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PubMed1982

Thymectomy for myasthenia gravis: a changing perspective.

A review of 28 patients with nonthymomatous myasthenia gravis who underwent thymectomy at the University of Colorado Health Sciences Center, Denver, from 1967 to 1979 shows significant stepwise changes in management and results. Comparison among three periods--period 1 (1967 to 1971), when thymectomy competed with prednisone,which were not given in the perioperative period (seven patients); period 2 (1974 to 1976), when thymectomy was followed by six months of prednisone therapy (ten patients); and period 3 (1977 to 1979), when prednisone was also given to prepare the patients for thymectomy (11 patients)--demonstrated a decreasing need for tracheostomy and respiratory support (86% v 10% v 0%), shorter stay in the intensive care unit (21 v 3 v 1 day), and shorter hospitalization (36 v 13 v 4 days). Remission or marked amelioration of symptoms occurred in 56% of group 1 and 100% of both groups 2 and 3. Earlier application of thymectomy and its performance through a short upper transverse sternotomy incision also contributed to the improved results.

Adult↗
PubMed1989

Acceleration of the onset of diabetes in NOD mice by thymectomy at weaning.

The effect of thymectomy performed at weaning (3 weeks) and at 6-7 weeks of age on the incidence of diabetes was examined in the non-Obese diabetic (NOD) mouse, a spontaneous model of immunologically mediated insulin-dependent diabetes similar to human type I diabetes. When performed at weaning, thymectomy led to a dramatic increase in the incidence of diabetes in NOD females in comparison to sham-thymectomized animals. Conversely, no change in the incidence of the disease or the expression of insulitis was noted when thymectomy was performed in NOD males. When delayed beyond 6-7 weeks of age, thymectomy had no effect on NOD males and females. Flow cytometry analysis of spleen cells from intact mice and mice thymectomized at weaning or at 6-7 weeks of age demonstrated a significant depletion of the T cell subsets in both groups of thymectomized animals. These results indicate that the onset of diabetes in NOD mice is submitted to thymic regulation and that the T cell depletion induced by thymectomy at weaning accelerates the disease, an effect possibly due to the loss of some T cell-dependent suppressor mechanisms.

Age Factors↗
PubMed1995

The effect of thymectomy on myasthenia gravis, thrombocytopenia, and granulocytopenia associated with thymoma: report of a case.

We report the case of a 47-year-old woman with thymoma who developed myasthenia gravis, thrombocytopenia, and granulocytopenia, simultaneously, the concurrent association of these four disorders being extremely rare. Thymectomy was performed, and, during the post-thymectomy course, there were surprising findings concerning the recovery of not only the myasthenia gravis but also of the hematologic disorders. Immediately after thymectomy, the myasthenic symptoms completely disappeared, and the granulocyte and platelet counts recovered to within the normal range within a few days. The laboratory data revealed no difference between pre- and post-thymectomy in the release of cytokines (tumor necrosis factor; TNF, interleukin; IL-2, and IL-6), anti-acetylcholine receptor antibody, or platelet-associated IgG. On the other hand, the serum level of anti-neutrophil cytoplasmic antibody (p-ANCA), against the myeloperoxidase of the granulocytes was dramatically decreased, after thymectomy, showing a significant correlation with the granulocyte count. According to our survey of the literature, this is the first report to show that the removal of a thymoma led to the dramatic resolution not only of myasthenia gravis but also of other associated diseases. It is possible that p-ANCA may be regulated by thymoma, thus causing severe granulocytopenia.

Agranulocytosis↗
PubMed1982

Prediction of the need for postoperative mechanical ventilation in myasthenia gravis: thymectomy compared to other surgical procedures.

