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Perioperative management in myasthenia gravis: republication of a systematic review and a proposal by the guideline committee of the Japanese Association for Chest Surgery 2014

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Abstract

Thymectomy is regarded as a useful therapeutic option for myasthenia gravis (MG), though perioperative management in MG patients is largely empirical. While evidence-based medicine is limited in the perioperative management of MG patients, treatment guidelines are required as a benchmark. We selected issues faced by physicians in clinical practice in the perioperative management of extended thymectomy for MG, and examined them with a review of the literature. The present guidelines have reached the stage of consensus within the Japanese Association for Chest Surgery.

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References

  1. Drachman DB. Medical progress—myasthenia-gravis. N Engl J Med. 1994;330(25):1797–810.

    CAS  PubMed  Google Scholar 

  2. Accreditation criterion of myasthenia gravis. Nervous muscle diseases study group, Welfare Labor Ministry. http://www.nanbyou.or.jp/sikkan/049_i.htm#.

  3. Jaretzki A 3rd, et al. Myasthenia gravis: recommendations for clinical research standards. Task force of the Medical Scientific Advisory Board of the Myasthenia Gravis Foundation of America. Neurology. 2000;55(1):16–23.

    PubMed  Google Scholar 

  4. Meriggioli MN, Sanders DB. Autoimmune myasthenia gravis: emerging clinical and biological heterogeneity. Lancet Neurol. 2009;8(5):475–90.

    PubMed Central  CAS  PubMed  Google Scholar 

  5. Hoch W, et al. Auto-antibodies to the receptor tyrosine kinase MuSK in patients with myasthenia gravis without acetylcholine receptor antibodies. Nat Med. 2001;7(3):365–8.

    CAS  PubMed  Google Scholar 

  6. Vincent A, Palace J, Hilton-Jones D. Myasthenia gravis. Lancet. 2001;357(9274):2122–8.

    CAS  PubMed  Google Scholar 

  7. Blalock A, et al. Myasthenia gravis and tumors of the thymic region: report of a case in which the tumor was removed. Ann Surg. 1939;110(4):544–61.

    PubMed Central  CAS  PubMed  Google Scholar 

  8. Sauerbruch EF. Mitteilungen aus dem Grenzgebieten der Medizin und Chirungie. 1913;25:746.

    Google Scholar 

  9. Schumacher E, Roth J. Thymektomie bei einem Fall von Morbus Basedowi mit Myasthenie. Mitt Grengeb Med Chir. 1912;25:746–65.

    Google Scholar 

  10. Kadota Y, et al. Altered T cell development in human thymoma is related to impairment of MHC class II transactivator expression induced by interferon-gamma (IFN-gamma). Clin Exp Immunol. 2000;121(1):59–68.

    PubMed Central  CAS  PubMed  Google Scholar 

  11. Leite MI, et al. Myasthenia gravis thymus: complement vulnerability of epithelial and myoid cells, complement attack on them, and correlations with autoantibody status. Am J Pathol. 2007;171(3):893–905.

    PubMed Central  PubMed  Google Scholar 

  12. Morgenthaler TI, et al. Thymoma. Mayo Clin Proc. 1993;68(11):1110–23.

    CAS  PubMed  Google Scholar 

  13. Mygland A, et al. Autoantibodies in thymoma-associated myasthenia gravis with myositis or neuromyotonia. Arch Neurol. 2000;57(4):527–31.

    CAS  PubMed  Google Scholar 

  14. Scadding GK, et al. Acetylcholine receptor antibody synthesis by thymic lymphocytes: correlation with thymic histology. Neurology. 1981;31(8):935–43.

    CAS  PubMed  Google Scholar 

  15. Scarpino S, et al. Expression of autoimmune regulator gene (AIRE) and T regulatory cells in human thymomas. Clin Exp Immunol. 2007;149(3):504–12.

    PubMed Central  CAS  PubMed  Google Scholar 

  16. Schluep M, et al. Acetylcholine receptors in human thymic myoid cells in situ: an immunohistological study. Ann Neurol. 1987;22(2):212–22.

    CAS  PubMed  Google Scholar 

  17. Strobel P, et al. Selective loss of regulatory T cells in thymomas. Ann Neurol. 2004;56(6):901–4.

    PubMed  Google Scholar 

  18. Lindberg C, et al. Remission rate after thymectomy in myasthenia gravis when the bias of immunosuppressive therapy is eliminated. Acta Neurol Scand. 1992;86(3):323–8.

