Meta-analysis of subxiphoid approach versus lateral approach for thoracoscopic Thymectomy

Same-day discharge for patients undergoing subxiphoid thoracoscopic thymectomy for small tumours without myasthenia gravis: a prospective, single-arm clinical trial

OBJECTIVES

Subxiphoid thoracoscopic surgery is an effective method for treating thymic tumours. We performed the first evaluation of the safety and feasibility of same-day discharge (SDD) in patients undergoing this procedure and summarized their associated clinical experience.

METHODS

We conducted a single-arm, single-centre prospective clinical trial. This study was registered at www.chictr.org.cn (ChiCTR2300077148). The subjects were patients with a preoperative clinical diagnosis of thymic tumour. All eligible patients underwent examinations and preparations at the preoperative preparation centre and subsequently underwent a subxiphoid thoracoscopic thymectomy. The evaluation indicators included R0 (complete resection without residual tumour) resection rate, SDD completion rate, 30-day postoperative readmission rate, number of emergency visits, perioperative complication rate, length of stay and total medical costs.

RESULTS

A total of 39 patients were enrolled between November 2023 and April 2024. All patients underwent subxiphoid thoracoscopic resection of the thymic tumours to achieve R0 resection. The completion rate of the SDD surgery was 92.3% (36/39). The perioperative complication rate was 5.6% (2/36 patients). Only 2.8% (1/36) of the patients were readmitted within 1 month of an emergency visit due to pneumothorax. The median length of stay was 11 h (interquartile range 10-14), and the median total medical cost was 19 400 renminbi (interquartile range 18 500-21 100).

CONCLUSIONS

The SDD procedure may be safe and feasible for selected patients undergoing subxiphoid thoracoscopic thymectomy, based on a small sample size. Large-scale studies are needed to confirm these preliminary findings.

Minimally invasive thymectomy for patients with thymoma: surgical, oncological and neurological outcomes

Background

Traditionally, sternotomy has been the gold standard approach for the treatment of thymomas. However, interest in minimally invasive techniques such as video-assisted and robot-assisted thymectomy is gaining momentum. Concerns have been raised over the possibility of en-bloc resection using minimal access techniques due to limited working space and increased tumour manipulation leading to tumour breach and recurrence.

Methods

An observational cohort study was conducted at a tertiary referral centre from 1 April 2012 to 31 December 2020 and followed up until 31 March 2023. Consecutive patients of thymoma were evaluated for demography, symptoms and imaging preoperatively and included for the study. Post minimally invasive thymectomy, surgical, neurological and oncological outcomes were evaluated through out-patient and telephonic follow-up.

Results

Fifty-two patients underwent minimally invasive thymectomy. Video-assisted thoracoscopic surgery for thymectomy was used in 49 patients (94.2%) with 3 (5.8%) patients undergoing robot-assisted thoracoscopic surgery. Median tumour size was 4 cm (interquartile range (IQR) 3-5) with a median operative duration of 150 min (IQR 120-180), blood loss of 135 ml (IQR 42.5-250), post-operative stay of 3 days (IQR 2-4) and no 30-day surgery related morbidity and mortality. Annual contrast-enhanced computed tomography imaging, available in 46 (88.5%) patients, showed no recurrence at a median follow-up of 43 (IQR, 21-75) months. No symptoms suggesting recurrence was noted at a median clinical follow-up of 57 (IQR 44-95.5) months and 88.5% patients were expected to survive a period of 10 years.

Conclusion

Minimally invasive thymectomy is technically feasible with minimal morbidity and acceptable intermediate-term oncological outcomes in patients suffering with thymoma.

Trial registration

Institute ethical committee approval: Ref no. IECPG-551/14.11.2018.Clinical Trial Registry of India: Ref no. CTRI/2019/04/018784.

Initial results of uniportal and robot-assisted subxiphoid thymectomy

Background

We previously reported on subxiphoid uniportal thymectomy (SUT) and subxiphoid robotic thymectomy (SRT). This descriptive study aimed to evaluate the feasibility and safety of both SUT and SRT techniques.

