Download PDF
Semin Neurol 2004; 24(1): 49-62
DOI: 10.1055/s-2004-829596
Copyright © 2004 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA.

Thymectomy in the Management of Myasthenia Gravis

Alfred Jaretzki1  III , Kenneth M. Steinglass1 , Joshua R. Sonett1 , 2
  • 1Professor of Clinical Surgery, Department of Surgery, New York Presbyterian Hospital, Columbia Presbyterian Medical Center, College of Physicians & Surgeons, Columbia University, New York, New York
  • 2Associate Professor of Clinical Surgery, Department of Surgery, New York Presbyterian Hospital, Columbia Presbyterian Medical Center, College of Physicians & Surgeons, Columbia University, New York, New York
Further Information

Publication History

Publication Date:
01 July 2004 (online)

    Permissions and Reprints

There continues to be a debate regarding the effectiveness of thymectomy in the treatment of nonthymomatous myasthenia gravis (MG) and, when undertaken, which thymectomy technique is the procedure of choice. The debate persists primarily because of the lack of controlled prospective studies. Analysis has been complicated by the absence, until very recently, of accepted objective definitions of severity of the illness and response to therapy as well as variable patient selection, timing of surgery, type of surgery, and methods of analysis of results. Without resolution of these issues by properly controlled prospective studies, there can be no unequivocal determination of the effectiveness of thymectomy or valid comparison of the various thymectomy techniques. In this review, based on previous analyses, attempts will be made to clarify some of the controversial issues concerning thymectomy for nonthymomatous MG and make limited recommendations based on the best available evidence.

KEYWORDS

Nonthymomatous myasthenia gravis - transcervical thymectomy - transsternal thymectomy - video-assisted thoracic surgery “VATS” thymectomy - life table analysis - crude analysis - nonrandom prospective studies

REFERENCES

  • 1 Jaretzki III A. Thymectomy for myasthenia gravis: an analysis of the controversies regarding technique and results.  Neurology. 1997;  48(suppl 5) S52-S63
    CrossrefPubMedGoogle Scholar
  • 2 Jaretzki III A. Thymectomy. In: Kaminski HJ Myasthenia Gravis and Related Disorders. Totowa, NJ; Humana Press 2002: 235-267
    Google Scholar
  • 3 Blalock A, Harvey A M, Ford F F, Lilienthal Jr J. The treatment of myasthenia gravis by removal of the thymus gland.  JAMA. 1941;  117 1529-1533
    CrossrefPubMedGoogle Scholar
  • 4 Masaoka A, Nagaoka Y, Kotake Y. Distribution of thymic tissue at the anterior mediastinum: current procedures in thymectomy.  J Thorac Cardiovasc Surg. 1975;  70 747-754
    PubMedGoogle Scholar
  • 5 Jaretzki III A, Wolff M. “Maximal” thymectomy for myasthenia gravis: surgical anatomy and operative technique.  J Thorac Cardiovasc Surg. 1988;  96 711-716
    PubMedGoogle Scholar
  • 6 Fukai I, Funato Y, Mizuno Y, Hashimoto T, Masaoka A. Distribution of thymic tissue in the mediastinal adipose tissue.  J Thorac Cardiovasc Surg. 1991;  101 1099-1102
    PubMedGoogle Scholar
  • 7 Keynes G. The surgery of the thymus gland.  Br J Surg. 1946;  32 201-214
    PubMedGoogle Scholar
  • 8 Kirschner P A, Osserman K E, Kark A E. Studies in myasthenia gravis: transcervical total thymectomy.  JAMA. 1969;  209 906-910
    CrossrefPubMedGoogle Scholar
  • 9 Kark A E, Kirschner P A. Total thymectomy by the transcervical approach.  Br J Surg. 1971;  58 321-326
    CrossrefPubMedGoogle Scholar
