- Email: [email protected]
Preoperative Use of Steroids in Patients With Myasthenia Gravis
1946
CORRESPONDENCE
that local infiltration of the vasodilator caused dilatation of the small branches and bleeding, which caused difficulty in skeletonizing the conduit. Moreover it has been shown that vasospasm is avoided and the graft flows are better in skeletonized ITAs and are comparable with pedicle ITAs with intraluminal papaverine injection [4]. We congratulate the authors on their extensive experience with a useful technique. Pankaj Saxena, MCh, DNB Robert Tam, FRACS Department of Cardiothoracic Surgery The Prince Charles Hospital Rode Road, Chermside Brisbane, QLD 4032 Australia e-mail: [email protected]
References 1. Nair UR, Javangula K, Mulay AV. Papaverine dissection for harvesting internal mammary artery (letter). Ann Thorac Surg 2006;81:1945. 2. Saxena P, Mejia R, Tam R. Hydrodissection technique of harvesting left internal thoracic artery. Ann Thorac Surg 2005;80:355– 6. 3. Mulay AV, Dev KK, Nair RU. Prevention of internal thoracic artery spasm. Ann Thorac Surg 1997;64:564. 4. Choi JB, Lee SY. Skeletonized and pedicle internal thoracic artery grafts: effects on free flow during bypass. Ann Thorac Surg 1996;61:909 –13.
Preoperative Use of Steroids in Patients With Myasthenia Gravis To the Editor:
MISCELLANEOUS
We read with interest the article by Endo and colleagues [1]. We agree that the use of steroids before thymectomy in patients with myasthenia gravis markedly decreases the rate of postoperative respiratory insufficiency. As did Endo and coworkers [1], we found that the rate of infectious complications after transsternal thymectomy is not increased, even if high doses of steroids exceeding 1 mg/kg/day of prednisone are used [2]. The difference between our strategy and that described by Endo and colleagues [1] concerns the indications for steroids. Contrary to Endo and colleagues [1], we do not use steroids in patients with class I and IIa myasthenia according to the Osserman classification. In these patients the risk of a postoperative myasthenic crisis is negligible, and in our opinion there is no need for steroids, which may cause complications. The patients in class I and IIa represent a considerable part of Endo and colleagues’ [1] programmed steroid treatment group (class I, 17 patients; class IIa, 12 patients; overall 29 of 67 patients). In addition, we usually start steroid therapy at lower doses (about 0.5 mg/kg/day of prednisone), and increase the dose every second day until the optimal dose of about 1 mg/kg/day is reached. It usually takes 2 to 3 weeks to stabilize the patient’s status before thymectomy. This mode of steroid treatment decreases the risk of exacerbation of myasthenia, which may occur in the second week of therapy. The author’s statement, “Remission occurred not after a thymectomy but after steroid treatment in 4 patients in the occasional treatment group” suggests that steroids affect the complete remission rate after thymectomy. It must be stressed that such a relation has never been proven. © 2006 by The Society of Thoracic Surgeons Published by Elsevier Inc
Ann Thorac Surg 2006;81:1942– 8
In conclusion, we congratulate Endo and coworkers [1] on their approach to operative treatment of myasthenia; however we suggest more selective use of steroids and stress that steroids have no proven impact on late results of myasthenia. Marcin Zielin´ski, MD, PhD Jaroslaw Kuzdzal, MD Department of Thoracic Surgery Pulmonary Hospital ul.Gładkie 1 Zakopane, 34-500 Poland e-mail: [email protected]; [email protected]
References 1. Endo S, Yamaguchi T, Saito N, et al. Experience with programmed steroid treatment with thymectomy in nonthymomatous myasthenia gravis. Ann Thorac Surg 2004;77:1745–50. 2. Zielinski M, Kuzdzal J, Staniec B, et al. Safety for preoperative use of steroids for transsternal thymectomy in myasthenia gravis. Eur J Cardiothorac Surg 2004;26:407–11.
Reply To the Editor: We thank Drs Zielinski and Kuzdzal [1] for their interest in our recent article on the preoperative use of steroids in patients with myasthenia gravis (MG). As described in our article [2], 60% of our patients with ocular MG advanced to generalized MG; although ocular MG is essentially the same disease as generalized MG [3]. One of 6 patients who had postoperative respiratory failure was classified with class I myasthenia according to the Osserman classification. We recommend preoperative steroid use in patients with ocular MG as well as generalized MG. An optimal dose of steroid remains unclear; however we have recently treated at a dose of about 1 mg/kg/day. In patients with class I and IIa myasthenia according to the Osserman classification, the dose of steroid is intentionally decreased when clinical symptoms resolve. The risk of exacerbation of myasthenia, which may indeed occur in the second week of therapy, is usually taken care of by neurologists in our hospital. We greatly appreciated the comments; however it is worth noting that in the near future, the new agent of tacrolisum as an immunosuppressive treatment will constitute an alternate treatment strategy for myasthenia gravis. Shunsuke Endo, MD Department of Thoracic & Cardiovascular Surgery Jichi Medical School Minamikawachi-machi Kawachi-gun Tochigi, 329-0498 Japan e-mail: [email protected]
References 1. Zielin´ski M, Kuzdzal J. Preoperative use of steroids in patients with myasthenia gravis (letter). Ann Thorac Surg 2006;81: 1946. 2. Endo S, Yamaguchi T, Saito N, et al. Experience with programmed steroid treatment with thymectomy in nonthymomatous myasthenia gravis. Ann Thorac Surg 2004;77:1745–50. 0003-4975/06/$32.00
CORRESPONDENCE
that local infiltration of the vasodilator caused dilatation of the small branches and bleeding, which caused difficulty in skeletonizing the conduit. Moreover it has been shown that vasospasm is avoided and the graft flows are better in skeletonized ITAs and are comparable with pedicle ITAs with intraluminal papaverine injection [4]. We congratulate the authors on their extensive experience with a useful technique. Pankaj Saxena, MCh, DNB Robert Tam, FRACS Department of Cardiothoracic Surgery The Prince Charles Hospital Rode Road, Chermside Brisbane, QLD 4032 Australia e-mail: [email protected]
References 1. Nair UR, Javangula K, Mulay AV. Papaverine dissection for harvesting internal mammary artery (letter). Ann Thorac Surg 2006;81:1945. 2. Saxena P, Mejia R, Tam R. Hydrodissection technique of harvesting left internal thoracic artery. Ann Thorac Surg 2005;80:355– 6. 3. Mulay AV, Dev KK, Nair RU. Prevention of internal thoracic artery spasm. Ann Thorac Surg 1997;64:564. 4. Choi JB, Lee SY. Skeletonized and pedicle internal thoracic artery grafts: effects on free flow during bypass. Ann Thorac Surg 1996;61:909 –13.
