Thymectomy

K. Marilakshmi

Nursing Educator, Kauvery Hospital, Tirunelveli

Abstract

One half of cortical thymoma patients develop myasthenia gravis (MG), an autoimmune disease affecting the voluntary muscles, while 15% of MG patients have thymomas. Thymectomy has been a mainstay in the treatment of myasthenia gravis and the management of such surgical patients is extremely demanding both at the physicians and at the nurses level. In this paper, we review some of the nursing interventions for patients with MG undergoing surgical removal of the thymus gland.

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The pathophysiological role of the thymus in myasthenia graves, and the mechanism of therapeutic effect of thymectomy, are incompletely understood. Nevertheless, thymectomy is a valuable treatment modality in selected patients with generalized myasthenia graves. There are several types of thymectomy operation, but no one operative approach is clearly superior to the others. Total removal of the thymus gland is essential. Additional excision of associated mediastinal and cervical tissue, that may harbor ectopic thymic rests, is a controversial surgical issue. Surgeons that advocate thymectomy through small, cosmetically favourable, incisions usually believe that simple removal of the thymus gland is an adequate operation. Surgeons that emphasize the importance of removing extra thymic tissue, in addition to the thymus gland, usually favour greater operative exposure through a median sternotomy. To minimize operative morbidity, surgery for myasthenia graves requires a multidisciplinary (neurology, surgery, anesthesia) approach to peri-operative care.

Background

Patient came with the complaints of difficulty in swallowing for 3 months. She had a past history of Hypothyroidism and Myasthenia gravis with thymoma. She already took Tab.Thyroxine-100 microgram and IV IGg-2g\kg at ESI. She had an iron deficiency anemia and fibro adenoma of breast. Excision of breast was done at an outside hospital, after the investigation the consultant planned for thymectomy surgery.

Examination

  1. CVS: S1, S2 is present
  2. RS: NVBS
  3. P\A: Soft
  4. CNS: NFND
  5. SAO2: 97% at room air
  6. BP: 120/90
  7. HR: 80beats\min
  8. RR: 15breath\min
  9. TEMP: 99.5F

Investigation

ECHO:

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Ultrasound

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CECT Chest

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BIOPSY

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Provisional diagnosis

  1. Myasthenia gravis
  2. Cystic thymoma

Surgical notes

The patient went for thymectomy with excursion under general anesthesia. Removed the left lobe of the thymus and placed in the drain.

Medication

  1. Tab.Thyroxine -100 micrograms
  2. Tab.gravidor – 60mg
  3. Tab.nysolone – 5mg.

Diet advice

A well balanced diet was recommended with more iron rich foods.

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Nursing management

1. Monitor the patients ability to swallow or cough

Since the primary symptom of MG is muscle weakness, it is important to monitor the patients ability to swallow or cough. This can help determine the progression of the disease and the need for additional interventions to protect the patients airway.

2. Suction secretions as needed

Suctioning secretions help patients with MG who are unable to cough or swallow.

3. Elevate the head of the bed

Elevating the head of the bed improves lung expansion and makes breathing easier.

4. Educate on myasthenia gravis crisis

An MG crisis occurs when the respiratory muscles weaken and result in respiratory failure. This can be life-threatening and requires emergency assistance. Educate the client to seek assistance if they notice dyspnea, accessory muscle use, and a weak cough.

5. Refer for pulmonary function tests.

PFTs can assist in diagnosing MG as well as monitoring the progression of the disease. Not all patients will experience respiratory muscle involvement, but routine assessment can help prevent a crisis or other complications.

Outcome

On the day of discharge patient was hemodynamically stable.

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