Journal of Cardiothoracic and Vascular Anesthesia 36 (2022) 3814
3816
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Editorial
A New Postthymectomy Care Algorithm—
Postanesthesia Care Unit Versus Intensive Care Unit
After Robotic-Assisted Thoracoscopic Surgery: Does It
Make a Difference?
MYASTHENIA GRAVIS (MG) is a rare autoimmune dis-
ease that is characterized by fluctuating muscle weakness due
to autoantibodies against the acetylcholine receptor or other
related functional molecules at the neuromuscular junction.1
Thymoma frequently is associated with several types of dis-
eases, of which MG is the most common. It is diagnosed in
10% to 15% of these patients.2 Resection of the thymoma
remains the main therapeutic strategy. In recent years, focus
has shifted from thoracotomy and transsternal thymectomy
toward minimally invasive approaches, including video-
assisted thoracoscopic surgery (VATS) and robotic-assisted
thoracoscopic surgery (RATS).1 RATS in particular offers
some unique advantages, including capacity for
10 £ magnification, 3-dimensional vision, and highly precise
dissections of the thymus. These minimally invasive surgical
techniques present a challenge for the anesthesiologist due to
the impact of MG on perioperative anesthetic management.
One of the main challenges in patients with MG undergoing
thymectomy by RATS is the prediction of the need for postop-
erative mechanical ventilation3,4 and the level of postoperative
recovery care—that is, in the postanesthesia care unit or inten-
sive care unit (ICU). In this issue of the Journal, Scheriau et
al5 reported a retrospective, single-center study of postopera-
tive respiratory complications and the care environment (ICU
v recovery room/surgical ward) in patients who underwent thy-
mectomy by RATS for MG. The primary focus of the report
was on 72 patients who underwent RATS thymectomy from
2014 to 2019, prior to implementation of a postthymectomy
care algorithm. The authors reported, in some detail, the respi-
ratory complications that occurred in this patient group, with
myasthenic crisis reported in 5.6% of their patient cohort.
Additionally, the authors described their new postthymectomy
care algorithm, in which patients are predetermined for ICU
versus recovery room/surgical ward based on preoperative
DOI
: of original article: http://dx.doi.org/10.1053/j.jvca.2022.05.024.
https://doi.org/10.1053/j.jvca.2022.06.030
1053-0770/Ó 2022 Elsevier Inc. All rights reserved.
criteria (ie, presence of bulbar symptoms, myasthenic crisis
within the previous 3 months, functional vital capacity <70%
or forced expiratory volume in the first second <70%, body
mass index >28 kg/m2, or Osserman score >IIb). The new
postthymectomy algorithm also prescribes an observation
period of 4 hours for non-ICU patients and criteria for progres-
sion to the surgical ward (ie, absence of bulbar symptoms,
neck strength, ability to count to 50 without observed dysar-
thria, and ability to swallow water). The outcomes of 30
patients who underwent RATS thymectomy after implementa-
tion of this new algorithm briefly were described.
Contribution to Existing Knowledge
Several previous studies have focused on which preopera-
tive and intraoperative factors may predict the need for post-
thymectomy mechanical ventilation or the risk of myasthenic
crisis. Liu et al6 conducted a systematic review and meta-anal-
ysis of 25 studies (including 3,728 patients and 692 myas-
thenic crisis cases) that investigated risk factors associated
with postthymectomy myasthenic crisis. These included pre-
operative factors (eg, history of myasthenic crisis, bulbar
symptoms, advanced Osserman stages, pyridostigmine dosage,
serum acetylcholine receptor antibody level, preoperative lung
function, and disease duration before thymectomy), surgical
factors (eg, intraoperative blood loss, World Health Organiza-
tion thymic classification, and surgical approach), and postop-
erative factors (eg, postoperative lung function and major
postoperative complications).6 Studies specific to RATS thy-
mectomy have reported low incidence of postoperative myas-
thenic crisis (2.2%-5.4%), without providing specific
recommendations for risk stratification in this patient popula-
tion.7-8
The level of care (ICU v non-ICU) has been studied less
commonly as an outcome. Scheriau et al5 presented their expe-
rience of implementing an algorithm for bypassing ICU care in
 Editorial / Journal of Cardiothoracic and Vascular Anesthesia 36 (2022) 3814
3816
postthymectomy patients as a somewhat novel practice or
departure from typical practice. Although postoperative care
for the transsternal approach to thymectomy may include post-
operative mechanical ventilation and ICU care,3 minimally
invasive approaches, such as VATS and RATS, may require
less intensive care.4 A prior study of a perioperative manage-
ment protocol in VATS-extended thymectomy reported a
reduction in postthymectomy ICU admission after implemen-
tation of the protocol, from 26% ICU admission preprotocol to
6.8% ICU admission postprotocol, and demonstrated the feasi-
bility of safe postoperative care for thymectomy patients out-
side of an ICU setting.9 When combined with the low
postoperative myasthenic crisis incidence reported for RATS
thymectomy,7,8 it may be reasonable to extrapolate that non-
ICU care also can be safe for RATS thymectomy patients. It
has been advocated that postoperative disposition and patient
monitoring should be determined based on the patient’s clini-
cal presentation to include appropriateness for extubation and
surgical and anesthetic course.10
Study Limitations
As with many studies on this topic, the generalizability of
the results of this study was limited by the single-center retro-
spective study design and the limited sample size. In addition,
as the findings of this study largely were descriptive, the
absence of statistical analysis limited the interpretation of
effect size of their intervention.