    CAS  PubMed  Google Scholar 

  19. Masaoka A, et al. Extended thymectomy for myasthenia gravis patients: a 20-year review. Ann Thorac Surg. 1996;62(3):853–9.

    CAS  PubMed  Google Scholar 

  20. Newsom-Davis J, et al. Status of the thymectomy trial for nonthymomatous myasthenia gravis patients receiving prednisone. Ann N Y Acad Sci. 2008;1132:344–7.

    CAS  PubMed  Google Scholar 

  21. Gronseth GS, Barohn RJ. Practice parameter: thymectomy for autoimmune myasthenia gravis (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2000;55(1):7–15.

    CAS  PubMed  Google Scholar 

  22. Bulkley GB, et al. Extended cervicomediastinal thymectomy in the integrated management of myasthenia gravis. Ann Surg. 1997;226(3):324–34 (discussion 334-5).

    PubMed Central  CAS  PubMed  Google Scholar 

  23. Mack MJ. Video-assisted thoracoscopy thymectomy for myasthenia gravis. Chest Surg Clin N Am. 2001;11(2):389–405 (xi-xii).

    CAS  PubMed  Google Scholar 

  24. Sonett JR, Jaretzki A 3rd. Thymectomy for nonthymomatous myasthenia gravis: a critical analysis. Ann N Y Acad Sci. 2008;1132:315–28.

    PubMed  Google Scholar 

  25. Masaoka A, Nagaoka Y, Kotake Y. Distribution of thymic tissue at the anterior mediastinum. Current procedures in thymectomy. J Thorac Cardiovasc Surg. 1975;70(4):747–54.

    CAS  PubMed  Google Scholar 

  26. Pompeo E, et al. Long-term outcome of thoracoscopic extended thymectomy for nonthymomatous myasthenia gravis. Eur J Cardiothorac Surg. 2009;36(1):164–9.

    PubMed  Google Scholar 

  27. Shiono H, et al. Comparison of outcomes after extended thymectomy for myasthenia gravis: bilateral thoracoscopic approach versus sternotomy. Surg Laparosc Endosc Percutan Tech. 2009;19(6):424–7.

    PubMed  Google Scholar 

  28. Kondo K, Monden Y. Thymoma and myasthenia gravis: a clinical study of 1,089 patients from Japan. Ann Thorac Surg. 2005;79(1):219–24.

    PubMed  Google Scholar 

  29. Christensen PB, et al. Incidence and prevalence of myasthenia gravis in western Denmark: 1975 to 1989. Neurology. 1993;43(9):1779–83.

    CAS  PubMed  Google Scholar 

  30. Compston DA, et al. Clinical, pathological, HLA antigen and immunological evidence for disease heterogeneity in myasthenia gravis. Brain. 1980;103(3):579–601.

    CAS  PubMed  Google Scholar 

  31. Evoli A, et al. Clinical characteristics and prognosis of myasthenia gravis in older people. J Am Geriatr Soc. 2000;48(11):1442–8.

    CAS  PubMed  Google Scholar 

  32. Ishii W, et al. Comparison of the histological and immunohistochemical features of the thymus in young- and elderly-onset myasthenia gravis without thymoma. J Clin Neurosci. 2007;14(2):110–5.

    CAS  PubMed  Google Scholar 

  33. Evoli A, et al. Therapeutic options in ocular myasthenia gravis. Neuromuscul Disord. 2001;11(2):208–16.

    CAS  PubMed  Google Scholar 

  34. Nakamura H, et al. Delayed remission after thymectomy for myasthenia gravis of the purely ocular type. J Thorac Cardiovasc Surg. 1996;112(2):371–5.

    CAS  PubMed  Google Scholar 

  35. Schumm F, et al. Thymectomy in myasthenia with pure ocular symptoms. J Neurol Neurosurg Psychiatry. 1985;48(4):332–7.

    PubMed Central  CAS  PubMed  Google Scholar 

  36. Sommer N, et al. Ocular myasthenia gravis: response to long-term immunosuppressive treatment. J Neurol Neurosurg Psychiatry. 1997;62(2):156–62.

