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Thymic Surgery and Paraendocrine Syndromes

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Principles and Practice of Anesthesia for Thoracic Surgery

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Abstract

Indications for thymectomy typically include thymic mass or nonthymomatous myasthenia gravis (MG). Considerations for a patient with a thymic mass include potential for invasion or compression of cardiopulmonary structures causing life-threatening compromise particularly at induction of general anesthesia. Thymectomy for MG is never an emergency procedure and should not proceed without preoperative optimization by a multidisciplinary team specializing in the care of myasthenic patients. Anesthetic considerations for a patient with MG focus on preventing an exacerbation and minimizing the effect of surgical pain and residual anesthetics on postoperative respiratory function. Muscle relaxants and their reversal agents should be avoided in patients with MG whenever possible. Other principles include the use of short-acting agents, use of regional anesthesia for opioid-sparing effects, and proper perioperative management of anticholinestersases. Despite repeated efforts to determine what clinical features predict the need for postoperative ventilation, no criteria have been proven to be universally applicable in the myasthenic population. Many thoracic malignancies have commonly associated paraneoplastic syndromes with important implications for the anaesthesiologist. The most common extra-intestinal location of carcinoid tumors is the lungs; however, unlike their gastrointestinal counterparts, bronchial carcinoids are rarely ­secretory. Carcinoid syndrome must be optimized with at least 24 h of preoperative octreotide to minimize the life-threatening cardiopulmonary instability that can occur during a carcinoid crisis. Advanced carcinoid disease is associated with fibrosis which can lead to pulmonary hypertension or significant valvulopathy with progressive, severe, right-sided heart failure. For these reasons, patients presenting with carcinoid syndrome must have a preoperative echocardiogram.

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Authors and Affiliations

  1. Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, Toronto, ON, Canada

    Liza Chelico BSc, MD, FRCPC

  2. Department of Anesthesia and Pain Management, The Toronto General Hospital, University Health Network, Toronto, ON, Canada

    Karen McRae MDCM, FRCPC

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  1. Liza Chelico BSc, MD, FRCPC
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  1. University of Toronto, Staff Anesthesiologist, Professor of Anesthesia, Toronto, M5G 2C4, Ontario, Canada

    Peter Slinger, MD, FRCPC

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Chelico, L., McRae, K. (2011). Thymic Surgery and Paraendocrine Syndromes. In: Slinger, MD, FRCPC, P. (eds) Principles and Practice of Anesthesia for Thoracic Surgery. Springer, New York, NY. https://doi.org/10.1007/978-1-4419-0184-2_15

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  • DOI: https://doi.org/10.1007/978-1-4419-0184-2_15

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