Robotic Thymectomy Performed For Myasthenia Gravis Beyond Multiple Risks
JINGLONG LI, Dazhi Pang, Jitian Zhang, Jianguo Lu, Guangqiang Shao, Zhihai Liu, Taiyang Liuru, Jinjin Yan, Yanan Liang, Minghui Zhu.
The University of Hong Kong-Shenzhen Hospital, Shenzhen, China.
Objective: The purpose of this case report is to investigate how to break through multiple risk factors to perform robotic thymectomy in a patient with myasthenia gravis.Methods: The patient was a 39-year-old woman diagnosed with myasthenia gravis type IIb for 16 years with acetylcholine receptor antibodies (+). Cervical cancer was diagnosed 2 years ago and surgery for cervical cancer was performed, followed by concurrent chemoradiotherapy. The patient had a recurrence of cervical cancer 8 months ago and was treated with chemotherapy + bevacizumab for 6 cycles, followed by bevacizumab maintenance therapy, which was interrupted because of an exacerbation of myasthenia gravis 1 month ago. Because immunosuppression may be detrimental to bevacizumab maintenance therapy, the patient was treated with bromipyridamole alone at a dosage of 480 mg/day and still developed ptosis, dysphagia, and weakness of the extremities. The patient was referred to our department for a thymectomy.The patient underwent immunoglobulin therapy for 5 days. The patient was found to have hypothyroidism, upper respiratory tract infection, and urinary tract infection, all of which improved with treatment. The patient also developed granulocyte deficiency with a minimum neutrophil count of 0.74*109/l, which improved with the granulocyte stimulating factor. The patient was diagnosed with dry
syndrome and hydroxychloroquine was not used because of the possibility of worsening myasthenia gravis. Robotic thymectomy was performed with granulocyte stimulating factor. Enhanced recovery after surgery was applied during the perioperative period, no urinary catheter and no chest drain were placed, and the tracheal intubation was removed immediately after surgery. The patient began mobility and pulmonary function rehabilitation 6 hours after surgery.Results: The patient was discharged 10 days after the operation. The patient was followed up 1 week ago, the symptoms of myasthenia gravis were satisfactorily controlled, the 21st cycle of bevacizumab treatment had been administered, and no signs of cervical cancer recurrence or metastasis were seen on the follow-up.Conclusion: The implementation of enhanced recovery after surgery in the perioperative period of robotic thymectomy helps patients with neurological and oncological dilemmas in myasthenia gravis to gain access to treatment.
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