Preoperative Use of Steroids in Patients With Myasthenia Gravis To the Editor:
MISCELLANEOUS
We read with interest the article by Endo and colleagues [1]. We agree that the use of steroids before thymectomy in patients with myasthenia gravis markedly decreases the rate of postoperative respiratory insufficiency. As did Endo and coworkers [1], we found that the rate of infectious complications after transsternal thymectomy is not increased, even if high doses of steroids exceeding 1 mg/kg/day of prednisone are used [2]. The difference between our strategy and that described by Endo and colleagues [1] concerns the indications for steroids. Contrary to Endo and colleagues [1], we do not use steroids in patients with class I and IIa myasthenia according to the Osserman classification. In these patients the risk of a postoperative myasthenic crisis is negligible, and in our opinion there is no need for steroids, which may cause complications. The patients in class I and IIa represent a considerable part of Endo and colleagues’ [1] programmed steroid treatment group (class I, 17 patients; class IIa, 12 patients; overall 29 of 67 patients). In addition, we usually start steroid therapy at lower doses (about 0.5 mg/kg/day of prednisone), and increase the dose every second day until the optimal dose of about 1 mg/kg/day is reached. It usually takes 2 to 3 weeks to stabilize the patient’s status before thymectomy. This mode of steroid treatment decreases the risk of exacerbation of myasthenia, which may occur in the second week of therapy. The author’s statement, “Remission occurred not after a thymectomy but after steroid treatment in 4 patients in the occasional treatment group” suggests that steroids affect the complete remission rate after thymectomy. It must be stressed that such a relation has never been proven. © 2006 by The Society of Thoracic Surgeons Published by Elsevier Inc
Ann Thorac Surg 2006;81:1942– 8
In conclusion, we congratulate Endo and coworkers [1] on their approach to operative treatment of myasthenia; however we suggest more selective use of steroids and stress that steroids have no proven impact on late results of myasthenia. Marcin Zielin´ski, MD, PhD Jaroslaw Kuzdzal, MD Department of Thoracic Surgery Pulmonary Hospital ul.Gładkie 1 Zakopane, 34-500 Poland e-mail: [email protected]; [email protected]
References 1. Endo S, Yamaguchi T, Saito N, et al. Experience with programmed steroid treatment with thymectomy in nonthymomatous myasthenia gravis. Ann Thorac Surg 2004;77:1745–50. 2. Zielinski M, Kuzdzal J, Staniec B, et al. Safety for preoperative use of steroids for transsternal thymectomy in myasthenia gravis. Eur J Cardiothorac Surg 2004;26:407–11.
Reply To the Editor: We thank Drs Zielinski and Kuzdzal [1] for their interest in our recent article on the preoperative use of steroids in patients with myasthenia gravis (MG). As described in our article [2], 60% of our patients with ocular MG advanced to generalized MG; although ocular MG is essentially the same disease as generalized MG [3]. One of 6 patients who had postoperative respiratory failure was classified with class I myasthenia according to the Osserman classification. We recommend preoperative steroid use in patients with ocular MG as well as generalized MG. An optimal dose of steroid remains unclear; however we have recently treated at a dose of about 1 mg/kg/day. In patients with class I and IIa myasthenia according to the Osserman classification, the dose of steroid is intentionally decreased when clinical symptoms resolve. The risk of exacerbation of myasthenia, which may indeed occur in the second week of therapy, is usually taken care of by neurologists in our hospital. We greatly appreciated the comments; however it is worth noting that in the near future, the new agent of tacrolisum as an immunosuppressive treatment will constitute an alternate treatment strategy for myasthenia gravis. Shunsuke Endo, MD Department of Thoracic & Cardiovascular Surgery Jichi Medical School Minamikawachi-machi Kawachi-gun Tochigi, 329-0498 Japan e-mail: [email protected]
References 1. Zielin´ski M, Kuzdzal J. Preoperative use of steroids in patients with myasthenia gravis (letter). Ann Thorac Surg 2006;81: 1946. 2. Endo S, Yamaguchi T, Saito N, et al. Experience with programmed steroid treatment with thymectomy in nonthymomatous myasthenia gravis. Ann Thorac Surg 2004;77:1745–50. 0003-4975/06/$32.00