  • 10 Faulkner S L, Ehyai A S, Fisher R D, Fenichel G M, Bender H W. Contemporary management of myasthenia gravis: the clinical role of thymectomy.  Ann Thorac Surg. 1977;  23 348-352
    PubMedGoogle Scholar
  • 11 Olanow C W, Wechsler A S, Roses A D. A prospective study of thymectomy and serum acetylcholine receptor antibodies in myasthenia gravis.  Ann Surg. 1982;  196 113-121
    PubMedGoogle Scholar
  • 12 Vincent A, Newsom-Davis J, Newton P, Beck N. Acetylcholine receptor antibody and clinical response to thymectomy in myasthenia gravis.  Neurology. 1983;  33 1276-1282
    PubMedGoogle Scholar
  • 13 Hankins J R, Mayer R F, Satterfield J R et al.. Thymectomy for myasthenia gravis: 14 year experience.  Ann Surg. 1985;  201 618-625
    CrossrefPubMedGoogle Scholar
  • 14 Otto T J, Strugalska H. Surgical treatment for myasthenia gravis.  Thorax. 1987;  42 199-204
    PubMedGoogle Scholar
  • 15 Cooper J, Jaretzki III A, Mulder D G, Papatestas A S. Symposium: thymectomy for myasthenia gravis.  Contemp Surg. 1989;  34 65-86
    PubMedGoogle Scholar
  • 16 Verma P, Oger J. Treatment of acquired autoimmune myasthenia gravis: a topic review.  Can J Neurol Sci. 1992;  19 360-375
    PubMedGoogle Scholar
  • 17 Drachman D B. Myasthenia gravis.  N Engl J Med. 1994;  330 1797-1810
    CrossrefPubMedGoogle Scholar
  • 18 Penn A S. Thymectomy for myasthenia gravis. In: Lisak RP Handbook of Myasthenia Gravis and Myasthenic Syndromes. New York; Marcel Dekker 1994: 321-339
    Google Scholar
  • 19 Mack M J, Landreneau R D, Yim A P, Hazelrigg S R, Scruggs G R. Results of video-assisted thymectomy in patients with myasthenia gravis.  J Thorac Cardiovasc Surg. 1996;  112 1352-1360
    CrossrefPubMedGoogle Scholar
  • 20 Penn A S, Jaretzki III A, Wolff M, Chang H W, Tennyson V. Thymic abnormalities: antigen or antibody? Response to thymectomy in myasthenia gravis.  Ann N Y Acad Sci. 1981;  377 786-803
    PubMedGoogle Scholar
  • 21 Wekerle H, Muller-Hermelink H K. The thymus in myasthenia gravis.  Curr Top Pathol. 1986;  75 179-206
    PubMedGoogle Scholar
  • 22 Younger D S, Worrall B B, Penn A S. Myasthenia gravis: historical perspective and overview.  Neurology. 1997;  48(suppl 5) S1-S17
    PubMedGoogle Scholar
  • 23 Ruff R L. Neuromuscular junction physiology and pathophysiology. In: Kaminski HJ Myasthenia Gravis and Related Disorders. Totowa, NJ; Humana Press 2003: 1-13
    Google Scholar
  • 24 Masaoka A, Monden Y, Seike Y, Tanioka T, Kagotani K. Reoperation after transcervical thymectomy for myasthenia gravis.  Neurology. 1982;  32 83-85
    PubMedGoogle Scholar
  • 25 Rosenberg M, Jauregui W O, Vega M ED, Herrera M R, Roncoroni A J. Recurrence of thymic hyperplasia after thymectomy in myasthenia gravis: its importance as a cause of failure of surgical treatment.  Am J Med. 1983;  74 78-82
    CrossrefPubMedGoogle Scholar
  • 26 Henze A, Biberfeld P, Christensson B, Matell G, Pirskanen R. Failing transcervical thymectomy in myasthenia gravis, an evaluation of transsternal re-exploration.  Scand J Thorac Cardiovasc Surg. 1984;  18 235-238
    PubMedGoogle Scholar
  • 27 Rosenberg M, Jauregui W O, Herrera M R, Roncoroni A, Rojas O R, Olmedo G SM. Recurrence of thymic hyperplasia after trans-sternal thymectomy in myasthenia gravis.  Chest. 1986;  89 888-891
    PubMedGoogle Scholar
  • 28 Jaretzki III A, Penn A S, Younger D S et al.. “Maximal” thymectomy for myasthenia gravis: results.  J Thorac Cardiovasc Surg. 1988;  95 747-757
    PubMedGoogle Scholar
  • 29 Miller R G, Filler-Katz A, Kiprov D, Roan R. Repeat thymectomy in chronic refractory myasthenia gravis.  Neurology. 1991;  41 923-924
