Application of new surgical clinical classification and staging of myasthenia gravis in the perioperative period_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

ZHANG Yonghui , MA Wenqiang , HUANG Yuwei , ZHANG Zhiwen , WANG Meng , SHI Chenshuo , CUI Xinzheng ,  ZHANG Qingyong

Comprehensive Treatment Center for Myasthenia Gravis, Zhengzhou University People’s Hospital, Henan Provincial People’s Hospital, Zhengzhou, 450003, P. R. China;

Corresponding author：

ZHANG Qingyong, Email: zhangqy1975@126.com

Keywords：

Myasthenia gravis; clinical classification; clinical staging; score; myasthenic crisis

DOI：

10.7507/1007-4848.202211006

Video：

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Objective To exploring the effectiveness of perioperative application of new surgical clinical classification and staging for myasthenia gravis (MG) in reducing the incidence of postoperative myasthenic crisis (MC). Methods The clinical data of patients with generalized MG admitted to the Comprehensive Treatment Center for Myasthenia Gravis of Henan Provincial People’s Hospital from January 2018 to June 2022 were retrospectively analyzed, who were scored with myasthenia gravis-activities of daily living (MG-ADL) score and quantification of the myasthenia gravis (QMG) score at the first visit, 1 day before surgery, and 3 days after surgery. The patients were divided into a group A (typeⅡ) and a group B (typeⅢ+Ⅳ+Ⅴ) by the new surgical clinical classification and staging of MG according to the disease progression process, and all patients underwent expanded thoracoscopic thymus (tumor) resection after medication and other interventions to control symptoms in remission or stability. The incidence of MC and the efficiency rate after surgery were analyzed. The normal distribution method and percentile method were used to calculate the unilateral 95% reference range of the QMG score and MG-ADL score. Results Finally 126 patients were enrolled, including 62 males and 64 females, aged 13-71 years, with an average age of 46.00±13.00 years. There were 95 patients in the group A and 31 patients in the group B, and the differences of the preoperative baseline data between the two groups were not statistically significant (P>0.05). The incidence of postoperative MC was 1.05% (1/95) in the group A and 3.23% (1/31) in the group B (P>0.05). The effective one-sided 95% reference range of the QMG score and MG-ADL score 1 day before surgery was 0-7.75 and 0-5.00, and there was no postoperative death in both groups. Conclusion The new surgical clinical classification and staging of MG can guide the timing of surgery, which can benefit patients undergoing surgery for MG and greatly reduce the incidence of postoperative MC.

Citation： ZHANG Yonghui, MA Wenqiang, HUANG Yuwei, ZHANG Zhiwen, WANG Meng, SHI Chenshuo, CUI Xinzheng, ZHANG Qingyong. Application of new surgical clinical classification and staging of myasthenia gravis in the perioperative period. Chinese Journal of Clinical Thoracic and Cardiovascular Surgery, 2023, 30(6): 853-857. doi: 10.7507/1007-4848.202211006 Copy

