[Myasthenia gravis: perioperative complications of 1002 transsternal thymectomies - historical overwiev of 34 years long practice at one institution].

Thymectomy became an important part of the treatment of myasthenia gravis, since Alfred Blalock reported about his first surgery 80 years ago. Despite of several different surgical techniques already accepted abroad, sternal approach was the almost exclusive exposure for thymectomy in Hungary till 2006. In this publication, we analyze the direct surgical consequences and complications of this method. At the Surgical Department of Budai MÁV Hospital, 1002 transsternal thymectomies were performed during 34 years on patients suffering from myasthenia gravis. Surgeries were performed for neurological indications, following careful medical investigations, involving specialists in neurology and internal medicine. In cases associated with thymoma, surgery was indicated for two reasons: removal of the thymus and the tumor at the same time. Neurological indications, patient preparation, perioperative treatment and surgical technique have considerably changed during these 34 years. We interpret the results according to the two eras based on the most frequently applied surgical techniques (simple and extended thymectomy); we publish the data separately of the patients with thymoma and those who underwent repeated surgery, focusing basically on breath-related complications. The patients' age was 32 years on the average (8-73 years). Women/men ratio: 3.5:1. Myasthenia gravis was associated with thymoma in 12.7% of the patients. Repeated thymectomy was necessary in case of 11 patients; further two patients required repeated sternotomy after cardiac surgery. Respiratory failure occurred in 21,3% out of 525 myasthenic patients operated in the first 19-year-old era, emergency re-intubation and tracheostomy happened in 12,8% and in 11,2% as well. In the second 15-year-old period postoperative respiratory failure occurred in 12,7% with emergency re-intubation in 7,1% and tracheostomy only in 1,2% out of 338 myasthenic patients. Respiratory failure occurred in 19.1% out of 126 patients operated for thymoma; re-intubation was necessary in 12.8% of the cases and tracheostomy was performed in 20.6% of the patients. Respiratory failure occurred in 13 patients, who underwent repeated surgery (46.1%); the ratio of re-intubation was 15.4% and that of tracheostomies 46.1%. Serious surgical complications were infrequent also in the entire group of patients: 2 patients required repeated surgery due to sternal bleeding; one more patient underwent repeated surgery due to rupture of the drainage tube, 4 cases of mediastinitis in the first group, two cases of heart injury and one case of sternal disruption occurred in the second period. The overall mortality was 1.4%: 1.3% in the first period, 0.3% in the second period, 4% in the thymoma group and 7.7% after repeated surgeries. In a historical overview, the ratio of serious respiratory and airway complications and the mortality after transsternal thymectomies has considerably decreased, but the postoperative respiratory failure and the surgical risk of transsecting the sternum still pose a real risk.