    PubMedGoogle Scholar
  • 30 Kornfeld P, Merav A, Fox S, Maier K. How reliable are imaging procedures in detecting residual thymus after previous thymectomy.  Ann N Y Acad Sci. 1993;  681 575-576
    PubMedGoogle Scholar
  • 31 Masaoka A, Monden Y. Comparison of the results of transsternal simple, transcervical simple and extended thymectomy.  Ann N Y Acad Sci. 1981;  377 755-764
    CrossrefPubMedGoogle Scholar
  • 32 Matell G, Lebram G, Osterman P O, Pirskanen R. Follow up comparison of suprasternal vs transsternal method for thymectomy in myasthenia gravis.  Ann N Y Acad Sci. 1981;  377 844-845
    PubMedGoogle Scholar
  • 33 Jaretzki III A, Barohn R J, Ernstoff R N et al.. Myasthenia gravis: recommendations for clinical research standards.  Neurology. 2000;  55 16-23
    PubMedGoogle Scholar
  • 34 MG Task Force .Recommendations for clinical research standards. Standards www.myasthenia.org/clinical/research/standards 2002 www.myasthenia.org/research/MGFA_Standards.pdf
    Google Scholar
  • 35 Kark A E, Papatestas A E. Some anatomic features of the transcervical approach for thymectomy.  Mt Sinai J Med. 1971;  38 580-584
    PubMedGoogle Scholar
  • 36 Papatestas A E, Genkins G, Kornfeld P, Horowitz S, Kark A E. Transcervical thymectomy in myasthenia gravis.  Surg Gynecol Obstet. 1975;  140 535-540
    PubMedGoogle Scholar
  • 37 Ferguson M K. Transcervical thymectomy.  Semin Thorac Cardiovasc Surg. 1999;  11 59-64
    PubMedGoogle Scholar
  • 38 Kirby T J, Ginsberg R J. Transcervical thymectomy. In: Shields T, LoCicero J, Ponn R General Thoracic Surgery. 5th ed. Philadelphia; Lippincott Williams & Wilkins 2000: 2239-2242
    Google Scholar
  • 39 Austin E H, Olanow C W, Wechsler A S. Thymoma following transcervical thymectomy for myasthenia gravis.  Ann Thorac Surg. 1983;  35 548-550
    PubMedGoogle Scholar
  • 40 Cooper J, Al-Jilaihawa A, Pearson F, Humphrey J, Humphrey H E. An improved technique to facilitate transcervical thymectomy for myasthenia gravis.  Ann Thorac Surg. 1988;  45 242-247
    CrossrefPubMedGoogle Scholar
  • 41 Bril V, Kojic S, Ilse W, Cooper J. Long-term clinical outcome after transcervical thymectomy for myasthenia gravis.  Ann Thorac Surg. 1998;  65 1520-1522
    CrossrefPubMedGoogle Scholar
  • 42 Calhoun R F, Ritter J H, Guthrie T J et al.. Results of transcervical thymectomy for myasthenia gravis in 100 consecutive patients.  Ann Surg. 1999;  230 555-561
    CrossrefPubMedGoogle Scholar
  • 43 Meyers B F, Cooper J. Transcervical thymectomy for myasthenia gravis.  Chest Surg Clin N Am. 2001;  11 363-368
    PubMedGoogle Scholar
  • 44 Shrager J B, Deeb M E, Mick R et al.. Transcervical thymectomy for myasthenia gravis achieves results comparable to thymectomy by sternotomy.  Ann Thorac Surg. 2002;  74 320-327
    CrossrefPubMedGoogle Scholar
  • 45 Durelli L, Maggi G, Casadio C, Ferri R, Rendine S, Bergamini L. Actuarial analysis of the occurrence of remission following thymectomy for myasthenia gravis in 400 patients.  J Neurol Neurosurg Psychiatry. 1991;  54 406-411
    PubMedGoogle Scholar
  • 46 Klingen G, Johansson L, Westerholm C J, Sundstroom C. Transcervical thymectomy with the aid of mediastinoscopy for myasthenia gravis: eight years, experience.  Ann Thorac Surg. 1977;  23 342-347
    PubMedGoogle Scholar
  • 47 Kirby T J, Ginsberg R J. Transcervical thymectomy. In: Shields TW Mediastinal Surgery. Philadelphia; Lea & Febiger 1991: 3693-3771
    Google Scholar
  • 48 Hagan J A, Patterson G A. Surgery of myasthenia gravis. In: Pearson FG Thoracic Surgery. New York; Churchill Livingstone 1995: 1511-1521
