Myasthenia gravis surgery: Difference between revisions

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==Overview==
==Overview==
The mainstay of surgical treatment of [[Myasthenia gravis|MG]] is [[thymectomy]]. [[Thymectomy]] means removing as much [[Thymus|thymic]] tissue as possible. This treatment is done for patients with [[thymoma]] and even in patients without [[thymoma]] and who have generalized [[Myasthenia gravis|MG]] with [[Acetylcholine receptor|AChR]] [[antibodies]].
== Indications ==
* This treatment is done for patients with [[thymoma]] and even in patients without [[thymoma]] and who have generalized [[Myasthenia gravis|MG]] with [[Acetylcholine receptor|AChR]] [[antibodies]].<ref name="pmid21860784">{{cite journal |vauthors=Romi F |title=Thymoma in myasthenia gravis: from diagnosis to treatment |journal=Autoimmune Dis |volume=2011 |issue= |pages=474512 |date=2011 |pmid=21860784 |pmc=3155972 |doi=10.4061/2011/474512 |url=}}</ref><ref name="pmid20402760">{{cite journal |vauthors=Skeie GO, Apostolski S, Evoli A, Gilhus NE, Illa I, Harms L, Hilton-Jones D, Melms A, Verschuuren J, Horge HW |title=Guidelines for treatment of autoimmune neuromuscular transmission disorders |journal=Eur. J. Neurol. |volume=17 |issue=7 |pages=893–902 |date=July 2010 |pmid=20402760 |doi=10.1111/j.1468-1331.2010.03019.x |url=}}</ref><ref name="pmid20842584">{{cite journal |vauthors=Jani-Acsadi A, Lisak RP |title=Myasthenia gravis |journal=Curr Treat Options Neurol |volume=12 |issue=3 |pages=231–43 |date=May 2010 |pmid=20842584 |doi=10.1007/s11940-010-0070-0 |url=}}</ref><ref name="pmid20927659">{{cite journal |vauthors=Kumar V, Kaminski HJ |title=Treatment of myasthenia gravis |journal=Curr Neurol Neurosci Rep |volume=11 |issue=1 |pages=89–96 |date=February 2011 |pmid=20927659 |doi=10.1007/s11910-010-0151-1 |url=}}</ref><ref name="pmid27358333">{{cite journal |vauthors=Sanders DB, Wolfe GI, Benatar M, Evoli A, Gilhus NE, Illa I, Kuntz N, Massey JM, Melms A, Murai H, Nicolle M, Palace J, Richman DP, Verschuuren J, Narayanaswami P |title=International consensus guidance for management of myasthenia gravis: Executive summary |journal=Neurology |volume=87 |issue=4 |pages=419–25 |date=July 2016 |pmid=27358333 |pmc=4977114 |doi=10.1212/WNL.0000000000002790 |url=}}</ref><ref name="pmid27509100">{{cite journal |vauthors=Wolfe GI, Kaminski HJ, Aban IB, Minisman G, Kuo HC, Marx A, Ströbel P, Mazia C, Oger J, Cea JG, Heckmann JM, Evoli A, Nix W, Ciafaloni E, Antonini G, Witoonpanich R, King JO, Beydoun SR, Chalk CH, Barboi AC, Amato AA, Shaibani AI, Katirji B, Lecky BR, Buckley C, Vincent A, Dias-Tosta E, Yoshikawa H, Waddington-Cruz M, Pulley MT, Rivner MH, Kostera-Pruszczyk A, Pascuzzi RM, Jackson CE, Garcia Ramos GS, Verschuuren JJ, Massey JM, Kissel JT, Werneck LC, Benatar M, Barohn RJ, Tandan R, Mozaffar T, Conwit R, Odenkirchen J, Sonett JR, Jaretzki A, Newsom-Davis J, Cutter GR |title=Randomized Trial of Thymectomy in Myasthenia Gravis |journal=N. Engl. J. Med. |volume=375 |issue=6 |pages=511–22 |date=August 2016 |pmid=27509100 |pmc=5189669 |doi=10.1056/NEJMoa1602489 |url=}}</ref>


==Surgery==
==Surgery==
{{main|thymectomy}}
* The mainstay of surgical treatment of [[Myasthenia gravis|MG]] is [[thymectomy]]. [[Thymectomy]] means removing as much [[Thymus|thymic]] tissue as possible.<ref name="pmid18567883">{{cite journal |vauthors=Sonett JR, Jaretzki A |title=Thymectomy for nonthymomatous myasthenia gravis: a critical analysis |journal=Ann. N. Y. Acad. Sci. |volume=1132 |issue= |pages=315–28 |date=2008 |pmid=18567883 |doi=10.1196/annals.1405.004 |url=}}</ref>  
 
Thymectomy, the surgical removal of the [[thymus]], is essential in cases of [[thymoma]] in view of the potential neoplastic effects of the tumor. However, the procedure is more controversial in patients who do not show thymic abnormalities.  Although some of these patients improve following thymectomy, some patients experience severe exacerbations and the highly controversial concept of "therapeutic thymectomy" for patients with thymus hyperplasia is disputed by many experts and efforts are underway to unequivocally answer this important question. 
 
