy for Myasthenia Gravis: Surgical Outcome. Ann Thorac Surg 2006; 81:305-8. [PMID: 16368387 DOI: 10.1016/j.athoracsur.2005.07.050] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2004] [Revised: 07/15/2005] [Accepted: 07/18/2005] [Indexed: 11/20/2022]
Abstract
BACKGROUND Transsternal thymectomy is well established in the treatment of myasthenia gravis. Surgical strategy and patient selection, however, remain controversial. This paper reports the experience of a supraregional center looking into the influence of different preoperative risk factors on surgical outcome. METHODS Between 1987 and 1998, 85 consecutive patients (65 female; mean age, 30.5 years) were enrolled. The mean preoperative Myasthenia Gravis Foundation of America stage was 2.3. The preoperative, early, and late follow-up data were analyzed retrospectively. RESULTS Mean follow-up was 4.5 years (range, 1 to 14; 376 follow-up years). Mean duration of disease before surgery was 31 months. There were no operative or late deaths. Eight patients had major complications. Seventy-two patients were free from any early or late morbidity. Immunosupression therapy patients were more prone to have complications. At their last visit, 15 patients (17%) were in complete remission; 67 reported clinical improvement. Sixty-three were asymptomatic or in stage I on no or minimal treatment. Remission and clinical improvement were not predicted by patient's age, sex, duration of disease prior to surgery, thymic pathology, or antiacetylcholine receptor antibodies titer. Greater severity of symptoms before surgery was associated with greater subsequent improvement. Remission at 1 year predicted remission at the end of follow-up. CONCLUSIONS Transsternal thymectomy for myasthenia gravis is safe and effective. It benefits most patients, especially those with severe symptoms. The long interval from diagnosis to surgery demonstrates it is never too late for thymectomy.
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Affiliation(s)
- Hassan Kattach
- Department of Cardiothoracic Surgery, John Radcliffe Hospital, Oxford, United Kingdom
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20
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Téllez-Zenteno JF, Cardenas G, Estañol B, Garcia-Ramos G, Weder-Cisneros N. Associated conditions in myasthenia gravis: response to thymectomy. Eur J Neurol 2005; 11:767-73. [PMID: 15525299 DOI: 10.1111/j.1468-1331.2004.00968.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
To compare the response of thymectomy in patients with associated conditions (PWAC) and without associated conditions (PWOAC). Comparative, retrospective. 198 patients with the established diagnosis of myasthenia gravis who had a thymectomy between 1987 and 2000, and who were folowed up for at least 3 years. We formed two groups, one with associated conditions and the second without associated conditions. The patients were divided into four groups: (i) patients in remission, (ii) patients with improvement, (iii) patients without changes, and (iv) patients whose condition worsened. Associated conditions (AC) were found in 49 patients (26%). The main associated conditions were hyperthyroidism in 16 patients (33%) hypothyroidism in seven (14%), rheumatoid arthritis in five (10%) and hypothyroidism and Sjogren syndrome in three (6%). Concerning the response of thymectomy, 13 patients WAC showed remission (27%), vs. 54 patients WOAC (39%). Twenty patients WAC showed improvement (41%) vs. 46 WOAC (33%). Thirteen patients WAC had no changes (27%) vs. 37 WOAC (26%). Finally, in three patients WAC their condition worsened (6%) vs. three WOAC (2%). The response to thymectomy was high (69%) in both groups. We did not identify significant differences.
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Affiliation(s)
- J F Téllez-Zenteno
- Department of Neurology, Instituto Nacional de Ciencias Medicas y Nutricion, Salvador Zubiran, Delegacion Tlalpan, Mexico.
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Romi F, Gilhus NE, Varhaug JE, Myking A, Skeie GO, Aarli JA. Thymectomy and antimuscle antibodies in nonthymomatous myasthenia gravis. Ann N Y Acad Sci 2003; 998:481-90. [PMID: 14592917 DOI: 10.1196/annals.1254.062] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
The clinical effect of thymectomy in early- and late-onset myasthenia gravis (MG) and the correlation to MG severity, pharmacological treatment, and antimuscle antibodies were examined in two series of consecutive acetylcholine receptor (AChR) antibody-positive nonthymoma MG patients. The results indicate a benefit of thymectomy in early-onset MG, but no obvious clinical benefit in late-onset MG. The presence of muscle autoantibodies did not influence the outcome of thymectomy in early-onset MG. In late-onset MG, improvement is least likely in patients with titin and/or RyR antibodies. Thymectomy should always be considered shortly after MG onset in early-onset MG patients and might only be considered in late-onset patients who have early-onset-like immunological characteristics.