    PubMed Central  CAS  PubMed  Google Scholar 

  37. Okumura M, et al. Biological implications of thymectomy for myasthenia gravis. Surg Today. 2010;40(2):102–7.

    PubMed  Google Scholar 

  38. Monden Y, et al. Effects of preoperative duration of symptoms on patients with myasthenia gravis. Ann Thorac Surg. 1984;38(3):287–91.

    CAS  PubMed  Google Scholar 

  39. Nieto IP, et al. Prognostic factors for myasthenia gravis treated by thymectomy: review of 61 cases. Ann Thorac Surg. 1999;67(6):1568–71.

    CAS  PubMed  Google Scholar 

  40. Uchino M, et al. Clinical analysis of 114 patients with myasthenia gravis (MG). Investigation of the actual condition of increasing aged patients with MG and efficacy of extended thymectomy. Neurol Therap. 2000;17:355–9.

    Google Scholar 

  41. Motomura M. Standard treatment for late-onset myasthenia gravis in Japan. Rinsho Shinkeigaku. 2011;51(8):576–82.

    PubMed  Google Scholar 

  42. Perlo VP, Arnason B, Castleman B. The thymus gland in elderly patients with myasthenia gravis. Neurology. 1975;25(3):294–5.

    CAS  PubMed  Google Scholar 

  43. Lanska DJ. Indications for thymectomy in myasthenia gravis. Neurology. 1990;40(12):1828–9.

    CAS  PubMed  Google Scholar 

  44. Aarli JA. Myasthenia gravis in the elderly: is it different? Ann N Y Acad Sci. 2008;1132:238–43.

    PubMed  Google Scholar 

  45. Matsuzaki Y, et al. Influence of age on extended thymectomy as a treatment for myasthenia gravis. Ann Thorac Cardiovasc Surg. 1998;4(4):192–5.

    CAS  PubMed  Google Scholar 

  46. Monden Y, et al. Myasthenia gravis in elderly patients. Ann Thorac Surg. 1985;39(5):433–6.

    CAS  PubMed  Google Scholar 

  47. Tsuchida M, et al. Efficacy and safety of extended thymectomy for elderly patients with myasthenia gravis. Ann Thorac Surg. 1999;67(6):1563–7.

    CAS  PubMed  Google Scholar 

  48. Nagaishi A, et al. Survey on perioperative and postoperative treatment for Myasthenia Gravis patients with thymectomy. Jpn Assoc Res Thymus. 2011;30:36.

    Google Scholar 

  49. Rodriguez M, et al. Myasthenia gravis in children: long-term follow-up. Ann Neurol. 1983;13(5):504–10.

    CAS  PubMed  Google Scholar 

  50. Andrews PI, et al. Race, sex, and puberty influence onset, severity, and outcome in juvenile myasthenia gravis. Neurology. 1994;44(7):1208–14.

    CAS  PubMed  Google Scholar 

  51. Leite MI, et al. IgG1 antibodies to acetylcholine receptors in ‘seronegative’ myasthenia gravis. Brain. 2008;131(Pt 7):1940–52.

    PubMed Central  PubMed  Google Scholar 

  52. Leite MI, et al. Fewer thymic changes in MuSK antibody-positive than in MuSK antibody-negative MG. Ann Neurol. 2005;57(3):444–8.

    PubMed  Google Scholar 

  53. Hayashi A, et al. Heterogeneity of immunopathological features of AChR/MuSK autoantibody-negative myasthenia gravis. J Neuroimmunol. 2007;189(1–2):163–8.

    CAS  PubMed  Google Scholar 

  54. Higuchi O, Hamuro J, Motomura M, Yamanashi Y. Autoantibodies to low-density lipoprotein receptor-related protein 4 in myasthenia gravis. Ann Neurol. 2011;69(2):418–22.

    CAS  PubMed  Google Scholar 

  55. Engel AG, Lambert EH, Santa T. Study of long-term anticholinesterase therapy. Effects on neuromuscular transmission and on motor end-plate fine structure. Neurology. 1973;23(12):1273–81.

    CAS  PubMed  Google Scholar 

  56. Newsom-Davis J. Therapy in myasthenia gravis and Lambert-Eaton myasthenic syndrome. Semin Neurol. 2003;23(2):191–8.

    PubMed  Google Scholar 

  57. Skeie GO, et al. Guidelines for treatment of autoimmune neuromuscular transmission disorders. Eur J Neurol. 2010;17(7):893–902.

