Thymic Surgery and Paraendocrine Syndromes

  • Daniel Sellers
  • Karen McRaeEmail author


Myasthenia gravis is a complex autoimmune disease, the pathogenesis of which involves hypertrophy or tumor of the thymus gland. We review recent advances in our understanding of the autoimmune basis of the disease and the place of thymectomy for malignant and nonmalignant disease. We review considerations for anesthetizing the patient with myasthenia gravis, with particular emphasis on the problems of the anterior mediastinal mass, management of muscle relaxants and anticholinesterases, prediction of postoperative ventilatory failure, and differentiation of myasthenic vs cholinergic crisis. We also describe the Lambert-Eaton myasthenic syndrome, with particular reference to the differences in presentation and management compared to myasthenia gravis. Carcinoid syndrome is an infrequently occurring problem in thoracic surgery but potentially serious and difficult to manage without experience, so we review the pathogenesis and clinical presentation of carcinoid syndrome and its prophylaxis and specific treatment with octreotide and serotonin antagonists.


Myasthenia Carcinoid syndrome Respiratory failure Heart disease Surgery 



Adrenocorticotrophic hormone


Corticotrophin-releasing hormone


Computed tomography


Central venous pressure




Growth-hormone-releasing hormone


Intravenous immunoglobulin


Lambert-Eaton syndrome


Lipoprotein receptor-related protein 4


Multiple endocrine neoplasia


Myasthenia gravis


Myasthenia Gravis Foundation of America


Muscle-specific kinase


Nondepolarizing muscle relaxants


Neuromuscular junction


Small cell lung cancer


Syndrome of inappropriate release of antidiuretic hormone


Thoracic epidural anesthesia


Total intravenous anesthesia


Thyroid-stimulating hormone


Video-assisted thoracic surgery


  1. 1.
    Souza C, Muller N. Imaging of the mediastinum. In: Patterson G, Cooper J, Deslauriers J, Lerut A, Luketich J, Rice T, editors. Pearson’s thoracic and esophageal surgery. 3rd ed. Philadelphia: Churchill Livingstone; 2008. p. 1477–505.CrossRefGoogle Scholar
  2. 2.
    Souadjian JV, Enriquez P, Silverstein MN, Pépin JM. The spectrum of diseases associated with thymoma. Coincidence or syndrome? Arch Intern Med. 1974;134(2):374–9.PubMedCrossRefPubMedCentralGoogle Scholar
  3. 3.
    Maggi G, Casadio C, Cavallo A, Cianci R, Molinatti M, Ruffini E. Thymoma: results of 241 operated cases. Ann Thorac Surg. 1991;51(1):152–6.PubMedCrossRefPubMedCentralGoogle Scholar
  4. 4.
    Blumberg D, Burt ME, Bains MS, Downey RJ, Martini N, Rusch V, et al. Thymic carcinoma: current staging does not predict prognosis. J Thorac Cardiovasc Surg. 1998;115(2):303–9.PubMedCrossRefPubMedCentralGoogle Scholar
  5. 5.
    Miller BS, Rusinko RY, Fowler L. Synchronous thymoma and thymic carcinoid in a woman with multiple endocrine neoplasia type 1: case report and review. Endocr Pract. 2008;14(6):713–6.PubMedCrossRefPubMedCentralGoogle Scholar
  6. 6.
    Falkson CB, Bezjak A, Darling G, Gregg R, Malthaner R, Maziak DE, et al. The management of thymoma: a systematic review and practice guideline. J Thorac Oncol. 2009;4(7):911–9.PubMedCrossRefPubMedCentralGoogle Scholar
  7. 7.
    Tomaszek S, Wigle DA, Keshavjee S, Fischer S, Cowen D, Richaud P, et al. Thymomas: review of current clinical practice. Ann Thorac Surg. 2009;87(6):1973–80.PubMedPubMedCentralCrossRefGoogle Scholar
  8. 8.
    Lerro A, De Luca G. Giant Thymolipoma causing cardiocompressive syndrome with chronic heart failure. Ann Thorac Surg. 2009;87(2):644.PubMedCrossRefPubMedCentralGoogle Scholar
  9. 9.
    Jiang X, Fang Y, Wang G. Giant thymolipoma involving both chest cavities. Ann Thorac Surg. 2009;87(6):1960.PubMedCrossRefPubMedCentralGoogle Scholar
  10. 10.