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Affiliation(s)
- Fredrik Romi
- Department of Neurology, Haukeland University Hospital, N-5021 Bergen, Norway.
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22
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Abstract
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.
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Affiliation(s)
- Alfred Jaretzki
- College of Physicians and Surgeons, Columbia University, Department of Surgery, Columbia Presbyterian Medical Center, New York, NY, USA.
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23
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Romi F, Gilhus NE, Varhaug JE, Myking A, Skeie GO, Aarli JA. Thymectomy and anti-muscle autoantibodies in late-onset myasthenia gravis. Eur J Neurol 2002; 9:55-61. [PMID: 11784377 DOI: 10.1046/j.1468-1331.2002.00352.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Thymectomy is still widely carried out in myasthenia gravis (MG) patients, but its role, especially in late-onset MG patients, is not established. These patients are immunologically heterogeneous, some with thymoma-like and others with early onset-like features. We evaluated whether any therapeutic effects of thymectomy correlate with the presence of non-acetylcholine receptor (AChR) muscle antibodies. The severity of MG, and titin and ryanodine receptor (RyR) antibodies, were assessed yearly starting from MG onset in 21 thymectomized and 22 non-thymectomized AChR antibody positive late-onset MG patients, who were followed for 2, 3 and 5 years. Clinical or pharmacological remission were seen in six of 11 titin antibody negative but none of the 10 titin antibody positive thymectomized patients, however, the non-thymectomized cases showed an opposite trend. The three MG-related deaths were all in patients with titin antibodies. There was no significant difference in MG severity between thymectomized and non-thymectomized patients; 2 years after MG onset, both groups were significantly improved. This study showed no dramatic benefit from thymectomy in late-onset MG in general. Any limited improvement appeared less likely in cases with titin and/or RyR antibodies.
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Affiliation(s)
- F Romi
- Department of Neurology, Haukeland University Hospital, Bergen, Norway.
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León Atance P, González Aragoneses F, Moreno Mata N, García Fontán E, León Medina D, Naranjo Gómez J, Muñoz Blanco J, Orusco Palomino E, Folqué Gómez E. [Thymectomy in myasthenia gravis]. Arch Bronconeumol 2001; 37:235-9. [PMID: 11412515 DOI: 10.1016/s0300-2896(01)75060-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To analyze outcome after thymectomy in patients with myasthenia gravis (MG). MATERIAL AND METHODS Thirty-five patients with MG underwent surgery in our service between June 1987 and June 1998. Ten had associated thymomas. Preoperative Osserman classification showed 2 at level I, 20 at level IIA, 11 at level IIB and 2 at level III. Extended thymectomy through a medial sternotomy was performed in all. RESULTS Postoperative complications developed in three patients (1 medullary aplasia, 1 postoperative reintubation, 1 myasthenic crisis). Mean follow-up was 89 months, with 22.8% achieving complete remission and 97.1% reporting improvements. The results were similar in the 10 patients with thymomas (20% full remission and 90% showing improvement). By DeFilippi classification, 22.8% were in class 1, 22.8% in class 2, 51.4% in class 3 and 2.8% in class 4. By Osserman classification, 9 were in the same category before and after surgery, 12 had improved one level, 10 had improved 2 levels, 3 had improved 3 levels and 1 patient had improved 4 levels. CONCLUSION Thymectomy is an appropriate therapeutic procedure in the multidisciplinary treatment of patients with MG and it is the approach of choice for patients with associated thymomas. The intra- and post-operative complication rate is low and the rate of clinical improvement is high.
