Surgical treatment of early-stage thymomas: robot-assisted thoracoscopic surgery versus transsternal thymectomy

Robotic portal resection for mediastinal tumours: a prospective observational study

BACKGROUND

To demonstrate the effectiveness and feasibility of robotic portal resection (RPR) for mediastinal tumour using a prospectively collected database.

METHODS

Data from 73 consecutive patients with mediastinal tumours who underwent RPRs were prospectively collected from August 2018 to April 2023. All patients underwent chest and abdominal enhanced computed tomography (CT) and preoperative multidisciplinary team (MDT) discussion. The patients were stratified into two groups based on tumour size: Group A (tumour size < 4 cm) and Group B (tumour size ≥ 4 cm). General clinical characteristics, surgical procedures, and short outcomes were promptly recorded.

RESULTS

All of the cases were scheduled for RPRs. One patient (1/73, 1.4%) was switched to a small utility incision approach because of extensive pleural adhesion. Two patients (2.8%) converted to sternotomy, however, no perioperative deaths occurred. Most of the tumours were located in the anterior mediastinum (51/73, 69.9%). Thymoma (27/73, 37.0%) and thymic cyst (16/73, 21.9%) were the most common diagnoses. The median diameter of tumours was 3.2 cm (IQR, 2.4-4.5 cm). The median total operative time was 61.0 min (IQR, 50.0-90.0 min). The median intraoperative blood loss was 20 mL (IQR, 5.0-30.0 ml), and only one patient (1.4%) experienced an intraoperative complication. The median length of hospital stay was 3 days (IQR, 2-4 days). Compared with Group A, the median total operative time and console time of Group B were significantly longer (P = 0.006 and P = 0.003, respectively). The volume of drainage on the first postoperative day was greater in group B than in group A (P = 0.013).

CONCLUSION

RPR is a safe and effective technique for mediastinal tumour treatment, which can expand the application of minimally invasive surgery for the removal of complicated mediastinal tumours.

Anterior mediastinal tumor surgery applying single-port thoracoscopy using the subxiphoid approach

Background

This study aims to investigate the effectiveness of application of single-port thoracoscopy using the subxiphoid approach in anterior mediastinal tumor surgery.

Methods

Between June 2014 and June 2016, a total of 108 patients (59 males, 49 females; mean age: 64.9±7.5 years; range, 45 to 79 years) with anterior mediastinal tumors were randomized into subxiphoid (experimental) or right chest (control) groups. Single-port thoracoscopy using the subxiphoid approach was performed in the subxiphoid group, while thoracoscopy using the right thoracic approach was performed in the control group. Preand postoperative pain stress indicators, Visual Analog Scale scores, quality of life scores, postoperative tumor recurrence, and five-year survival rates were compared between the groups.

Results

There were no mortality or serious complications in either group. The mean Visual Analog Scale pain scores on postoperative Days 1 and 7 were 6.5±0.8 and 2.9±0.8 in the subxiphoid group, respectively, compared to 7.2±0.8 and 3.4±0.8 in the control group (p<0.05 for all), respectively. The mean quality of life scores on postoperative Days 1 and 7 were 81.5±5.0 and 79.3±7.7, respectively, in the subxiphoid group compared to 72.4±4.3 and 71.3±4.8 in the control group, respectively (p<0.05 for all). Postoperative pain and pain mediator indexes were lower in the subxiphoid group (p<0.05 for all). The postoperative tumor recurrence rates were 3.70% and 20.37% in the subxiphoid and control groups, respectively (p=0.008). The five-year survival rates were 85.2% and 63.0% in the subxiphoid and control groups, respectively (p=0.008).

Conclusion

Single-port thoracoscopy using the subxiphoid approach is technically feasible, safe, and effective in performing surgery for anterior mediastinal tumors with an intact capsule and a tumor diameter of ≤5 cm.

Surgical, Radiation, and Systemic Treatments of Patients With Thymic Epithelial Tumors: A Systematic Review

INTRODUCTION

Thymic epithelial tumors are rare and are classified as thymoma, thymic carcinoma, and thymic neuroendocrine tumors. The objective of this systematic review was to evaluate the treatment options for patients with thymic epithelial tumors.

METHODS

This systematic review was developed by Ontario Health (Cancer Care Ontario)'s Program in Evidence-Based Care and by the Lung Cancer Disease Site Group. MEDLINE, EMBASE, and the Cochrane Library were searched for studies comparing surgical, radiotherapy, or systemic treatments against any combination of these treatments in patients with thymic epithelial tumors. Meta-analyses were conducted with clinically homogenous studies.

