Thymectomy is more effective than conservative treatment for myasthenia gravis regarding outcome and clinical improvement Kai Bachmann, MD, a Doreen Burkhardt, MD, b Inken Schreiter, MD, a Jussuf Kaifi, MD, a Paulus Schurr, MD, a Christoph Busch, MD, a Gunther Thayssen, MD, b Jakob R. Izbicki, MD, a and Tim Strate, MD, a Hamburg, Germany Background. Myasthenia gravis (MG) is an autoimmune disease with a tremendous impact on the quality of life. Controversies over which patients should be operated on because they may benefit most from thymectomy are still ongoing. The aim of this study was to report our long-term results of patients with MG with comparison of thymectomy and conservative treatment. Methods. We report a series of 252 patients with MG. Survival data were generated. Patients were seen in the outpatient clinic, where a modified Osserman score and quality of life score were evaluated at the end of the follow-up period for all surviving patients. Results. A total of 172 patients with MG were followed after thymectomy or with conservative treatment for a median time of 9.8 years. Patients who underwent thymectomy had significantly greater rates of remission and improvement compared with conservative treatment. Furthermore, they had a significantly greater survival. Conclusion. Currently, different effective modalities of treatment are available in patients with MG. In our long-term follow-up, thymectomy was superior to conservative treatment regarding overall survival, clinical improvement, and remission rate. Therefore, thymectomy should be considered strongly for all patients with generalized MG. (Surgery 2009;145:392-8.) From the Department of General, Visceral, and Thoracic Surgery, a and the Department of Neurology, b University Medical Center Hamburg-Eppendorf, Hamburg, Germany MYASTHENIA GRAVIS (MG) was named originally due to its frequent fatal outcome. It is characterized by progressive weakness of the voluntary skeletal muscles due to dysfunction of the neuromuscular junction, as well as a decrease in the number of acetylcholine receptors mediated by autoanti- bodies directed against the subunit of the nicotinic receptors in the motor end plate. The thymus is known to play an important role in T-lymphocyte education and self-tolerance. The relationship between MG and pathology of the thymus was noted in 1901 by Weigert after finding a thymoma. 1 The first thymectomy was performed by Sauerbruch in 1911 in a patient with hyperthyroidism and MG. 2 In 1939, Blalock published a series showing an improvement of MG after thymectomy. 3 During the following years, thy- mectomy gained widespread acceptance in the treatment of MG. Therefore, thymic pathology is thought to be an important mediator in develop- ment of MG. So far, we have found no publication of prospective, randomized trials comparing conser- vative versus operative treatment. Therefore, con- troversies on selection of patients for thymectomy are still ongoing. The aim of treatment in MG is to improve the neuroclinical symptoms, quality of life (QOL), and survival. Long-term data in MG are scarce. There- fore, this long-term study was designed to compare thymectomy versus conservative treatment con- cerning survival, rate of remission, and rate of clinical improvement. Additionally, the QOL was evaluated in all patients. METHODS Study design and patients. This study was ap- proved by the ethics committee of the Hamburg Accepted for publication November 20, 2008. Reprint requests: Kai Bachmann, MD, University Medical Center Hamburg-Eppendorf, Department of General, Visceral and Thoracic Surgery, Martinistrasse 52, 20246 Hamburg, Germany. E-mail: k.bachmann@uke.uni-hamburg.de. 0039-6060/$ - see front matter Ó 2009 Mosby, Inc. All rights reserved. doi:10.1016/j.surg.2008.11.009 392 SURGERY