    Ceran S, Tulek B, Sunam G, Suerdem M. Respiratory failure caused by giant thymolipoma. Ann Thorac Surg. 2008;86(2):661–3.PubMedCrossRefPubMedCentralGoogle Scholar
  11. 11.
    Johnson SB, Eng TY, Giaccone G, Thomas CR. Thymoma: update for the new millennium. Oncologist. 2001;6(3):239–46.PubMedCrossRefPubMedCentralGoogle Scholar
  12. 12.
    Korst RJ, Kansler AL, Christos PJ, Mandal S. Adjuvant radiotherapy for thymic epithelial tumors: a systematic review and meta-analysis. Ann Thorac Surg. 2009;87(5):1641–7.PubMedCrossRefPubMedCentralGoogle Scholar
  13. 13.
    Girard N, Mornex F, Van Houtte P, Cordier J-F, van Schil P. Thymoma: a focus on current therapeutic management. J Thorac Oncol. 2009;4(1):119–26.PubMedCrossRefPubMedCentralGoogle Scholar
  14. 14.
    Venuta F, Rendina EA, Coloni GF. Multimodality treatment of thymic tumors. Thorac Surg Clin. 2009;19(1):71–81.PubMedCrossRefPubMedCentralGoogle Scholar
  15. 15.
    Pascuzzi RM. The history of myasthenia gravis. Neurol Clin. 1994;12(12):231–42.PubMedCrossRefPubMedCentralGoogle Scholar
  16. 16.
    Jolly F. Uber myasthenia gravis pseudoparalytica. Berliner Klin Wochenshur. 1895;32:1.Google Scholar
  17. 17.
    Grob D, Brunner N, Namba T, Pagala M. Lifetime course of myasthenia gravis. Muscle Nerve. 2008;37(2):141–9.PubMedCrossRefPubMedCentralGoogle Scholar
  18. 18.
    Engel AG, Lambert EH, Howard FM. Immune complexes (IgG and C3) at the motor end-plate in myasthenia gravis: ultrastructural and light microscopic localization and electrophysiologic correlations. Mayo Clin Proc. 1977;52(5):267–80.PubMedPubMedCentralGoogle Scholar
  19. 19.
    Pestronk A, Drachman DB, Self SG. Measurement of junctional acetylcholine receptors in myasthenia gravis: clinical correlates. Muscle Nerve. 1985;8(3):245–51.PubMedCrossRefPubMedCentralGoogle Scholar
  20. 20.
    Drachman DB. Myasthenia gravis. N Engl J Med. 1994;330(25):1797–810.PubMedCrossRefPubMedCentralGoogle Scholar
  21. 21.
    Engel AG, Tsujihata M, Lindstrom JM, Lennon VA. The motor end plate in myasthenia gravis and in experimental autoimmune myasthenia gravis. A quantitative ultrastructural study. Ann N Y Acad Sci. 1976;274:60–79.PubMedCrossRefPubMedCentralGoogle Scholar
  22. 22.
    Thomas CR, Wright CD, Loehrer PJ. Thymoma: state of the art. J Clin Oncol. 1999;17:2280–9.PubMedCrossRefPubMedCentralGoogle Scholar
  23. 23.
    Castleman B. The pathology of the thymus gland in myasthenia gravis. Ann N Y Acad Sci. 1966;135(1):496–503.PubMedCrossRefPubMedCentralGoogle Scholar
  24. 24.
    Osserman KE, Genkins G. Studies in myasthenia gravis: review of a twenty-year experience in over 1200 patients. Mt Sinai J Med. 1971;38(6):497–537.PubMedPubMedCentralGoogle Scholar
  25. 25.
    Gilhus NE, Verschuuren JJ. Myasthenia gravis: subgroup classification and therapeutic strategies. Lancet Neurol. 2015;14:1023–36.PubMedCrossRefPubMedCentralGoogle Scholar
  26. 26.
    Gibson TC. The heart in myasthenia gravis. Am Heart J. 1975;90(3):389–96.PubMedCrossRefPubMedCentralGoogle Scholar
  27. 27.
    Johannessen KA, Mygland A, Gilhus NE, Aarli J, Vik-Mo H. Left ventricular function in myasthenia gravis. Am J Cardiol. 1992;69(1):129–32.PubMedCrossRefPubMedCentralGoogle Scholar
  28. 28.
    Hofstad H, Ohm OJ, Mørk SJ, Aarli JA. Heart disease in myasthenia gravis. Acta Neurol Scand. 1984;70(3):176–84.PubMedCrossRefPubMedCentralGoogle Scholar
  29. 29.
    Shivamurthy P, Matthew W, Parker A. Cardiac manifestation of myasthenia gravis: a systematic review. IJC Metab Endocr. 2014;5:3–6.CrossRefGoogle Scholar
  30. 30.
    Suzuki S, Baba A, Kaida K, Utsugisawa K, Kita Y, Tsugawa J, et al. Cardiac involvements in myasthenia gravis associated with anti-Kv1.4 antibodies. Eur J Neurol. 2014;21(2):223–30.PubMedCrossRefPubMedCentralGoogle Scholar
  31. 31.
