Risk Factors of Myasthenic Crisis after Thymectomy for Patients with Myasthenia Gravis: A Meta-analysis_Chinese Journal of Evidence-Based Medicine

Authors：

 QIANKun-jie ¹ , ZHANGLi-wei ² , LIDe-sheng ² , JULAITIAiniwaer ² , YILIYAERXiaheding ² ,  SUNQing-chao ²

1. Department of Cardiothoracic Surgery, the First Affiliated Hospital School of Shihezi University Medical College, Shihezi 832003, China;
2. Department of Thoracic Surgery, the First Affiliated Hospital of Xinjiang Medical University, Urumqi 830054, China;

Corresponding author：

SUNQing-chao, Email: sqc1116@yahoo.com

Keywords：

Thymectomy; Myasthenic crisis; Risk factor; Systematic review; Meta-analysis; Case-control study

DOI：

10.7507/1672-2531.20160122

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Objective To explore the risk factors of myasthenic crisis after thymectomy (MCAT) for patients with myasthenia gravis (MG). Methods We searched PubMed, EMbase, The Cochrane Library (Issue 8, 2015), Web of Knowledge, CBM, CNKI and WanFang Data from inception to August 31, 2015, to collect case-control studies and retrospective cohort studies about the MCAT for patients with MG. Two reviewers independently screened literature, extracted data and assessed the risk of bias of included studies. Then meta-analysis was performed using Stata 13.0 software. Results A total of 17 studies involving 394 patients with myasthenic crisis and 1642 controls were included. Of the 17 studies, 11 were retrospective cohort studies and 6 were case-control studies. The results of meta-analysis showed that:a) univariate analysis indicated that history of myasthenic crisis (OR=8.05, 95%CI 5.80 to 11.15, P<0.01), bulbar symptoms (OR=5.10, 95%CI 3.01 to 8.67, P<0.01), preoperative severity of gravis (Osserman-stage) (OR=10.55, 95%CI 7.28 to 15.30, P<0.01), postoperative pulmonary infection (OR=10.77, 95%CI 3.88 to 29.95, P<0.01), thymoma (OR=2.37, 95%CI 1.50 to 3.75, P<0.01), dose of pyridostigmine (MD=0.45, 95%CI 0.29 to 0.62, P<0.01), AChRAb level >100 nmol/L (OR=12.14, 95%CI 4.80 to 30.73, P<0.01) and operation time (MD=0.57, 95%CI 0.26 to 0.88, P<0.01) were the risk factors of MCAT; b) multivariate analysis showed that, history of myasthenic crisis (OR=5.06, 95%CI 2.30 to 11.14, P<0.01), bulbar symptoms (OR=5.21, 95%CI 2.62 to 10.35, P<0.01), preoperative severity of gravis (Osserman-stage) (OR=5.82, 95%CI 2.60 to 13.04, P<0.01) and AChRAb level >100 nmol/L (OR=8.38, 95%CI 3.31 to 23.08, P<0.01) were the independent risk factors of MCAT. Conclusion The independent risk factors of MCAT for patients with MG are history of myasthenic crisis, bulbar symptoms, preoperative severity of gravis (Osserman-stage) and AChRAb level >100 nmol/L.

Citation： QIANKun-jie, ZHANGLi-wei, LIDe-sheng, JULAITIAiniwaer, YILIYAERXiaheding, SUNQing-chao. Risk Factors of Myasthenic Crisis after Thymectomy for Patients with Myasthenia Gravis: A Meta-analysis. Chinese Journal of Evidence-Based Medicine, 2016, 16(7): 788-794. doi: 10.7507/1672-2531.20160122 Copy

