Thymectomy for myasthenia gravis

Kirithika1*, Cesily Priya2, Sri Preethi3, Jaya Menon 4

1Staff Nurse, Kauvery Hospital, Heartcity Trichy, Tamil Nadu

2 Nursing Incharge Kauvery Hospital, Heartcity Trichy, Tamil Nadu

3Assistant Nursing Superintendent, Kauvery Hospital, Heartcity Trichy, Tamil Nadu

4Nursing Superintendent, Kauvery Hospital, Heartcity Trichy, Tamil Nadu

*Correspondence

Abstract

Myasthenia Gravis (MG) is a chronic autoimmune neuromuscular disorder characterized by fluctuating skeletal muscle weakness caused by antibodies against the acetylcholine receptor or related proteins at the neuromuscular junction. Thymectomy is an established surgical treatment, particularly in patients with thymoma or generalized myasthenia gravis, as it improves symptoms and reduces the need for immunosuppressive therapy. This case study describes the clinical presentation, diagnosis, medical and surgical management, nursing care, and outcome of a patient who underwent thymectomy. Comprehensive perioperative management and multidisciplinary care resulted in successful recovery without major complications.

Keywords Thymectomy; Myasthenia gravis; Thymoma; Median sternotomy; Nursing management

Introduction

The thymus plays an important role in the development of the immune system and is closely associated with the pathogenesis of myasthenia gravis. Thymectomy involves surgical removal of the thymus gland and is recommended for patients with thymoma and many patients with generalized myasthenia gravis. The procedure can improve long-term neurological outcomes and reduce disease severity. Effective perioperative nursing care is essential to prevent respiratory complications and promote recovery.

Case Presentation

A 57-year-old male presented with progressive muscle weakness for one year. He complained of diplopia, dysphagia, generalized fatigue, and weaknesses that worsened with activity and improved with rest. He had history of hypertension. Neurological evaluation confirmed generalized myasthenia gravis.

Presenting Complaints

  • Diplopia (double vision)
  • Generalized muscle weakness
  • Difficulty swallowing (dysphagia)
  • Fatigue

Investigations

  • Positive acetylcholine receptor antibody test
  • CT scan of the chest
  • Lipid profile
  • Routine blood investigations
  • ECG and chest X-ray
  • Echo
  • Arterial blood gas analysis (preoperative assessment)

Lab Investigation

TestResult
Urea10-50 mg/dl
Creatinine0.5-1.3 mg/dl
Total Bilirubin0.2-1.2 mg/dl
Direct Bilirubin0-0.5 mg/dl
Indirect Bilirubin0.2-0.7 mg/dl
Total Protein6.0-8.0 g/dl
Serum Albumin3.5-5.2 g/dl
Globulin1.5-3.5 g/dl
Aspartate Aminotransferase (AST)5-34 U/L
Alanine Aminotransferase (ALT)0-45 U/L
Alkaline Phosphatase (ALP)55-149 U/L
Gamma-Glutamyl Transferase (GGT)10-55 U/L
HbA1c<5.6%
FBS70-100 mg/dl
PPBS70-140 mg/dl
InvestigationPatient Value
Hemoglobin14.7 g/dL
Packed Cell Volume43.60%
Total RBC Count4.80
Mean Corpuscular Volume90.8 fL
Mean Corpuscular Hemoglobin30.6 pg
Total WBC Count11180 cells/cumm
Neutrophil84.80%
Lymphocyte8.90%
Monocyte6.00%
Eosinophil0.20%
Basophil0.10%
Absolute Neutrophil Count9490 cells/µL
Platelet Count206000 cells/cum
Sodium134 mmol/L
Potassium3.8 mmol/L
Chloride106 mmol/L
Bicarbonate25 mEq/L
Total Cholesterol183 mg/dL
Triglycerides104 mg/dL
HDL-Cholesterol61 mg/dL
LDL-Cholesterol113.66 mg/dL
VLDL-Cholesterol21 mg/dL

Other Investigations: ACHR Antibodies – Positive (1.0)

Fig (1): ECG

Other Investigation: USG Abdomen and Pelvis

Impression

  • Fatty Liver
  • Right Renal Calculus and Simple Cortical Cyst
  • Mild Prostatomegaly and Significant Post void Residual Urine

Management

Medical Management

  • Pyridostigmine
  • Corticosteroids (Prednisolone)
  • Immunosuppressive therapy (Azathioprine)
  • plasmapheresis
  • Antibiotics

Pain management: Respiratory support as needed

Surgical Management

  • The patient underwent median sternotomy thymectomy under general anesthesia.
  • Surgical Procedure
  • Median sternotomy performed.
  • Complete removal of the thymus gland and surrounding fatty tissue.
  • Hemostasis achieved.
  • Mediastinal drain inserted.
  • Sternum closed with stainless-steel wires.
  • Patient shifted to the CTICU for postoperative monitoring.

Nursing Management

Preoperative Nursing Care

  • Assess respiratory status.
  • Assess swallowing ability.
  • Administer prescribed medications.
  • Explain surgical procedure.
  • Teach deep breathing and coughing exercises.
  • Prepare for surgery.
  • Provide psychological support.

Postoperative Nursing Care

  • Continuous ECG and vital sign monitoring.
  • Airway maintenance and ventilator care if required.
  • Frequent respiratory assessment.
  • Pain assessment and management.
  • Chest drains monitoring.
  • Wound care using aseptic technique.
  • Monitor for myasthenic crisis.
  • Encourage incentive spirometry.
  • Early ambulation.
  • Monitor intake and output.
  • Nutritional support.
  • Patient education regarding medications and follow-up.

Discussion

Thymectomy is a well-established treatment for patients with thymoma and generalized myasthenia gravis. Removal of the thymus reduces autoimmune activity, improves muscle strength, and decreases the requirement for immunosuppressive medications. Successful perioperative care requires close monitoring of respiratory function, early recognition of myasthenic or cholinergic crises, effective pain management, and early mobilization. Nursing interventions play a critical role in preventing complications and facilitating recovery.

Outcome

The patient recovered without postoperative respiratory complications. She was successfully extubated on the first postoperative day. Chest drains were removed after adequate drainage ceased. Muscle strength gradually improved, and swallowing difficulties decreased. The patient was discharged in stable condition with instructions regarding medications, breathing exercises, activity progression, and regular neurological follow-up.

Conclusion

Thymectomy is an effective surgical treatment for patients with generalized myasthenia gravis. A multidisciplinary approach involving neurologists, cardiothoracic surgeons, anesthesiologists, and nurses ensures optimal patient outcomes. Comprehensive perioperative nursing care is essential to prevent respiratory complications, promote recovery, and improve long-term quality of life.

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