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Affiliation(s)
- P León Atance
- Cirugía Torácica. Hospital General Universitario Gregorio Marañón. Madrid
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25
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Vázquez-Pelillo J, Gil Alonso J, Díaz-Agero P, García Sánchez-Girón J, Roca Serrano R, Díez Tejedor E, Casillas Pajuelo M. [Prognostic factors and outcome of thymectomy in 80 cases of myasthenia gravis]. Arch Bronconeumol 2001; 37:166-70. [PMID: 11412500 DOI: 10.1016/s0300-2896(01)75045-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To analyze the results of thymectomy in our series of patients with myasthenia gravis (MG) and to study the influence of the most common prognostic factors. MATERIAL AND METHODS Eighty MG patients over a period of 23 years underwent thymectomy consecutively in our hospital. Preoperative assessment included clinical evaluation of muscle weakness, edrophonium testing, electromyography, lung function testing, chest X-rays and CAT scans. Symptoms were assessed by the Osserman scale. The surgical approach was amplified transsternal thymectomy. The prognostic factors studied were sex, age, clinical stage, duration of disease before surgery and histology of the thymus. Clinical outcome was assessed using Millichap and Dodge's criteria. Follow-up was by the chest surgery and neurology departments. RESULTS Complete remission was observed in 29 cases (36.2%) and significant improvement in 42 (52.5%). Complications developed in 9 patients (11.2%). Most patients were women (53/27) and outcomes for men and women were not statistically different. Mean age was 36 years (range 11-79), with no significant difference in outcome for patients who were older or younger than 60 years of age. Nor were differences evident related to presurgical clinical stage or levels of severity (I + IIa/IIb + III). Differences in outcome were highly significantly related to duration of disease (< 24 / > 24 months) (p = 0.0022), such that outcome was more satisfactory when the pre-surgical course of disease was shorter, provided that no thymoma was present. CONCLUSIONS Amplified transsternal thymectomy was safe and effective for those patients with MG. When disease had been present for less than two years, the prognosis was better.
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Affiliation(s)
- J Vázquez-Pelillo
- Servicios de Cirugía Torácica. Hospital Universitario La Paz. Madrid
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26
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Abt PL, Patel HJ, Marsh A, Schwartz SI. Analysis of thymectomy for myasthenia gravis in older patients: a 20-year single institution experience. J Am Coll Surg 2001; 192:459-64. [PMID: 11294402 DOI: 10.1016/s1072-7515(01)00795-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Thymectomy has become recognized as an integral element in the care of the patient with myasthenia gravis. Although the number of elderly patients with myasthenia is substantial, little data exist demonstrating the efficacy and morbidity of thymectomy in this population. STUDY DESIGN We retrospectively analyzed 126 cervicomediastinal thymectomies performed at a single university hospital from 1980 to 1998. Patients 55 years or older were compared with those less than 55. Efficacy was measured by determining the change in Osserman score, the rate of remission during followup, and the reduction in medication requirements after thymectomy. RESULTS Older patients (n = 28) had similar Osserman scores (p = 0.8) and similar rates of complete and partial remission as the younger group (n = 98) at a mean +/- SEM followup of 58 +/- 5 months. The two groups did not differ in the number (p = 0.4) and doses of medications used to control myasthenic symptoms after operation. Older age was associated with an increased length of hospitalization (13.8 +/- 3.2 days versus 9.7 +/- 0.6 days, p = 0.05) and a higher incidence of reintubation, and longer ventilatory support (2.6 +/- 1.3 days versus 0.1 +/- 0.1 days, p = 0.001). CONCLUSIONS Increased age does not alter the outcomes of thymectomy for myasthenia gravis. Older patients can expect to have similar responses and require a similar number of postoperative medications as younger patients, but with a higher short-term morbidity.
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Affiliation(s)
- P L Abt
- Department of Surgery, The University of Rochester School of Medicine and Dentistry, NY, USA
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27
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Mediastinum. Surgery 2001. [DOI: 10.1007/978-3-642-57282-1_58] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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28
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Nieto IP, Robledo JP, Pajuelo MC, Montes JA, Giron JG, Alonso JG, Sancho LG. Prognostic factors for myasthenia gravis treated by thymectomy: review of 61 cases. Ann Thorac Surg 1999; 67:1568-71. [PMID: 10391256 DOI: 10.1016/s0003-4975(99)00310-0] [Citation(s) in RCA: 62] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Medical treatment for myasthenia gravis (MG) involves the use of anticholinesterase agents, immunosuppressive drugs, plasmapheresis, and gamma-globulin. However, these agents result in a complete clinical remission rate as low as 15%. As a consequence, thymectomy, preferably by transsternal approach, has become increasingly accepted as an efficacious procedure for MG, with reported complete clinical remission rates as high as 80%. METHODS We have the clinical records of 61 patients diagnosed with MG at La Paz University Hospital, Madrid, Spain, from January 1977 to December 1994. All patients underwent thymectomy. The purpose of this investigation was to determine the major prognostic factors predicting MG outcome after operation. RESULTS Our results indicate that patients with a length of the disease from onset to operation shorter than 8 months have the best prognosis. Ossermann stages I and III are also associated with higher complete clinical remission rates. In contrast, neither age nor sex were found to be significantly related to MG outcome after thymectomy, although female patients have better prognosis than men, and the younger the patient the more likely is complete clinical remission. Pathologic findings after the operation were not found to be of prognostic value either. CONCLUSIONS We conclude that thymectomy is a beneficial procedure for MG patients, with a complete clinical remission rate of 46% at 5 years postoperatively in our series. Therefore we advocate thymectomy for MG patients as early as possible in the course of disease because time elapsed from diagnosis to operation is the main determinant of the outcome.