1.	Alshekhlee A, Miles JD, Katirji B, et al. Incidence and mortality rates of myasthenia gr-avis and myasthenic crisis in US hospitals. Neurology, 2009, 72(18):1548-1554.
2.	Richman DP, Agius MA. Treatment of autoimmune myasthenia gravis. Neurology, 2012, 61(12):1652-1661.
3.	Gritti P, Sgarzi M, Carrara B, et al. A standardized protocol for the perioperative management of myasthenia gravis patients. Experience with 110 patients. Acta Anaesthesiol Scand, 2012, 56(1):66-75.
4.	Wendell LC, Levine JM. Myasthenic crisis. Neurohospitalist, 2011, 1(1):16-22.
5.	Phillips LH. The epidemiology of myasthenia gravis. Semin Neurol, 2004, 24(1):17-20.
6.	Lee HS, Lee HE, Bae MK, et al. Predictive factors for myasthenic crisis after videosco-pic thymectomy in patients with myasthenia gravis. Muscle Nerve, 2015, 52(2):216-220.
7.	刘晓青, 桑岭, 陈思蓓, 等. 重症肌无力患者胸腺切除术后危象的分析. 广东医学, 2014, 35(23):3667-3669.
8.	Leuzzi G, Meacci E, Cusumano G, Cesario A, Chiappetta M, et al. Thymectomy in my-asthenia gravis:proposal for a predictive score of postoperative myasthenic crisis. Eur J Cardiothorac Surg, 2014, 45(4):76-88.
9.	Stang A. Critical evaluation of the Newcastle-Ottawa scale for the assessment of the qu-ality of nonrandomized studies in meta-analyses. Eur J Epidemiol, 2010, 25(9):603-605.
10.	Watanabe A, Watanabe T, Obama T, et al. Prognostic factors for myasthenic crisis after transsternal thymectomy in patients with myasthenia gravis. J Thorac Cardiovasc Surg, 2004, 127(3):868-876.
11.	Nam TS, Lee SH, Kim BC, et al. Clinical characteristics and predictive factors of myasthenic crisis after thymectomy. J Clin Neurosci, 2011, 18(9):1185-1188.
12.	Chu XY.Xue ZQ Wang RW, et al. Predictors of postoperative myasthenic crisis in pat-ients with myasthenia gravis after thymectomy. Chin Med J (Engl), 2011, 124(8):1246-1250.
13.	Yu SS,Lin J, Fu XG, et al. Risk factors of myasthenic crisis after thymectomy in 178generalized myasthenia gravis patients in a five-year follow-up study. 中国医药指南, 2015(7):112-112,113.
14.	Choi KH, Nam TS, Lee SH, et al. Preoperative pulmonary function is strongly related to myasthenic crisis after thymectomy. Neurol India, 2014, 62(2):164-168.
15.	Ando T, Omasa M, Kondo T, et al. Predictive factors of myasthenic crisis after extended thymectomy for patients with myasthenia gravis. Eur J Cardiothorac Surg, 2015, 48(5):705-709.
16.	王志农, 何斌, 徐志云, 等. 重症肌无力行胸腺切除术后危象的防治(附98例分析). 第二军医大学学报, 2003, 24(11):1175-1177.
17.	梁胜景, 林辉, 贺福榜. 重症肌无力胸腺切除术后发生危象的原因及对策. 医学文献, 2005, 24(4):467-469.
18.	王旭广, 杨鲲鹏, 寿化山, 等. 重症肌无力胸腺切除术后发生肌无力危象的危险因素. 中华胸心血管外科杂志, 2006, 22(4):268-269.
19.	刘卫彬, 门丽娜, 唐白云, 等. 全身型重症肌无力患者术后危象的相关因素分析. 中华医学杂志, 2006, 86(39):2737-2740.
20.	陈佶, 庞烈文, 陈志明, 等. 重症肌无力患者胸腺切除术后危象发生的多因素分析. 中国临床神经科学, 2007, 15(2):169-173.
21.	马金山, 王小雷, 陈康, 等. 重症肌无力病人胸腺切除术后危象发生的多因素分析. 中华胸心血管外科杂志, 2011, 27(1):27-29.
22.	牛耀东, 王铁栓, 赵松, 等. 重症肌无力术后早期危象的预测因素. 中华国老年学杂志, 2011, 33(10):2362-2364.
23.	张捷, 李双玲, 王东信等. 重症肌无力伴胸腺瘤患者术后发生肌无力危象的危险因素分析. 实用医学杂志, 2013, 29(10):50-52.
24.	Thomas CE, Mayer SA, Gungor Y, et al. Myasthenic crisis:clinical features, mortality, complications, and risk factors for prolonged intubation. Neurology, 1997, 48(5):1253-1260.
25.	Rabinstein AA, Wijdicks EF. Warning signs of imminent respiratory failure in neurolog-ical patients. Semin Neurol, 2003, 23(1):97-104.
26.	Lacomis D. Myasthenic Crisis. Neurocrit Care, 2005, 3(3):189-194.
27.	Jani-Acsadi A, Lisak RP. Myasthenic crisis:guidelines for prevention and treatment. J Neurol Sci, 2007, 261(1-2):127-133.
28.	Ahmed S, Kirmani JF, Janjua N, et al. An Update on Myasthenic Crisis. Curr Treat Options Neurol, 2005, 7(2):129-141.
29.	Cormier Y, Kashima H, Summer W, et al. Upper airways obstruction with bilateral vocal cord paralysis. Chest, 1979, 75(4):423-427.
30.	Conti-Fine BM, Milani M, Kaminski HJ. Myasthenia gravis:past, present, and future. J Clin Invest, 2006, 116(11):2843-2854.
31.	Aarli JA. Late-onset myasthenia gravis:a changing scene. Arch Neurol, 1999, 56(1):25-27.
32.	Dushay KM, Zibrak JD, Jensen WA. Myasthenia gravis presenting as isolated respiratory failure. Chest, 1990, 97(1):232-234.
33.	Bershad EM, Feen ES, Suarez JI. Myasthenia gravis crisis. South Med J, 2008, 101(1):63-69.
34.	Chevrolet JC, Deleamont P. Repeated vital capacity measurements as predictive parameters for mechanical ventilation need and weaning success in the Guillain-Barre syndrome. Am Rev Respir Dis, 1991, 144(4):814-818.
35.	Prigent H, Orlikowski D, Letilly N, et al. Vital capacity versus maximal inspiratory pressure in patients with Guillain-Barré syndrome and myastheniagravis. Neurocrit Care, 2012, 17(2):236-239.
36.	Loach AB, Young AC, Spalding JM, et al. Postoperative management after thymectomy. Br Med J, 1975, 1(5953):309-312.
37.	Deymeer F, Gungor-Tuncer O, Yilmaz V, et al. Clinical comparison of anti-MuSK-vsantiAChR-positive and seronegative myasthenia gravis. Neurology, 2007, 68(8):609-611.
38.	Nicolle MW. Myasthenia gravis. Neurologist, 2002, 8(1):2-21.
39.	Aurangzeb S, Tariq M, M, et al. Relationship between anti-acetylcholine receptor antibody titres and severity of myasthenia gravis. J Pak Med Assoc, 2009, 59(5):289-292.
40.	Kalita J, Kohat AK, Misra UK. Predictors of outcome of myasthenic crisis. Neurol Sci, 2014, 35(7):1109-1114.

