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Eur J Cardiothorac Surg 2006;30:688-689
© 2006 Elsevier Science NL
Letters to the Editor |
a Department of Surgery, Tokyo Metropolitan Fuchu Hospital, Tokyo, Japan
b Department of Surgery I, Tokyo Women's Medical University, School of Medicine, Tokyo, Japan
c Department of Respirology, Tokyo Metropolitan Tama Cancer Detection Center, Tokyo, Japan
Received 12 June 2006; accepted 17 July 2006.
* Corresponding author. Address: Department of Surgery, Tokyo Metropolitan Fuchu Hospital, Musashidai 2-9-2, Fuchu City, Tokyo 183-8524, Japan. Tel.: +81 42 323 5111; fax: +81 42 323 9205. (Email: kanzaki{at}fuchu-hp.fuchu.tokyo.jp).
Key Words: Myasthenia gravis • Thymectomy • Steroid therapy • Postthymectomy myasthenic crisis
We read the article of Sekine and associates [1] titled ‘Does perioperative high-dose prednisolone have clinical benefits for generalized myasthenia gravis?’ with great interest.
Thymectomy should be performed in hospitals that have extensive experience not only with the surgery but also with preoperative and postoperative management of myasthenia gravis. Recently, perioperative high-dose prednisone has been used and clinical benefits were provided [2,3]. The reason why we do not use preoperative steroid is because continuous use of steroid is not desirable for the fear of poor wound healing and the occurrence of postoperative infection.
Between 1987 and 2004, a total of 174 patients with generalized myasthenia gravis were experienced at our hospital. One hundred sixty-five patients were administered anticholinesterase inhibitors that improved the symptoms, but 9 patients (5.1%) were myasthenia gravis preoperatively and were hospitalized for the administration of steroid therapy, next all patients were subjected to extended thymectomy. Transsternal extended thymectomy via median sternotomy was performed under general anesthesia by a few skilled surgeons in our hospital. As a rule, patients were extubated at the end of the procedure. On postoperative day 1, the patients were given their regular dose of pyridostigmine while being careful in a cholinergic crisis. About 4 weeks after surgery, steroid therapy was performed by administering 1.5–2 mg/kg (max 100 mg/body), a regimen which gradually was changed to every other day medication and finally a gradual reduction of dosage. Postoperative respiratory insufficiency was noted when a patient underwent mechanical ventilation for more than 24 h during the first 7 days after surgery. Eight patients (4.6%) experienced postthymectomy myasthenic crisis, underwent mechanical ventilation, and received high-dose steroid therapy immediately. There were no steroid related complications such as sternal dehiscence, wound dehiscence, and wound suppuration.
Preoperative preparation should optimize the patient's strength and especially respiratory function, but prednisone should be avoided if possible because prednisone increases the risk of side effects. Comparing the authors’ report with our result, no difference in the incidence of both postoperative myasthenic crisis and respiratory insufficiency was found. Should not preoperative steroid therefore be used for a limited patient such as fluctuating or refractory myasthenia gravis after administration of acetylcholinesterase inhibitors?
Footnotes
The authors of the original paper [1] were invited to comment on this Letter to the Editor but declined the offer.
References
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