Methods

Between March 2011 and December 2022, 268 patients underwent subxiphoid thymectomy. In cases demonstrating no evidence of invasion into other organs, SUT was selected due to its minimal invasiveness. In cases where the tumor was in contact with the innominate vein or those with suspected invasion into other organs, SRT with additional intercostal ports was selected due to the enhanced operability provided by the robotic system. The patients' backgrounds and the perioperative outcomes of each technique were evaluated.

Results

SUT was performed in 207 patients, while SRT was performed in 61 patients. In the SUT group, 15 patients required an additional intercostal port, and 2 patients required a median sternotomy; the SUT completion rate was 91.78%. The median operative time was 117.00 [interquartile range (IQR), 88.00-148.50] min, with a median blood loss of 5.00 (IQR, 1.00-5.00) mL. Combined resection was performed in 11 (5.31%) patients, and postoperative complications were observed in 4 patients (1.93%). None of the patients in the SRT group required median sternotomy. The median operative time was 203.00 (IQR, 158.00-278.00) min, with a median blood loss of 5.00 (IQR, 5.00-22.00) mL. Combined resection was performed in 14 patients (22.95%), and postoperative complications were observed in 5 patients (8.20%). No mortalities occurred in either group.

Conclusions

Subxiphoid thymectomy is a safe and feasible technique for both early and advanced stages of the disease requiring complex surgical procedures.

Robotic-assisted versus video-assisted thoracoscopic surgery for thymic epithelial tumours, from the European Society of Thoracic Surgeons Database

OBJECTIVES

Minimally invasive thymectomy is an accepted approach for early-stage thymic epithelial neoplasia, reducing pain and length of stay compared with open surgery. In this study, we compare robotic and video-assisted thymectomy to assess pathological resection status, overall and disease-free survival.

METHODS

Data were retrieved from the European Society of Thoracic Surgeons prospectively maintained thymic database. Eighty-two international centres were invited to participate in the ESTS registry. Thirty-seven centres agreed to take part. We included all patients who had undergone complete thymectomy for malignancy through a minimally invasive approach and excluded patients in whom complete data were not available.

RESULTS

Between October 2001 and May 2021, a total of 899 patients with thymic malignancy underwent minimal access surgical resection and were included in the study. A propensity matched analysis was conducted with interrogation of 732 patients. Median age was 55 years, and 408 (56%) patients were female. Propensity matched was performed with 1:1 matching for surgical approach (video assisted = 366, robot assisted = 366). Robot-assisted surgery conferred significantly lower odds of incomplete resection (R1; 0.203 95% CI 0.13-0.317; P < 0.001). However, there was no difference in terms of overall and disease-free survival between the 2 techniques.

CONCLUSIONS

In this analysis, after adjusting for thymoma stage, the odds of incomplete surgical resection were higher in patients undergoing video-assisted surgery than robotic. However, there was no difference in overall or disease-free survival. With data maturation and increased follow-up, this would need repeat analysis and perhaps may provide more credence to the concept of a prospective randomized study to compare outcomes in thymic epithelial neoplasia by surgical approach with a standardized pathological work-up.

Subxiphoid video-assisted thoracoscopic extend thymectomy with sternal suspension for thymoma

BACKGROUND

Thymoma is a primary tumor of the thymus, commonly located in the anterior mediastinum. Most thymomas are benign or low-grade malignant, but they can invade surrounding organs or metastasize. The primary treatment for thymoma is surgical resection. Traditional methods involve open thoracotomy, but it is traumatic, with slow recovery and many complications. In recent years, with the development of thoracoscopic techniques, thoracoscopic total thymectomy has gradually become the preferred method for small size thymomas due to its minimally invasive, safe, and effective.

METHODS

This paper introduces a thoracoscopic extend thymectomy technique, the subxiphoid video-assisted thoracoscopic extend thymectomy with sternal suspension. This method involves placing hooks at the upper and lower ends of the sternum to suspend the sternum upward, increasing the thoracic cavity space and facilitating thoracoscopic operations. This research reviews the clinical data of 59 patients with early-stage thymomas treated with this technique at our center since 2020 and analyzes the perioperative therapeutic efficacy and safety. It also compares the outcomes with those of 17 patients who underwent thoracoscopic approaches.

