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Thoracic epidural anesthesia for transsternal thymectomy in myasthenia gravis.

Myasthenia gravis is an autoimmune disorder characterized by varying degrees of muscle weakness, progressive muscle fatigue, ptosis, ophthalmoplegia, and bulbar symptoms secondary to destruction of postsynaptic acetylcholine receptors (1). Although infrequently encountered-prevalence is estimated to be 1 in 20,OOC~patients with myasthenia gravis represent a significant management problem for the anesthesiologist (1). Anesthetic concerns center on the myasthenic patient’s unpredictable response to skeletal muscle relaxants and potential for postoperative respiratory failure resulting in prolonged dependence on mechanical ventilation (2-5). Early surgical intervention in the form of transcervical or transsternal thymectomy has become a mainstay in the aggressive management in selected patients with myasthenia gravis (68). Although controversy persists over the risks and benefits of the transcervical and transsternal thymectomy approaches with regard to long-term outcome, it is clear that the transthoracic approach carries a greater risk of postoperative respiratory compromise (4,5,7). In this case report we describe the use of a thoracic epidural anesthetic in combination with a light general anesthetic to provide excellent surgical conditions and improved postoperative analgesia in two patients with progressive