Perioperative outcomes and mid-term effects in performing video- assisted thoracoscopic extended thymectomy for myasthenia gravis: subxiphoid versus right thoracic approaches

Abstract

Background: Approaches of thoracoscopic thymectomy for myasthenia gravis (MG) are debatable. The subxiphoid approach is widely utilized recent years for its better visualization of the anterior mediastinum. In the present study, we compared perioperative outcomes and mid-term effects of the extended thymectomy for MG between the subxiphoid approach and the routine right-thoracic approach. Methods: One hundred and thirty-one MG patients treated with thoracoscopic extended thymectomy were analyzed. Among them, 68 patients were operated on via the subxiphoid approach and the other 63 via the conventional right-side unilateral approach. The patient outcomes were retrospectively reviewed and evaluated. Mid-term clinical outcome was assessed according to the classification system proposed by the Myasthenia Gravis Foundation of America (MGFA). Clinical efficacy and variables influencing outcome were evaluated by the Kaplan-Meier method and Cox proportional hazards regression analysis. Results: Compared with the right thoracic approach, the duration of the procedure via the subxiphoid approach was significantly shorter (P=0.035), the rates of total thymectomy were higher (P=0.028), and the pain scores on postoperative days 1, 3, and 7 were significantly lower (P<0.001, P<0.001, and P=0.03, respectively). A total of 112 patients with MG were followed up. The subxiphoid approach group reported higher rates of complete stable remission (CSR) and effective treatment of MG, although these differences were not statistically significant (Z=−0.484, P=0.627). By multivariate Cox proportional hazards modes analysis, the chance of CSR was significantly increased when age <40 (OR: 2.

Neurological outcomes of extended thymectomy for thymomatous myasthenia gravis: Subxiphoid vs. trans-sternal approaches

“…After a 5-10 case learning curve, only patients with extensive invasion required conversion to an open sternotomy. The mean operative time in the subxiphoid group was 98 min, similar to other studies (13,18,21,22) with a range of 95-147 min. The blood loss in our study was 29.2 ml, which was also similar to their results, with a range of 25.5-73.8 ml.…”

“…Furthermore, a comparison of the perioperative and follow-up outcomes of patients with MG who underwent subxiphoid-subcostal or unilateral thoracoscopic thymectomy showed that only pain scores were significantly lower in the subxiphoid group postoperatively. However, the myasthenia crisis was less frequent, and the neurological results were better ( 21 , 22 ).…”

“…Viet Anh Le reported that when they compared left-sided and right-sided VATS, as well as VATS and open surgery, there was no association between MG results and VATS sites between the two surgical approaches ( 30 ). In addition, another study showed no significant correlation between surgical approach and neurological outcomes ( 22 ). However, robotic surgical treatment for patients with thymoma and concomitant MG effectively improved neurological outcomes ( 10 ).…”

Subxiphoid thoracoscopic thymectomy for myasthenia gravis

“…The operation included en bloc resection of the thymus and peripheral fatty tissue as completely as possible. A uniportal and three-port thoracoscopic thymectomy was performed as reported [ 3 , 6 ], and a single transverse incision about 2.5–3.5 cm was made 1 cm below the xiphoid, with or without 2 0.5-cm extrapleural thoracic ports under the bilateral costal arches. Both mediastinal pleura were opened up to the internal thoracic vessels, with the right side first.…”

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

“…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.…”