1. Alshekhlee A, Miles JD, Katirji B, et al. Incidence and mortality rates of myasthenia gr-avis and myasthenic crisis in US hospitals. Neurology, 2009, 72(18):1548-1554.
2. Richman DP, Agius MA. Treatment of autoimmune myasthenia gravis. Neurology, 2012, 61(12):1652-1661.
3. Gritti P, Sgarzi M, Carrara B, et al. A standardized protocol for the perioperative management of myasthenia gravis patients. Experience with 110 patients. Acta Anaesthesiol Scand, 2012, 56(1):66-75.
4. Wendell LC, Levine JM. Myasthenic crisis. Neurohospitalist, 2011, 1(1):16-22.
5. Phillips LH. The epidemiology of myasthenia gravis. Semin Neurol, 2004, 24(1):17-20.
6. Lee HS, Lee HE, Bae MK, et al. Predictive factors for myasthenic crisis after videosco-pic thymectomy in patients with myasthenia gravis. Muscle Nerve, 2015, 52(2):216-220.
7. 刘晓青, 桑岭, 陈思蓓, 等. 重症肌无力患者胸腺切除术后危象的分析. 广东医学, 2014, 35(23):3667-3669.
8. Leuzzi G, Meacci E, Cusumano G, Cesario A, Chiappetta M, et al. Thymectomy in my-asthenia gravis:proposal for a predictive score of postoperative myasthenic crisis. Eur J Cardiothorac Surg, 2014, 45(4):76-88.
9. Stang A. Critical evaluation of the Newcastle-Ottawa scale for the assessment of the qu-ality of nonrandomized studies in meta-analyses. Eur J Epidemiol, 2010, 25(9):603-605.
10. Watanabe A, Watanabe T, Obama T, et al. Prognostic factors for myasthenic crisis after transsternal thymectomy in patients with myasthenia gravis. J Thorac Cardiovasc Surg, 2004, 127(3):868-876.
11. Nam TS, Lee SH, Kim BC, et al. Clinical characteristics and predictive factors of myasthenic crisis after thymectomy. J Clin Neurosci, 2011, 18(9):1185-1188.
12. Chu XY.Xue ZQ Wang RW, et al. Predictors of postoperative myasthenic crisis in pat-ients with myasthenia gravis after thymectomy. Chin Med J (Engl), 2011, 124(8):1246-1250.
13. Yu SS,Lin J, Fu XG, et al. Risk factors of myasthenic crisis after thymectomy in 178generalized myasthenia gravis patients in a five-year follow-up study. 中国医药指南, 2015(7):112-112,113.
14. Choi KH, Nam TS, Lee SH, et al. Preoperative pulmonary function is strongly related to myasthenic crisis after thymectomy. Neurol India, 2014, 62(2):164-168.
15. Ando T, Omasa M, Kondo T, et al. Predictive factors of myasthenic crisis after extended thymectomy for patients with myasthenia gravis. Eur J Cardiothorac Surg, 2015, 48(5):705-709.
16. 王志农, 何斌, 徐志云, 等. 重症肌无力行胸腺切除术后危象的防治(附98例分析). 第二军医大学学报, 2003, 24(11):1175-1177.
17. 梁胜景, 林辉, 贺福榜. 重症肌无力胸腺切除术后发生危象的原因及对策. 医学文献, 2005, 24(4):467-469.
18. 王旭广, 杨鲲鹏, 寿化山, 等. 重症肌无力胸腺切除术后发生肌无力危象的危险因素. 中华胸心血管外科杂志, 2006, 22(4):268-269.
19. 刘卫彬, 门丽娜, 唐白云, 等. 全身型重症肌无力患者术后危象的相关因素分析. 中华医学杂志, 2006, 86(39):2737-2740.
20. 陈佶, 庞烈文, 陈志明, 等. 重症肌无力患者胸腺切除术后危象发生的多因素分析. 中国临床神经科学, 2007, 15(2):169-173.