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Affiliation(s)
- I P Nieto
- Department of General and Digestive Surgery, La Paz University Hospital, Madrid, Spain.
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29
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Tsuchida M, Yamato Y, Souma T, Yoshiya K, Watanabe T, Aoki T, Hayashi J. Efficacy and safety of extended thymectomy for elderly patients with myasthenia gravis. Ann Thorac Surg 1999; 67:1563-7. [PMID: 10391255 DOI: 10.1016/s0003-4975(99)00167-8] [Citation(s) in RCA: 43] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The number of elderly patients who are diagnosed as myasthenia gravis (MG) is increasing in Japan. Although several factors affecting thymectomy have been well documented, few studies have focused on the efficacy and safety of thymectomy for elderly patients older than 60 years. METHODS We evaluated 94 patients with MG who underwent extended thymectomy, and divided them into two groups: patients younger than 59 years and patients older than 60 years. Preoperative patient data, pathology of the thymus, complications, and clinical outcome were evaluated. RESULTS In 69 young patients and 25 elderly patients, we observed no significant differences between the two groups with regard to preoperative data. Thymic hyperplasia was present in 45% of the young group and 16% of the elderly group. Remission and improvement rate were 40% and 57% in the young group and 8% and 75% in the elderly group, respectively. There were no serious complications, except one early death due to gastrointestinal bleeding in the elderly group. CONCLUSIONS We conclude that thymectomy is a safe and effective alternative for elderly patients with MG.
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Affiliation(s)
- M Tsuchida
- Department of Thoracic and Cardiovascular Surgery, Niigata University School of Medicine, Japan
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30
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Abstract
Transcervical thymectomy is appropriate for managing carefully selected patients with myasthenia gravis due to its noninvasive nature, good cosmetic results, and favorable long-term outcomes. Contraindications to its use include the presence of a thymoma and advanced age. In optimally prepared patients, the operative complication rate is negligible and the average length of hospital stay is 1 to 2 days. The ultimate results of therapy often are not evident for several years postoperatively, indicating that comprehensive preoperative and postoperative treatment by a qualified neurologist is essential in optimizing outcomes. A meta-analysis of long-term results shows that 90% of patients who undergo the operation are improved, 80% become asymptomatic, and 50% achieve a complete remission.
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Affiliation(s)
- M K Ferguson
- Department of Surgery, The University of Chicago, IL 60637, USA
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31
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Yim AP, Kay RL, Izzat MB, Ng SK. Video-assisted thoracoscopic thymectomy for myasthenia gravis. Semin Thorac Cardiovasc Surg 1999; 11:65-73. [PMID: 9930715 DOI: 10.1016/s1043-0679(99)70022-5] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Thymectomy is an established therapy in the management of generalized myasthenia gravis, in addition to medical treatment. However, the optimal surgical approach to thymectomy has remained controversial. There are advocates for transternal, transcervical approaches or "maximal" thymectomy. Video-assisted thoracic surgery (VATS) presents a new approach to thymectomy and forms the basis of this article, in which we discuss patient selection, technique, and results. We believe complete thymectomy, comparable with the transternal approach, could be achieved by VATS. Our intermediate-term results compare well with other surgical techniques. By minimizing chest wall trauma, VATS not only causes less postoperative pain, shortens hospital stay, gives better cosmetic results but also leads to wider acceptance by patients (and their neurologists) for earlier surgery. However, the true role of this approach in thoracic surgery awaits long-term results.