In a recent report Leventhal, Orkin, and Hirsh described a scoring system felt to be of value in predicting the need for postoperative mechanical ventilation in patients with myasthenia gravis undergoing thymectomy. Leventhal, et al. identified four risk factors felt to have predictive value, namely: (1) duration of myasthenia gravis greater than or equal to 6 years, (2) chronic respiratory disease, (3) dose of pyridostigmine greater than or equal to 750 mg per day, and (4) vital capacity less than or equal to 2.9 litres. Forty-six patients with myasthenia gravis who received 68 general anaesthetics were studied retrospectively. They represented the past 10 years' anaesthetic experience with myasthenia gravis at the Vancouver General Hospital. The patients were divided into two groups: (1) those who underwent thymectomy, and (2) those who underwent procedures other than thymectomy. Using the risk factors of Leventhal, et al., a predictive score was assessed for each patient; the time of postoperative tracheal extubation was also noted for each patient. From this study it was concluded that the scoring system proposed by Leventhal, et al. may have been of some value in predicting whether or not a particular patient undergoing thymectomy was likely to need ventilation postoperatively. In 41 myasthenics who had procedures other than thymectomy, however, this scoring system was found to be of no value.

Adolescent↗
PubMed1996

Antihypertensive effect of thymectomy in Lyon hypertensive rats. Vascular reactivity, renal histology, and sodium excretion.

The aim of this study was to search for the possible mechanisms involved in the antihypertensive effect of neonatal thymectomy that we previously observed in Lyon hypertensive (LH) rats. To that end, we studied in LH and normotensive control (LN) rats the consequences of neonatal thymectomy on vascular reactivity, renal structure, and pressure-natriuresis. The increase in pressor responses to angiotensin I and phenylephrine noted in LH rats as compared to LN animals was abolished by neonatal thymectomy. Histological study showed that kidneys from LH rats exhibited arterial wall hypertrophy, segmental hyalinization of the glomeruli, and were infiltrated by mononuclear cells. All these features of kidney injury were reduced in neonatally thymectomized LH rats. Lastly, the responses of isolated perfused kidneys from LH rats to stepwise reductions in renal perfusion pressure differed from those of LN rats by decreased renal perfusion flow and natriuresis. Neonatal thymectomy tended to improve sodium excretion in parallel with a slight decrease in renal vascular resistances. It is concluded that the normalization of vascular responsiveness to vasoconstrictor factors, the alleviation of renal lesions and, to a lesser extent, the moderate improvement of pressure natriuresis may account, at least in part, for the antihypertensive effect of neonatal thymectomy in LH rats.

Animals↗
PubMed1990

Myasthenia gravis: effect of thymectomy in 425 patients. A 15-year experience.

We report 425 myasthenic patients who underwent thymectomy during the last 15 years. The authors analyse the results of thymectomy in separate groups, including thymomas (12.7%), childhood myasthenia (9.4%) and combined cases (12.4%). They evaluate the results according to the Disability Status Scale based on a points system. Three series were evaluated: patients operated upon between 1972-1977, 1977-1982 and 1982-1987. Although the results in all three series were good, there has been steady improvement over the years. Childhood myasthenia gravis gave the best results but thymectomy was beneficial in the combined (immunological) group, in long-lasting myasthenia and in thymomas. Factors influencing the results of thymectomy were patients' age, time interval between onset of disease and thymectomy, resistence to therapy and thymic tumour. Thymic activity as reflected in germinal centres can also influence the results: the more active the thymus, the better the results.

Adolescent↗
PubMed2004

Manubriotomy versus median sternotomy in thymectomy for myasthenia gravis. Evaluation of the pulmonary status.

OBJECTIVE: In a prospective study, the effect of thymectomy on the pulmonary status of 50 consecutive patients with myasthenia gravis was evaluated over a time range of 4 years in the Chest and Chest surgery departments in the Cairo University Clinics and Thoracic Surgery Department of the Evangelisches Krankenhaus Duisburg-Nord. METHODS: The patients were divided into two groups: Group I included 26 patients who underwent thymectomy through median sternotomy. The mean age of the patients in this group was 24.8+/-10.5 (5-41) years. They were 19 females and seven males. Thirteen of the patients were in Myasthenia Gravis Foundation of America (MGFA) class IIa, and 12 were in class IIb, and one was in class IIIa. Group II included 24 patients who underwent thymectomy through manubriotomy. The mean age of the patients in this group was 25.2+/-9.2 (12-41) years. They were 13 females and 11 males. Eight of the patients were in MGFA class 2a, 14 were in class IIb, and two were in class IIIa. RESULTS: When compared to group I in which postoperative ventilation was required in 15.4% of patients, postoperative ventilation was not necessary in patients of group II with a statistically significant difference (P=0.04). The mean duration of stay in the intensive care unit was 111.4h in group II, and 169.7h in group I (P=0.03). The peak inspiratory flow rate and the forced vital capacity were also statistically significantly better in group II. There was no mortality in both groups, and the morbidity was higher in the median sternotomy group. CONCLUSION: Thymectomy through a manubriotomy, which allows extensive removal of ectopic thymic tissue in addition to the thymus through a less invasive approach than a full median sternotomy, is associated with a significantly smoother postoperative course and less pulmonary complications, when compared with thymectomy through a full median sternotomy.