RESULTS

The results show that subxiphoid video-assisted thoracoscopic total thymectomy with sternal suspension is an innovative and effective surgical method, achieving the same tumor eradication as other thoracic surgeries. The flexible switching of observation ports provides a more comprehensive surgical field, reduces surgical trauma and complications, and improves the surgical outcomes and quality of life for patients.

Subxiphoid Single-Port Robotic Thymectomy Using the Single-Port Robotic System versus VATS: A Multi-Institutional, Retrospective, and Propensity Score-Matched Study

Subxiphoid thymectomy is a novel alternative to the transthoracic approach and sternotomy, with potential benefits, such as reduced postoperative pain and faster recovery. We previously reported the initial experience with subxiphoid single-port robotic-assisted thoracic surgery (SRATS) thymectomy using the single-port robotic system (SPS). However, the efficacy of this technique remains unknown. Thus, this study examined the multi-institutional experience with SRATS thymectomy and compared the perioperative outcomes of this technique to those of subxiphoid single-port video-assisted thoracic surgery (SVATS) thymectomy. The data of patients who underwent subxiphoid SRATS and SVATS thymectomy, performed by three thoracic surgeons at three institutions between September 2018 and May 2024, were retrospectively collected. In total, 110 patients were included, with 85 and 25 undergoing SRATS and SVATS thymectomy, respectively. After propensity score matching, 25 patients were included in each group. The SRATS group was associated with a lower conversion rate to multi-port surgery (0% vs. 20%, p = 0.05), shorter chest tube drainage duration (1.32 ± 0.75 vs. 2.00 ± 1.29 days, p = 0.003), and a shorter postoperative hospital stay (2.52 ± 1.00 vs. 5.08 ± 5.20 days, p = 0.003). Subxiphoid SRATS thymectomy using the SPS is feasible and is a good alternative to conventional thymectomy. Further studies are necessary to confirm its benefits.

A proof-of-concept study: advantages of the subxiphoid over the lateral intercostal approach

OBJECTIVES

The study was designed to evaluate the superiority of the subxiphoid approach compared with the lateral intercostal approach during the operation and other perioperative indices.

METHODS

Patients diagnosed with anterior mediastinal disease in our hospital between January 2018 and October 2019 were prospectively assigned to 2 groups; 1 group underwent the lateral intercostal approach and 1 group underwent the subxiphoid approach of video-assisted thoracoscopic surgery to resect the diseased tissue. The PaCO2, SaO2, PaO2 and circulation changes were recorded during the operation; the neutrophil-to-lymphocyte ratio and other perioperative outcomes, including clinical and surgical results, operating time, blood loss, postoperative complication and postoperative pain score were compared.

RESULTS

A total of 59 patients diagnosed with an anterior mediastinal tumour or myasthenia gravis underwent a video-assisted thoracoscopic resection. Thirty-one patients were treated via the subxiphoid approach, and 28 patients were treated via the lateral intercostal approach. The PaCO2 increased significantly and the SaO2 remained stable in the subxiphoid group during the operation, whereas PaCO2 increased significantly and SaO2 decreased at the same time in the lateral intercostal group. Operations were more frequently interrupted for the hypoxia or circulation disturbance during the process of dissecting the thymus in the lateral intercostal approach. Compared with the lateral intercostal approach, patients treated via the subxiphoid approach experienced less inflammation and exhibited lower pain scores and shorter postoperative hospital stays. There were no significant differences in postoperative complications between the 2 groups. All of the patients recovered well when discharged.

CONCLUSIONS

Our study results suggested that the subxiphoid approach has less of an influence on the pulmonary circulation than the lateral intercostal approach, that the whole procedure is safer and easier and that the subxiphoid approach may be the ideal choice for patients with anterior mediastinal disease.

Risk factors for diaphragmatic injury in subxiphoid video-assisted thoracoscopic surgery

BACKGROUND

Subxiphoid video-assisted thoracoscopic surgery (VATS) is considered a safe and feasible operation for anterior mediastinal mass resection. However, diaphragmatic injury, presented as tearing or puncturing, may occur during subxiphoid VATS despite of low incidence. This study aims to explore risk factors for diaphragmatic injury in subxiphoid VATS, as well as strategies to reduce occurrence of the injury.