RESULTS

A total of 106 studies were included, mainly from observational studies. There was an overall survival benefit with postoperative radiotherapy for patients with thymic carcinoma (hazard ratio = 0.65, 95% confidence interval: 0.47-0.89) and for patients with thymoma (hazard ratio = 0.70, 95% confidence interval: 0.59-0.82), especially for those with a high risk for mortality. Patients with thymic carcinoma or thymoma had a response to chemotherapy. Selection bias affected the results for studies that evaluated neoadjuvant chemotherapy or minimally invasive surgical techniques. Furthermore, the overall survival benefit found for adjuvant chemotherapy may have been confounded by the administration of postoperative radiotherapy.

CONCLUSIONS

For patients with thymoma or thymic carcinoma, the literature is of low quality and subject to bias. There were overall survival benefits with postoperative radiotherapy. The results of this systematic review were used to inform treatment recommendations in a clinical practice guideline. Future large-scale prospective studies that control for confounders are needed.

Robot-assisted thoracoscopic surgery vs. sternotomy for thymectomy: A systematic review and meta-analysis

Introduction

Surgeons have widely regarded sternotomy (ST) as the standard surgical method for thymectomy. Minimally invasive methods for thymectomy, including video-assisted and robot-assisted thoracoscopic surgery (RATS), have been explored. There are some studies have researched and compared the outcomes of patients after robotic and sternotomy procedure.

Methods

We searched the databases of Pubmed, the Cochrane Library, Embase and selected the studies on the efficacy and safety of RATS or ST for thymectomy. Meta-analysis was performed for operation time, operation blood loss, postoperative drainage time, operative complications and hospitalization time.

Results

A total of 16 cohort studies with 1,089 patients were included. Compared to ST, RATS is an appropriate alternative for thymectomy which reduced operation blood loss [standardized mean difference (SMD) = -1.82, 95% confidence interval (95% CI): (-2.64, -0.99), p = 0.000], postoperative drainage time [SMD = -2.47, 95% Cl: (-3.45, -1.48), p = 0.000], operative complications [odds ratio (OR) = 0.31, 95% Cl: (0.18, 0.51), p = 0.000] and hospitalization time [SMD = -1.62, 95% Cl: (-2.16, -1.07), p = 0.000].

Conclusions

This meta-analysis based on cohort studies shows that RATS has more advantages over ST. Therefore, RATS is a more advanced and suitable surgical method for thymectomy.

Post-Operative Outcomes Associated With Open Versus Robotic Thymectomy: A Propensity Matched Analysis

To compare post-operative outcomes associated with thymectomy performed using either open or robotic approaches. Retrospective cohort study from a single-center prospective registry consisting of patients undergoing thymectomy between 2000 and 2020. Patients were grouped according to surgical approach (open vs robotic). A propensity-score matching analysis was performed in a 2:1 open to robotic ratio, and surgical outcomes were evaluated. We analyzed 234 thymectomies (155 open; 79 robotic). Myasthenia gravis was present in 23.2% and 32.9% (P = 0.249) in the open and in the robotic group, respectively. All covariates were balanced in the matched groups (open n = 114; robotic n =5 9), except lesion size. The robotic approach was significantly associated with shorter surgical time (median 95 vs 65 minutes, P < 0.001), lesser clinical (21.1% vs 6.8%, P = 0.016) and surgical (11.4% vs 1.7%, P = 0.036) complications during the same hospitalization, less Clavien-Dindo grade 2 or higher complication rates (28.1 vs 15.3%, P = 0.048), chest tube duration (median: 3 vs 0 days, P < 0.001) and in-hospital length of stay (median: 5 vs 0 days, P < 0.001). Bleeding (P = 0.214), ICU length of stay (P = 0.167), reoperation rate (open, 1.8% vs robotic 0%), 90-day mortality (P = 0.341) and readmission rate post discharge (P = 0.277) were similar between the groups. In the matched population with primary thymic epithelial tumors, the completeness of resection rate was similar (open, 92.1% vs robotic 96.8%, P = 0.66.). Robotic thymectomy is associated with improved post-operative outcomes when compared to open thymectomy, without compromising the goals of oncologic surgery. Longer follow-up is needed to ensure oncologic equivalence.