    Suzuki S, Utsugisawa K, Yoshikawa H, Motomura M, Matsubara S, Yokoyama K, et al. Autoimmune targets of heart and skeletal muscles in myasthenia gravis. Arch Neurol. 2009;66(11):1334–8.PubMedCrossRefPubMedCentralGoogle Scholar
  32. 32.
    Daroff RB. The office Tensilon test for ocular myasthenia gravis. Arch Neurol. 1986;43(8):843–4.PubMedCrossRefPubMedCentralGoogle Scholar
  33. 33.
    Sussman J, Farrugia ME, Maddison P, Hill M, Leite MI, Hilton-Jones D. Myasthenia gravis: Association of British Neurologists’ management guidelines. Pract Neurol. 2015;15(3):199–206.PubMedCrossRefPubMedCentralGoogle Scholar
  34. 34.
    Sanders DB, Wolfe GI, Benatar M, Evoli A, Gilhus NE, Illa I, et al. International consensus guidance for management of myasthenia gravis. Neurology. 2016;87(4):419–25.PubMedPubMedCentralCrossRefGoogle Scholar
  35. 35.
    Skeie GO, Apostolski S, Evoli A, Gilhus NE, Illa I, Harms L, et al. Guidelines for treatment of autoimmune neuromuscular transmission disorders. Eur J Neurol. 2010;17(7):893–902.PubMedCrossRefPubMedCentralGoogle Scholar
  36. 36.
    Osserman KE. Myasthenia gravis. New York: Grune & Stratton; 1958.Google Scholar
  37. 37.
    Jaretzki A, Barohn RJ, Ernstoff RM, Kaminski HJ, Keesey JC, Penn AS, et al. Myasthenia gravis: recommendations for clinical research standards. Task Force of the Medical Scientific Advisory Board of the Myasthenia Gravis Foundation of America. Ann Thorac Surg. 2000;70(1):327–34.PubMedCrossRefPubMedCentralGoogle Scholar
  38. 38.
    Nicolle MW. Myasthenia gravis. Neurologist. 2002;8(1):2–21.PubMedCrossRefPubMedCentralGoogle Scholar
  39. 39.
    Baraka A. Anaesthesia and myasthenia gravis. Reply Can J Anaesth. 1992;39(5):1002–3.CrossRefGoogle Scholar
  40. 40.
    Sathasivam S. Steroids and immunosuppressant drugs in myasthenia gravis. Nat Clin Pract Neurol. 2008;4(6):317–27.PubMedCrossRefPubMedCentralGoogle Scholar
  41. 41.
    Pinching AJ, Peters DK, Newsom DJ. Remission of myasthenia gravis following plasma exchange. Lancet. 1976;308(8000):1373–6.CrossRefGoogle Scholar
  42. 42.
    Gajdos P, Chevret S, Toyka K. Intravenous immunoglobulin for myasthenia gravis. Gajdos P, editor. Cochrane Database Syst Rev. 2008;(1):CD002277.Google Scholar
  43. 43.
    Arsura E. Experience with intravenous immunoglobulin in myasthenia gravis. Clin Immunol Immunopathol. 1989;53(2):S170–9.PubMedCrossRefPubMedCentralGoogle Scholar
  44. 44.
    Blalock A, Mason MF, Morgan HJ, Riven SS. Myasthenia gravis and tumors of the thymic region: report of a case where the tumor was removed. Ann Surg. 1939;110(4):544–61.PubMedPubMedCentralCrossRefGoogle Scholar
  45. 45.
    Blalock A, Harvey A, Ford F. The treatment of myasthenia gravis by removal of the thymus gland. JAMA. 1941;117:1529–33.CrossRefGoogle Scholar
  46. 46.
    Blalock A. Thymectomy for the treatment of myasthenia gravis. Report of twenty cases. J Thorac Surg. 1944;13:316–39.Google Scholar
  47. 47.
    Mulder DG, Graves M, Herrmann C. Thymectomy for myasthenia gravis: recent observations and comparisons with past experience. Ann Thorac Surg. 1989;48(4):551–5.PubMedCrossRefPubMedCentralGoogle Scholar
  48. 48.
    de Perrot M, Bril V, McRae K, Keshavjee S. Impact of minimally invasive trans-cervical thymectomy on outcome in patients with myasthenia gravis. Eur J Cardiothorac Surg. 2003;24(5):677–83.PubMedCrossRefPubMedCentralGoogle Scholar
  49. 49.
    Bachmann K, Burkhardt D, Schreiter I, Kaifi J, Busch C, Thayssen G, et al. Long-term outcome and quality of life after open and thoracoscopic thymectomy for myasthenia gravis: analysis of 131 patients. Surg Endosc Other Interv Tech. 2008;22(11):2470–7.CrossRefGoogle Scholar
  50. 50.
    Prokakis C, Koletsis E, Salakou S, Apostolakis E, Baltayiannis N, Chatzimichalis A, et al. Modified maximal thymectomy for myasthenia gravis: effect of maximal resection on late neurologic outcome and predictors of disease remission. Ann Thorac Surg. 2009;88(5):1638–45.PubMedCrossRefPubMedCentralGoogle Scholar