METHODS

We retrospectively reviewed clinical records of 44 consecutive adult patients who underwent subxiphoid VATS. These patients were divided into two groups: diaphragmatic injury group and non-injury group. Perioperative outcomes and anatomic features derived from 3D CT reconstructions were compared between the two groups.

RESULTS

Significant differences were observed in operation time (223.25 ± 92.57 vs. 136.28 ± 53.05, P = 0.006), xiphoid length (6.47 ± 0.85 vs. 4.79 ± 1.04, P = 0.001) and length of the xiphoid below the attachment point on the diaphragm (24.86 ± 12.02 vs. 14.61 ± 9.25, P = 0.029). Odds ratio for the length of the xiphoid below the attachment point on the diaphragm was 1.09 (1.001-1.186), P = 0.048 by binary logistic regression analysis.

CONCLUSIONS

We identified the length of the xiphoid below the attachment point on the diaphragm as an independent risk factor for diaphragm injury during subxiphoid VATS. Prior to subxiphoid VATS, a 3D chest CT reconstruction is recommended to assess the patients' anatomic variations within the xiphoid process. For patients with longer xiphoid process, a higher incision at the middle and upper part of the xiphoid process, and partial xiphoid process resection or xiphoidectomy is preferred.

Surgical outcomes of thoracoscopic thymectomy via the single-port subxiphoid approach versus the unilateral intercostal approach

OBJECTIVES

The purpose of this study was to explore the safety and feasibility of video-assisted thoracic surgery (VATS) total thymectomy via the single-port subxiphoid approach compared with the intercostal approach.

METHODS

From January 2018 to May 2022, patients who underwent VATS total thymectomy via the subxiphoid or unilateral intercostal approach and diagnosed with Masaoka-Koga stage I-II, non-myasthenic thymoma were included in this study. Perioperative outcomes, immediate and long-term pain evaluations were compared in a propensity score-matching analysis.

RESULTS

In total, 95 patients were included and underwent the subxiphoid approach (n = 37) and the intercostal approach (n = 58). Propensity score yielded 2 well-matched cohorts of 30 patients and there was no significant demographical imbalance between the 2 groups. Compared with the intercostal approach, the subxiphoid group demonstrated favourable perioperative outcomes including the intraoperative blood loss (P = 0.025) and the median duration of hospital stay (P = 0.083). The immediate and long-term pain evaluations revealed that the subxiphoid group reported lower visual analogue scales at postoperative 24 h and lower total doses of fentanyl bolus infusions during hospitalization (P = 0.004 and 0.018, respectively), along with lower long-term neuropathic pain scale scores (P = 0.005) than patients in the intercostal group.

CONCLUSIONS

VATS thymectomy via the single-port subxiphoid approach showed favourable perioperative outcomes compared to the intercostal approach. Moreover, the subxiphoid approach seemed both to cause minimal immediate postoperative pain and to have advantages in reducing long-term neuropathic pain compared with the intercostal approach.

Comparison of short-term results of subxiphoid and conventional video-assisted thoracoscopic surgery in diagnostic wedge resections

BACKGROUND

This study aimed to compare early results in patients who underwent subxiphoid wedge resection with those operated on using a multiportal approach.

METHODS

We retrospectively evaluated 151 patients who underwent diagnostic wedge resection for suspected interstitial lung disease. Patients who underwent wedge resection via subxiphoid video-assisted thoracoscopic surgery and conventional video-assisted thoracoscopic surgery were compared.

RESULTS

The study included 90 men (59.6%) and 61 women (40.4%) with a mean age of 54.8 ± 12 years. Of these, 127 patients underwent conventional video-assisted thoracoscopic surgery and 24 patients underwent subxiphoid video-assisted thoracoscopic surgery. Postoperative complications occurred in 13 patients (8.6%), with no significant difference according to surgical technique. Sex was a significant factor in the rate of complications (12.2% in men vs. 3.2% in women). There was no intraoperative mortality; the 30-day mortality rate was 4% (n = 6). Five nonsurviving patients were in the conventional video-assisted thoracoscopic surgery group and 1 was in the subxiphoid video-assisted thoracoscopic surgery group (p = 0.95).

CONCLUSION

The results of this study indicate that the subxiphoid approach reduced procedure time and length of hospital stay in the early period, while there was no significant difference between the techniques in terms of complications or mortality. Based on these findings, we conclude that surgical outcomes were as successful with the subxiphoid approach as with conventional video-assisted thoracoscopic surgery.