    Google Scholar
  • 49 Sugarbaker D J. Thoracoscopy in the management of anterior mediastinal masses.  Ann Thorac Surg. 1993;  56 653-656
    CrossrefPubMedGoogle Scholar
  • 50 Roviaro G, Rebuffat C, Varoli F, Vergani C, Maciocco M, Scalambra S M. Videothoracoscopic excision of mediastinal masses: indications and technique.  Ann Thorac Surg. 1994;  58 1679-1684
    CrossrefPubMedGoogle Scholar
  • 51 Sabbagh M N, Garza J JS, Patten B. Thoracoscopic thymectomy in patients with myasthenia gravis.  Muscle Nerve. 1995;  18 1475-1477
    CrossrefPubMedGoogle Scholar
  • 52 Yim A PC, Kay R LC, Ho J KS. Video-assisted thoracoscopic thymectomy for myasthenia gravis.  Chest. 1995;  108 1440-1443
    CrossrefPubMedGoogle Scholar
  • 53 Mineo T C, Pompeo E, Ambrogi V, Sabato A F, Bernardi G, Casciani C U. Adjuvant pneumomediastinum in thoracoscopic thymectomy for myasthenia gravis.  Ann Thorac Surg. 1996;  62 1210-1212
    CrossrefPubMedGoogle Scholar
  • 54 Ruckert J C, Gellert K, Muller J M. Operative technique for thoracoscopic thymectomy.  Surg Endosc. 1999;  13 943-946
    CrossrefPubMedGoogle Scholar
  • 55 Mack M J, Scruggs G R. Video-assisted thymectomy. In: Shields T, LoCicero J, Ponn R General Thoracic Surgery, 5th ed. Philadelphia; Lippincott Williams & Wilkins 2000: 2243-9
    Google Scholar
  • 56 Mack M J. Video-assisted thoracoscopy thymectomy for myasthenia gravis.  Chest Surg Clin N Am. 2001;  11 389-405
    PubMedGoogle Scholar
  • 57 Uchiyama A, Shimizu S, Murai H, Kuroki S, Okido M, Tanaka M. Infrasternal mediastinoscopy thymectomy in myasthenia gravis: surgical results in 23 patients.  Ann Thorac Surg. 2001;  72 1902-1905
    CrossrefPubMedGoogle Scholar
  • 58 Ashton R C, McGinnis K M, Connery C P, Swistel D S, Ewing D R, DeRose J J. Total endoscopic robotic thymectomy for myasthenia gravis (case report).  Ann Thorac Surg. 2003;  75 569-571
    CrossrefPubMedGoogle Scholar
  • 59 Novellino L, Longoni M, Spinelli L et al.. “Extended” thymectomy, without sternotomy, performed by cervicotomy and thoracoscopic technique in the treatment of myasthenia gravis.  Int Surg. 1994;  79 378-381
    PubMedGoogle Scholar
  • 60 Scelsi R, Ferro M T, Scelsi L et al.. Detection and morphology of thymic remnants after video-assisted thoracoscopic thymectomy (VATET) in patients with myasthenia gravis.  Int Surg. 1996;  81 14-17
    PubMedGoogle Scholar
  • 61 Blalock A, Mason M F, Morgan H J, Riven S S. Myasthenia gravis and tumors of the thymus region: report of a case in which the tumor was removed.  Am Surg. 1939;  110 544-561
    CrossrefPubMedGoogle Scholar
  • 62 Clagett O T, Eaton L M. Surgical treatment of myasthenia gravis.  J Thorac Surg. 1947;  16 62-80
    PubMedGoogle Scholar
  • 63 Blalock A. Thymectomy in the treatment of myasthenia gravis: report of 20 cases.  J Thorac Surg. 1944;  13 1291-1308
    PubMedGoogle Scholar
  • 64 Olanow C W, Wechsler A S. The surgical management of myasthenia gravis. In: Sabiston DC, Spencer FC Gibbon's Surgery of the Chest, 4th ed. Philadelphia; WB Saunders 1983: 849-869
    Google Scholar
  • 65 Olanow C W, Wechsler A S. The surgical management in myasthenia gravis. In: Sabiston DC Jr Textbook of Surgery, 14th ed. Philadelphia; WB Saunders 1991: 1801-1814
    Google Scholar
  • 66 Trastek V F, Pairolero P C. Standard thymectomy. In: TW Shields Mediastinal Surgery. Philadelphia; Lea & Febiger 1991: 365-368
    Google Scholar
  • 67 Trastek V F, Pairolero P C. Surgery of the thymus gland. In: Shields TW General Thoracic Surgery, 4th ed. Baltimore; William & Wilkins 1994: 1770-1781