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Affiliation(s)
- A P Yim
- Department of Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, Shaitin, New Territories
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32
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Hopkins MA, Azimuddin K, Steichen F. Thoracoscopic thymectomy for myasthenia gravis. MINIM INVASIV THER 1999. [DOI: 10.3109/13645709909153133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Abstract
A consistent, planned approach to thymectomy for patients with myasthenia gravis has been used at the University of North Carolina since 1977. This involves a sternotomy, with excision of the entire thymus and adjacent fatty tissues from the thyroid to the diaphragm and laterally to 1 cm from each phrenic nerve. Between 1977 and 1993, 100 consecutive patients were treated in this manner with no mortality. Eight-four percent of patients were extubated in the operating room or within 1 hour of surgery, and no patients experienced postoperative respiratory difficulty. After a mean follow-up of 65 months, 78% of all patients improved by at least one modified Osserman classification, and 69% of patients with preoperative class I, II, or III disease (maximal preoperative severity) are in pharmacological remission. We conclude that transsternal thymectomy is associated with minimal morbidity and no mortality, and results in long-term improvement in symptoms for patients with myasthenia gravis.
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Affiliation(s)
- W Scott
- Division of Cardiothoracic Surgery, University of North Carolina School of Medicine, Chapel Hill, USA
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Loscertales J, Jiménez Merchán R, Arenas Linares CJ, García Díaz F, Girón Arjona JC, Congregado Loscertales M, Martínez Parra C, Izquierdo Ayuso G. [The treatment of myasthenia gravis by video thoracoscopic thymectomy. The technic and the initial results]. Arch Bronconeumol 1999; 35:9-14. [PMID: 10047914 DOI: 10.1016/s0300-2896(15)30318-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
The primary role of thymectomy for the treatment of myasthenia gravis is currently undisputed. Traditionally, the approach of choice has been sternotomy, although a transcervical route has also been advocated because of its lower rate of associated morbidity. Our department performed thymectomy using a video-assisted thoracoscopic technique in 7 patients (2 men and 5 women) between March 1993 and October 1995. The patients' mean age was 43.4 years (range 20 to 66 years). Complications were few, consisting of 2 cases of pneumothorax due to contralateral opening of the pleura, resolved by pleural drainage. No deaths occurred. Clinical results over periods of observation ranging from 14 to 44 months were excellent in 2 cases of complete remission; good in 3 patients with considerable reduction in drug requirements; and fair in 2 patients who continued to need the same doses of medication throughout the 14 months after thymectomy. The technique we propose is less aggressive than mid-sternotomy, offering incontrovertible advantages and leading to faster. No patient required assisted ventilation for longer than 4 hours and the maximum time spent in the intensive care unit was 24 hours. We therefore suggest that thymectomy to treat myasthenia gravis be performed by thoracoscopy.
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Affiliation(s)
- J Loscertales
- Servicio de Cirugía General y Torácica, Hospital Universitario Virgen Macarena, Sevilla.
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Abstract
The pathophysiological role of the thymus in myasthenia gravis, and the mechanism of therapeutic effect of thymectomy, are incompletely understood. Nevertheless, thymectomy is a valuable treatment modality in selected patients with generalised myasthenia gravis. There are several types of thymectomy operation, but no one operative approach is clearly superior to the others. Total removal of the thymus gland is essential. Additional excision of associated mediastinal and cervical tissue, that may harbor ectopic thymic rests, is a controversial surgical issue. Surgeons that advocate thymectomy through small, cosmetically favourable, incisions usually believe that simple removal of the thymus gland is an adequate operation. Surgeons that emphasise the importance of removing extrathymic tissue, in addition to the thymus gland, usually favour greater operative exposure through a median sternotomy. To minimise operative morbidity, surgery for myasthenia gravis requires a multidisciplinary (neurology, surgery, anaesthesia) approach to peri-operative care.
