Looking for the best management of myasthenia gravis at the Tg.Mures Clinic of Anesthesia and Intensive Care.

Thymectomy is one of the current management strategies for myasthenia gravis. This is observational study focused on the evolution of the surgical and anesthesiological strategies applied to the patients submitted to thymectomy initially by maximal sternotomy (in the years 1994-1998), followed by unconditioned reorientation towards thymectomy by VATS. A number of 103 patients are included, 51 thymectomy by left VATS. All the thoracoscopic thymectomy were performed in general anesthesia, the lungs were separated by left selective intubation, and the left lung was deflated during the surgical procedure. The surgical complications appeared mainly in the VATS group: one pericardial and one myocardial lesion leading to sternotomy (minimal blood loss, uneventful recovery), contralateral pleural lesion with pneumothorax. The classical approach accounted for one hemothorax. The postoperative mortality was zero in the VATS group vs. 6 out of 52 pts in the sternotomy group. The postoperative evolution confronted the anesthesiologist with the classical crises of myasthenia. Death occurred within the first three weeks following surgery. The demise in 3 cases was due to cardiac complications (preexisting cardiomyopathy complicated by ventricular arrhythmia) and respiratory failure plus sepsis (for the remaining cases that we lost). The treatment options in the ICU are discussed: plasmapheresis, immunosuppression, ventilatory support. VATS is appropriate for almost all thymectomy, but the outcome is heavily based on a team approach: neurologist, surgeon and anesthetist.

[Two steps liver resection with right portal vein ligation for two giant hemangiomas of the left and right lobes]. / Rezectie hepatica în doi timpi cu ligatura de ram port drept pentru doua hemangioame gigante de lob drept si stâng hepatic.

The liver failure is one of the most life threatening complication after extensive liver resections. In resections that exceed 70% of liver parenchyma, a two steps approach with portal branch ligation is the best alternative. The aim of the paper is to present the management of a 65-year-old female admitted into hospital for two giant symptomatic liver hemangiomas in the left lobe: segment III-20 cm. and in the right lobe: segments V-VIII-19 cm, which were non-resectable in the same intervention because the small amount of liver parenchyma left, and for these we decided a two steps surgery: left atypical resection with right portal vein ligation in the first step, attending 4 month for atrophy-hypertrophy process, and then right typical hepatectomy for second hemangioma who practically occupied all right liver. The postoperative course, was favorable after both interventions, with 7 days postsurgery hospitalisation, despite some hepatic failure symptoms: coagulation disturbance, increasing of bilirubin and ALAT, ASAT levels, ascites.