    Google Scholar
  • 68 Granone P, Margaritora S, Cesario A, Galetta D. Thymectomy (transsternal) in myasthenia gravis via video-assisted infra-mammary cosmetic incision.  Eur J Cardiothorac Surg. 1999;  15 861-863
    CrossrefPubMedGoogle Scholar
  • 69 Miller J I, Mansour K A, Hatcher Jr C R. Median sternotomy T incision for thymectomy in myasthenia gravis.  Ann Thorac Surg. 1982;  34 473-474
    PubMedGoogle Scholar
  • 70 LoCicero III J. The combined cervical and partial sternotomy approach for thymectomy.  Chest Surg Clin N Am. 1996;  6 85-93
    PubMedGoogle Scholar
  • 71 Kagotani K, Monden Y, Nakaha K et al.. Anti-acetylcholine receptor antibody titer with extended thymectomy in myasthenia gravis.  J Thorac Cardiovasc Surg. 1985;  90 7-12
    PubMedGoogle Scholar
  • 72 Monden Y, Nakahara K, Fujii Y et al.. Myasthenia gravis in elderly patients.  Ann Thorac Surg. 1985;  39 433-436
    PubMedGoogle Scholar
  • 73 Mulder D G, Graves M, Hermann Jr C. Thymectomy for myasthenia gravis: recent observations and comparison with past experience.  Ann Thorac Surg. 1989;  48 551-555
    PubMedGoogle Scholar
  • 74 Fujii N, Itoyama Y, Machi M, Goto I. Analysis of prognostic factors in thymectomized patients with myasthenia gravis: correlation between thymic lymphoid cell subsets and postoperative clinical course.  J Neurol Sci. 1991;  105 143-149
    CrossrefPubMedGoogle Scholar
  • 75 Nussbaum M S, Rosenthal G J, Samaha F J et al.. Management of myasthenia gravis by extended thymectomy with anterior mediastinal dissection.  Surgery. 1992;  112 681-688
    PubMedGoogle Scholar
  • 76 Frist W H, Thirumalai S, Doehring C B et al.. Thymectomy for the myasthenia gravis patient: Factors influencing outcome.  Ann Thorac Surg. 1994;  57 334-338
    PubMedGoogle Scholar
  • 77 Masaoka A, Yamakawa Y, Niwa H et al.. Extended thymectomy for myasthenia gravis: a 20 year review.  Ann Thorac Surg. 1996;  62 853-859
    CrossrefPubMedGoogle Scholar
  • 78 Detterbeck F C, Scott W W, Howard J F et al.. One hundred consecutive thymectomies for myasthenia gravis.  Ann Thorac Surg. 1996;  62 242-245
    CrossrefPubMedGoogle Scholar
  • 79 Mulder D G. Extended transsternal thymectomy.  Chest Surg Clin N Am. 1996;  6 95-105
    PubMedGoogle Scholar
  • 80 Masaoka A. Extended trans-sternal thymectomy for myasthenia gravis.  Chest Surg Clin N Am. 2001;  11 369-387
    PubMedGoogle Scholar
  • 81 Steinglass K M. Extended transsternal thymectomy for myasthenia gravis (videocassette). Chicago; The Society of Thoracic Surgeons 2002
    Google Scholar
  • 82 Fischer J E, Grinvalski H T, Nussbaum M S, Sayers H K, Cole R E, Samaha F J. Aggressive surgical approach for drug-free remission from myasthenia gravis.  Ann Surg. 1987;  205 496-503
    PubMedGoogle Scholar
  • 83 Hatton P, Diehl J, Daly B DT et al.. Transternal radical thymectomy for myasthenia gravis: a 15-year review.  Ann Thorac Surg. 1989;  47 838-840
    PubMedGoogle Scholar
  • 84 Grandjean J G, Lucchi M, Mariani M. Reversed-T upper mini-sternotomy for extended thymectomy in myasthenia gravis.  Ann Thorac Surg. 2000;  70 1423-1425
    CrossrefPubMedGoogle Scholar
  • 85 Mulder D M. Extended transsternal thymectomy. In: Shields TW General Thoracic Surgery. 5th ed. Philadelphia; Lippincott Williams & Wilkins 2000: 2233-2237
    Google Scholar
  • 86 Bulkley G B, Bass K N, Stephenson R et al.. Extended cervicomediastinal thymectomy in the integrated management of myasthenia gravis.  Ann Surg. 1997;  226 324-335
    CrossrefPubMedGoogle Scholar