Adolescent↗
PubMed2007

A comparison of outcomes after robotic open extended thymectomy for myasthenia gravis.

OBJECTIVE: The aim of this study was to analyze the effect of the surgical approach on surgical and neurologic outcomes after extended thymectomy for myasthenia gravis. METHODS: A retrospective analysis of the institutional extended thymectomies for myasthenia gravis within the last decade was performed. Patients of group A (open access by total median sternotomy; n=10; 1996-2002) and of group B (video assisted thoracoscopic surgery approach with the da Vinci robotic system; n=9; 2003-2006) did not differ with regard to gender distribution, age, body mass index, American Association of Anaesthetists score and Osserman classification of myasthenia gravis. Primary endpoints were surgical complications and the symptomatic/neurologic outcome of the extended thymectomy. Secondary endpoints were operating times and hospital stay. RESULTS: Median follow-up was 74+/-23 months in group A and 13+/-10 months in group B. Surgical complications occurred in 4 patients in group A (requiring 2 re-interventions) and in 1 patient in group B (p<0.05). The median dose of Pyridostigminbromid was reduced 3 and 6 months postoperatively in group A to 80% and 60% of the preoperative level and in group B to 66% and 60% of the preoperative level, respectively. Within the first postoperative year all patients of group B had an improvement of their disease whereas 2 patients of group A did not benefit from thymectomy or had a worsening of symptoms. Operating times were significantly shorter in group A (110 (42-152) min vs 154 (94-312) min, p<0.05), hospital stay was significantly shorter in group B (5 (4-15) vs 10 (10-23) days, p<0.05). CONCLUSIONS: The results of this small series favour the robotic approach for extended thymectomy for myasthenia gravis in respect of both surgical and early neurologic outcome. However, prospective randomized trials are required to prove a general validity.

Female↗
PubMed2000

Thoracoscopic thymectomy in autoimmune myasthesia: results of left-sided approach.

BACKGROUND: We undertook to analyze the results of video-assisted thoracoscopic thymectomy through a left-sided approach in patients with autoimmune myasthenia. METHODS: Between 1993 and 1997, 31 patients underwent thoracoscopic thymectomy by a uniform left-sided approach. There were 8 men and 23 women with a mean age of 34 +/- 12 years. RESULTS: Preoperative duration of disease was 14.8 +/- 11 months. There were no operative deaths or major complications. The mean hospital stay was 5.2 +/- 2.8 days. Mean follow-up was 39.6 +/- 15 months and was 100% complete. At 48 months, remission and improvement rates were 36% and 96%, respectively. Shorter duration of symptoms (< 12 months) correlated with improved outcome (13 of 13 patients versus 10 of 14 patients; p = 0.036). Age, sex, Osserman class, corticosteroid therapy, presence of ectopic thymic tissue, and temporary postoperative symptom increase (deterioration) did not affect outcome. CONCLUSIONS: Thoracoscopic thymectomy facilitated the goal of early thymectomy. Through a left-sided approach, improvement or remission was achieved in more than 95% of the patients. Thoracoscopic thymectomy should be considered a valid less invasive alternative to the most radical open approaches.

Adult↗
PubMed1999

Prognostic factors for myasthenia gravis treated by thymectomy: review of 61 cases.

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.

Adolescent↗
PubMed1983

Thymectomy for myasthenia gravis in children.

