Safety for preoperative use of steroids for transsternal thymectomy in myasthenia gravis☆

Abstract

Objective: Effects of preoperative steroids on morbidity and mortality after transsternal thymectomy are analyzed. Methods: There were 620 transsternal thymectomies for myasthenia gravis performed in the period . There were 547 patients with nonthymomatous myasthenia, including 17 patients submitted to repeated thymectomy (rethymectomy) and 46 patients with thymoma. There were 522 upper median sternotomies performed in the period 1973 -1997 and 98 complete median sternotomies performed in the period 1998-2002 (74 patients without thymoma, 7 thymomas and 17 rethymectomies). One hundred and seventeen of these 620 patients were taking steroids preoperatively. The impact of steroids use on postoperative respiratory insufficiency (ventilator), need for tracheostomy, superficial wound dehiscence, superficial wound suppuration, sternal dehiscence and mortality was analyzed. Results: The rate of morbidity and mortality in the steroids and the no-steroids groups included respiratory insufficiency necessitating the use of a ventilator in 46/503 patients from the nosteroids group (9.1%) and 8/117 patients from the steroids group (6.8%; P ¼ 0:4260), need for tracheostomy in 14/503 patients from the nosteroids group (2.8%) and 3/117 patients from the steroids group (2.6%; P ¼ 0:9054). Complications with wound healing (including sternal dehiscence, superficial wound dehiscence and superficial wound suppuration) occurred in 47/503 (9.3%) patients from the no-steroids group and in 1/117 (0.9%) patient from the steroids group ðP ¼ 0:0023Þ: The overall complications rate was 30.6% (154/503) in the no-steroids group and 11.1% (13/117) in the steroids group ðP ¼ 0:0001Þ: Mortality rate in the no-steroids group was 0.4% (2/503 patients) and none in the steroids group. Morbidity in patients with complete sternotomy was low, respiratory insufficiency in three patients (3.1%), and superficial wound suppuration in one patient (1.0%), no other morbidity and no mortality. Changing morbidity in periods 1973-1980, 1981-1990 and 1991-2002 is analyzed. Conclusions: Preoperative use of steroids for transsternal thymectomy in patients with myasthenia gravis had no negative impact on morbidity and mortality, conversely, the results in patients taking steroids were better, with significant difference of results regarding the overall complication rates and the overall complication rates of wound healing. q

Preoperative Low-Dose Steroid Can Prevent Respiratory Insufficiency After Thymectomy in Generalized Myasthenia Gravis

“…Maximum bleeding in the present study was 175 ml in a patient who has received steroids. ‘Respiratory insufficiency' was defined as restrictive dysfunction requiring mechanical ventilation occurring within 3 days after thymectomy in the absence of other accidental causes of postoperative cardiopulmonary complications, such as pulmonary embolism or severe pneumonia, and a total postoperative mechanical ventilation support time of >24 h [1,4,5,6,7,8,9,10,11]. The effects of anesthetic agents disappeared within a few hours after surgery, but respiratory insufficiency persisted beyond this period.…”

“…The reported incidence of PRI varies, but can be as high as 30-50% [1,2,3]. Preoperative treatment with steroids was previously reported to decrease the risk of PRI (table 1) [1,2,3,4,5,6,7,8,9,10,11] but detailed information on the use of steroids is very limited. Previous studies administered high doses of steroids (80-120 mg) daily or on alternate days before thymectomy [4,5,6,7,11] and included patients with ocular MG [5,6,7].…”

“…Previous studies administered high doses of steroids (80-120 mg) daily or on alternate days before thymectomy [4,5,6,7,11] and included patients with ocular MG [5,6,7]. Many previous studies evaluating the usefulness of preoperative steroids (table 1) [1,4,5,6,7,8,9,10,11] included patients who received other preoperative treatments such as immunosuppressants, intravenous immunoglobulins, or plasmapheresis and showed that preoperative steroid use did not significantly decrease the risk of PRI [1,3,8,9]. Two studies showing that preoperative steroid use was significantly related to PRI included patients with ocular MG or patients who were given occasional steroid pulse therapy before thymectomy [5,6].…”

“…Because high-dose steroids significantly increase the risk of adverse effects such as glucose tolerance [4], osteoporosis [4], cataract [4], the problem of tissue healing [12] or surgical complications such as infection [6,8], we studied patients with generalized MG who had received low-dose steroids before thymectomy to investigate whether low-dose steroids might prevent PRI.…”

Low-Dose Steroid after Thymectomy in Myasthenia Gravis: Is It a Complete Solution for Postoperative Respiratory Insufficiency?

“…Postoperative respiratory insufficiency after thymectomy in Myasthenia gravis (MG) is a critical condition [1]. Currently, preventive strategies like the use of preoperative steroids after thymectomy show controversial results [2].…”