  51. 51.
    Pompeo E, Tacconi F, Massa R, Mineo D, Nahmias S, Mineo TC. Long-term outcome of thoracoscopic extended thymectomy for nonthymomatous myasthenia gravis. Eur J Cardio Thorac Surg. 2009;36(1):164–9.CrossRefGoogle Scholar
  52. 52.
    Gronseth GS, Barohn RJ. Practice parameter: thymectomy for autoimmune myasthenia gravis (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2000;55:7–15.PubMedCrossRefPubMedCentralGoogle Scholar
  53. 53.
    Wolfe GI, Kaminski HJ, Aban IB, Minisman G, Kuo H-C, Marx A, et al. Randomized trial of thymectomy in myasthenia gravis. N Engl J Med. 2016;375(6):511–22.PubMedPubMedCentralCrossRefGoogle Scholar
  54. 54.
    Lucchi M, Van Schil P, Schmid R, Rea F, Melfi F, Athanassiadi K, et al. Thymectomy for thymoma and myasthenia gravis. A survey of current surgical practice in thymic disease amongst EACTS members. Interact Cardiovasc Thorac Surg. 2012;14:765–70.PubMedPubMedCentralCrossRefGoogle Scholar
  55. 55.
    Calhoun RF, Ritter JH, Guthrie TJ, Pestronk A, Meyers BF, Patterson GA, et al. Results of transcervical thymectomy for myasthenia gravis in 100 consecutive patients. Ann Surg. 1999;230(4):555–559–561.PubMedPubMedCentralCrossRefGoogle Scholar
  56. 56.
    Howard J. Physician issues. In: Howard J, editor. Myasthenia gravis a manual for the healthcare provider. St Paul: Myasthenia Gravis Foundation of America; 2008. p. 8–30.Google Scholar
  57. 57.
    Gracey DR, Divertie MB, Howard FM. Mechanical ventilation for respiratory failure in myasthenia gravis. Two-year experience with 22 patients. Mayo Clin Proc. 1983;58(9):597–602.PubMedPubMedCentralGoogle Scholar
  58. 58.
    Fernando M, Paterson HS, Byth K, Robinson BM, Wolfenden H, Gracey D, et al. Outcomes of cardiac surgery in chronic kidney disease. J Thorac Cardiovasc Surg. 2014;148(5):2167–73.PubMedCrossRefPubMedCentralGoogle Scholar
  59. 59.
    Leventhal SR, Orkin FK, Hirsh RA. Prediction of the need for postoperative mechanical ventilation in myasthenia gravis. Anesthesiology. 1980;53(1):26–30.PubMedCrossRefPubMedCentralGoogle Scholar
  60. 60.
    Eisenkraft JB, Papatestas AE, Kahn CH, Mora CT, Fagerstrom R, Genkins G. Predicting the need for postoperative mechanical ventilation in myasthenia gravis. Anesthesiology. 1986;65(1):79–82.PubMedCrossRefPubMedCentralGoogle Scholar
  61. 61.
    Grant RP, Jenkins LC. Prediction of the need for postoperative mechanical ventilation in myasthenia gravis: thymectomy compared to other surgical procedures. Can Anaesth Soc J. 1982;29(2):112–6.PubMedCrossRefPubMedCentralGoogle Scholar
  62. 62.
    Gracey DR, Divertie MB, Howard FM, Payne WS. Postoperative respiratory care after transsternal thymectomy in myasthenia gravis. A 3-year experience in 53 patients. Chest. 1984;86(1):67–71.PubMedCrossRefPubMedCentralGoogle Scholar
  63. 63.
    Younger DS, Braun NM, Jaretzki A, Penn AS, Lovelace RE. Myasthenia gravis: determinants for independent ventilation after transsternal thymectomy. Neurology. 1984;34(3):336–40.PubMedCrossRefPubMedCentralGoogle Scholar
  64. 64.
    El-Bawab H, Hajjar W, Rafay M, Bamousa A, Khalil A, Al-Kattan K. Plasmapheresis before thymectomy in myasthenia gravis: routine versus selective protocols. Eur J Cardio Thorac Surg. 2009;35(3):392–7.CrossRefGoogle Scholar
  65. 65.
    Spence PA, Morin JE, Katz M. Role of plasmapheresis in preparing myasthenic patients for thymectomy: initial results. Can J Surg. 1984;27(3):303–5.PubMedPubMedCentralGoogle Scholar
  66. 66.
    Baraka A, Taha S, Yazbeck V, Rizkallah P. Vecuronium block in the myasthenic patient: influence of anticholinesterase therapy. Anaesthesia. 1993;48(7):588–90.PubMedCrossRefPubMedCentralGoogle Scholar
