Comparison of intravenous immunoglobulin and plasma exchange as preoperative preparations for thymectomy: A systematic review
Main Article Content
Keywords
Intravenous immunoglobulin, myasthenia gravis, plasma exchange, thymectomy
Abstract
Background: Myasthenia gravis is an autoimmune neuromuscular disease. Thymectomy is a recommended procedure for patients with thymoma, in conjunction with medical therapies. Previous research has explored the use of intravenous immunoglobulin (IVIG) and plasma exchange (PLEX) as preoperative interventions. Despite this, there remains a gap in clinicians' understanding of the comparative efficacy of IVIG or PLEX for preoperative optimization. This review aims to evaluate the relative effectiveness of IVIG and PLEX as preoperative preparations for thymectomy.
Methods: This systematic review was conducted in alignment with the Cochrane Handbook, Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), and Synthesis Without Meta-analysis (SWiM) guidelines. Inclusion criteria comprised full-text manuscripts published between January 2000 and August 2024 that compared IVIG and PLEX as preoperative preparations for thymectomy, regardless of study design. Only studies involving human subjects and those that specifically compared the methodology and outcomes of IVIG and PLEX were included. A comprehensive search was performed across six databases. The quality of included studies and their risk of bias were thoroughly assessed.
Results: The initial search yielded 5,780 articles from databases. Following a rigorous screening process, four studies met the inclusion criteria and underwent detailed quality and risk of bias assessment, with all included studies demonstrating good quality. Most studies demonstrated comparable outcomes between IVIG and PLEX regarding ICU stay, hospitalization duration, and intubation outcomes, indicating that the safety of thymectomy was not significantly influenced by the type of immunomodulation. Nevertheless, IVIG tended to be associated with shorter hospitalization duration, while some studies reported lower postoperative intubation rates and shorter preoperative hospitalization compared with PLEX.
Conclusion: Both IVIG and PLEX demonstrated comparable safety profiles during the perioperative period of thymectomy. Although most outcomes were not significantly different between the two interventions, several studies suggested potential advantages of IVIG, including shorter hospitalization duration and lower postoperative intubation rates. Therefore, IVIG may be considered a viable alternative to PLEX for preoperative preparation before thymectomy.
References
2. Vincent A, McConville J, Farrugia ME, Bowen J, Plested P, Tang T, Evoli A, Matthews I, Sims G, Dalton P. Antibodies in myasthenia gravis and related disorders. Ann N Y Acad Sci. 2003;998(1):324–335. Available from: https://doi.org/10.1196/annals.1254.036.
3. Hohlfeld R, Wekerle H. The immunopathogenesis of myasthenia gravis. In: Engel AG (ed) Myasthenia gravis and myasthenic disorders. Oxford university press. 2012;81:60. Available from: https://doi.org/10.1016/S0072-9752(07)01505-9.
4. Grob D, Brunner N, Namba T, Pagala M. Lifetime course of myasthenia gravis. Muscle Nerve. 2008; 37(2):141–149. Available from: https://doi.org/10.1002/mus.20950.
5. Keesey JC. Clinical evaluation and management of myasthenia gravis. Muscle Nerve. 2004;29(4):484–505. Available from: https://doi.org/10.1002/mus.20030.
6. Meriggioli MN, Sanders DB. Autoimmune myasthenia gravis: emerging clinical and biological heterogeneity. Lancet Neurol. 2009;8(5):475–490. Available from: https://doi.org/10.1016/S1474-4422(09)70063-8.
7. Zinman L, Bril V. IVIG treatment for myasthenia gravis. Ann N Y Acad Sci. 2008;1132(1):264–270. Available from: https://doi.org/10.1196/annals.1405.038.
8. Zinman L, Ng E, Bril V. IV immunoglobulin in patients with myasthenia gravis: a randomized controlled trial. Neurology. 2007;68(11):837–841. Available from: https://doi.org/10.1212/01.wnl.0000256698.69121.45.