    CAS  PubMed  Google Scholar 

  58. Krucylak PE, Naunheim KS. Preoperative preparation and anesthetic management of patients with myasthenia gravis. Semin Thorac Cardiovasc Surg. 1999;11(1):47–53.

    CAS  PubMed  Google Scholar 

  59. Inada Y. Anesthesia in uncommon diseases, Anesthesia 21 centurey. 2000. p. 4–8.

  60. Okumura M et al., Thymectomy for Myasthenia Gravis. The 15th Chest Surgery Seminar, The 67th Annual Meeting of the Japanese Association for Chest Surgery 2009. p. 35–39.

  61. Fujii Y. Myasthenia Gravis. http://www.med.nagoya-cu.ac.jp/surg2.dir/mgenglish/index.html.

  62. Kadota Y. et al., Perioperative treatment of myasthenia gravis., Knack & Pitfalls for the specialists in general thoracic surgery. Bunkodo, Tokyo, 2010. p. 141–145.

  63. Munsat TL. Anticholinesterase abuse in myasthenia gravis. J Neurol Sci. 1984;64(1):5–10.

    CAS  PubMed  Google Scholar 

  64. Diaz-Manera J, Rojas-Garcia R, Illa I. Treatment strategies for myasthenia gravis. Expert Opin Pharmacother. 2009;10(8):1329–42.

    CAS  PubMed  Google Scholar 

  65. Cosi V, et al. Effectiveness of steroid treatment in myasthenia gravis: a retrospective study. Acta Neurol Scand. 1991;84(1):33–9.

    CAS  PubMed  Google Scholar 

  66. Pascuzzi RM, Coslett HB, Johns TR. Long-term corticosteroid treatment of myasthenia gravis: report of 116 patients. Ann Neurol. 1984;15(3):291–8.

    CAS  PubMed  Google Scholar 

  67. Warmolts JR, Engel WK, Whitaker JN. Alternate-dy prednisone in a patient with myasthenia gravis. Lancet. 1970;2(7684):1198–9.

    CAS  PubMed  Google Scholar 

  68. Huang CS, et al. Factors influencing the outcome of transsternal thymectomy for myasthenia gravis. Acta Neurol Scand. 2005;112(2):108–14.

    PubMed  Google Scholar 

  69. Nagane Y, et al. Early aggressive treatment strategy against myasthenia gravis. Eur Neurol. 2011;65(1):16–22.

    PubMed  Google Scholar 

  70. Endo S, et al. Experience with programmed steroid treatment with thymectomy in nonthymomatous myasthenia gravis. Ann Thorac Surg. 2004;77(5):1745–50.

    PubMed  Google Scholar 

  71. Mann JD, Johns TR, Campa JF. Long-term administration of corticosteroids in myasthenia gravis. Neurology. 1976;26(8):729–40.

    CAS  PubMed  Google Scholar 

  72. Yamaguchi Y, et al. Favorable results of thymectomy combined with prednisolone alternate-day administration in myasthenia gravis. Jpn J Surg. 1987;17(1):14–20.

    CAS  PubMed  Google Scholar 

  73. Hara M, et al. Evaluation of treatment for myasthenia gravis in 37 patients. The effect of pre-thymectomy corticosteroid therapy. Neurol Therap. 1994;11(1):57–65.

    Google Scholar 

  74. Arai H, Ito N, Hirayama K. Long-term corticosteroid therapy combined with thymectomy in generalized myasthenia gravis. Neurol Therap. 1995;12(5):437–43.

    Google Scholar 

  75. Bromberg MB, et al. Randomized trial of azathioprine or prednisone for initial immunosuppressive treatment of myasthenia gravis. J Neurol Sci. 1997;150(1):59–62.

    CAS  PubMed  Google Scholar 

  76. Evoli A, et al. Long-term results of corticosteroid therapy in patients with myasthenia gravis. Eur Neurol. 1992;32(1):37–43.

    CAS  PubMed  Google Scholar 

  77. Joint Committee of the Japanese Society for Neuroimmunology and the Japanese Society of Neurological Therapeutics, Treatment Guidelines for Myasthenia Gravis., http://www.jsnt.gr.jp/guideline/meneki.html.

  78. Torda C, Wolff HG. Effect of blood serum from patients with myasthenia gravis on the synthesis of acetylcholine in vitro. J Clin Invest. 1944;23(5):649–56.

