Thymectomy In Myasthenic Patients Research Articles

Thymectomy in Myasthenic Patients With Thymoma: Killing Two Birds With One Stone

Thymoma and myasthenia gravis share several pathogenetic aspects including the role of surgery as a therapeutic option. Extended thymectomy is associated with excellent survival and good local control, especially in early stages, and its role for the neurologic disease has been recently validated. The aim of this study is evaluating oncologic and neurologic outcomes of myasthenic patients with thymoma who underwent extended thymectomy. We retrospectively collected surgical, oncologic, and neurologic data of all myasthenic patients with thymoma who underwent extended thymectomy at our department from January 1994 to December 2016. Clinical and pathologic data, neurologic remission rate, and overall survival and disease-free interval were analyzed. In all, 219 patients underwent extended thymectomy. The B2 histotype was the most represented thymoma (24.2%), and the most prevalent pathologic Masaoka stage was IIB (37.9%). The overall survival and disease-free survival were statistically different between early stage and advanced stage. During the surveillance, 33 patients (15.1%) had recurrences, treated in 21 cases with iterative surgery. Regarding neurologic outcomes, 75 patients (34.2%) reached a complete stable remission, 84 (38.4%) a pharmacologic remission, 51 (23.3%) had an improvement of their symptoms, and in 9 patients (4.1%) myasthenia was unchanged or worsened. Surgery is a cornerstone in the treatment of patients with both thymoma and myasthenia gravis. Extended thymectomy, as proposed by Masaoka, offers considerable oncologic outcomes with an excellent survival and low recurrence rate of thymoma; moreover, surgery leads to remarkable neurologic results.

Use of ProSeal(®) LMA and thoracic epidural in myasthenia patients for trans-sternal thymectomy: A case series.

Myasthenia gravis is an autoimmune disease, resulting from the production of antibodies against the acetylcholine receptors of the neuromuscular endplate. Muscular weakness and fatigability are the hallmarks of myasthenia gravis. Myasthenic patients are sensitive to non-depolarising relaxants and post-operative ventilatory support may be required in high-risk patients. This can be attributed partly to endotracheal intubation and use of intermediate or long-acting muscle relaxants in such cases. The rate of post-operative ventilation after a trans-sternal thymectomy has been reported to be more than 50% in myasthenia gravis patients.[1] Two techniques have been recommended for general anaesthesia in the myasthenic patient. Due to the unpredictable response to succinylcholine and the marked sensitivity to non-depolarising muscle relaxants, some anaesthesiologists avoid muscle relaxants and depend on deep inhalational anaesthesia for tracheal intubation and maintenance of anaesthesia.[2,3] However, others utilise a balanced technique which includes the use of muscle relaxants, without the need for deep inhalational anaesthesia with its concomitant respiratory and cardiovascular side effects, provided neuromuscular transmission is monitored. In this paper, we would like to describe a new and successful technique of using ProSeal® laryngeal mask airway (LMA) with thoracic epidural for three cases who underwent trans-sternal thymectomy. We avoided muscle relaxant during the entire course of surgery and none of our cases required post-operative ventilation.

Anesthetic Management of Myasthenia Gravis: COPD and Asthma Patient

Abstract Introduction Conduction of general anesthesia and perioperative management of the patients with compromised lung functions and myasthenia gravis, presented for major abdominal surgery, pos...

Myasthenia Gravis

Treatment of patients with acquired (autoimmune) myasthenia gravis should rely on evidence-based therapeutic choices, taking into account the individual's needs according to disease severity (mild to severe), extent (ocular or generalized), comorbidities (including other autoimmune diseases, infections, thymoma, and pregnancy), age, iatrogenic factors (the risks and benefits of therapy), patient autonomy and quality of life, financial burden to the patient, and associated health care costs. Therapy is aimed at managing symptoms by improving neuromuscular junction transmission (cholinesterase inhibitors) and/or modifying the underlying immunopathogenetic cause of acquired myasthenia gravis via immunosuppression or immunomodulation. Myasthenic patients with operable thymoma should be referred for surgery and closely followed up for tumor recurrence. A concerted international effort is addressing treatment recommendations for thymectomy in myasthenic patients with no radiologic evidence of thymoma who are positive for circulating acetylcholine receptor antibodies. There is a lack of evidence-based treatment guidelines for both acute and long-term management of ocular myasthenia. Acute management of myasthenic crisis requires intensive monitoring of the patient and institution of an efficient and safe treatment such as plasma exchange. Patient education is essential to a comprehensive long-term treatment plan.