21. 马金山, 王小雷, 陈康, 等. 重症肌无力病人胸腺切除术后危象发生的多因素分析. 中华胸心血管外科杂志, 2011, 27(1):27-29.
22. 牛耀东, 王铁栓, 赵松, 等. 重症肌无力术后早期危象的预测因素. 中华国老年学杂志, 2011, 33(10):2362-2364.
23. 张捷, 李双玲, 王东信等. 重症肌无力伴胸腺瘤患者术后发生肌无力危象的危险因素分析. 实用医学杂志, 2013, 29(10):50-52.
24. Thomas CE, Mayer SA, Gungor Y, et al. Myasthenic crisis:clinical features, mortality, complications, and risk factors for prolonged intubation. Neurology, 1997, 48(5):1253-1260.
25. Rabinstein AA, Wijdicks EF. Warning signs of imminent respiratory failure in neurolog-ical patients. Semin Neurol, 2003, 23(1):97-104.
26. Lacomis D. Myasthenic Crisis. Neurocrit Care, 2005, 3(3):189-194.
27. Jani-Acsadi A, Lisak RP. Myasthenic crisis:guidelines for prevention and treatment. J Neurol Sci, 2007, 261(1-2):127-133.
28. Ahmed S, Kirmani JF, Janjua N, et al. An Update on Myasthenic Crisis. Curr Treat Options Neurol, 2005, 7(2):129-141.
29. Cormier Y, Kashima H, Summer W, et al. Upper airways obstruction with bilateral vocal cord paralysis. Chest, 1979, 75(4):423-427.
30. Conti-Fine BM, Milani M, Kaminski HJ. Myasthenia gravis:past, present, and future. J Clin Invest, 2006, 116(11):2843-2854.
31. Aarli JA. Late-onset myasthenia gravis:a changing scene. Arch Neurol, 1999, 56(1):25-27.
32. Dushay KM, Zibrak JD, Jensen WA. Myasthenia gravis presenting as isolated respiratory failure. Chest, 1990, 97(1):232-234.
33. Bershad EM, Feen ES, Suarez JI. Myasthenia gravis crisis. South Med J, 2008, 101(1):63-69.
34. Chevrolet JC, Deleamont P. Repeated vital capacity measurements as predictive parameters for mechanical ventilation need and weaning success in the Guillain-Barre syndrome. Am Rev Respir Dis, 1991, 144(4):814-818.
35. Prigent H, Orlikowski D, Letilly N, et al. Vital capacity versus maximal inspiratory pressure in patients with Guillain-Barré syndrome and myastheniagravis. Neurocrit Care, 2012, 17(2):236-239.
36. Loach AB, Young AC, Spalding JM, et al. Postoperative management after thymectomy. Br Med J, 1975, 1(5953):309-312.
37. Deymeer F, Gungor-Tuncer O, Yilmaz V, et al. Clinical comparison of anti-MuSK-vsantiAChR-positive and seronegative myasthenia gravis. Neurology, 2007, 68(8):609-611.
38. Nicolle MW. Myasthenia gravis. Neurologist, 2002, 8(1):2-21.
39. Aurangzeb S, Tariq M, M, et al. Relationship between anti-acetylcholine receptor antibody titres and severity of myasthenia gravis. J Pak Med Assoc, 2009, 59(5):289-292.
40. Kalita J, Kohat AK, Misra UK. Predictors of outcome of myasthenic crisis. Neurol Sci, 2014, 35(7):1109-1114.

Chinese Journal of Evidence-Based Medicine

Risk Factors of Myasthenic Crisis after Thymectomy for Patients with Myasthenia Gravis: A Meta-analysis

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