Analysis of Survey On Surgical Management of Myasthenia Gravis

In this survey respondents were asked about their routine approach to assessment and management of patients with non-thymomatous myasthenia gravis (MG).� The majority of respondents surgically manage myasthenia gravis.� Two-thirds of them perform this operation via a full or partial sternotomy.� About 20% of surgeons use VATS approaches, and transcervical and robotic approaches each were used by 5%.

Almost 85% of respondents consider the diagnosis of myasthenia gravis or MG with more than ocular symptoms to be sufficient indications for surgery.� A minority of surgeons, just over 15%, indicated that patients needed to have generalized symptoms before they would consider recommending thymectomy.� The most common surgical goal, favored by two-thirds of respondents, was complete thymectomy, whereas one-third believe that an extended or radical thymectomy is appropriate for management of MG.

Advanced age does not appear to be a contraindication to thymectomy for MG, even though some reports in the literature suggest that outcomes with regards to resolution of MG symptoms are not as favorable in older patients.� Preoperative preparation appears to include 2 or more different techniques for most surgeons.

Almost all surgeons obtain a CT scan as part of the preoperative evaluation.� Only 40% measure lung function, and just over 50% assess acetylcholine receptor antibody status.� MRI is not favored as a method of preoperative evaluation in these patients.� Interestingly, if a small encapsulated nodule consistent with a thymoma is discovered during a minimally invasive thymectomy, two-thirds of respondents would complete the thymectomy using a minimally invasive approach.

This was the first survey in this portal to attract relatively equal numbers of respondents from North America, Europe, and Asia, and there was a larger number than usual of respondents from Africa as well.

1. Do you perform thymectomy for myasthenia gravis?
	answered question		113
	skipped question		0
		Response Percent	Response Count
Yes		98.2%	111
No, that disease is not treated surgically in my center		0.0%	0
No, that disease is treated surgically by other surgeons in my center		1.8%	2

2. What is your standard surgical approach to non-thymomatous myasthenia gravis?
	answered question		113
	skipped question		0
		Response Percent	Response Count
Partial sternotomy		17.7%	20
Full sternotomy		50.4%	57
Transcervical		5.3%	6
Thoracoscopic, bilateral		4.4%	5
Thoracoscopic, unilateral		16.8%	19
Robotic assisted of any type		5.3%	6

3. What is your intent when performing thymectomy for MG?
	answered question		113
	skipped question		0
		Response Percent	Response Count
Complete thymectomy		63.7%	72
Extended or radical thymectomy		36.3%	41
Other		0.0%	0

4. What are your indications for surgery for MG?
	answered question		112
	skipped question		1
		Response Percent	Response Count
Any patient diagnosed with MG is a candidate		49.1%	55
Disease beyond ocular involvement		34.8%	39
Severe generalized disease		16.1%	18

5. Is older age a contraindication to thymectomy for myasthenia gravis?
	answered question		113
	skipped question		0
		Response Percent	Response Count
Definitely		2.7%	3
Maybe		30.1%	34
Probably not		35.4%	40
No		31.9%	36

6. What adjuncts do you or your medical colleagues use to prepare MG patients for surgery (check all that apply)?
	answered question		110
	skipped question		3
		Response Percent	Response Count
Plasmapheresis		65.5%	72
Steroids		70.9%	78
Other pharmacologic immunosuppression		30.9%	34
Intravenous IgG		48.2%	53

7. What evaluations are routine prior to thymectomy for MG (check all that apply)?
	answered question		112
	skipped question		1
		Response Percent	Response Count
CT		97.3%	109
PFTs		39.3%	44
MRI		8.0%	9
Acetylcholine receptor antibody measurement		53.6%	60

8. If a 1.5 cm encapsulated nodule suspicious for thymoma is discovered intraoperatively during a minimally invasive or transcervical thymectomy, how do you manage this?
	answered question		109
	skipped question		4
		Response Percent	Response Count
Convert to an open operation		23.9%	26
Continue with a minimally invasive approach as planned		65.1%	71
Other		11.0%	12

9. In what region do you practice?
	answered question		113
	skipped question		0
		Response Percent	Response Count
North America		31.9%	36
Europe		23.0%	26
Asia		25.7%	29
Africa		5.3%	6
Central or South America		13.3%	15
Australia/New Zealand		0.9%	1