  67. 67.
    Ropper A, Samuels M. Myasthenia gravis and related disorders of the neuromuscular junction. In: Adams and Victor’s principles of neurology. 9th ed. New York: McGraw-Hill; 2009. p. 1405–21.Google Scholar
  68. 68.
    Girnar DS, Weinreich AI. Anesthesia for transcervical thymectomy in myasthenia gravis. Anesth Analg. 1976;55(1):13–7.PubMedCrossRefPubMedCentralGoogle Scholar
  69. 69.
    Krucylak PE, Naunheim KS. Preoperative preparation and anesthetic management of patients with myasthenia gravis. Semin Thorac Cardiovasc Surg. 1999;11(1):47–53.PubMedCrossRefPubMedCentralGoogle Scholar
  70. 70.
    Kim JM, Mangold J. Sensitivity to both vecuronium and neostigmine in a sero-negative myasthenic patient. Br J Anaesth. 1989;63(4):497–500.PubMedCrossRefPubMedCentralGoogle Scholar
  71. 71.
    Lumb AB, Calder I. “Cured” myasthenia gravis and neuromuscular blockade. Anaesthesia. 1989;44(10):828–30.PubMedCrossRefPubMedCentralGoogle Scholar
  72. 72.
    Azar I. The response of patients with neuromuscular disorders to muscle relaxants: a review. Anesthesiology. 1984;61(2):173–87.PubMedCrossRefPubMedCentralGoogle Scholar
  73. 73.
    Fujita Y, Moriyama S, Aoki S, Yoshizawa S, Tomita M, Kojima T, et al. Estimation of the success rate of anesthetic management for thymectomy in patients with myasthenia gravis treated without muscle relaxants: a retrospective observational cohort study. J Anesth [Internet]. 2015 [cited 2016 Dec 20];29(5):794–7. Available from: PubMedCrossRefPubMedCentralGoogle Scholar
  74. 74.
    Postevka E. Anesthetic implications of myasthenia gravis: a case report. AANA J. 2013;81(5):386–8.PubMedPubMedCentralGoogle Scholar
  75. 75.
    Blitt CD, Wright WA, Peat J. Pancuronium and the patient with myasthenia gravis. Anesthesiology. 1975;42(5):624–6.PubMedCrossRefPubMedCentralGoogle Scholar
  76. 76.
    Book W, Abel M, Eisenkraft J. Anesthesia and neuromuscular diseases. Anesthesiol Clin North Am. 1996;14:515–42.CrossRefGoogle Scholar
  77. 77.
    Petrun AM, Mekiš D, Kamenik M. Successful use of rocuronium and sugammadex in a patient with myasthenia. Eur J Anaesthesiol. 2010;27(10):917–8.PubMedCrossRefPubMedCentralGoogle Scholar
  78. 78.
    Unterbuchner C, Fink H, Blobner M. The use of sugammadex in a patient with myasthenia gravis. Anaesthesia. 2010;65(3):302–5.PubMedCrossRefPubMedCentralGoogle Scholar
  79. 79.
    de Boer HD, Shields MO, Booij LHDJ. Reversal of neuromuscular blockade with sugammadex in patients with myasthenia gravis: a case series of 21 patients and review of the literature. Eur J Anaesthesiol [Internet]. 2014 [cited 2016 Aug 24];31(12):715–21. Available from:
  80. 80.
    Ulke ZS, Yavru A, Camci E, Ozkan B, Toker A, Senturk M. Rocuronium and sugammadex in patients with myasthenia gravis undergoing thymectomy. Acta Anaesthesiol Scand. 2013;57(6):745–8.CrossRefGoogle Scholar
  81. 81.
    Ortiz-Gó Mez JR, Palacio-Abizanda FJ, Fornet-Ruiz I. Failure of sugammadex to reverse rocuronium-induced neuromuscular blockade a case report. Eur J Anaesthesiol. 2014;31:708–9.CrossRefGoogle Scholar
  82. 82.
    Eisenkraft JB, Book WJ, Mann SM, Papatestas AE, Hubbard M. Resistance to succinylcholine in myasthenia gravis: a dose-response study. Anesthesiology. 1988;69(5):760–3.PubMedCrossRefPubMedCentralGoogle Scholar
  83. 83.
    Juste BJ, Ibañez C. Bats of the Gulf of Guinea islands: faunal composition and origins. Biodivers Conserv. 1994;3(9):837–50.CrossRefGoogle Scholar
  84. 84.
    Baraka A, Baroody M, Yazbeck V. Repeated doses of suxamethonium in the myasthenic patient. Anaesthesia. 1993;48(9):782–4.PubMedCrossRefPubMedCentralGoogle Scholar
  85. 85.
    Nilsson E, Muller K. Neuromuscular effects of isoflurane in patients with myasthenia gravis. Acta Anaesthesiol Scand. 1990;34(2):126–31.PubMedCrossRefPubMedCentralGoogle Scholar