9. Jensen P, Bril V. A comparison of the effectiveness of intravenous immunoglobulin and plasma exchange as preoperative therapy of myasthenia gravis. J Clin Neuromuscul Dis. 2008;9(3):352–355. Available from: https://doi.org/10.1097/CND.0b013e3181660807.
10. Gajdos P, Chevret S, Toyka KV. Plasma exchange for generalised myasthenia gravis. Cochrane Database of Systematic Reviews. 2002;4. Available from: https://doi.org/10.1002/14651858.CD002275.
11. Gajdos P, Chevret S, Toyka KV. Intravenous immunoglobulin for myasthenia gravis. Cochrane Database of Systematic Reviews. 2012;12. Available from: https://doi.org/10.1002/14651858.CD002277.
12. Chiu HC, Chen WH, Yeh JH. The six-year experience of plasmapheresis in patients with myasthenia gravis. Ther Apheresis. 2000;4(4):291–295. Available from: https://doi.org/10.1046/j.1526-0968.2000.004004291.x.
13. Arsura EL, Bick A, Brunner NG, Namba T, Grob D. High-dose intravenous immunoglobulin in the management of myasthenia gravis. Arch Intern Med. 1986;146(7):1365. Available from: https://doi.org/10.1001/archinte.1986.00360190143020.
14. Gajdos P, Chevret S, Clair B, Tranchant C, Chastang C. Clinical trial of plasma exchange and high-dose intravenous immunoglobulin in myasthenia gravis. Ann Neurol. 1997;41(6):789–796. Available from: https://doi.org/10.1002/ana.410410615.
15. Rønager J, Ravnborg M, Hermansen I, Vorstrup S. Immunoglobulin treatment versus plasma exchange in patients with chronic moderate to severe myasthenia gravis. Artif Organs. 2001;25(12):967–973. Available from: https://doi.org/10.1046/j.1525-1594.2001.06717.x.
16. Lanska DJ. Indications for thymectomy in myasthenia gravis. Neurology. 1990;40(12):1828. Available from: https://doi.org/10.1212/wnl.40.12.1828.
17. Frist WH, Thirumalai S, Doehring CB, Merrill WH, Stewart JR, Fenichel GM, Bender HW. Thymectomy for the myasthenia gravis patient: factors influencing outcome. Ann Thorac Surg. 1994;57(2):334–338. Available from: https://doi.org/10.1016/0003-4975(94)90993-8.
18. Huang CS, Hsu HS, Kao KP, Huang MH, Huang BS. Intravenous immunoglobulin in the preparation of thymectomy for myasthenia gravis. Acta Neurol Scand. 2003;108(2):136–138. Available from: https://doi.org/10.1034/j.1600-0404.2003.00131.x.
19. Nellar JP, Dominguez A, Llorens-Figueroa J, Ferra-Betancourt A, Pardo A, Quiala M, Gali Z. A comparative study of intravenous immunoglobulin and plasmapheresis preoperatively in myasthenia. Rev Neurol. 2001;33(5):413–416. Available from: https://pubmed.ncbi.nlm.nih.gov/11727205/.
20. A Alipour-Faz, M Shojaei, H Peyvandi, D Ramzi, M Oroei, FGhadiri, M Peyvandi. A comparison between IVIG and plasma exchange as preparations before thymectomy in myasthenia gravis patients. ActaNeurol Belg. 2017;117:245–249. Available from: https://doi.org/10.1007/s13760-016-0689-z.
21. Abdelmotaleb, MS. Intravenous Immunoglobulin vs. Plasma Exchange as Preoperative Preparations before Thymectomy in Myasthenia Gravis Patients. Menoufia Med J. 2022;35: 699-703. Available from: https://doi.org/10.4103/mmj.mmj_84_22.
22. Heatwole C, Johnson N, Holloway R, Noyes K. Plasma exchange versus intravenous immunoglobulin for myasthenia gravis crisis: an acute hospital cost comparison study. J Clin Neuromuscul Dis. 2011;13:85–94. Available from: https://doi.org/10.1097/CND.0b013e31822c34dd.