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

Watanabe, Atsushi; Watanabe, Toshiaki; Obama, Takuro; Mawatari, Tohru; Ohsawa, Hisayoshi; Ichimiya, Y; Takahashi, Noriyuki; Kusajima, Katsuyuki; Abe, Tomio

doi:10.1016/j.jtcvs.2003.07.036

Cited by 92 publications

(84 citation statements)

References 28 publications

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“…58 A multicenter, single-blind, randomized controlled trial is currently investigating the benefit of thymectomy in non-thymomatous MG. 59 Postoperative myasthenic crisis is common after thymectomy; the incidence ranges from 12% to 34%. 60,61 Postoperative crisis in these patients has been related to a history of myasthenic crisis, preoperative presence of bulbar weakness, preoperative serum AChR antibody levels >100 nmol/L, and intraoperative blood loss of >1 L. 61 …”

Section: Thymectomymentioning

confidence: 99%

Myasthenic Crisis

Wendell

Levine²

2011

The Neurohospitalist

191

193

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Myasthenic crisis is a complication of myasthenia gravis characterized by worsening of muscle weakness, resulting in respiratory failure that requires intubation and mechanical ventilation. Advances in critical care have improved the mortality rate associated with myasthenic crisis. This article reviews the epidemiology of myasthenic crisis and discusses patient evaluation. Therapeutic options including mechanical ventilation and pharmacological and surgical treatments are also discussed.

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Section: Thymectomymentioning

confidence: 99%

Myasthenic Crisis

Wendell

Levine²

2011

The Neurohospitalist

191

193

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“…Co-existing lung disease, Pyridostigmine doses >750 mg/day, a pre-operative forced vital capacity <2.9 L 7 , severe bulbar symptoms and severe myasthenia gravis with previous respiratory crisis and cardiorespiratory disease 8 , a preoperative serum level of anti-acetylcholine receptor antibody >100 nmol/l and intraoperative blood loss >1000 ml were risk factors for postoperative mechanical ventilation 9,10 . Our patient had mild restrictive pulmonary function, a bulbar involvement.…”

Section: Discussionmentioning

confidence: 99%

Postoperative Phrenic Nerve Palsy, A Cause Of Prolonged Mechanical Ventilation In Trans-Sternal Thymectomy

Sharma

2015

J. Kathmandu Med. Coll.

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Post trans-sternal thymectomy, the patient may develop respiratory failure, usually due to myasthenic crisis or cholinergic crisis. These crises may prolong mechanical ventilation and impede on-table extubation. We report a case of respiratory failure due to unilateral phrenic nerve palsy in a case of myasthenia gravis. A 35 year old female, known case of myasthenia gravis was posted for trans-sternal thymectomy. Anaesthesia was induced with Propofol, Fentanyl and low dose of Atracurium. Thymoma was incasing right subclavian vein and was adherent with the pericardium, Masaoka Grade III. Blood loss was approximately 200ml. Immediate post operative period showed low tidal volume, tachypnea and tachycardia in spite of train of four ratio >0.9. Patient was kept intubated with suspicion of myasthenic crisis and the dose of Pyridostigmine was increased, but this lead to increased cholinergic symptoms. Pain was addressed with thoracic epidural analgesia. Chest radiograph done later in the evening showed elevated right hemi diaphragm, thereby, confi rming the diagnosis of phrenic nerve palsy.Diffi cult dissection in this case has resulted in right phrenic nerve palsy. Phrenic nerve palsy has to be considered as a cause of respiratory failure post sternotomy thymectomy, especially in case of Masaoka grade III and IV.

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“…Rapid immunotherapy with plasmapheresis or intravenous immunoglobulin should be performed before thymectomy in patients with preoperative respiratory or bulbar signs. This will help in the postoperative period as well as in reducing preoperatively given corticosteroid levels [44]. Seggia et al [45] showed that plasmapheresis significantly improves respiratory functions and muscle strength in patients with myasthenia treated with thymectomy and significantly reduces hospitalization times.…”

Section: Surgical Methodsmentioning

confidence: 99%

Thymectomy in Myasthenia Gravis

Aydın¹,

Ulaş²,

Mutlu³

et al. 2017

Eurasian J Med

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In recent years, thymectomy has become a widespread procedure in the treatment of myasthenia gravis (MG). Likelihood of remission was highest in preoperative mild disease classification (Osserman classification 1, 2A). In absence of thymoma or hyperplasia, there was no relationship between age and gender in remission with thymectomy. In MG treatment, randomized trials that compare conservative treatment with thymectomy have started, recently. As with non-randomized trials, remission with thymectomy in MG treatment was better than conservative treatment with only medication. There are four major methods for the surgical approach: transcervical, minimally invasive, transsternal, and combined transcervical transsternal thymectomy. Transsternal approach with thymectomy is the accepted standard surgical approach for many years. In recent years, the incidence of thymectomy has been increasing with minimally invasive techniques using thoracoscopic and robotic methods. There are not any randomized, controlled studies which are comparing surgical techniques. However, when comparing non-randomized trials, it is seen that minimally invasive thymectomy approaches give similar results to more aggressive approaches.Keywords: Extended thymectomy, follow-up, myasthenia gravis, thoracoscopic thymectomy ÖZ Miyastenia gravis tedavisinde son yıllarda timektomi giderek yaygınlaşan bir prosedür haline geldi. Preoperatif hafif hastalık sınıflaması (Osserman sınıflaması 1, 2A) olanlarda remisyon ihtimali en yüksek olarak gösterildi. Timoma veya hiperplazi yokluğunda timektomi ile remisyon sağlamada yaş ve cinsiyetin ilişkisi gösterilemedi. Miyastenia gravis tedavisinde timektomi ile konservatif tedaviyi karşılatıran randomize çalışmalar yeni yayınlanmaya başlandı. Nonrandomize çalışmalarda olduğu gibi Miyastenia gravis tedavisinde timektomi ile remisyon, sadece ilaçla konservatif tedaviden daha iyi bulundu. Cerrahi yaklaşım için transservikal, minimal invaziv, transsternal ve kombine transservikal transsternal timektomi olmak üzere dört major yöntem bulunmaktadır. Transsternal yaklaşımla timektomi yıllardır kabul gören standart cerrahi yaklaşımdır. Son yıllarda torakoskopik ve robotik yöntemin kullanıldığı minimal invaziv tekniklerle timektomi sıklığı artmaktadır. Cerrahi teknikleri karşılaştıran randomize, kontrollü çalışmalar bulunmamaktadır. Ancak nonrandimize çalışmalar arasındaki karşılaştırmalara bakıldığında minimal invaziv timektomi yaklaşımlarının daha agresif yaklaşımlara benzer sonuçlar verdiği görülmektedir.

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

Cited by 92 publications

References 28 publications

Myasthenic Crisis

Myasthenic Crisis

Postoperative Phrenic Nerve Palsy, A Cause Of Prolonged Mechanical Ventilation In Trans-Sternal Thymectomy

Thymectomy in Myasthenia Gravis

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