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Abstract

Abstract Background Persistent hiccups are an uncommon but potentially disabling complication after thoracic surgery. Their pathophysiology remains incompletely understood and involves a complex reflex arc including phrenic, vagal, and sympathetic afferent pathways. We report an unusual case of persistent hiccups occurring immediately after diaphragmatic plication of a previously denervated hemidiaphragm in a patient with myasthenia gravis. Case presentation A 53-year-old man with acetylcholine receptor antibody-positive myasthenia gravis underwent extended robotic thymectomy for recurrent thymoma, including intentional sacrifice of the left phrenic nerve. One year later, he developed progressive exertional dyspnea related to left diaphragmatic paralysis, with marked positional impairment on pulmonary function testing. Because of significant functional limitation, robotic left diaphragmatic plication was performed. Persistent hiccups developed immediately after surgery and were severe enough to interfere with sleep and oral intake. No metabolic, gastric, or medication-related trigger was identified. Despite previous phrenic nerve sacrifice, a postoperative reflex-mediated mechanism involving residual or alternative afferent pathways was suspected. Baclofen was considered undesirable because of the patient’s myasthenia gravis and impaired respiratory mechanics. Low-dose gabapentin was therefore initiated, resulting in progressive improvement and complete resolution of hiccups within 96 hours at a dose of 200 mg daily, without respiratory deterioration or myasthenic exacerbation. No recurrence was observed at 6-week follow-up. Conclusion Persistent hiccups may occur after diaphragmatic plication despite previous ipsilateral phrenic nerve sacrifice, suggesting that diaphragmatic motor denervation does not abolish all sensory pathways capable of activating the hiccup reflex. Gabapentin may represent a useful therapeutic option in selected patients with myasthenia gravis when baclofen is considered undesirable, although careful clinical monitoring remains warranted.