Comparison of different surgical approaches for anterior mediastinal tumor

Abstract

Background: Different video-assisted thoracoscopic surgery (VATS) approaches may related to heterogeneous clinical outcomes in anterior mediastinal tumor surgery. Herein, we assessed the comparison between the subxiphoid and intercostal approach, and also compare the left versus the right incision in the intercostal approach for anterior mediastinal tumor patients. Methods: Clinical data of patients receiving thoracoscopic anterior mediastinal tumor resection were retrospectively collected. Patients were divided into two groups according to the approaches: subxiphoid and the intercostal group. The intercostal group was further subdivided into two groups according to different sides: left and right incision group. Intraoperative and postoperative variables were compared between subgroups. Results: A total of 238 patients were consecutively included in this analysis; 198 (83.2%) patients received intercostal procedure and 40 (16.8%) patients received subxiphoid approach. After 1:1 propensity score matching, all baseline characters were well balanced between intercostal and subxiphoid approach, left and right intercostal approach. The visual analogue scale (VAS) pain score was lower in patients underwent subxiphoid approach than intercostal group at first post-operative evaluation in 12-24 h (4.36 vs. 2.23; P=0.03). According to left and right approach, postoperative drainage time (1.9 vs. 1.2 days, P=0.016), postoperative drainage volume (312.1 vs. 193.9 mL, P=0.041) and hospitalization time (5.3 vs. 4.1 days, P=0.043) were significantly increased in the left thoracic approach group compared with the right thoracic approach. Conclusions: Subxiphoid approach is associated with less pain compared with intercostal approach. The right intercostal thoracic approach may offer better clinical effect of short-term postoperative recovery.

Short-term analysis of uniport video-assisted thoracoscopic surgery via the subxiphoid approach without chest tube drainage for anterior mediastinal tumors: a comparative retrospective study

“…They found that the VAS score was lower in patients who underwent the subxiphoid approach than in the intercostal group. Postoperative drainage time, postoperative drainage volume, and hospitalization time were significantly increased in the left thoracic approach group compared with the right thoracic approach group (6). According to previous reports, the most likely complication of the LA approach is phrenic nerve paralysis, while for the subxiphoid approach, it is dyspnea (18).…”

“…Through the LA (intercostal), the thoracoscope the contralateral phrenic nerve and the upper pole of the thymus, increasing the risk of intraoperative damage to phrenic nerve-related blood vessels. On the other hand, the intercostal nerve injury caused by the intercostal incision is inevitable, resulting in chronic postoperative intercostal neuralgia and skin paresthesia in the nerve distribution area (6). Suda et al proposed a surgical approach via the subxiphoid approach, which effectively avoided intercostal nerve injury (7).…”

Effect Evaluation of Subxiphoid and Intercostal Thymectomy: A Meta-Analysis and Systematic Review

“…More importantly, our study found that SVATS thymectomy significantly reduced the VAS scores of patients on the day, the third day and seventh day after the operation. However, whether uniportal or multiportal surgery, the IVATS approach will cause damage to the intercostal nerve to varying degrees ( 24 ), causing postoperative long-term chest pain and numbness. The SVATS can avoid the injury to the intercostal nerve and reduce the postoperative pain to a great extent, especially within one week after operation ( 18 , 22 , 23 , 25 ).…”

“…So, we believe that SVATS is more suitable for thymectomy than IVATS. However, Mao et al ( 24 ) and Qiu et al ( 28 ) also pointed out that it should be used with caution for obese patients [body mass index (BMI) greater than 30] and patients with poor cardiac function in SVTAS thymectomy. Because the operation space of the SVATS is small, the excessive mediastinal fat in obese patients may further reduce the operation space and increase the intraoperative risk.…”

A novel method of subxiphoid video-assisted thoracic surgery for thymectomy

“…Since it was firstly proposed in 1999 by Kido et al (4), subxiphoid video-assisted thoracic surgery (S-VATS) has become the main approach for anterior mediastinal tumor resection under thoracoscopic surgery. Compared with the intercostal thoracic approach, S-VATS provides a better operative view (6) and reduces the operative time, blood loss, postoperative hospital stay, and postoperative pain (7,8).…”