Prospective, randomized comparison of ketorolac vs. Thoracic epidural analgesia with non-muscle relaxant anaesthesia after thymectomy in myasthenic patients

We test the hypothesis that ketorolac or thoracic epidural anaesthesia (TEA) without neuromuscular blockers improves pain control and pulmonary functions after thymectomy in seventy five myasthenic patients. They were randomly allocated received, either a saline placebo (n=25), ketorolac 15 mg, followed by IVI for 7.5 mg.h -1 for 12 hours (n=25), or TEA with 10 mL of bupivacaine 0.5%, followed by 8 mL.h -1 of bupivacaine 0.125% for 12 hours (n=25). Anaesthesia was induced with fentanyl (1.0 μg.kg -1 ) and propofol and maintained with propofol and 67% N2O. Patients receiving ketorolac and TEA had a smaller increase in HR and MAP, lower supplementary doses of fentanyl, shorter emergence and extubation times (P<0.001), and PACU stay, lower respiratory rate, better pain control, for the first 12 postoperative hours, higher PEFR values at 1 and 6 h, and no patient had to be re-intubated postoperatively. Seven patients in TEA group needed IV ephedrine. In conclusion, the use of ketorolac is safe and might be an alternative to TEA in providing excellent intra-operative anaesthesia, early extubation, and postoperative analgesia in myasthenic patients after thymectomy. This article has won the first prize in the competition session during the cardiothoracic symposium in Cairo 12-16Feb 2007

Microscopic thymoma

Microscopic thymoma was first described in 1976 and remains in the latest WHO classification (2004). It defines an epithelial proliferation, with <1 mm in diameter, usually multifocal, that preferentially occurs in patients suffering from myasthenia gravis without a macroscopically evident tumour. A series of 87 thymectomies realised in myasthenic patients between 1992 and 2005 was reviewed. We describe three cases of microscopic thymoma: two male and one female with an average age of 41.6 years. All patients suffered from myasthenia gravis positive for acetylcholine receptor antibodies without any tumour detectable on chest tomodensitometric examination. Thymectomy was performed in all cases, enlarged to the mediastinal fat in one. Microscopic examination revealed three type-A microscopic thymoma, one multifocal, associated with lymphoid hyperplasia in two cases. After surgery, all patients had clinically improved. In summary, chest computed tomography is unable to detect microscopic thymoma. Histological examination of the entire specimen is indicated after thymectomy in myasthenic patients even if the thymus appears normal on radiographic examination. The role of microscopic thymoma as a predictor of clinical thymoma has not been proven.

Reversed-T upper mini-sternotomy for extended thymectomy in myasthenic patients

A minimally invasive approach for extended thymectomy in myasthenic patients is described. Through an 8- to 10-cm midline skin incision with a reversed-T upper mini-sternotomy, an extended thymectomy was performed. The mediastinal fat was removed beginning from the diaphragm up to the thyroid gland, and to each phrenic nerve, laterally. Extended thymectomy through a reversed-T upper mini-sternotomy warrants complete excision of thymic tissue while allowing a short hospitalization and good cosmetic result.

Depletion of helper/inducer T cells after thymectomy in myasthenic patients

Using monoclonal anti-T-cell antibodies, we have studied peripheral blood T-cell subsets in 53 patients with myasthenia gravis before and after thymectomy (Tx). Before Tx, the mean OKT4 OKT8 ratio was higher in patients than in controls. Furthermore some patients showed a high number of cells reacting simultaneously with the OKT4 and OKT8 antibodies. Shortly after surgery, the helper/suppressor ratio was increased in most of the patients, and the doubly reactive subset decreased to normal levels. However, 6 to 12 months after Tx the OKT4 OKT8 ratio was significantly decreased, particularly in patients showing clinical improvement. The percentage of total T cells was slightly but significantly reduced. A group of 14 patients studied more than 2 years after Tx presented very low OKT4 OKT8 ratios. Thymectomy in MG appears to lead to a gradual decrease of the T-helper subset which could contribute to its favorable effect on the course of the disease.

URINARY 17-HYDROXYCORTICOSTEROIDS, 17-KETOSTEROIDS, PREGNANEDIOL AND PREGNANETRIOL IN PATIENTS WITH MYASTHENIA GRAVIS.

Urinary steroids in 13 patients with myasthenia gravis were analytically examined in order to investigate whether or not any endocrinological disturbances existed in myasthenic patients.Urinary excretion of 17-OHCS, 17-KS and pregnanediol, and the recovery of injected progesterone estimated as pregnanediol were normal in almost all cases examined before and after thymectomy.The hydroxylation of the position 21 and 11 of the steroid ring were considered to be within normal range.Although some definite changes in the ratios of 5β-H-steroids to 5α-H-steroids were found (before and after thymectomy), further studies on othersurgical operations would be necessary to decide whether or not such changes arespecific to thymectomy in myasthenic patients.