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2.	常婷, 李柱一. 胸腺切除在重症肌无力治疗中的证据及争议. 中华神经科杂志, 2020, 53(6): 405-409.
3.	Nelke C, Stascheit F, Eckert C, et al. Independent risk factors for myasthenic crisis and disease exacerbation in a retrospective cohort of myasthenia gravis patients. J Neuroinflammation, 2022, 19(1): 89.
4.	Kanai T, Uzawa A, Sato Y, et al. A clinical predictive score for postoperative myasthenic crisis. Ann Neurol, 2017, 82(5): 841-849.
5.	Osserman KE, Kornfeld P, Cohen E, et al. Studies in myasthenia gravis; review of two hundred eighty-two cases at the Mount Sinai Hospital, New York City. AMA Arch Intern Med, 1958, 102(1): 72-81.
6.	Jaretzki A, Barohn RJ, Ernstoff RM, et al. Myasthenia gravis: Recommendations for clinical research standards. Task Force of the Medical Scientific Advisory Board of the Myasthenia Gravis Foundation of America. Ann Thorac Surg, 2000, 70(1): 327-334.
7.	Cui XZ, Ji XY, Gao F, et al. Evaluation of the new classification and surgical strategy for myasthenia gravis. Am Surg, 2012, 78(12): 1329-1335.
8.	崔新征, 李立, 杨鲲鹏, 等. 新的重症肌无力外科临床分型和分期的应用. 郑州大学学报(医学版), 2012, 47(3): 303-305.
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10.	Wolfe GI, Kaminski HJ, Aban IB, et al. Randomized trial of thymectomy in myasthenia gravis. N Engl J Med, 2016, 375(6): 511-522.
11.	Huang Y, Su L, Zhang Y, et al. Risk factors for postoperative myasthenic crisis after thymectomy in patients with myasthenia gravis. J Surg Res, 2021, 262: 1-5.
12.	Leuzzi G, Meacci E, Cusumano G, et al. Thymectomy in myasthenia gravis: Proposal for a predictive score of postoperative myasthenic crisis. Eur J Cardiothorac Surg, 2014, 45(4): e76-e88.
13.	Iori E, Mazzoli M, Ariatti A, et al. Predictors of outcome in patients with myasthenic crisis undergoing non-invasive mechanical ventilation: A retrospective 20 year longitudinal cohort study from a single Italian center. Neuromuscul Disord, 2021, 31(12): 1241-1250.
14.	钱昆杰, 张力为, 李德生, 等. 重症肌无力胸腺切除术后发生肌无力危象危险因素的Meta分析. 中国循证医学杂志, 2016, 16(7): 788-794.
15.	Liu C, Liu P, Zhang XJ, et al. Assessment of the risks of a myasthenic crisis after thymectomy in patients with myasthenia gravis: A systematic review and meta-analysis of 25 studies. J Cardiothorac Surg, 2020, 15(1): 270.
16.	Liu Y, Zhang J, Wu W, et al. Subxiphoid thoracoscopic thymectomy for myasthenia gravis. Interact Cardiovasc Thorac Surg, 2022, 34(3): 482-484.
17.	黄川, 佟宏峰, 孙耀光, 等. 单操作孔胸腔镜胸腺扩大切除治疗重症肌无力: 附45例报告. 中国肺癌杂志, 2020, 23(3): 156-161.
18.	Scheriau G, Weng R, Lassnigg A, et al. Perioperative management of patients with myasthenia gravis undergoing robotic-assisted thymectomy—A retrospective analysis and clinical evaluation. J Cardiothorac Vasc Anesth, 2022, 36(10): 3806-3813.
19.	庞天宝, 黄朋伟, 崔新征, 等. 胸腺切除治疗重症肌无力的效果及影响因素分析. 中华医学杂志, 2019, 99(41): 3232-3236.
20.	崔新征, 张清勇, 马文强, 等. 快速康复外科在重症肌无力外科治疗中的应用. 中国实用神经疾病杂志, 2020, 23(5): 432-435.
21.	Chen K, Li Y, Yang H. Poor responses and adverse outcomes of myasthenia gravis after thymectomy: Predicting factors and immunological implications. J Autoimmun, 2022, 132: 102895.