  • 87 Kaplan E L, Meier P. Nonparametric estimation from incomplete observations.  J Am Stat Assoc. 1958;  53 457-481
    CrossrefPubMedGoogle Scholar
  • 88 Lawless J F. Life tables, graphs, and related procedures. In: Lawless JF Statistical Models and Methods for Life Table Data. New York; John Wiley & Sons 1982: 52-94
    Google Scholar
  • 89 Weinberg A, Gelijns A, Moskowitz A, Jaretzki A. Myasthenia gravis: outcomes analysis. <www.myasthenia.org/research/Clinical_Research_Standards.htm> Reprints: Myasthenia Gravis Foundation of America, Inc., 1821 University Avenue West (Suite S256), St. Paul, MN-55104-2897 2000
    Google Scholar
  • 90 Olak J, Chiu R CJ. A surgeon's guide to biostatistical inferences: part II.  ACS Bull. 1993;  78 27-31
    PubMedGoogle Scholar
  • 91 Papatestas A E, Genkins G, Kornfield P et al.. Effects of thymectomy in myasthenia gravis.  Ann Surg. 1987;  206 79-88
    CrossrefPubMedGoogle Scholar
  • 92 Blackstone E H. Outcome analysis using hazard function methodology.  Ann Thorac Surg. 1996;  61 S2-S7
    CrossrefPubMedGoogle Scholar
  • 93 Sanders D B, Kaminski H J, Jaretzki III A, Phillips II L H. Thymectomy for myasthenia gravis in older patients [Letter to Editor].  J Am Coll Surg. 2001;  193 340-341
    CrossrefPubMedGoogle Scholar
  • 94 McQuillen M P, Leone M G. A treatment carol: thymectomy revisited.  Neurology. 1977;  27 1103-1106
    CrossrefPubMedGoogle Scholar
  • 95 Viet H R, Schwab R S. Thymectomy for myasthenia gravis. In: Veit HR Records of Experience of Massachusetts General Hospital. Springfield, IL; Charles C. Thomas 1960: 597-607
    Google Scholar
  • 96 Oosterhuis H J. Observations of the natural history of myasthenia gravis and the effect of thymectomy.  Ann N Y Acad Sci. 1981;  377 678-689
    PubMedGoogle Scholar
  • 97 Gronseth S, Barohn R J. Practice parameters: thymectomy for autoimmune myasthenia gravis (an evidence base review).  Neurology. 2000;  55 7-15
    CrossrefPubMedGoogle Scholar
  • 98 Buckingham J M, Howard F M, Bernatz P E. The value of thymectomy in myasthenia gravis: a computer-assisted matched study.  Ann Surg. 1976;  184 453-458
    PubMedGoogle Scholar
  • 99 Mantegazza R, Baggi F, Bernasconi P et al.. Video-assisted thoracoscopic extended thymectomy (VATET) and extended transsternal thymectomy (T-3b) in non-thymomatous myasthenia gravis patients: remission after 6 years of follow-up.  J Neurol Sci. 2003;  212 31-36
    CrossrefPubMedGoogle Scholar
  • 100 Rodriguez M, Gomez M R, Howard F, Taylor W F. Myasthenia gravis in children: long term follow-up.  Ann Neurol. 1983;  13 504-510
    CrossrefPubMedGoogle Scholar
  • 101 Mulder D G, Herrmann Jr C, Keesey J, Edwards H. Thymectomy for myasthenia gravis.  Am J Surg. 1983;  146 61-66
    CrossrefPubMedGoogle Scholar
  • 102 Lanska D. Indications for thymectomy in myasthenia gravis.  Neurology. 1990;  40 1828-1829
    CrossrefPubMedGoogle Scholar
  • 103 Keesey J C. A treatment algorithm for autoimmune myasthenia in adults.  Ann N Y Acad Sci. 1998;  841 753-768
    PubMedGoogle Scholar
  • 104 Daroff R B. Ocular myasthenia. In: Kaminski HJ Myasthenia Gravis and Related Disorders. Totowa, NJ; Humana Press 2003: 115-128
    Google Scholar
  • 105 Schumm F, Wietholter H, Fateh-Mogbadan A, Dichgans J. Thymectomy in myasthenia with pure ocular symptoms.  J Neurol Neurosurg Psychiatry. 1985;  48 332-337
    PubMedGoogle Scholar
  • 106 Evoli A, Batocchi A P, Minisci C, DiShino C, Tonali P. Therapeutic options in ocular myasthenia gravis.  Neuromuscul Disord. 2001;  11 208-216
    CrossrefPubMedGoogle Scholar