Clinical analysis of subxiphoid vs. lateral approaches for treating early anterior mediastinal thymoma

Objective

To investigate the clinical efficacy of the subxiphoid approach for early anterior mediastinal thymoma and evaluate its advantages over the lateral intercostal approach.

Methods

A total of 345 patients with early anterior mediastinal thymoma were retrospectively analyzed from January 2016 to December 2020 in the First Affiliated Hospital of Soochow University. Out of these, 99 patients underwent subxiphoid video-assisted thoracoscopic thymectomy and 246 patients underwent transthoracic video-assisted thoracoscopic thymectomy. We compared the intraoperative conditions (such as operation time and intraoperative blood loss), postoperative conditions [such as postoperative pleural drainage volume, extubation time, postoperative hospital stay, and postoperative visual analogue scale (VAS) pain score], and postoperative complications (such as death, pneumonia, delayed wound healing, cardiac arrhythmia, and phrenic nerve injury) of the two groups and analyzed the clinical advantages of the subxiphoid approach for treating early anterior mediastinal thymoma.

Results

There was no significant difference between the two groups in terms of general clinical features, operation time, and postoperative complications (P > 0.05).However, there was a significant difference in terms of intraoperative blood loss, postoperative pleural drainage volume, tube extubation time, postoperative hospital stay, postoperative VAS pain score, and postoperative analgesics (a significantly decreased flurbiprofen axetil amount) (P < 0.05).

Conclusion

Compared with the lateral intercostal thoracic approach, the subxiphoid approach had advantages in terms of intraoperative blood loss, postoperative hospital stay, tube extubation time, postoperative pleural drainage volume, postoperative VAS pain score, and analgesics dosage. It could provide a better view of the bilateral pleural cavities and more thorough thymectomy and superior cosmesis, and it proved to be a safe and feasible minimally invasive surgical method.

Clinical Application of Thoracoscopic Resection of Anterior Mediastinal Tumors under the Xiphoid Process

Objective

To explore the feasibility and advantages of thoracoscopic resection of anterior mediastinal tumors through subxiphoid and lateral thoracic approaches.

Method

74 patients with anterior mediastinal tumors hospitalized in our hospital from January 2019 to January 2022 were retrospectively analyzed. They were divided into the lateral chest group (31 cases) and the infraxiphoid group (43 cases) according to different operation methods. The tumor size, operation time, intraoperative bleeding, postoperative pain score, postoperative complications, postoperative drainage tube removal time, and hospital stay were compared between the two groups.

Result

The intraoperative bleeding and postoperative pain scores in the subxiphoid group were better than those in the lateral chest group. There was no significant difference in operation time and postoperative complications between the two groups.

Conclusion

Compared with the lateral thoracic approach, the thoracoscopic subxiphoid approach can be more safe and effective in resectioning anterior mediastinal tumors.

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

Background

It still remains unclear whether subxiphoid video-assisted thoracoscopic surgery (SVATS) thymectomy is safe and reasonable. This meta-analysis aims at assessing the effectiveness and safety of SVATS for thymoma in comparison with that of intercostal video-assisted thoracoscopic surgery (IVATS) thymectomy.

Methods

All the relevant data systematically analyzed in this thesis were retrieved from PubMed, the Cochrane Library, web of science, EMBASE, and ClinicalTrials.gov. The time span for data retrieval was from the date of database establishment to March 2022. The outcome indicators include operation time, intraoperative blood loss, duration of postoperative drainage, postoperative hospital days, visual analogue scale (VAS) score on the day of operation, VAS score on postoperative day 3, and VAS score on postoperative day 7; postoperative complications were analyzed in our meta-analysis.