Robot-assisted thymectomy in large anterior mediastinal tumors: A comparative study with video-assisted thymectomy and open surgery

BACKGROUND

The aim of this study was to evaluate the safety and effectiveness of robot-assisted thymectomy (RAT) in large anterior mediastinal tumors (AMTs) (size ≥6 cm) compared with video-assisted thymectomy (VAT) and open surgery.

METHODS

A total of 132 patients with large AMTs who underwent surgical resection from January 2016 to June 2022 were included in this study. A total of 61 patients underwent RAT, 36 patients underwent VAT and 35 patients underwent open surgery. Perioperative outcomes were compared.

RESULTS

There were no significant differences in tumor size (p = 0.141), or pathological types (p = 0.903). Compared with the open group, the RAT and VAT groups were associated with a shorter operation time (115.00 vs. 160.00, p = 0.012; 122.50 vs. 160.00, p = 0.071), and less blood loss (50.00 vs. 200.00, p < 0.001; 50.00 vs. 200.00, p < 0.001), respectively. The rate of conversion in the RAT group was similar to that in the VAT group (6.56% vs. 13.89%, p = 0.229). Concomitant resection was less frequently performed in the VAT group than in the RAT and open groups (5.56% vs. 31.15%, p = 0.040; 5.56% vs. 31.43%, p = 0.006). VAT patients had a lower drainage volume (365.00 vs. 700.00 and 910.00 mL, p < 0.001), shorter duration of chest tube (2.00 vs. 3.00 and 4.00, p < 0.001), and shorter hospital stay (5.00 vs. 6.00 and 7.00, p < 0.001) than the RAT and open groups. There was no 30-day mortality in any group. No difference was seen in R0 resection rates (p = 0.846). The postoperative complication rates were similar among the three groups (p = 0.309). Total in-hospital costs (66493.90 vs. 33581.05 and 42876.40, p < 0.001) were significantly higher in the RAT group.

CONCLUSIONS

RAT is safe and effective for the resection of large AMTs compared to VAT and open surgery. Vascular resection in RAT is technically feasible. A long-term follow-up is required.

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.

Limited resection for early-stage thymoma: minimally invasive resection does not mean limited resection

Standard resection for patients with thymoma is resection of thymoma with total thymectomy (TTx) via median sternotomy. Hence, limited resection for thymoma means a lesser extent of resection of normal thymus compared with a standard procedure, i.e. resection of thymoma with partial thymectomy (PTx). In contrast, minimally invasive resection has been defined as resection of thymoma with TTx via a less-invasive approach. However, to date, few studies have precisely evaluated the differences in surgical and oncological outcomes among these three procedures. This report summarizes the differences among these three procedures with a review of studies (January 2000 to December 2020) focusing on the difference in surgical and oncological outcomes and presents current issues in the surgical management of thymoma. In this report, 16 studies were identified; 5 compared standard resection to limited resection, 9 compared standard resection to minimally invasive resection and 2 compared limited resection to minimally invasive resection. Most studies reported that the surgical and oncological outcomes of limited resection or minimally invasive resection were similar to those of standard resection in patients with early-stage thymoma. However, they did not include a sufficient follow-up period. Both limited resection and minimally invasive resection for early-stage thymoma might be reasonable treatment options. However, they are still promising modes of resection. Further studies with a long follow-up period are needed.

Comparison of Early Postoperative Outcomes of Patients Undergoing Robot-Assisted and Transsternal Thymectomy

Objective: Robot-assisted thoracoscopic surgery (RATS) is a minimally invasive technique that has been used in thymectomy operations in recent years. Minimally invasive surgical techniques offer less postoperative pain, a shorter length of hospital stay, and faster recovery compared to conventional surgical techniques. In our study, we aimed to compare the outcomes of robotic and transsternal thymectomies by analyzing the operative and postoperative data of these two approaches. Methods: Twelve robotic thymectomy patients and 16 transsternal thymectomy patients who were operated on in our clinic in 2018 were included in the study. Results: There was no significant difference between the two groups in terms of operative time (p=0.231). The median chest tube duration was 1.5 [range, 1-2] days in robotic thymectomy and 2.5 [range, 1-3.75] days in transsternal thymectomy. However, there was no statistically significant difference between the two groups (p=0.082). The amount of chest tube drainage was significantly lower in the robotic thymectomy group (p=0.006). The length of hospital stay was also significantly shorter in robotic thymectomy patients (p<0.001). Conclusion: The amount of chest tube drainage was lower and the length of hospital stay was shorter in the robotic surgery compared to the transsternal approach. There was no significant difference between the two techniques in terms of operative time. Within today's minimally invasive surgical techniques, robotic thymectomy can be considered a practical, comfortable, and safe technique with better early postoperative outcomes. Keywords: Robot-Assisted Thymectomy, Thymectomy, Transsternal Thymectomy

Midterm Results for Robotic Thymectomy for Malignant Disease

BACKGROUND

There are limited reports on robotic thymectomy for malignant disease. Our objectives are to review our experience and midterm outcomes.