Myasthenia gravis is rare in childhood. In the last 12 years, we have treated eight children under 16 years of age for this disease. There were six girls and two boys, a ratio of 3:1. Age of presentation of symptoms ranged from 10 to 16 years (mean 11 3/4). There was no significant family history and there were no significant associated diseases. Antibodies were measured in six patients and were all negative. All patients were given cholinergic drugs and five had corticosteroids as well. Three underwent tracheostomies because of severe respiratory insufficiency. There was clinical deterioration or no improvement in spite of increasing doses of medication; hence, thymectomy was performed in all after an average duration of symptoms of 12 months (range 4 to 17). All thymectomies were done through median sternotomy. There was no postoperative morbidity or mortality. No thymoma was found. Four had lymphoid hyperplasia, in three, the thymus looked normal and in one it looked very atrophic. Dramatic amelioration with eventual complete recovery was seen in six, with an average follow-up of 7.3 years (3 to 11) after thymectomy. Two patients are only one year after thymectomy and are improving progressively. We recommend early thymectomy in myasthenia gravis of childhood on the basis of very encouraging results.

Adolescent↗
PubMed1999

Thymectomy for myasthenia gravis: a 27-year experience.

OBJECTIVE: Thymectomy is considered an effective therapeutic option for patients with myasthenia gravis (MG). We reviewed our 27-year experience with surgical treatment of MG with respect to long-term results and factors affecting outcome. METHODS: Between 1970 and 1997, we performed 232 thymectomies for MG. Fifteen patients were lost to follow-up; the remaining 217 form the object of our study. Sixty-two patients (28.4%) had thymoma. Myasthenia was graded according to a modified Osserman classification: 51 patients (23.5%) were in class I, 81(37.3%) in class IIA, 52 (24%) in class IIB, 26 (12%) in class III and seven (3.2%) in class IV. Mean duration of symptoms before the operation was 12+/-10 months. Fifty-eight thymectomies for thymoma were performed through a median sternotomy and four through a clamshell incision. Forty-six thymectomies for non-thymomatous MG were performed through a standard cervicotomy, 101 procedures through a partial upper sternal-splitting incision and eight through a complete median sternotomy. RESULTS: Operative mortality was 0.92% (two patients). After a mean follow-up of 119 months, 71% of all patients improved their clinical status (25% without medications and asymptomatic; 46% with a reduction of medications and/or clinically improved); 39 (18%) have a stable disease with no clinical modifications; 12 (5%) presented a deterioration of their clinical status with worse symptoms, required more medications, or both. Thirteen patients (6%) died because of MG (mean survival 34.3+/-3.6 months). The presence of a thymoma negatively influenced the prognosis. Younger patients showed a more favorable outcome as well as patients with a shorter duration of symptoms before the operation; patients with lower classes of myasthenia showed a higher rate of remission. CONCLUSIONS: Thymectomy is effective in the management of patients with MG at all stages with low morbidity. Patients with thymoma present a less favorable outcome.

Adult↗
PubMed1999

Video-assisted thoracoscopic thymectomy for myasthenia gravis.

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.

Anesthesia, General↗
PubMed2001

Analysis of thymectomy for myasthenia gravis in older patients: a 20-year single institution experience.

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.

Adolescent↗
PubMed2004

[Video-assisted thoracoscopic thymectomy for the treatment of myasthenia gravis].

OBJECTIVE: Traditionally, thymectomy for myasthenia gravis has been performed using either a transcervical approach or a median sternotomy. However, excision of the thymic tissue by video-assisted thoracoscopic surgery is less aggressive and recovery is faster. The aim of this study was to evaluate the usefulness and outcomes of video-assisted thoracoscopic thymectomy. PATIENTS AND METHODS: Over the past 10 years, we have performed 25 video-assisted thoracoscopic thymectomies on patients with myasthenia gravis at our unit. This study included 16 women and 9 men, with a mean age of 48.1 years (range, 14-74 years). Right-side (22 cases) or left-side (3 cases) thoracoscopic surgery was performed, with a mean intervention time of 110 minutes (range, 60-193 minutes). RESULTS: No patient required assisted ventilation for more than 4 hours and the maximum stay in intensive care was less than 24 hours. Complications from surgery included 3 cases of contralateral pneumothorax, 1 pleural effusion, and 2 intraoperative hemorrhages from the thymic vein, all of which were resolved by video-assisted thoracoscopy. Likewise, 3 cases required conversion (due to hemorrhaging in 2 patients and technical difficulties in 1) and 2 required a second thoracoscopic intervention. No deaths occurred and clinical outcome was excellent in 11 cases (medical treatment no longer required), good in 10 (reduced medical treatment), and poor in 4 (no changes). CONCLUSIONS: Video-assisted thoracoscopic thymectomy is effective in the treatment of myasthenia gravis and improves patient recovery. In addition, the excellent surgical view allows the thymectomy to be performed with absolute safety.