In this retrospective, cohort study, the authors did not seem
to define clearly the comparator cohorts. The comparator
cohorts could be interpreted to be patients undergoing RATS
thymectomy from 2014 to 2019 who developed postoperative
respiratory complications versus those who did not develop
postoperative respiratory complications. Another interpreta-
tion of the comparator cohorts could be that one cohort was
the prealgorithm patient group (2014-2019) and the other
cohort was the postalgorithm patient group (2020-2022).
Patient populations before and after implementation of the
new algorithm have some apparent differences, with at least
30% to 45% of prealgorithm patients meeting one or more cri-
teria for postoperative ICU care ,compared with 20% of postal-
gorithm patients.
Notably, details of neuromuscular blockade patient monitor-
ing were not included. This represents a significant omission
due to the potential impact of residual neuromuscular blockade
on respiratory function in this patient population. The
increased sensitivity to nondepolarizing neuromuscular block-
ade agents in patients with MG warrants exercising caution in
administering these agents and close monitoring of their
effects. Although it is reported that train-of-four (TOF) moni-
toring was used to guide neuromuscular blockade agent man-
agement in the prealgorithm group, TOF parameters (eg, TOF
count, TOF ratio) prior to extubation were not reported. Given
that neuromuscular blockade reversal was administered in
only 47% of the patients who received neuromuscular block-
ade agents, it would be difficult to exclude the role of residual
neuromuscular blockade in postoperative respiratory
3815
complications, especially in such a high-risk population.
Indeed, a retrospective, observational study of postthymec-
tomy patients demonstrated a reduction in myasthenic crisis in
patients who received the neuromuscular blockade reversal
agent sugammadex.11
Others have described successful extubation in the operating
room in patients with MG undergoing VATS thymectomy. In a
small series of 10 patients with MG undergoing VATS thy-
mectomy, rocuronium was administered and titrated to TOF
parameters.12 At the conclusion of surgery and prior to extuba-
tion, the patients received sugammadex, 2 mg/kg. In this
report, all patients were extubated in the operating room after
administration of sugammadex, and none of the patients
required mechanical ventilation due to respiratory failure or
myasthenic crisis. This preliminary report12 appeared to indi-
cate that in patients with MG undergoing minimally invasive
thymectomy, reversal with sugammadex may facilitate early
extubation, and this should be considered as a factor when
immediate extubation is possible.
Future Work
In this study, Scheriau et al5 presented their experience that
patients after RATS thymectomy can bypass ICU care safely
in their center. A systematic validation of their algorithm
would strengthen its utility and value. The generalizability of
their algorithm and experience could vary greatly depending
on patient population and center-specific resources and care
protocols.
We appreciate the contributions of Scheriau et al on this
important topic and welcome further work in future studies.
Conflict of Interest
None.
Javier H Campos, MD*,1
Dionne Peacher, MDy
*
Perioperative Services, Roy and Lucille Carver College of Medicine, Univer-
sity of Iowa Health Care, Iowa City, Iowa
y
Division of Cardiothoracic Anesthesia, Roy and Lucille Carver College of
Medicine, University of Iowa Health Care, Iowa City, Iowa
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