    PubMed Central  CAS  PubMed  Google Scholar 

  79. Torda C, Wolff HG. Effects of adrenocorticotrophic hormone on neuro-muscular function in patients with myasthenia gravis. Proc Soc Exp Biol Med. 1949;71(3):432–5.

    CAS  PubMed  Google Scholar 

  80. Brunner NG, Namba T, Grob D. Corticosteroids in management of severe, generalized myasthenia gravis. Effectiveness and comparison with corticotropin therapy. Neurology. 1972;22(6):603–10.

    CAS  PubMed  Google Scholar 

  81. Jenkins RB. Treatment of myasthenia gravis with prednisone. Lancet. 1972;1(7754):765–7.

    CAS  PubMed  Google Scholar 

  82. Seybold ME, Drachman DB. Gradually increasing doses of prednisone in myasthenia gravis. Reducing the hazards of treatment. N Engl J Med. 1974;290(2):81–4.

    CAS  PubMed  Google Scholar 

  83. Saag KG. Prevention of glucocorticoid-induced osteoporosis. South Med J. 2004;97(6):555–8.

    PubMed  Google Scholar 

  84. Matsuyama H, Irita K, et al. Steroid coverage: current concept. J Clin Anesth (Jpn). 2004;28(2):219–25.

    Google Scholar 

  85. Nicholson G, Burrin JM, Hall GM. Peri-operative steroid supplementation. Anaesthesia. 1998;53(11):1091–104.

    CAS  PubMed  Google Scholar 

  86. Tasch MD. Corticosteroids and anesthesia. Curr Opin Anaesthesiol. 2002;15(3):377–81.

    PubMed  Google Scholar 

  87. Coursin DB, Wood KE. Corticosteroid supplementation for adrenal insufficiency. JAMA. 2002;287(2):236–40.

    CAS  PubMed  Google Scholar 

  88. Marik PE, Varon J. Requirement of perioperative stress doses of corticosteroids: a systematic review of the literature. Arch Surg. 2008;143(12):1222–6.

    CAS  PubMed  Google Scholar 

  89. Yong SL, et al. Supplemental perioperative steroids for surgical patients with adrenal insufficiency. Cochrane Database Syst Rev. 2009; (4):367.

  90. Arsura E, et al. High-dose intravenous methylprednisolone in myasthenia gravis. Arch Neurol. 1985;42(12):1149–53.

    CAS  PubMed  Google Scholar 

  91. Lindberg C, Andersen O, Lefvert AK. Treatment of myasthenia gravis with methylprednisolone pulse: a double blind study. Acta Neurol Scand. 1998;97(6):370–3.

    CAS  PubMed  Google Scholar 

  92. Arai H, Omiyama J, HIrayama K. Methylprednisolone pulse therapy for patients with intractable generalized myasthenia gravis. Neurol Therap. 1988;5(3):265–71.

    Google Scholar 

  93. Tuchiyama M, Yuasa R. Intermittent methylprednisolone pulse therapy for ocular muscle myasthenia gravis. Neurol Therap. 1995;12(3):219–21.

    Google Scholar 

  94. Ciafaloni E, et al. Retrospective analysis of the use of cyclosporine in myasthenia gravis. Neurology. 2000;55(3):448–50.

    CAS  PubMed  Google Scholar 

  95. Evoli A, et al. Successful treatment of myasthenia gravis with tacrolimus. Muscle Nerve. 2002;25(1):111–4.

    PubMed  Google Scholar 

  96. Tada M, et al. Long-term therapeutic efficacy and safety of low-dose tacrolimus (FK506) for myasthenia gravis. J Neurol Sci. 2006;247(1):17–20.

    CAS  PubMed  Google Scholar 

  97. Tindall RS, et al. A clinical therapeutic trial of cyclosporine in myasthenia gravis. Ann N Y Acad Sci. 1993;681:539–51.

    CAS  PubMed  Google Scholar 

  98. Tindall RS, et al. Preliminary results of a double-blind, randomized, placebo-controlled trial of cyclosporine in myasthenia gravis. N Engl J Med. 1987;316(12):719–24.

    CAS  PubMed  Google Scholar 

  99. Ponseti JM, et al. Tacrolimus for myasthenia gravis: a clinical study of 212 patients. Ann N Y Acad Sci. 2008;1132:254–63.

