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Perioperative medical management and outcome following thymectomy for myasthenia gravis

Catherine Chevalley, MD^*, Anastase Spiliopoulos, MD, Marc de Perrot, MD, Jean-Marie Tschopp, MD and Marc Licker, MD^*

^* From the Division of Anesthesiology and
Unit of Thoracic Surgery, University Hospital of Geneva, and
Thorax Medical Center of Montana, Switzerland.

Address correspondence to: Dr. Marc Licker, Division d'Anesthésiologie, Hôpital Cantonal Universitaire, CH- 1211 GENEVA 14, Switzerland. Phone: 00-41-22-3827402; Fax: 00-41-22-3727690; E-mail: marc-joseph.licker{at}hcuge.ch

Purpose: To describe the evolution of the perioperative management of myasthenia gravis (MG) patients undergoing thymectomy and to question the need for systematic postoperative ventilation.

Clinical features: We collected data retrospectively from 36 consecutive MG patients who underwent thymectomy over a 21-yr period, via transthoracic, -cervical or -sternal incisions (n=5, n=7, n=24, respectively). From 1980 to 1993, a balanced anesthetic technique (n=24) included various inhalational agents with opiates and myorelaxants (in eight cases); 22 patients were admitted to the intensive care unit (ICU). Since 1994, iv propofol was combined with epidural bupivacaine and sufentanil (n=12); all patients were admitted to the postanesthesia care unit.

Short-term postoperative ventilation (median time four hours, range from three to 48 hr) was required in eight patients who had longer hospital stay (median stay=12 days, range (8–28) vs five days (4–15) for patients with early extubation, P <0.05) but similar clinical improvement six months after thymectomy.

Postoperative ventilatory support was required more frequently when a balanced anesthetic technique was used (odds ratio=4.2 (1.1–9.7), P=0.03) and particularly when myorelaxants were given (odds ratio=13.9 (2.1–89.8), P=0.009). Leventhal's scoring system had low sensitivity (22.2%) and positive predictive values (25%).

Conclusions: Our data show that the severity of MG failed to predict the need for postoperative ventilation. A combined anesthetic technique was a safe and cost-effective alternative to balanced anesthesia as it provided optimal operating conditions and resulted in fewer admissions in ICU and shorter hospital stays.

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