METHODS

We reviewed a single-surgeon prospective database for patients who underwent planned robotic resection for malignancy from January 2010 to June 2019.

RESULTS

Two hundred thirteen patients underwent resection of an anterior mediastinal mass, all of which were planned for a robotic approach. Of these, 84 (39%) underwent robotic thymectomy for malignant disease. Thymoma was the most common pathology resected (68%). Median tumor size was 4.7 cm (interquartile range, 2.9-6.3), and median operative time was 81.5 minutes (interquartile range, 64-104). All except 1 patient had a complete (R0) resection (98.8%). There were 2 (2.3%) unplanned but elective conversions to open surgery, 1 of which required cardiopulmonary bypass. Median length of stay was 1 day (range, 0-9) with 1 readmission (1.2%). Major morbidity occurred in 3 patients (3.5%), and there were no 30- or 90-day mortalities. In patients with thymoma, follow-up was complete at a median of 32 months (range, 1-98), and 1 patient (1.8%) had an ipsilateral chest recurrence. To date there have been no patient deaths.

CONCLUSIONS

Robotic thymectomy for patients with malignant disease is safe with excellent perioperative outcomes. A robotic approach achieves a high rate of complete R0 resection, even for larger tumors. For patients with thymoma local recurrence is low after midterm follow-up, but longer-term analysis is needed to determine oncologic durability.

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

Background

Compared with traditional open surgery for thymectomy, video-assisted thoracoscopic surgery (VATS) reduces hospital stay, decreases postoperative pain, and recovers faster. VATS has become increasingly popular in the past decade. VATS techniques to perform a thymectomy include subxiphoid video-assisted thoracoscopic surgery (SVATS) or lateral video-assisted thoracoscopic surgery (LVATS). In this study, our objective was to systematically review on VATS thymectomy and draw a meta-analysis on the outcomes between the two approaches.

Methods

We searched online databases and identified studies from database inception to 2019 that compared SVATS to LVATS thymectomy. Study endpoints included operative time, operative blood loss, length of hospital stay, postoperative pleural drainage, postoperative complications, conversion to open, oncologic outcomes.

Results

Four hundred seventy-one patients were included in this study, for which 200 and 271 patients underwent SVATS and LVATS thymectomy, respectively. Patients in the SVATS group had significantly less operative time, operative blood loss, length of hospital stay, and postoperative complications were identified. There was no statistical difference in postoperative pleural drainage, conversion to open and oncologic outcomes. No hospital deaths were recorded for either procedure.

Conclusions

While randomized controlled studies are required to make definitive conclusions, this meta-analysis suggests that SVATS thymectomy is safe and can achieve good and safe operative and perioperative outcomes similar or better to LVATS thymectomy.

Robotic assisted minimally invasive thymectomy with simultaneous bilateral thoracoscopy and contralateral phrenic nerve visualization

Background

Thoracoscopic approaches to thymectomy and anterior mediastinal mass resection has become increasingly common due to the potential for decreased blood loss and hospital length of stay. However, contralateral mediastinal and phrenic nerve visualization if often difficult from these unilateral approaches, which may affect the ability to achieve a full phrenic to phrenic dissection Herein, we present our early experience of robotic assisted minimally invasive thymectomy (RAMIT) with simultaneous bilateral thoracoscopy and contralateral phrenic nerve visualization.

Methods

This was a retrospective review of all sequential patients undergoing RAMIT with simultaneous bilateral thoracoscopy from January 2015 to May 2016. This study was approved by our Institutional Review Board (PRO15080367). Individual patient consent was waived.

