Surgical treatment of myasthenia gravis in two major Middle East teaching hospitals: factors influencing outcome

BACKGROUND

The results of thymectomy on patients with generalised myasthenia gravis have been widely reported. However, there is no information on whether the experience of western countries can be generalised to the population of the Middle East. The purpose of this study was to evaluate the safety and efficacy of thymectomy in patients with myasthenia gravis in a Middle East patient population and to identify clinical and histopathological factors associated with improved long term outcome of surgery.

METHODS

In a prospective study, sixty three patients (aged 1.5-51 years) were treated in two university teaching hospitals between 1984 and 1991 and followed up for a mean of four years. Close communication was established with neurologists to obtain early referral. Radical anterior mediastinal dissection through a median sternotomy was performed in all patients. The response was evaluated by modified Osserman's classification.

RESULTS

Eighteen patients achieved complete remission and a further 39 improved, producing an overall response rate of 90.5%. Patients with milder disease (stage II) had a higher response rate (97%) than those with more advanced disease (78%). Patients operated on with less than three years of symptoms had a better outcome (94%) than those with longer duration of preoperative symptoms, especially in non-thymomatous patients. Age and sex had no effect on the outcome. There was no effect on response rate if patients had hyperplastic or non-specific thymic histological findings, but patients with thymoma fared worse.

CONCLUSIONS

These results are comparable with reports from the western world and represent the first prospective study from the Middle East. Thymectomy is indicated for all patients suffering from generalised myasthenia gravis soon after the diagnosis is made, regardless of age, stage, thymic pathology, and preoperative clinical status.

Mechanical circulatory support during repair of thoracic aortic injuries improves morbidity and prevents spinal cord injury

OBJECTIVE

Evaluation of mechanical circulatory support (MCS) vs simple cross clamping (CC) during repair of traumatic descending thoracic aortic transections.

DESIGN

A retrospective analysis of all patients admitted with blunt traumatic injury to the descending thoracic aorta from August 1988 through March 1993. Patients were pseudorandomized to simple CC vs MCS according to the on-call surgeons' preferences.

SETTING

A level 1 trauma center in Seattle, Wash.

PATIENTS

Forty-two patients were admitted. Thirty (71%) survived, 21 of whom underwent repair with MCS and nine underwent repair with CC only.

INTERVENTION

Prompt aortic repair was performed either primary or by replacement with a Dacron graft.

MAIN OUTCOME MEASURES

Operative survivors were examined for new neurologic deficits, renal function, pulmonary failure, gastrointestinal tract complications, sepsis, and length of hospitalization. Causes of death in all patients were determined.

RESULTS

Twelve patients died, seven before surgery and five during surgery. In survivors, new neurologic deficits occurred in four (44%) of nine patients undergoing repair with CC and in none of the patients undergoing repair with MCS (P = .0005). Mean (+/- SEM) postoperative serum creatinine levels were higher in patients undergoing repair with CC (256 +/- 80 mumol/L [2.9 +/- 0.9 mg/dL]) than in patients undergoing repair with MCS (115 +/- 18 mumol/L [1.3 +/- 0.2 mg/dL]) (P < .05). Patients undergoing repair with CC had longer hospitalization and higher incidence of pulmonary, gastrointestinal, and septic complications, all of which approached statistical significance.

CONCLUSIONS

Mechanical extracorporeal perfusion of the distal aorta during occlusion of the thoracic aorta for traumatic descending thoracic aortic injuries may prevent spinal cord ischemia and reduce postoperative organ dysfunction.

Diagnosis and management of pericardial abscess in trauma patients

Pericardial infection is an uncommon clinical entity after traumatic injury. Although invasive intervention is rarely necessary for mild pericardial inflammation, pericardial abscess can be life-threatening. The charts of 27 patients with pericarditis requiring management in the intensive care unit and/or invasive intervention at Harborview Medical Center during a 10-year period were reviewed. Six cases of trauma-related pericarditis were identified, including three cases of pericardial abscess following torso trauma without initial cardiac or pericardial injury. Pericardial abscess following trauma was associated with the sepsis syndrome and multiple system organ failure (MSOF) in all patients. Computed tomography and pericardiocentesis were useful diagnostic adjuncts. All patients required thoracotomy for pericardial drainage and pericardiectomy. Successful surgical management of pericardial abscess contributed to the resolution of sepsis, multiple end-organ dysfunction and, ultimately, patient survival in all cases. We conclude that pericardial abscess, although rare, should be considered a potential occult site of sepsis capable of driving MSOF in trauma patients. Expedient diagnosis and surgical drainage are essential for successful patient outcome.

Tuberculosis and the surgeon

With the resurgence of active tuberculosis in the United States, surgeons may be called upon to participate in the management of primary tuberculosis as well as major complications of the disease. To define the role of surgery in the diagnosis and treatment of tuberculosis in the 1990s, a 5-year retrospective review of 121 tuberculosis patients requiring invasive procedures in the course of their work-up was performed. Mycobacterium tuberculosis was cultured in 68% of patients, and atypical mycobacteria in 19%. Tissue was required to achieve the definitive diagnosis in 36%. Of the 93 patients with pulmonary evidence of tuberculosis, 54% presented with a pulmonary complication, 19 of whom required operative intervention. Extrapulmonary tuberculosis affected 45% of patients, including nine with miliary tuberculosis. Patients testing seropositive for human immunodeficiency virus accounted for 11% of the patients seen, emphasizing that the re-emergence of tuberculosis is not confined to the immunosuppressed.