1. 中国免疫学会神经免疫分会. 中国重症肌无力诊断和治疗指南(2020版). 中国神经免疫学和神经病学杂志, 2021, 28(1): 1-12.
2. 常婷, 李柱一. 胸腺切除在重症肌无力治疗中的证据及争议. 中华神经科杂志, 2020, 53(6): 405-409.
3. Nelke C, Stascheit F, Eckert C, et al. Independent risk factors for myasthenic crisis and disease exacerbation in a retrospective cohort of myasthenia gravis patients. J Neuroinflammation, 2022, 19(1): 89.
4. Kanai T, Uzawa A, Sato Y, et al. A clinical predictive score for postoperative myasthenic crisis. Ann Neurol, 2017, 82(5): 841-849.
5. Osserman KE, Kornfeld P, Cohen E, et al. Studies in myasthenia gravis; review of two hundred eighty-two cases at the Mount Sinai Hospital, New York City. AMA Arch Intern Med, 1958, 102(1): 72-81.
6. Jaretzki A, Barohn RJ, Ernstoff RM, et al. Myasthenia gravis: Recommendations for clinical research standards. Task Force of the Medical Scientific Advisory Board of the Myasthenia Gravis Foundation of America. Ann Thorac Surg, 2000, 70(1): 327-334.
7. Cui XZ, Ji XY, Gao F, et al. Evaluation of the new classification and surgical strategy for myasthenia gravis. Am Surg, 2012, 78(12): 1329-1335.
8. 崔新征, 李立, 杨鲲鹏, 等. 新的重症肌无力外科临床分型和分期的应用. 郑州大学学报(医学版), 2012, 47(3): 303-305.
9. Wolfe GI, Herbelin L, Nations SP, et al. Myasthenia gravis activities of daily living profile. Neurology, 1999, 52(7): 1487-1489.
10. Wolfe GI, Kaminski HJ, Aban IB, et al. Randomized trial of thymectomy in myasthenia gravis. N Engl J Med, 2016, 375(6): 511-522.
11. Huang Y, Su L, Zhang Y, et al. Risk factors for postoperative myasthenic crisis after thymectomy in patients with myasthenia gravis. J Surg Res, 2021, 262: 1-5.
12. Leuzzi G, Meacci E, Cusumano G, et al. Thymectomy in myasthenia gravis: Proposal for a predictive score of postoperative myasthenic crisis. Eur J Cardiothorac Surg, 2014, 45(4): e76-e88.
13. Iori E, Mazzoli M, Ariatti A, et al. Predictors of outcome in patients with myasthenic crisis undergoing non-invasive mechanical ventilation: A retrospective 20 year longitudinal cohort study from a single Italian center. Neuromuscul Disord, 2021, 31(12): 1241-1250.
14. 钱昆杰, 张力为, 李德生, 等. 重症肌无力胸腺切除术后发生肌无力危象危险因素的Meta分析. 中国循证医学杂志, 2016, 16(7): 788-794.
15. Liu C, Liu P, Zhang XJ, et al. Assessment of the risks of a myasthenic crisis after thymectomy in patients with myasthenia gravis: A systematic review and meta-analysis of 25 studies. J Cardiothorac Surg, 2020, 15(1): 270.
16. Liu Y, Zhang J, Wu W, et al. Subxiphoid thoracoscopic thymectomy for myasthenia gravis. Interact Cardiovasc Thorac Surg, 2022, 34(3): 482-484.
17. 黄川, 佟宏峰, 孙耀光, 等. 单操作孔胸腔镜胸腺扩大切除治疗重症肌无力: 附45例报告. 中国肺癌杂志, 2020, 23(3): 156-161.
18. Scheriau G, Weng R, Lassnigg A, et al. Perioperative management of patients with myasthenia gravis undergoing robotic-assisted thymectomy—A retrospective analysis and clinical evaluation. J Cardiothorac Vasc Anesth, 2022, 36(10): 3806-3813.
19. 庞天宝, 黄朋伟, 崔新征, 等. 胸腺切除治疗重症肌无力的效果及影响因素分析. 中华医学杂志, 2019, 99(41): 3232-3236.
20. 崔新征, 张清勇, 马文强, 等. 快速康复外科在重症肌无力外科治疗中的应用. 中国实用神经疾病杂志, 2020, 23(5): 432-435.
21. Chen K, Li Y, Yang H. Poor responses and adverse outcomes of myasthenia gravis after thymectomy: Predicting factors and immunological implications. J Autoimmun, 2022, 132: 102895.

Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Application of new surgical clinical classification and staging of myasthenia gravis in the perioperative period

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