Ann Thorac Surg 2008;85:1842. doi:10.1016/j.athoracsur.2007.12.062
© 2008 The Society of Thoracic Surgeons
Correspondence
Patients With Myasthenia With Oropharyngeal Involvement Need Medical Preparation Before Thymectomy
Marcin Zieli
ski, MD, PhD
Department of Thoracic Surgery of the Pulmonary Hospital, ul. G
adkie 1, Zakopane, 34-500 Poland
(Email: marcinz{at}mp.pl).
To the Editor:
I read with interest the article Yu and colleagues [1]. The authors should be congratulated for the relatively large group of patients. The quantitative evaluation of the patients by the same neurologist with use of the new Myasthemia Gravis Foundation of America (MGFA) classification is another advantage of the study. However, I have several serious concerns about this study.
The most serious disadvantage is the absence of information regarding treatment of patients with oropharyngeal involvement and myasthenia before surgery. The authors should be reminded that in patients undergoing thymectomy all efforts should be made to reduce the severity of myasthenia as much as possible. Such patients virtually always need preparation for thymectomy with steroids, immunosuppressive drugs, plasmapheresis, or intravenous immunoglobulins. Thymectomy should be performed only after the patients achieve an optimal clinical state. In such circumstances the risk of postoperative myasthenic crisis is minimalized considerably. The rate of pneumonia and myasthenic crisis in the group of patients with oropharyngeal involvement in the current study is 9 of 47 (19.1%) and 13 of 47 (27.7%), respectively, which are unacceptably high and seem to be the result of inadequate preparation of patients for surgery.
Also, I can not agree with the authors' statement that in the literature "less attention is paid to the treatment of generalized myasthenia gravis (GMG) with oropharyngeal involvement." The data for analyzing this problem were presented in many published articles in which late results of treatment for different classes of myasthenia are given [2–6]. In most studies, remission rates for patients with myasthenia with oropharyngeal involvement (classes IIB and III according to the classification of Osserman and Genkins) are not statistically different from results of patients with class I and IIA myasthenia (without oropharyngeal involvement). Therefore, the problem raised by the authors is not new. Similarly, in the presented study the results at 3-year and 5-year follow-ups were not statistically different in patients with and without oropharyngeal involvement.
Lack of data regarding the numbers of patients with and without oropharyngeal involvement who underwent video-assisted thoracic surgery (VATS) or transsternal extended thymectomy makes analysis of results even more difficult. It has not yet been proved that results of VATS thymectomy are equivalent to results of transsternal extended thymectomy. According to Jaretzki, VATS thymectomy is much less extensive than extended transsternal thymectomy. Thus one must expect that the complete remission rate is probably lower with VATS thymectomy [7].
It is also relevant that readers of the current study were not informed if the selection criteria for transsternal was extended and VATS thymectomy were the same.
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References
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- Yu L, Li J, Ma S, et al. Different characteristics of nonthymomatous generalized myasthenia gravis with and without oropharyngeal involvement Ann Thorac Surg 2007;84:1694-1698.[Abstract/Free Full Text]
- Masaoka A, Yamakawa Y, Niwa H, et al. Extended thymectomy for myasthenia gravis patients: a 20-year review Ann Thorac Surg 1996;62:853-859.[Abstract/Free Full Text]
- Bulkley GB, Bass KN, Stephenson GR, et al. Extended cevicomediastinal thymectomy in the integrated management of myasthenia gravis Ann Surg 1997;226:324-335.[Medline]
- Shrager JB, Nathan D, Brinster CJ, et al. Outcomes after 151 extended transcervical thymectomies for myasthenia gravis Ann Thorac Surg 2006;82:1863-1869.[Abstract/Free Full Text]
- Detterbeck F, Scott W, Howard J, et al. One hundred consecutive thymectomies for myasthenia gravis Ann Thorac Surg 1996;62:242-245.[Abstract/Free Full Text]
- Zieliski M, Ku
da J, Szlubowski A, Soja J. Comparison of late results of basic transsternal and extended transsternal thymectomies in the treatment of myasthenia gravis Ann Thorac Surg 2004;78:253-258.[Abstract/Free Full Text] - Jaretzki III A. Thymectomy for myasthenia gravis: analysis of the controversies regarding technique and results Neurology 1997;48(Suppl 5):S52-S63.[Free Full Text]
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