  86. 86.
    Kiran U, Choudhury M, Saxena N, Kapoor P. Sevoflurane as a sole anaesthetic for thymectomy in myasthenia gravis. Acta Anaesthesiol Scand. 2000;44(3):351–3.PubMedCrossRefPubMedCentralGoogle Scholar
  87. 87.
    Nishi M, Nakagawa H, Komatsu R, Natsuyama T, Tanaka Y. Neuromuscular effects of sevoflurane in a patient with myasthenia gravis. J Anesth. 1993;7(2):237–9.PubMedCrossRefPubMedCentralGoogle Scholar
  88. 88.
    Madi-Jebara S, Yazigi A, Hayek G, Haddad F, Antakly MC. Sevoflurane anesthesia and intrathecal sufentanil-morphine for thymectomy in myasthenia gravis. J Clin Anesth. 2002;14:558–9.PubMedCrossRefPubMedCentralGoogle Scholar
  89. 89.
    Gritti P, Carrara B, Khotcholava M, Bortolotti G, Giardini D, Lanterna LA, et al. The use of desflurane or propofol in combination with remifentanil in myasthenic patients undergoing a video-assisted thoracoscopic-extended thymectomy. Acta Anaesthesiol Scand. 2009;53(3):380–9.PubMedCrossRefPubMedCentralGoogle Scholar
  90. 90.
    Hübler M, Litz RJ, Albrecht DM. Combination of balanced and regional anaesthesia for minimally invasive surgery in a patient with myasthenia gravis. Eur J Anaesthesiol. 2000;17(5):325–8.PubMedCrossRefPubMedCentralGoogle Scholar
  91. 91.
    Sener M, Bilen A, Bozdogan N, Kilic D, Arslan G. Laryngeal Mask Airway insertion with total intravenous anesthesia for transsternal thymectomy in patients with myasthenia gravis: report of 5 cases. J Clin Anesth. 2008;20(3):206–9.PubMedCrossRefPubMedCentralGoogle Scholar
  92. 92.
    Mekis D, Kamenik M. Remifentanil and high thoracic epidural anaesthesia: a successful combination for patients with myasthenia gravis undergoing transsternal thymectomy. Eur J Anaesthesiol. 2005;22(5):397–9.PubMedCrossRefPubMedCentralGoogle Scholar
  93. 93.
    Bouaggad A, Bouderka MA, Abassi O. Total intravenous anaesthesia with propofol for myasthenic patients. Eur J Anaesthesiol. 2005;22(5):393–4.PubMedCrossRefPubMedCentralGoogle Scholar
  94. 94.
    de José Maria B, Carrero E, Sala X. Myasthenia gravis and regional anaesthesia. Can J Anaesth. 1995;42(2):178–9.PubMedCrossRefPubMedCentralGoogle Scholar
  95. 95.
    Matsuo S, Rao DB, Chaudry I, Foldes FF. Interaction of muscle relaxants and local anesthetics at the neuromuscular junction. Anesth Analg. 1978;57(5):580–7.PubMedCrossRefPubMedCentralGoogle Scholar
  96. 96.
    Burgess FW, Wilcosky B. Thoracic epidural anesthesia for transsternal thymectomy in myasthenia gravis. Anesth Analg. 1989;69(4):529–31.PubMedCrossRefPubMedCentralGoogle Scholar
  97. 97.
    Chevalley C, Spiliopoulos A, de Perrot M, Tschopp JM, Licker M. Perioperative medical management and outcome following thymectomy for myasthenia gravis. Can J Anaesth. 2001;48(5):446–51.PubMedCrossRefPubMedCentralGoogle Scholar
  98. 98.
    Akpolat N, Tilgen H, Gürsoy F, Saydam S, Gürel A. Thoracic epidural anaesthesia and analgesia with bupivacaine for transsternal thymectomy for myasthenia gravis. Eur J Anaesthesiol. 1997;14(2):220–3.PubMedCrossRefPubMedCentralGoogle Scholar
  99. 99.
    Kirsch JR, Diringer MN, Borel CO, Hanley DF, Merritt WT, Bulkley GB. Preoperative lumbar epidural morphine improves postoperative analgesia and ventilatory function after transsternal thymectomy in patients with myasthenia gravis. Crit Care Med. 1991;19(12):1474–9.PubMedCrossRefPubMedCentralGoogle Scholar
  100. 100.
    Nilsson E, Perttunen K, Kalso E. Intrathecal morphine for post-sternotomy pain in patients with myasthenia gravis: effects on respiratory function. Acta Anaesthesiol Scand. 1997;41(5):549–56.PubMedCrossRefPubMedCentralGoogle Scholar
  101. 101.
    Pierce ST. Paraendocrine syndromes. Curr Opin Oncol. 1993;5(4):639–45.PubMedCrossRefPubMedCentralGoogle Scholar
  102. 102.
    Toothaker TB, Rubin M. Paraneoplastic neurological syndromes. Neurologist. 2009;15(1):21–33.PubMedCrossRefPubMedCentralGoogle Scholar
