Posted by Rapid and complete reversal of residual neuromuscular blockade (rNMB) is essential for safe postoperative recovery in patients with myasthenia gravis (MG) undergoing video-assisted thoracoscopic (VATS) thymectomy. Although sugammadex provides a novel approach for reversing rocuronium-induced neuromuscular blockade, its efficacy in this high-risk population under routine-practice conditions—where reversal timing relies on clinical judgment—remains incompletely characterized. This multicenter randomized controlled trial (RCT) compared the efficacy of sugammadex versus neostigmine for reversing rNMB in patients with mild MG undergoing VATS thymectomy, specifically under this pragmatic, experience-guided scenario.
Patients and Methods: In this prospective, superiority-design RCT, MG patients scheduled for VATS thymectomy were randomized 1:1 to receive either sugammadex (2 mg/kg) or neostigmine (0.05 mg/kg with atropine 0.02 mg/kg) for reversal of rocuronium-induced neuromuscular blockade. All patients received a standard induction dose of rocuronium (0.6 mg/kg). The attending anesthesiologist, blinded to both the reversal agent and all quantitative neuromuscular monitoring data, managed blockade using a minimal-dose strategy (boluses only for clinical signs of inadequate block). This blinded anesthesiologist determined reversal timing based on clinical judgment, with administration contingent upon independent verification of a TOF count ≥ 2. The primary outcome was recovery time (interval from reversal agent administration to normalized TOF ratio of ≥ 0.9), analyzed with the Mann–Whitney U-test. Secondary outcomes included extubation time, operating room stay duration, and incidence of rNMB at extubation and post-anesthesia care unit (PACU) arrival.
Results: Among 62 randomized patients (31 per group), all patients received reversal at a train-of-four (TOF) count of ≥ 2 (median count at reversal: 3 in both groups). Sugammadex achieved significantly faster recovery (median 2.62 [IQR 1.83– 3.28] minutes; range 0.92– 5.80 minutes) versus neostigmine (14.63 [12.22– 16.30] minutes; range 10.97– 28.81 minutes), with an estimated median difference of 12.01 minutes (95% CI: 9.50– 14.52; P < 0.001). The sugammadex group also demonstrated: shorter extubation time (P < 0.001), reduced operating room (OR) stay (P < 0.001), and lower incidence of rNMB at extubation and PACU arrival (both P < 0.01). The incidence of postoperative complications was similar between groups.
Conclusion: In patients with MG undergoing VATS thymectomy, this pragmatic trial simulating routine practice demonstrates that sugammadex provides faster and more reliable reversal of moderate neuromuscular blockade (median TOF count 3) than neostigmine, leading to clinically meaningful reductions in recovery time (by 12.01 minutes), extubation time, and rNMB incidence.
Hu C, Liu S, Xi C, Du Y, Su S, Wang Y, Wu L, Chen H, Wang G. Sugammadex versus Neostigmine Reversal After Thoracoscopic Thymectomy in Myasthenia Gravis: A Multicenter, Randomized Controlled Trial. Drug Des Devel Ther. 2025;19:11965-11976. https://doi.org/10.2147/DDDT.S573927