Results

In 13 studies of this paper, there were 1,198 cases included. Among them, 563 cases were treated by SVATS thymectomy and 635 cases by IVATS thymectomy. There was no significant difference in the operation time [113.38 vs. 119.91  min, 95% confidence interval (CI): -0.70-0.15, p = 0.20) and the incidence of intraoperative and postoperative complications (RR = 0.82, 95% CI: 0.58-1.15, p = 0.25) between SVATS thymectomy and IVATS thymectomy. However, SVATS thymectomy significantly reduced the amount of intraoperative blood loss (47.68 vs. 66.69  mL, SMD = -0.57, 95% CI: -0.95 to -0.18, p = 0.004), postoperative drainage days (2.12 vs. 2.72 days, SMD = -0.46, 95% CI: -0.74 to -0.18, p = 0.001), postoperative hospital stays (4.53 vs. 5.91 days, SMD = -0.64, 95% CI: -0.96 to -0.31, p = 0.0001), and VAS scores after the operation.

Discussion

SVATS thymectomy is safe and feasible, and the perioperative effect is better than IVATS thymectomy to a certain extent, which is worthy of popularization and further research.Systematic Review Registration: https://www.crd.york.ac.uk/PROSPERO/.

Feasibility of Video-Assisted Thoracoscopic Surgery via Subxiphoid Approach in Anterior Mediastinal Surgery: A Meta-Analysis

Background

Accumulating researches show potential advantages of video-assisted thoracoscopic surgery (VATS) via the subxiphoid approach, and this meta-analysis aims to investigate the efficacy and safety of the subxiphoid approach for anterior mediastinal surgery.

Methods

Relevant studies were retrieved by searching Embase and PubMed databases (from the inception to October 1, 2021). Primary outcomes included postoperative pain, intraoperative blood loss, operation time, chest tube duration, and hospital length of stay. All meta-analyses were performed by using random-effects models.

Results

Overall, 14 studies with 1,279 patients were included, with 504 patients undergoing anterior mediastinal surgery via subxiphoid approach and 775 via other approaches. The pooled results indicated that the subxiphoid approach was associated with reduced postoperative pain indicated by visual analog scale [weight mean difference (WMD): 24 h: -2.27, 95% CI, -2.88 to -1.65, p < 0.001; 48-72 h: -1.87, 95% CI, -2.53 to -1.20, p < 0.001; 7 days: -0.98, 95% CI, -1.35 to -0.61, p < 0.001], shortened duration of chest tube drainage (WMD: -0.56 days, 95% CI, -0.82 to -0.29, p < 0.001), shortened hospital length of stay (WMD: -1.46 days, 95% CI, -2.28 to -0.64, p < 0.001), and reduced intraoperative blood loss (WMD: -26.44 mL, 95% CI, -40.21 to -12.66, p < 0.001) by comparison with other approaches in anterior mediastinal surgery. Besides, it has no impact on operation time and the incidence of complications of transition to thoracotomy, postoperative pleural effusion, phrenic nerve palsy, and lung infection.

Conclusions

Our study suggests that the subxiphoid approach is a feasible alternative approach and even can be a better option for anterior mediastinal surgery. Further, large-scale multicenter randomized controlled trials are needed to validate this finding.

Thymic tumours: a single center surgical experience and literature review on the current diagnosis and management of thymic malignancies

OBJECTIVE

This study aimed to provide an extensive overview of clinical and pathological findings along with various therapeutic options analyzing in addiction, retrospectively, the surgical outcomes of a single center cohort.

BACKGROUND

Thymic neoplasms are rare thoracic tumors which commonly are located in the anterior mediastinum and are associated with a wide spectrum of clinical presentations. They may run an indolent course or could present a very aggressive biologic progression with infiltration of mediastinal structures and presence of distant metastases. The pathogenesis of these tumors is so far not completely clear. Several treatment modalities in a multidisciplinary setting have to be considered in order to provide the best treatment for patients affected by thymic tumors.

METHODS

We conducted a retrospective cohort analysis of all patients who underwent surgery due to thymic tumor in a university hospital located in Switzerland (Bern University Hospital) and then we performed a narrative review of the English literature using PubMed, Embase, Cochrane Database of Systematic Reviews and Scopus.

CONCLUSIONS

Minimally invasive techniques play an important role in the treatment of thymic tumors. A careful patients selection in a multidisciplinary setting is mandatory in order to offer the best treatment for patients affected by thymic tumors.

