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Autoimmune myasthenia gravis: place of thymectomy and preferred technique

They confirmed data from other centres, indicating that this is a safe and technically effective technique for removal of the thymus gland in MG with a low complication rate.2,3 A small percentage of patients require conversion to open sternotomy and, rarely, phrenic nerve palsy may complicate the procedure.1,3 Advantages include the fact that it is a less invasive procedure with a lower perioperative morbidity and hospitalization time. In addition, the adverse longterm consequences of sternotomy are avoided, most notably chronic post-sternotomy pain, which is moderate or severe in almost 15% of myasthenic patients treated with thymectomy involving sternotomy.4 These problems, together with the cosmetic implication of a sternotomy scar in a young female patient, are probably the major deterrents to open thymectomy in many patients’ minds. Of more potential concern is the appreciable morbidity of conventional thymectomy techniques. In one recent retrospective analysis of 324 cases, 104 patients had minor complications, but no less than 71 patients had major complications including: (i) external bleeding, (ii) sternal disruption, (iii) tracheal stenosis, (iv) pneumonia, (v) heart failure and, in most patients with major complications, (vi) respiratory insufficiency.5 This series highlights that most major complications of open thymectomy relate to the myasthenia itself with postoperative respiratory weakness, rather than the surgery. Anecdotal experience suggests that these complications can be minimized or eliminated with no need for routine postoperative ventilation by introducing preoperative plasma exchange or gamma globulin infusion into treatment protocols.