  • 107 Rubin J W, Ellison R G, Moore H V, Pai G P. Factors affecting response to thymectomy for myasthenia gravis.  J Thorac Cardiovasc Surg. 1981;  82 720-728
    PubMedGoogle Scholar
  • 108 Monden Y, Nakahara K, Kagotani K et al.. Effects of preoperative duration of symptoms on patients with myasthenia gravis.  Ann Thorac Surg. 1984;  38 287-291
    PubMedGoogle Scholar
  • 109 DeFilippi V J, Richman D P, Ferguson M K. Transcervical thymectomy for myasthenia gravis.  Ann Thorac Surg. 1994;  57 194-197
    PubMedGoogle Scholar
  • 110 Kaminski H J. Treatment of myasthenia gravis. In: Kaminski HJ Myasthenia Gravis and Related Disorders. Totowa, NJ; Humana Press 2003: 197-221
    Google Scholar
  • 111 Adams C, Theodorescu D, Murphy E, Shandling B. Thymectomy in juvenile myasthenia gravis.  J Child Neurol. 1990;  5 215-218
    CrossrefPubMedGoogle Scholar
  • 112 Andrews P I, Massey J M, Howard J F, Sanders D B. Race, sex, and puberty influence onset, severity, and outcome in juvenile myasthenia gravis.  Neurology. 1994;  44 1208-1214
    CrossrefPubMedGoogle Scholar
  • 113 Andrews P I. A treatment algorithm for autoimmune myasthenia gravis in children.  Ann N Y Acad Sci. 1998;  841 789-802
    CrossrefPubMedGoogle Scholar
  • 114 Seybold M E. Thymectomy in childhood myasthenia gravis.  Ann N Y Acad Sci. 1998;  841 731-741
    CrossrefPubMedGoogle Scholar
  • 115 Kirschner P A. Reoperation on the thymus. A critique.  Chest Surg Clin N Am. 2001;  11 439-445
    PubMedGoogle Scholar
  • 116 Pompeo E, Nofroni I, Iavicoli N, Mineo T C. Thoracoscopic completion thymectomy in refractory nonthymomatous myasthenia.  Ann Thorac Surg. 2000;  70 918-923
    CrossrefPubMedGoogle Scholar
  • 117 Mussi A, Lucchi M, Murri L, Ricciardi R, Luchini L, Angeletti C A. Extended thymectomy in myasthenia gravis: a team-work of neurologist, thoracic surgeon, and anaesthesist may improve the outcome.  Eur J Cardiothorac Surg. 2001;  19 570-575
    CrossrefPubMedGoogle Scholar
  • 118 Houghton A. Variation in outcome of surgical procedures.  Br J Surg. 1994;  81 653-650
    PubMedGoogle Scholar
  • 119 Crawford F A, Anderson R P, Clark R E et al.. Volume requirements for cardiac surgery credentialing: a critical examination.  Ann Thorac Surg. 1996;  61 12-16
    CrossrefPubMedGoogle Scholar
  • 120 Silvestri G A, Handy J, Lackland D, Corley E, Reed C E. Specialists achieve better outcomes than generalists for lung cancer surgery.  Chest. 1998;  114 675-680
    CrossrefPubMedGoogle Scholar
  • 121 Krucylak P E, Naunheim K S. Preoperative preparation and anesthetic management of patients with myasthenia gravis.  Semin Thorac Cardiovasc Surg. 1999;  11 47-53
    PubMedGoogle Scholar
  • 122 Younger D S, Braun N MT, Jaretzki III A, Penn A S, Lovelace A E. Myasthenia gravis: determinants for independent ventilation after transsternal thymectomy.  Neurology. 1984;  34 336-340
    PubMedGoogle Scholar
  • 123 d'Empaire G, Hoaglin D C, Perlo V P, Pontoppidan H. Effect of prethymectomy plasma exchange on postoperative respiratory function in myasthenia gravis.  J Thorac Cardiovasc Surg. 1985;  89 592-596
    PubMedGoogle Scholar
  • 124 Cumming W JK, Hudgson P. The role of plasmapheresis in preparing patients with myasthenia for thymectomy.  Muscle Nerve. 1986;  9 S155-S158
    PubMedGoogle Scholar
  • 125 Gotti P, Spinelli A, Marconi G et al.. Comparative effects of plasma exchange and pyridostigmine on expiratory muscle strength and breathing pattern in patients with myasthenia gravis.  Thorax. 1995;  50 1080-1086
    PubMedGoogle Scholar