    CAS  PubMed  Google Scholar 

  100. Nagane Y, et al. Efficacy of low-dose FK506 in the treatment of Myasthenia gravis–a randomized pilot study. Eur Neurol. 2005;53(3):146–50.

    CAS  PubMed  Google Scholar 

  101. Davies TH, Ning YM, Sanchez ER. Differential control of glucocorticoid receptor hormone-binding function by tetratricopeptide repeat (TPR) proteins and the immunosuppressive ligand FK506. Biochemistry. 2005;44(6):2030–8.

    CAS  PubMed  Google Scholar 

  102. Takamori M, et al. Anti-ryanodine receptor antibodies and FK506 in myasthenia gravis. Neurology. 2004;62(10):1894–6.

    CAS  PubMed  Google Scholar 

  103. Palace J, Newsom-Davis J, Lecky B. A randomized double-blind trial of prednisolone alone or with azathioprine in myasthenia gravis. Myasthenia Gravis Study Group. Neurology. 1998;50(6):1778–83.

    CAS  PubMed  Google Scholar 

  104. Munakata R, et al. The effect of combined therapy with immunoadsorption and high-dose intravenous methylprednisolone on myasthenia gravis. Eur Neurol. 2002;48(2):115–7.

    PubMed  Google Scholar 

  105. Newsom-Davis J, et al. Long-term effects of repeated plasma exchange in myasthenia gravis. Lancet. 1979;1(8114):464–8.

    CAS  PubMed  Google Scholar 

  106. Matsuo H, et al. Plasmapheresis-plasma exchange therapy in myasthenia gravis, Treatments of Myasthenia gravis 2003. Neulrological Medicine. 2003;59(3):249–54.

    Google Scholar 

  107. Gajdos P, Chevret S, Toyka K. Plasma exchange for myasthenia gravis. Cochrane Database Syst Rev. 2002; (4):CD002275.

  108. Gajdos P, et al. Long-term effects of plasma exchange in myasthenia. Results of a randomized study. Presse Med. 1983;12(15):939–42.

    CAS  PubMed  Google Scholar 

  109. Nagayasu T, et al. Beneficial effects of plasmapheresis before thymectomy on the outcome in myasthenia gravis. Jpn J Thorac Cardiovasc Surg. 2005;53(1):2–7.

    PubMed  Google Scholar 

  110. Arsura EL, et al. High-dose intravenous immunoglobulin in the management of myasthenia gravis. Arch Intern Med. 1986;146(7):1365–8.

    CAS  PubMed  Google Scholar 

  111. Elovaara I, et al. EFNS guidelines for the use of intravenous immunoglobulin in treatment of neurological diseases: EFNS task force on the use of intravenous immunoglobulin in treatment of neurological diseases. Eur J Neurol. 2008;15(9):893–908.

    CAS  PubMed  Google Scholar 

  112. Zinman L, Ng E, Bril V. IV immunoglobulin in patients with myasthenia gravis: a randomized controlled trial. Neurology. 2007;68(11):837–41.

    CAS  PubMed  Google Scholar 

  113. Dalakas MC. Intravenous immunoglobulin in autoimmune neuromuscular diseases. JAMA. 2004;291(19):2367–75.

    CAS  PubMed  Google Scholar 

  114. Jensen P, Bril V. A comparison of the effectiveness of intravenous immunoglobulin and plasma exchange as preoperative therapy of myasthenia gravis. J Clin Neuromuscul Dis. 2008;9(3):352–5.

    PubMed  Google Scholar 

  115. Huang CS, et al. Intravenous immunoglobulin in the preparation of thymectomy for myasthenia gravis. Acta Neurol Scand. 2003;108(2):136–8.

    PubMed  Google Scholar 

  116. O’Riordan JI, et al. The management and outcome of patients with myasthenia gravis treated acutely in a neurological intensive care unit. Eur J Neurol. 1998;5(2):137–42.

    PubMed  Google Scholar 

  117. Younger DS, Raksadawan N. Medical therapies in myasthenia gravis. Chest Surg Clin N Am. 2001;11(2):329–36.

    CAS  PubMed  Google Scholar 

  118. Chaudhuri A, Behan PO. Myasthenic crisis. QJM. 2009;102(2):97–107.

    CAS  PubMed  Google Scholar 

  119. Kuks JBM, Oosterhuis HJG. Clinical presentation of myasthenia gravis. In: H.J. Kaminski HJ, editors. Neurology: myasthenia gravis and related disorders. NJ: Humana Press Inc; 2003. p. 93–114.