Subxiphoid thoracoscopic thymectomy for myasthenia gravis

We investigated the efficacy of subxiphoid thoracoscopic thymectomy in patients with myasthenia gravis. The data of 37 consecutive cases were reviewed. 2 cases of postoperative myasthenia gravis crisis and 4 cases of residual mediastinal fat tissue were recorded. Moreover, 29 patients presented the neurological outcomes, and complete stable remission was achieved in 5 (17.2%) cases. Subxiphoid thymectomy is technically feasible. High-quality evidence is warranted before this approach can be recommended.

Robot-Assisted Thoracic Surgery Thymectomy

Robotic thymectomy has been adopted recently and has been shown to be safe and feasible in treating thymic tumors and myasthenia gravis. The surgical indications of robotic technology are expanding, with advantages including an excellent surgical view and sophisticated manipulation. Herein, we describe technical aspects, considerations, and outcomes of robotic thymectomy.

The Early Perioperative Outcomes of Subxiphoid Approach Versus Lateral Intercostal Approach Thoracoscopic Thymectomy for Thymic Tumors: A Meta-Analysis

Objectives: To systematically evaluate the early perioperative outcomes regarding the safety and efficacy of subxiphoid thoracoscopic thymectomy (STT) versus lateral intercostal thoracoscopic thymectomy (LITT) for patients with thymic tumors. Methods: A thorough literature search of the following online databases was performed: Web of Science, PubMed, Embase, Cochrane Library, Google Scholar, and ClinicalTrials.gov. Original research articles published before December 30, 2020, that compared STT with LITT were included. Meta-analysis was performed for early perioperative outcomes, including blood loss, pain score, duration of hospital stay, operative time, chest tube drainage time, and incidence of postoperative complications. Results: Six studies that included 604 patients were finally selected for our analysis, with 296 cases of STT and 308 cases of LITT. Our results showed that compared with LITT, STT was associated with less blood loss (standardized mean difference = -0.81, 95% confidence interval [CI] = -1.49 to -0.14, P = .02), a lower pain score (weighted mean difference [WMD] = -2.55, 95% CI = -3.52 to -1.59; P < .00001), and a shorter hospital stay (WMD = -1.37, 95% CI = -2.37 to -0.36; P = .008), whereas there were no significant differences with regard to the operative time (WMD = -10.04, 95% CI = -22.29 to 2.21, P = .11), chest tube drainage time (WMD = -0.58, 95% CI = -1.17 to 0.02, P = .06), and the incidence of postoperative complications (odds ratio = 0.75, 95% CI = 0.39 to 1.44, P = .38). Conclusions: The current analysis suggests that STT is superior to LITT with respect to the early perioperative outcomes, and STT is a safe and effective surgical method for patients with thymic tumors.

Safety of subxiphoid uniportal video-assisted thoracoscopic surgery for anterior mediastinal tumour in obese patients

Introduction

Subxiphoid uniportal video-assisted thoracoscopic surgery (VATS) has been gradually applied for the treatment of anterior mediastinal tumour (AMT). However, whether obesity is a risk factor for subxiphoid uniportal VATS for AMT is still unknown.

Aim

To explore the safety and short-term outcome of subxiphoid uniportal VATS for AMT in obese patients.

Material and methods

The clinical data of 142 patients who received VATS via subxiphoid approach for AMT were analysed. According to body mass index (BMI), the patients were divided into an obese group (BMI ≥ 28 kg/m²) and a non-obese group (BMI < 28 kg/m²). Then, the clinical and surgical characteristics between the obese group and the non-obese group were analysed to explore the effect of obesity on VATS for AMT. The pain scores were evaluated by the Numeric Rating Scale.

Results

The operative time and tracheal intubation time using subxiphoid uniportal VATS for AMT in the obese group were longer than that in the non-obese group (p < 0.05). However, there was no obvious difference in intraoperative blood loss, chest tube drainage time, chest tube drainage volume, and length of hospital stay between the obese group and the non-obese group (p > 0.05). Moreover, there was also no significant difference in postoperative complications, including pulmonary complications, wound infection, arrhythmia, and pulmonary leak, between the obese group and the non-obese group. In addition, the pain scores in the obese group were similar to those in the non-obese group.

Conclusions

Although obesity might prolong operative time of subxiphoid uniportal VAST for AMT, it does not increase the rate of postoperative complications. An experienced centre can properly conduct VAST via subxiphoid approach when treating AMT in obese patients.