  • 126 Kas J, Kiss D, Simon V, Svastics E, Major L, Szobor A. Decade-long experience with surgical therapy of myasthenia gravis: early complications of 324 transsternal thymectomies.  Ann Thorac Surg. 2001;  72 1691-1697
    CrossrefPubMedGoogle Scholar
  • 127 Jaretzki III A, Phillips II L, Aarli J, Kaminski H J, Sanders D B. Preoperative preparation of patients with myasthenia gravis forestalls postoperative respiratory complications following thymectomy [Letter to Editor].  Ann Thorac Surg. 2003;  75 1068-1069
    CrossrefPubMedGoogle Scholar
  • 128 Mayer S A. Intensive care of the myasthenic patient.  Neurology. 1997;  48(Suppl 5) S70-S81
    CrossrefPubMedGoogle Scholar
  • 129 Jaretzki III A. Transcervical/transsternal “maximal” thymectomy for myasthenia gravis. In: Shields T, LoCicero J, Ponn R General Thoracic Surgery. 5th ed. Philadelphia; Lippincott Williams & Wilkins 2000: 2223-2232
    Google Scholar
  • 130 Miller R G, Rosenberg J A. Force APPT. Care of patients with ALS: report of the Quality Standards Subcommittee of the AAN.  Neurology. 1999;  52 1311-1323
    PubMedGoogle Scholar
  • 131 Kirklin J W, Blackstone E H. Clinical studies with non-randomly assigned treatment. In: Kirklin, JW, Barrett-Boyes BG Cardiac Surgery. 2nd ed. New York; Churchill-Livingstone 1993: 269-270
    Google Scholar
  • 132 Benson K, Hart A J. A comparison of observational studies and randomized, controlled trials.  N Engl J Med. 2000;  342 1878-1886
    CrossrefPubMedGoogle Scholar
  • 133 Concato J, Shah N, Horwitz R I. Randomized, controlled trials, observational studies, and the hierarchy of research designs.  N Engl J Med. 2000;  342 1887-1892
    CrossrefPubMedGoogle Scholar
  • 134 Blackstone E H. Breaking down barriers: helpful breakthrough statistical methods you need to understand better.  J Thorac Cardiovasc Surg. 2001;  122 430-439
    CrossrefPubMedGoogle Scholar
  • 135 Blackstone E H, Rice T W. Clinical-pathological conference: use and choice of statistical methods for the clinical study, “Superficial adenocarcinoma of the esophagus”.  J Thorac Cardiovasc Surg. 2001;  122 1063-1076
    CrossrefPubMedGoogle Scholar
  • 136 Blackstone E H. Comparing apples and oranges.  J Thorac Cardiovasc Surg. 2002;  123 8-15
    CrossrefPubMedGoogle Scholar
  • 137 Heagerty P J, Zeger S L. Marginal regression models for clustered ordinal measurements.  J Am Stat Assoc. 1996;  91 1024-1036
    PubMedGoogle Scholar
  • 138 Wolfe G I, Herbelin L, Nations S P, Foster B, Bryan W W, Barohn R J. Myasthenia gravis activities of daily living profile.  Neurology. 1999;  52 1487-1489
    PubMedGoogle Scholar
  • 139 Jaeschke R, Guyatt G H. How to develop and validate a new quality of life instrument. In: Spilker B Quality of Life Assessments in Clinical Trials. New York; Raven Press 1990: 47-57
    Google Scholar
  • 140 Ashour M H, Jain S K, Kattan K M et al.. Maximal thymectomy for myasthenia gravis.  Eur J Cardiothorac Surg. 1995;  9 461-464
    CrossrefPubMedGoogle Scholar
  • 141 Emeryk B, Strugalska M H. Evaluation of results of thymectomy in myasthenia gravis.  J Neurol. 1976;  211 155-168
    PubMedGoogle Scholar
  • 142 Hayat G, Mohyuddin Y A, Naunheim K. Efficacy of thymectomy in myasthenia gravis.  Mo Med. 1995;  92 252-257
    PubMedGoogle Scholar
  • 143 Clark R E, Marbarger J P, West P N et al.. Thymectomy for myasthenia gravis in the young adult.  J Thorac Cardiovasc Surg. 1980;  80 696-701
    PubMedGoogle Scholar
  • 144 Wilkins Jr E W. Thymectomy.  Modern Techniques in Surg. 1981;  38 1-13
    PubMedGoogle Scholar

Alfred Jaretzki IIIM.D. 

21 Little Point Street, P.O. Box 365, Essex

CT 06426

Email: aj31@columbia.edu