  120. Phillips LH. The epidemiology of myasthenia gravis. Semin Neurol. 2004;24(1):17–20.

    PubMed  Google Scholar 

  121. Juel VC. Myasthenia gravis: management of myasthenic crisis and perioperative care. Semin Neurol. 2004;24(1):75–81.

    PubMed  Google Scholar 

  122. Watanabe A, et al. Prognostic factors for myasthenic crisis after transsternal thymectomy in patients with myasthenia gravis. J Thorac Cardiovasc Surg. 2004;127(3):868–76.

    PubMed  Google Scholar 

  123. Berrouschot J, et al. Therapy of myasthenic crisis. Crit Care Med. 1997;25(7):1228–35.

    CAS  PubMed  Google Scholar 

  124. Cohen MS, Younger D. Aspects of the natural history of myasthenia gravis: crisis and death. Ann N Y Acad Sci. 1981;377:670–7.

    CAS  PubMed  Google Scholar 

  125. Thomas CE, et al. Myasthenic crisis: clinical features, mortality, complications, and risk factors for prolonged intubation. Neurology. 1997;48(5):1253–60.

    CAS  PubMed  Google Scholar 

  126. Gracey DR, et al. Postoperative respiratory care after transsternal thymectomy in myasthenia gravis. A 3-year experience in 53 patients. Chest. 1984;86(1):67–71.

    CAS  PubMed  Google Scholar 

  127. Leventhal SR, Orkin FK, Hirsh RA. Prediction of the need for postoperative mechanical ventilation in myasthenia gravis. Anesthesiology. 1980;53(1):26–30.

    CAS  PubMed  Google Scholar 

  128. Walker MB. Case showing the effect of prostigmin on myasthenia gravis. Proc R Soc Med. 1935;28(6):759–61.

    PubMed Central  CAS  PubMed  Google Scholar 

  129. Jani-Acsadi A, Lisak RP. Myasthenic crisis: guidelines for prevention and treatment. J Neurol Sci. 2007;261(1–2):127–33.

    PubMed  Google Scholar 

  130. Yoshida S, Yamaguchi Y, Saito Y. Prediction of postoperative respiratory failure after thymectomy combined with prednisolone alternate-day administration in myasthenia gravis. J Jpn Assoc Chest Surg. 1997;11(2):136–43.

    Google Scholar 

  131. Adachi M, Uehira A, Urabe T, Tanaka A, Yamauchi N, Sato T. Prediction of the need for postoperative mechanical ventilation in myasthenia gravis patients. Masui. 1990;39(11):1484–90.

    CAS  PubMed  Google Scholar 

  132. Kaneda K, Amaha K, Tanaka N, et al. A new scoring system for predicting the need for postoperative mechanical ventilation in patients with myasthenia gravis. J Jpn Soc Intensive Care Med. 1995;1:7–13.

    Google Scholar 

  133. Gorback MS, Moon RE, Massey JM. Extubation after transsternal thymectomy for myasthenia gravis: a prospective analysis. South Med J. 1991;84(6):701–6.

    CAS  PubMed  Google Scholar 

  134. Mori T, et al. Changes in respiratory condition after thymectomy for patients with myasthenia gravis. Ann Thorac Cardiovasc Surg. 2003;9(2):93–7.

    PubMed  Google Scholar 

  135. Rabinstein AA, Mueller-Kronast N. Risk of extubation failure in patients with myasthenic crisis. Neurocrit Care. 2005;3(3):213–5.

    PubMed  Google Scholar 

  136. Blot F, Melot C. Indications, timing, and techniques of tracheostomy in 152 French ICUs. Chest. 2005;127(4):1347–52.

    PubMed  Google Scholar 

  137. Durbin CG Jr. Tracheostomy: why, when, and how? Respir Care. 2010;55(8):1056–68.

    PubMed  Google Scholar 

  138. MacIntyre NR, et al. Evidence-based guidelines for weaning and discontinuing ventilatory support: a collective task force facilitated by the American College of Chest Physicians; the American Association for Respiratory Care; and the American College of Critical Care Medicine. Chest. 2001;120(6 Suppl):375S–95S.

