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