Reappraisal of emergency room thoracotomy in a changing environment

The efficacy of resuscitative emergency room thoracotomy (ERT), particularly in blunt injury, has been questioned. Wide application of the procedure may not be cost effective. The risk of exposure and lethal infection to medical personnel during ERT is considerable. For the past decade, the policy at this institution has been to perform ERT on all moribund patients sustaining penetrating torso injury and all patients sustaining blunt injury with any evidence of cardiac electrical activity. To evaluate whether such a liberal policy is currently justified, the charts of all patients undergoing ERT over a 4-year period were reviewed. One hundred twelve patients underwent ERT; 24 (21%) sustained penetrating injury, 88 (79%) blunt injury. The overall survival rate was 1.8%. Penetrating injury had a 4.2% survival and blunt injury 1.1%. No patients with CPR initiated at the scene and required throughout transport survived. In those patients with both blood pressure and spontaneous respirations present in the field, survival rate was 11.8%. Survival rate in patients manifesting sinus rhythm or ventricular fibrillation upon arrival at the ER was 6.4%. No survivors were noted among patients coming to the hospital with an idioventricular rhythm or asystole. The total hospital charges for patients undergoing ERT exceeded reimbursement by $59,565. Screening for HIV and hepatitis could be documented in only two patients; both were negative. Liberal performance of ERT has dismal results, incurs monetary loss, and affords a greater potential for exposure to lethal infection. Emergency room thoracotomy is justified only when vital signs or a resuscitatible cardiac rhythm are present in the field or ER and deteriorate shortly before thoracotomy.(ABSTRACT TRUNCATED AT 250 WORDS)

Empyema thoracis. Factors influencing morbidity and mortality

The effects of delay in surgical treatment and the choice of operation on morbidity associated with empyema thoracis were evaluated in 122 consecutive patients. Patients (71 from a private practice and 51 from an inner-city trauma/indigent care facility) eligible for study were divided into treatment groups of chest tube only (CT = 39) and open drainage (OD = 19), or decortication (DC = 65). Delay in treatment was defined as greater than 3 days from recognition of empyema to CT and greater than 14 days to OD or DC when chest tubes were inadequate or were not used initially. Delay in OD significantly increased total illness (p = 0.023), days until removal of chest tubes (p = 0.037), and hospital stay (p = .048), but did not affect postoperative stay. Delay in DC increased total illness (p = 0.0001), but did not affect other variables. Delay in CT increased mortality from 3.4 percent to 16 percent. Delay did not increase mortality in OD and DC. DC was superior to OD in patients requiring major operation in total illness days (DC = 36.1 vs OD = 106.1) (p = 0.0005), days until removal of tubes (DC = 7.5 vs OD = 78.3) (p = 0.0001), and postoperative stay (DC = 11.6 vs OD = 17.3) (p = 0.018). Overall mortality was lowest in the DC group (6.1 percent). Delay in treatment increases morbidity and DC is more effective than OD in reducing morbidity and mortality when surgical intervention is necessary.

Idiopathic pulmonary fibrosis in adult respiratory distress syndrome. Diagnosis and treatment

Ten consecutive patients who presented initially with adult respiratory distress syndrome, and who did not respond to conventional treatment, underwent open lung biopsy early in the course of their illness. Idiopathic pulmonary fibrosis was diagnosed and aggressive treatment with methylprednisolone sodium succinate and nutritional support was initiated. Eight patients survived and have not required long-term corticosteroid therapy. Previous reports have documented a mortality of greater than 85% with this particular syndrome of idiopathic pulmonary fibrosis in adult respiratory distress syndrome.

Benefits of an intensive community surgical audit program

In addition to educational benefits, an intensive audit program has satisfied Joint Commission on the Accreditation of Hospitals requirements, allowed in-house Professional Standards Review Organization accreditation, increased percentage of surgery performed by qualified surgeons, and led to the establishment of an effective morbidity and mortality conference. Better methods of granting surgical privileges have been developed, and our accumulated statistics have been utilized to assure our local press and public that we are practicing good quality surgery.

Continuing medical education. The philosphy and use of audit

In 55 audits of 37 topics totaling 5,499 patient records, 94% of deficiencies were in the area of performance, while only 6% occurred in the area of lack of knowledge. In addition to defining problems, audit serves as an educational experience and a stimulus to improve practice.

Traumatic avulsion of the trachea associated with cricoid fracture

A 15-year-old girl sustained a cricoid fracture, avulsion of the trachea, and bilateral cord paralysis in a automobile injury. An airway was established by intubation, and primary repair was performed on the day of injury. A postoperative stricture was successfully managed by endoscopic dilatation and injection of triamcinolone into the stricture. Function of one vocal cord appears to be returning 6 months after the injury, and the patient is leading an active life.