Thymectomy - a Form of Treatment for Myasthenia Gravis General Information Leaflet 2

At the turn of the Century, abnormalities of the thymus gland were first noted in patients who had the symptoms of Myasthenia Gravis. Since the 1940’s, thymectomy (the surgical removal of the thymus gland) has been a part of MG therapy. At the present time, thymectomy is a widely accepted treatment form for many Myasthenics.

The thymus gland is located in the upper chest under the breastbone. It is composed of many small lobes and is shaped somewhat like a butterfly wing over the windpipe. Hormones produced by the thymus gland are thought to affect the immune system and the neuromuscular transmission although the exact role in Myasthenia Gravis is not completely understood.

When a thymectomy is being considered by the MG physician and Myasthenic, a referral is made to a surgeon who has experience of this type of surgery. The surgeon then examines the patient and reviews the various patient records, tests, and x-rays. Once it is decided that a thymectomy may be beneficial, hospital admission and surgical dates are arranged for the patient.

Thymectomy is not a new treatment for MG. Since the early 1940’s thymectomies have been performed around the world as part of the treatment for patients with MG. Not everyone diagnosed with MG will undergo a thymectomy. In some treatment centres, surgery is reserved for adolescents and young adults unless a tumour is suspected. Surgery may then be offered regardless of the patients age, so long as he or she is a reasonable surgical candidate.

Part of the preparation before surgery will be a visit from a member of the anaesthesia department. The anaesthetist will want to know about any allergies and about all medications that are being taken, and will then discuss the anaesthesia plan with the patient.

Food and fluids will be withheld after midnight, or on the day of surgery. Routine medication for Myasthenia may or may not be given.

On the morning of surgery, a pre-operative medicine may be given by injection. This medication can cause relaxation, drowsiness, and dryness of the mouth.

After surgery has been completed, a one to three hour stay in the recovery room, or post-anaesthesia room, is required. Once the effect of the anaesthetics has worn off, the patient will be transported to a room in the hospital. In this phase of the recovery, fluids and medication will be given by means of a needle in the vein called an intravenous, or I.V.

After surgery there may be an increase in muscle weakness in some patients. However, through close clinical observation by the health care team, treatment will be adjusted to meet individual needs.

Once fluids are tolerated by the mouth, the intravenous fluids will be stopped. Solid foods will be started slowly, and the patient’s medication will once more be given by mouth.

Length of stay in the hospital varies for each patient. Thymectomy may lessen the severity of the myasthenic symptoms; however, the degree to which the symptoms are lessened differs in each patient. A slight improvement in muscle strength, or a remission may occur. Remission, which may be either temporary or permanent, is the complete elimination of symptoms without medication.

The following are some of the most common questions that Myasthenics ask about when they consider thymectomy surgery. Since each patient’s situation is unique, it is essential to remember to discuss any questions about this surgery with your MG physician and surgeon.

1. What will my surgery look like?
   
   The surgery is usually performed in two ways. The first is the transsternal incision (most common) in which the incision is made length-wise on the chest and the breastbone (sternum) is split open. The second type of incision involves a cross shaped incision and splitting of the breastbone. The surgeon will make the decision about the best way to make the incision. The resulting scar is normally a thin line on the skin which is red to pink in colour and fades in time. If the patient is concerned about the scar, he/she should discuss them with the surgeon.
   
   
2. Who will put me to sleep?
   
   The anaesthetist is the specialised doctor who will put the patient to sleep. Prior to surgery, the anaesthetist will meet the patient to discuss how the patient will be put to sleep, the use of any special drugs that will be needed to help the patient relax before surgery, and how the patient will generally feel after surgery. It is essential that the patient tells this doctor, as well as all the doctors and nurses, about the medication being taken and about any allergies or reactions to medicines, foods or other substance. When discussing medication include non-prescription (e.g. aspirin, paracetemol) as well as prescription medicines.
   
   
3. How long will I be in hospital?
   
   This depends on many factors - severity of MG, dosage of drugs, etc. It is customary for the patient to stay in an Intensive Therapy Unit for 24 - 48 hours after the operation. This is to ensure that everything is proceeding normally and if so they will then be transferred back to their ward and start getting up in a few days. If progress is maintained and the home conditions are satisfactory, the patient will probably be allowed home in 7 - 10 days. Very occasionally if the patient has some breathing difficulties he or she may temporarily be connected to a ventilator so as to ease this problem. Although this may sound frightening it is not really and it will provide a lot of relief to the patient.
   
   The number of days in the hospital varies with each patient and surgeon, but most patients will be walking the day following surgery and be ready for discharge from hospital within a few days.
   
   
4. Will it hurt?
   
   Most patients complain of some chest soreness and pain after surgery that can be lessened with pain medication. At intervals, the patient will be asked to do coughing and deep breathing exercises to clear the lungs of mucus. This does cause discomfort which can be lessened by hugging a pillow and supporting the chest while coughing. Pain medication can be taken prior to any activity or exercise to alleviate after-surgery discomfort. Women may find that wearing a bra after surgery will support the breasts and reduce chest soreness.
   
   
5. How long will I be out of work?
   
   The recovery period or time away from a job varies with the type of work that the patient does. A patient who does heavy lifting or construction work which will put a strain on the breastbone may be away from the job longer (to allow more time for the breastbone to heal) than someone who does desk work. Most patients take 4 - 6 weeks off for convalescence. The patient should discuss this with the surgeon prior to the surgery in order to plan the recovery time.
   
   
6. I feel frightened about the surgery ; is this normal?
   
   Everyone who encounters a new experience like this surgery will have fear and anxiety. This is very normal. To help cope with this the patient should speak to the doctors and nurses about any concerns even if they seem trivial. The patient may find it helpful to visit the doctor prepared with a written list of questions and concerns to discuss. Fears and concerns can also be discussed at the same time doctors talk to the patient about the risks of the surgery and anaesthetics and obtain written consent from the patient giving them permission to administer the anaesthesia and perform the surgery. Talking over fears with the doctors, nurses, family and friends can help keep the lines of communication open and help the patient get through this stressful time.
   
   

These are just a few of the many questions Myasthenics preparing for thymectomy surgery may have. It is encouraging to note that most patients have few problems after this surgery and are able to return to their usual activities relatively quickly. Patients may also have questions after surgery, so it is helpful to keep a paper and pen handy to write these down for further discussion. Doctors and nurses want patients to be as informed as possible and to be involved in their own care because this tends to make patients recover quicker with better outcomes.

The Association does its best to ensure that the information contained in this leaflet is complete and up to date at the time of publication, but cannot accept any legal liability whether for any inaccuracy or otherwise.

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