  103. 103.
    Tohyama T, Matsui K, Kitagawa K. Primary hepatic carcinoid tumor with carcinoid syndrome and carcinoid heart disease: a case report of a patient on long-term follow-up. Intern Med. 2005;44(9):958–62.PubMedCrossRefPubMedCentralGoogle Scholar
  104. 104.
    Zhang A, Xiang J, Zhang M, Zheng S. Primary hepatic carcinoid tumours: clinical features with an emphasis on carcinoid syndrome and recurrence. J Int Med Res. 2008;36(4):848–59.PubMedCrossRefPubMedCentralGoogle Scholar
  105. 105.
    Claret C, Chillarón JJ, Flores JA, Benaiges D, Aguiló R, García M, et al. Carcinoid tumor of the thymus associated with Cushing’s syndrome and dysgeusia: case report and review of the literature. Endocrine. 2010;37(1):1–5.PubMedCrossRefPubMedCentralGoogle Scholar
  106. 106.
    De Perrot M, Spiliopoulos A, Fischer S, Totsch M, Keshavjee S. Neuroendocrine carcinoma (carcinoid) of the thymus associated with Cushing’s syndrome. Ann Thorac Surg. 2002;73:675–81.PubMedCrossRefPubMedCentralGoogle Scholar
  107. 107.
    Modlin IM, Lye KD, Kidd M. A 5-decade analysis of 13,715 carcinoid tumors. Cancer. 2003;97(4):934–59.PubMedCrossRefPubMedCentralGoogle Scholar
  108. 108.
    Gustafsson BI, Kidd M, Chan A, Malfertheiner MV, Modlin IM. Bronchopulmonary neuroendocrine tumors. Cancer. 2008;113:5–21.PubMedCrossRefPubMedCentralGoogle Scholar
  109. 109.
    Lips CJM, Lentjes EGWM, Höppener JWM, Hoppener JW. The spectrum of carcinoid tumours and carcinoid syndromes. Ann Clin Biochem. 2003;40(Pt 6):612–27.PubMedCrossRefPubMedCentralGoogle Scholar
  110. 110.
    Ghevariya V, Malieckal A, Ghevariya N, Mazumder M, Anand S. Carcinoid tumors of the gastrointestinal tract. South Med J. 2009;102(10):1032–40.PubMedCrossRefPubMedCentralGoogle Scholar
  111. 111.
    Wells SA. Foreword. Curr Probl Surg. 2009;46(3):189.PubMedCrossRefPubMedCentralGoogle Scholar
  112. 112.
    Dierdorf SF. Carcinoid tumor and carcinoid syndrome. Curr Opin Anaesthesiol. 2003;16(3):343–7.PubMedCrossRefPubMedCentralGoogle Scholar
  113. 113.
    Bendelow J, Apps E, Jones LE, Poston GJ. Carcinoid syndrome. Eur J Surg Oncol. 2008;34(3):289–96.PubMedCrossRefPubMedCentralGoogle Scholar
  114. 114.
    Athanassiadi K, Exarchos D, Tsagarakis S, Bellenis I. Acromegaly caused by ectopic growth hormone-releasing hormone secretion by a carcinoid bronchial tumor: a rare entity. J Thorac Cardiovasc Surg. 2004;128(4):631–2.PubMedCrossRefPubMedCentralGoogle Scholar
  115. 115.
    Scheithauer BW, Carpenter PC, Bloch B, Brazeau P. Ectopic secretion of a growth hormone-releasing factor. Report of a case of acromegaly with bronchial carcinoid tumor. Am J Med. 1984;76(4):605–16.PubMedCrossRefPubMedCentralGoogle Scholar
  116. 116.
    Shrager JB, Wright CD, Wain JC, Torchiana DF, Grillo HC, Mathisen DJ. Bronchopulmonary carcinoid tumors associated with Cushing’s syndrome: a more aggressive variant of typical carcinoid. J Thorac Cardiovasc Surg. 1997;114(3):367–75.PubMedCrossRefPubMedCentralGoogle Scholar
  117. 117.
    Malchoff CD, Orth DN, Abboud C, Carney JA, Pairolero PC, Carey RM. Ectopic ACTH syndrome caused by a bronchial carcinoid tumor responsive to dexamethasone, metyrapone, and corticotropin-releasing factor. Am J Med. 1988;84(4):760–4.PubMedCrossRefPubMedCentralGoogle Scholar
  118. 118.
    Scanagatta P, Montresor E, Pergher S, Mainente M, Bonadiman C, Benato C, et al. Cushing’s syndrome induced by bronchopulmonary carcinoid tumours: a review of 98 cases and our experience of two cases. Chir Ital. 2004;56(1):63–70.PubMedPubMedCentralGoogle Scholar
  119. 119.
    Fischer S, Kruger M, McRae K, Merchant N, Tsao MS, Keshavjee S. Giant bronchial carcinoid tumors: a multidisciplinary approach. Ann Thorac Surg. 2001;71(1):386–93.PubMedCrossRefPubMedCentralGoogle Scholar