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Affiliation(s)
- J D Urschel
- Department of Thoracic Surgery, Roswell Park Cancer Institute, Buffalo, NY 14263-0001, USA
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O'Riordan JI, Miller DH, Mottershead JP, Pattison C, Hirsch NP, Howard RS. Thymectomy: its role in the management of myasthenia gravis. Eur J Neurol 1998; 5:203-209. [PMID: 10210833 DOI: 10.1046/j.1468-1331.1998.520203.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The management and clinical course of patients with myasthenia gravis admitted to a neurological intensive therapy unit (ITU) for thymectomy over a 66 month period were reviewed. There were 53 patients, 20 male and 33 female, mean age 35.2 years (18-74) and median ITU stay of 5 days (2-30). Indications for thymectomy were thymic enlargement on computed tomography (34%), persistence of generalized symptoms (38%), a combination of both (20%), steroid side effects or dependency (4%) and progressive bulbar symptoms (4%). Following thymectomy, thymic histology revealed thymic follicular hyperplasia (26/53; 49%), atrophy (11/53; 21%), thymoma (12/53; 23%) and normal thymus (4/53; 8%). Post-operatively 23% required prolonged intubation (> 48 hrs); two patients required a tracheostomy 10 and 13 days post-operatively. Plasma exchange was required for two patients (3.8%) due to persistent severe myasthenic weakness. Three patients (6%) developed a post-operative chest infection and one pseudomembranous colitis. There were no post-operative mortalities during the study period. After 2 years, 35% of patients were in remission and 46% had ocular or mild generalized symptoms only. Thymectomy for myasthenia gravis is followed by sustained clinical improvement in the majority of patients. The appropriate post-operative management of these patients is best undertaken in a specialized neuro-intensive care setting. Copyright Rapid Science Ltd
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Affiliation(s)
- JI O'Riordan
- Department of Clinical Neurology, Batten Harris Unit, The National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
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Mack MJ, Landreneau RJ, Yim AP, Hazelrigg SR, Scruggs GR. Results of video-assisted thymectomy in patients with myasthenia gravis. J Thorac Cardiovasc Surg 1996; 112:1352-9; discussion 1359-60. [PMID: 8911334 DOI: 10.1016/s0022-5223(96)70151-4] [Citation(s) in RCA: 136] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE The efficacy of video-assisted thoracic surgery for thymectomy with myasthenia gravis has not been examined. METHODS Thirty-three consecutive patients underwent total thymectomy by video-assisted techniques between 1992 and 1995. There were 13 male and 20 female patients with a mean age of 38.42 +/- 16.88 years (range 9 to 84 years). The procedures were performed by either a right (n = 11) or left (n = 22) thoracoscopic approach and all anterior mediastinal tissue was removed. RESULTS There was no perioperative mortality or long-term morbidity. One patient required conversion of the video-assisted technique to a lateral thoracotomy. All patients except one were extubated immediately. The mean hospital stay was 4.12 +/- 6.07 days (range 1 to 37 days) with a median of 3 days. Mean follow-up is 23.39 +/- 11.72 months (range 4 to 47 months). Clinical improvement was seen in 87.9% (29/33): one of two patients (50%) in stage I, 17 of 19 (89.4%) in stage IIA, eight of nine (88.8%) in stage IIB, and three of three (100%) in stage III. Metaanalysis of these results compared with results in nine published series in which other techniques were used showed no difference in clinical improvement after thymectomy between series. CONCLUSION We conclude that video-assisted thymectomy is as effective as the traditional open surgical approaches for performance of thymectomy in the management of patients with myasthenia gravis. In addition, the improved cosmesis of the video-assisted approach ideally will lead to earlier thymectomy in patients with myasthenia gravis.
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Affiliation(s)
- M J Mack
- Columbia Hospital at Medical City Dallas, Tex., USA
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Nakamura H, Taniguchi Y, Suzuki Y, Tanaka Y, Ishiguro K, Fukuda M, Hara H, Mori T. Delayed remission after thymectomy for myasthenia gravis of the purely ocular type. J Thorac Cardiovasc Surg 1996; 112:371-5. [PMID: 8751505 DOI: 10.1016/s0022-5223(96)70264-7] [Citation(s) in RCA: 46] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Twenty-two cases of purely ocular myasthenia gravis were reviewed to evaluate the long-term effects of thymectomy. Remission rate increased gradually with time (11.8% at 3 years, 23.1% at 5 years, and 33.3% at 10 years). Analysis of factors influencing remission with time showed that patients with short duration of illness attained remission significantly earlier (p = 0.035 at 5-year follow-up). One of 22 patients with purely ocular myasthenia gravis (4.5%) had disease progression. Because ocular myasthenia gravis often progresses to the generalized type and because duration of illness before operation is one of important factors influencing remission, we conclude that thymectomy in the earlier stages of the disease is the preferred treatment for ocular myasthenia gravis, just as for generalized myasthenia gravis.