There are a number of surgical approaches to the removal of the thymus gland: transsternal (through the [[sternum]], or breast bone), transcervical (through a small neck incision), and transthoracic (through one or both sides of the chest).  The transsternal approach is most common and uses the same length-wise incision through the sternum (breast bone)used for most open-heart surgery. The transcervical approach is a less invasive procedure that allows for removal of the entire thymus gland through a small neck incision. There has been no difference in success in symptom improvement between the transsternal approach and the minimally invasive transcervical approach.<ref name=Calhoun_1999>{{cite journal |author=Calhoun R, et al. |title=Results of transcervical thymectomy for myasthenia gravis in 100 consecutive patients. |journal=Annals of Surgery |volume=230 |issue=4 |pages=555-561 |year=1999 |pmid=10522725}}</ref>
 
Thymoma is relatively rare in younger (<40) patients, but paradoxically especially younger patients with generalized MG without thymoma benefit from thymectomy. Of course, resection is also indicated for those with a thymoma, but it is less likely to improve the MG symptoms.


==References==
==References==
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[[Category:Rheumatology]]
[[Category:Rheumatology]]
[[Category:Neurology]]
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Latest revision as of 18:23, 28 November 2018

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

The mainstay of surgical treatment of MG is thymectomy. Thymectomy means removing as much thymic tissue as possible. This treatment is done for patients with thymoma and even in patients without thymoma and who have generalized MG with AChR antibodies.

Indications

Surgery

References

  1. ↑ Romi F (2011). "Thymoma in myasthenia gravis: from diagnosis to treatment". Autoimmune Dis. 2011: 474512. doi:10.4061/2011/474512. PMC 3155972. PMID 21860784.
  2. ↑ Skeie GO, Apostolski S, Evoli A, Gilhus NE, Illa I, Harms L, Hilton-Jones D, Melms A, Verschuuren J, Horge HW (July 2010). "Guidelines for treatment of autoimmune neuromuscular transmission disorders". Eur. J. Neurol. 17 (7): 893–902. doi:10.1111/j.1468-1331.2010.03019.x. PMID 20402760.
  3. ↑ Jani-Acsadi A, Lisak RP (May 2010). "Myasthenia gravis". Curr Treat Options Neurol. 12 (3): 231–43. doi:10.1007/s11940-010-0070-0. PMID 20842584.
  4. ↑ Kumar V, Kaminski HJ (February 2011). "Treatment of myasthenia gravis". Curr Neurol Neurosci Rep. 11 (1): 89–96. doi:10.1007/s11910-010-0151-1. PMID 20927659.
  5. ↑ Sanders DB, Wolfe GI, Benatar M, Evoli A, Gilhus NE, Illa I, Kuntz N, Massey JM, Melms A, Murai H, Nicolle M, Palace J, Richman DP, Verschuuren J, Narayanaswami P (July 2016). "International consensus guidance for management of myasthenia gravis: Executive summary". Neurology. 87 (4): 419–25. doi:10.1212/WNL.0000000000002790. PMC 4977114. PMID 27358333.
  6. ↑ Wolfe GI, Kaminski HJ, Aban IB, Minisman G, Kuo HC, Marx A, Ströbel P, Mazia C, Oger J, Cea JG, Heckmann JM, Evoli A, Nix W, Ciafaloni E, Antonini G, Witoonpanich R, King JO, Beydoun SR, Chalk CH, Barboi AC, Amato AA, Shaibani AI, Katirji B, Lecky BR, Buckley C, Vincent A, Dias-Tosta E, Yoshikawa H, Waddington-Cruz M, Pulley MT, Rivner MH, Kostera-Pruszczyk A, Pascuzzi RM, Jackson CE, Garcia Ramos GS, Verschuuren JJ, Massey JM, Kissel JT, Werneck LC, Benatar M, Barohn RJ, Tandan R, Mozaffar T, Conwit R, Odenkirchen J, Sonett JR, Jaretzki A, Newsom-Davis J, Cutter GR (August 2016). "Randomized Trial of Thymectomy in Myasthenia Gravis". N. Engl. J. Med. 375 (6): 511–22. doi:10.1056/NEJMoa1602489. PMC 5189669. PMID 27509100.
  7. ↑ Sonett JR, Jaretzki A (2008). "Thymectomy for nonthymomatous myasthenia gravis: a critical analysis". Ann. N. Y. Acad. Sci. 1132: 315–28. doi:10.1196/annals.1405.004. PMID 18567883.

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