    CAS  PubMed  Google Scholar 

  139. Mori T, Yoshioka M, Iwatani K, et al. Two cases of wound infection from tracheostomy after transsternal-thymectomy for myasthenia gravis. J Jpn Assoc Chest Surg. 2004;18(5):670–5.

    Google Scholar 

  140. Bacchetta MD, et al. Comparison of open versus bedside percutaneous dilatational tracheostomy in the cardiothoracic surgical patient: outcomes and financial analysis. Ann Thorac Surg. 2005;79(6):1879–85.

    PubMed  Google Scholar 

  141. Byhahn C, et al. Early percutaneous tracheostomy after median sternotomy. J Thorac Cardiovasc Surg. 2000;120(2):329–34.

    CAS  PubMed  Google Scholar 

  142. Curtis JJ, et al. Tracheostomy: a risk factor for mediastinitis after cardiac operation. Ann Thorac Surg. 2001;72(3):731–4.

    CAS  PubMed  Google Scholar 

  143. Force SD, et al. Incidence of deep sternal wound infections after tracheostomy in cardiac surgery patients. Ann Thorac Surg. 2005;80(2):618–21.

    PubMed  Google Scholar 

  144. Grmoljez PF, et al. Major complications of median sternotomy. Am J Surg. 1975;130(6):679–81.

    CAS  PubMed  Google Scholar 

  145. Hubner N, et al. Percutaneous dilatational tracheostomy done early after cardiac surgery–outcome and incidence of mediastinitis. Thorac Cardiovasc Surg. 1998;46(2):89–92.

    CAS  PubMed  Google Scholar 

  146. Patel A, Swan P, Dunning J. Does a percutaneous tracheostomy have a lower incidence of complications compared to an open surgical technique? Interact CardioVasc Thorac Surg. 2005;4(6):563–8.

    PubMed  Google Scholar 

  147. Stamenkovic SA, et al. Is early tracheostomy safe in cardiac patients with median sternotomy incisions? Ann Thorac Surg. 2000;69(4):1152–4.

    CAS  PubMed  Google Scholar 

  148. Wagner F, et al. Percutaneous dilatational tracheostomy: results and long-term outcome of critically ill patients following cardiac surgery. Thorac Cardiovasc Surg. 1998;46(6):352–6.

    CAS  PubMed  Google Scholar 

  149. Agarwal R, Reddy C, Gupta D. Noninvasive ventilation in acute neuromuscular respiratory failure due to myasthenic crisis: case report and review of literature. Emerg Med J. 2006;23(1):e6.

    PubMed Central  CAS  PubMed  Google Scholar 

  150. Seneviratne J, et al. Noninvasive ventilation in myasthenic crisis. Arch Neurol. 2008;65(1):54–8.

    PubMed  Google Scholar 

  151. Seneviratne J, et al. Predictors of extubation failure in myasthenic crisis. Arch Neurol. 2008;65(7):929–33.

    PubMed  Google Scholar 

  152. Pascuzzi R. Myasthenia Gravis Foundation of America. Medications and myasthenia gravis. Available at: http://www.myasthenia.org/docs/MGFA_MedicationsandMG.pdf.

  153. McQuillen MP, Canter HE, O’Rourke JR. Myasthenic syndrome associated with antibiotics. Arch Neurol. 1968;18:402–15.

    CAS  PubMed  Google Scholar 

  154. Abe S, Takeuchi C, Kaneko T, Maeda M, Saitoh Y, Hikawa Y, Yasuda K. Propofol anesthesia combined with thoracic epidural anesthesia for thymectomy formyasthenia gravis–a report of eleven cases. Masui. 2001;50(11):1217–20.

    CAS  PubMed  Google Scholar 

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Acknowledgments

The authors thank the former guidelines committees of Japanese Association for Chest Surgery: Drs. Hiroaki Nomori and Masazumi Watanabe for their contribution to this work.

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The authors have declared that no Conflict of interest exists.

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Correspondence to Yoshihisa Kadota.

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This article is based on a study first reported in the web site of the Japanese Association for Chest Surgery; http://www.jacsurg.gr.jp/.

This review was submitted at the invitation of the editorial committee.

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Kadota, Y., Horio, H., Mori, T. et al. Perioperative management in myasthenia gravis: republication of a systematic review and a proposal by the guideline committee of the Japanese Association for Chest Surgery 2014. Gen Thorac Cardiovasc Surg 63, 201–215 (2015). https://doi.org/10.1007/s11748-015-0518-y

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