Adolescent↗
PubMed2003

Intravenous immunoglobulin in the preparation of thymectomy for myasthenia gravis.

OBJECTIVES: A clinical trial including six patients was conducted to assess the effect of intravenous immunoglobulin (IVIg) in the preparation of thymectomy for patients with myasthenia gravis (MG). MATERIAL AND METHODS: Six consecutive patients of type IIB MG treated with IVIg at a dose 0.4 g/kg daily for 5 days before thymectomy were enrolled in this study. RESULTS: All patients responded positively to this treatment. Improvement began to occur 1-9 days after starting the injection (mean 3.33 days), and reached a maximum in 3-19 days (mean 6.50 days). Thymectomy was performed 9-13 days (mean 11.20 days) after starting the injection in five of the six patients with uneventful post-operative courses. CONCLUSION: IVIg might be an alternative to plasmapheresis (PE) in the prethymectomy preparation of MG patients, and thymectomy should be performed within 2 weeks after IVIg treatment to minimize the perioperative complications. Controlled trial vs PE enrolling more patients is needed to assess the significance of the IVIg in the preparation of thymectomy for patients of MG.

Adult↗
PubMed2002

Video-assisted thoracoscopic thymectomy for myasthenia gravis.

BACKGROUND: Thymectomy is an effective, but radical therapy for myasthenia. Video-assisted thoracic surgery (VATS) may allow a minimally invasive alternative to the standard sternotomy approach. AIMS: To audit prospectively the outcome of VATS thymectomy for myasthenia gravis in a unit specializing in advanced VATS techniques. METHODS: Twenty-six patients underwent VATS thymectomy between 1997 and 2001. Most underwent preoperative plasma exchange therapy. Seventeen women and nine men with a median age of 36 years (range 17-71 years) had a right-sided VATS approach to remove all anterior mediastinal fat and thymic tissue. RESULTS: There was no perioperative mortality and all procedures were concluded successfully, with one patient requiring sternotomy. Twenty-five patients were extubated in theatre and one patient required 17 h of assisted ventilation. The other significant complication was a diathermy injury to the phrenic nerve, which recovered. Median postoperative stay was 4 days (range 2-6 days), with median postoperative chest drainage for 2 days (range 1-3 days). Three patients had progression of disease postoperatively. The remainder were asymptomatic (7), improved (14) or stable (2). CONCLUSION: In a dedicated unit with neurological and intensive care support, VATS thymectomy is a safe, effective method of obtaining remission or improvement in myasthenia gravis (MG). While achieving the same surgical goal, this approach offers advantages of improved cosmesis, shorter recovery time and minimal chest wall disruption over the gold standard of sternotomy. Better patient acceptance of this minimally invasive technique may result in wider application of the benefits of thymectomy in MG.

Adolescent↗
PubMed2004

Thymectomy in the management of myasthenia gravis.

There continues to be a debate regarding the effectiveness of thymectomy in the treatment of nonthymomatous myasthenia gravis (MG) and, when undertaken, which thymectomy technique is the procedure of choice. The debate persists primarily because of the lack of controlled prospective studies. Analysis has been complicated by the absence, until very recently, of accepted objective definitions of severity of the illness and response to therapy as well as variable patient selection, timing of surgery, type of surgery, and methods of analysis of results. Without resolution of these issues by properly controlled prospective studies, there can be no unequivocal determination of the effectiveness of thymectomy or valid comparison of the various thymectomy techniques. In this review, based on previous analyses, attempts will be made to clarify some of the controversial issues concerning thymectomy for nonthymomatous MG and make limited recommendations based on the best available evidence.

Data Interpretation, Statistical↗