  120. 120.
    Modlin IM, Shapiro MD, Kidd M. Carcinoid tumors and fibrosis: an association with no explanation. Am J Gastroenterol. 2004;99:2466–78.PubMedCrossRefPubMedCentralGoogle Scholar
  121. 121.
    Anderson AS, Krauss D, Lang R. Cardiovascular complications of malignant carcinoid disease. Am Heart J. 1997;134(4):693–702.PubMedCrossRefPubMedCentralGoogle Scholar
  122. 122.
    Zuetenhorst JM, Bonfrer JMGM, Korse CM, Bakker R, van Tinteren H, Taal BG. Carcinoid heart disease. Cancer. 2003;97(7):1609–15.PubMedCrossRefPubMedCentralGoogle Scholar
  123. 123.
    Kvols LK, Moertel CG, O’Connell MJ, Schutt AJ, Rubin J, Hahn RG. Treatment of the malignant carcinoid syndrome. Evaluation of a long-acting somatostatin analogue. N Engl J Med. 1986;315(11):663–6.PubMedCrossRefPubMedCentralGoogle Scholar
  124. 124.
    Vaughan DJ, Brunner MD. Anesthesia for patients with carcinoid syndrome. Int Anesthesiol Clin. 1997;35(4):129–42.PubMedCrossRefPubMedCentralGoogle Scholar
  125. 125.
    Farling PA, Durairaju AK. Remifentanil and anaesthesia for carcinoid syndrome. Br J Anaesth. 2004;92:893–5.PubMedCrossRefPubMedCentralGoogle Scholar
  126. 126.
    Veall GRQ, Peacock JE, Bax NDS, Reilly CS. Review of the anaesthetic management of 21 patients undergoing laparotomy for carcinoid syndrome. Br J Anaesth. 1994;72:335–41.PubMedCrossRefPubMedCentralGoogle Scholar
  127. 127.
    Cortinez FLI. Refractory hypotension during carcinoid resection surgery. Anaesthesia. 2000;55(5):505–6.CrossRefGoogle Scholar
  128. 128.
    Monteith K, Roaseg OP. Epidural anaesthesia for transurethral resection of the prostate in a patient with carcinoid syndrome. Can J Anaesth. 1990;37(3):349–52.PubMedCrossRefPubMedCentralGoogle Scholar
  129. 129.
    Orbach-Zinger S, Lombroso R, Eidelman LA. Uneventful spinal anesthesia for a patient with carcinoid syndrome managed with long-acting octreotide. Can J Anaesth. 2002;49(7):678–81.PubMedCrossRefPubMedCentralGoogle Scholar
  130. 130.
    Darnell RB, Posner JB. Paraneoplastic syndromes affecting the nervous system. Semin Oncol. 2006;33(3):270–98.PubMedCrossRefPubMedCentralGoogle Scholar
  131. 131.
    O’Neill GN. Acquired disorders of the neuromuscular junction. Int Anesthesiol Clin. 2006;44(2):107–21.PubMedCrossRefPubMedCentralGoogle Scholar
  132. 132.
    Lambert EH, Elmqvist D. Quantal components of endplate potentials in myasthenic syndrome. Ann NY Acad Sci. 1971;183(1):183–99.PubMedCrossRefPubMedCentralGoogle Scholar
  133. 133.
    Elmqvist D, Lambert EH. Detailed analysis of neuromuscular transmission in a patient with the myasthenic syndrome sometimes associated with bronchogenic carcinoma. Mayo Clin Proc. 1968;43(10):689–713.PubMedPubMedCentralGoogle Scholar
  134. 134.
    Molenaar PC, Newsom-Davis J, Polak RL, Vincent A. Eaton-Lambert syndrome: acetylcholine and choline acetyltransferase in skeletal muscle. Neurology. 1982;32(9):1061–5.PubMedCrossRefPubMedCentralGoogle Scholar
  135. 135.
    O’Neill JH, Murray NM, Newsom-Davis J. The Lambert-Eaton myasthenic syndrome. A review of 50 cases. Brain. 1988;111(Pt 3):577–96.PubMedCrossRefPubMedCentralGoogle Scholar
  136. 136.
    Telford RJ, Hollway TE, Telford RJ, Hollway TE. The myasthenic syndrome: anaesthesia in a patient treated with 3.4 diaminopyridine. Br J Anaesth. 1990;64(3):363–6.PubMedCrossRefPubMedCentralGoogle Scholar
  137. 137.
    Small S, Ali HH, Lennon VA, Brown RH, Carr DB, de Armendi A. Anesthesia for an unsuspected Lambert-Eaton myasthenic syndrome with autoantibodies and occult small cell lung carcinoma. Anesthesiology. 1992;76(1):142–5.PubMedCrossRefPubMedCentralGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.Department of Anesthesia and Pain ManagementToronto General Hospital, University Health NetworkTorontoCanada

Personalised recommendations