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Affiliation(s)
- H Nakamura
- Second Department of Surgery, Tottori University Faculty of Medicine, Yonago, Japan
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Busch C, Machens A, Pichlmeier U, Emskötter T, Izbicki JR. Long-term outcome and quality of life after thymectomy for myasthenia gravis. Ann Surg 1996; 224:225-32. [PMID: 8757388 PMCID: PMC1235346 DOI: 10.1097/00000658-199608000-00017] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE The authors identify criteria suitable to predict long-term clinical improvement and evaluate quality of life after thymectomy for myasthenia. DESIGN Retrospective analysis with long-term follow-up (mean 92 months) was conducted for 86 patients and questionnaire interviews were performed for 65 patients who underwent thymectomy between 1976 and 1993. MAIN OUTCOME MEASURES The authors used the Osserman Score and the European Organization for Research and Treatment of Cancer quality-of-life questionnaire. RESULTS After thymectomy, lasting benefits were achieved predominantly by patients with moderate and severe myasthenia, and this association was significant (p < 0.001) in both bivariable and multiple analyses. No correlation was observed between outcome and thymic pathology, patient age or gender, duration of disease, preoperative plasmapheresis, and medication. Restitution to normal was complete at most recent follow-up as to physical status, working ability, and cognitive and social functions, but some emotional and vegetative deficits remained. CONCLUSION Future patient selection for thymectomy should-apart from those with suspected thymoma-concentrate on patients with moderate and severe myasthenia unresponsive to conservative management.
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Affiliation(s)
- C Busch
- Department of Surgery, University of Hamburg, Germany
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Detterbeck FC, Scott WW, Howard JF, Egan TM, Keagy BA, Starek JK, Mill MR, Wilcox BR. One hundred consecutive thymectomies for myasthenia gravis. Ann Thorac Surg 1996; 62:242-5. [PMID: 8678650 DOI: 10.1016/0003-4975(96)00202-0] [Citation(s) in RCA: 48] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Between June 1997 and November 1993, 100 consecutive thymectomies for myasthenia gravis were performed at University of North Carolina Hospitals in Chapel Hill. METHODS A consistent, planned protocol involving preoperative, intraoperative, and postoperative care was followed. All thymectomies were performed through a median sternotomy with removal of all visible thymus and perithymic fat in the anterior mediastinum. RESULTS There was no perioperative mortality or longterm morbidity. Mean postoperative hospital stay was 6.3 days (range, 3 to 18 days). Ninety-six percent of the patients were extubated the day of the operation, and all patients were extubated within 24 hours. Mean postoperative intensive care unit stay was 1.2 days (range, 1 to 4 days). After a mean follow-up of 65 months (range, 1 to 199 months), 78% of all patients are improved by at least one modified Osserman classification when their current status is compared with their worst preoperative disease severity. In fact, 69% of patients with mild disease preoperatively (class I, II, or III maximal severity) are in pharmacologic remission (asymptomatic without regular medication), whereas 29% of patients with severe disease (class IV or V) are in remission (p = 0.0001). CONCLUSIONS Our programmatic approach to thymectomy through a sternotomy has shown minimal morbidity and mortality. It is beneficial to myasthenics at both ends of the age and severity spectrum.
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Affiliation(s)
- F C Detterbeck
- Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, USA
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Lewis RA, Selwa JF, Lisak RP. Myasthenia gravis: immunological mechanisms and immunotherapy. Ann Neurol 1995; 37 Suppl 1:S51-62. [PMID: 8968217 DOI: 10.1002/ana.410370707] [Citation(s) in RCA: 54] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
This review of the immunological aspects of myasthenia gravis and the immunotherapy of the disease emphasizes the current state of knowledge of the immunological events at the neuromuscular junction, and the immunoregulatory abnormalities noted in myasthenic patients. The treatment modalities available to the clinician are discussed in an attempt to provide information that will allow for a rational approach to therapy.
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Affiliation(s)
- R A Lewis
- Department of Neurology, Wayne State University School of Medicine, Detroit, MI 48201, USA
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