Results

Twenty-six patients [median age 58 (range, 29-76) years] were included in this study. Sixteen operations were performed for anterior mediastinal mass, 7 for non-thymomatous myasthenia gravis, and 3 for concurrent myasthenia gravis and thymoma. Median blood loss and hospital stay were 25 mL (range, 3-150 mL) and 3 days (range, 2-8 days), respectively. Twenty-one (80.8%) patients experienced an uncomplicated hospital course. The highest graded complication by Clavien Dindo Classification was a grade III due to pleural effusion requiring drainage via pleural catheter. One patient experienced asymptomatic hemidiaphram palsy postoperatively. There were no 90-day postoperative deaths.

Conclusions

RAMIT with simultaneous bilateral thoracoscopy is a feasible approach that may allow for enhanced visualization and more complete thymic resection compared to existing unilateral minimally invasive operations. Comparative studies and long-term follow up are needed to adequately assess the potential benefits of RAMIT.

A national analysis of open versus minimally invasive thymectomy for stage I to III thymoma

OBJECTIVE

The oncologic efficacy of minimally invasive thymectomy for thymoma is not well characterized. We compared short-term outcomes and overall survival between open and minimally invasive (video-assisted thoracoscopic and robotic) approaches using the National Cancer Data Base.

METHODS

Perioperative outcomes and survival of patients who underwent open versus minimally invasive thymectomy for clinical stage I to III thymoma from 2010 to 2014 in the National Cancer Data Base were evaluated using multivariable Cox proportional hazards modeling and propensity score-matched analysis. Predictors of minimally invasive use were evaluated using multivariable logistic regression. Outcomes of surgical approach were evaluated using an intent-to-treat analysis.

RESULTS

Of the 1223 thymectomies that were evaluated, 317 (26%) were performed minimally invasively (141 video-assisted thoracoscopic and 176 robotic). The minimally invasive group had a shorter median length of stay when compared with the open group (3 [2-4] days vs 4 [3-6] days, P < .001). In a propensity score-matched analysis of 185 open and 185 minimally invasive (video-assisted thoracoscopic + robotic) thymectomy, the minimally invasive group continued to have a shorter median length of stay (3 vs 4 days, P < .01) but did not have significant differences in margin positivity (P = .84), 30-day readmission (P = .28), 30-day mortality (P = .60), and 5-year survival (89.4% vs 81.6%, P = .20) when compared with the open group.

CONCLUSIONS

In this national analysis, minimally invasive thymectomy was associated with shorter length of stay and was not associated with increased margin positivity, perioperative mortality, 30-day readmission rate, or reduced overall survival when compared with open thymectomy.

Median sternotomy versus minimally invasive thymectomy for early-stage thymoma: A systematic review and meta-analysis protocol

BACKGROUND

The completeness of resection is an important prognostic factor for early resectable thymoma. Since its inception 2 decades ago, median sternotomy has been recognized as the gold standard method for the treatment of all types and stages of thyomas. Minimally invasive surgical techniques, including video-assisted and robot-assisted surgery, have been rapidly developed as an alternative to traditional open approach surgery. Compared with traditional open approach surgery, minimally invasive approach has better cosmetic effect, faster improvement of lung function, reduction of surgical trauma, length of stay, and complications. We believe that this is an appropriate time and there is a need for a systematic, comprehensive, and objective assessment of the 2 surgical modalities in order to provide reliable evidence for clinicians to determine the best treatment for patients with early resectable thymoma.

METHODS

Pubmed (Medline), Web of Science, Embase, Cochrane Central Register of Controlled Trials, and Google Scholar will be searched for relevant randomized controlled trials (RCTs), quasi-RCTs, and Hi-Q (high quality) prospective cohort trials published or unpublished in any language before March 1, 2020. Subgroup analysis will be performed in tumor pathological stage and ethnicity. PROSPERO registration number: CRD42019133724.

RESULTS

The results of this study will be published in a peer-reviewed journal.

CONCLUSION

This study will be the first to assess the efficacy and safety of median sternotomy recognized as the gold standard method for the treatment of all types and stages of thyomas and minimally invasive thymectomy for patients with early-stage thymoma. This study will assess whether minimally invasive thoracoscopic and robotic assisted thymectomy can be used as an alternative to traditional median sternotomy for patients with early resectable thymoma and provide high-quality and reliable evidence for clinicians' decision-making.

Comparing robotic and trans-sternal thymectomy for early-stage thymoma: a propensity score-matching study

OBJECTIVES

Minimally invasive techniques seem to be promising alternatives to open approaches in the surgical treatment of early-stage thymoma, although there are controversies because of lack of data on long-term results. The aim of the study was to evaluate the surgical and oncological results after robotic thymectomy for early-stage thymoma compared to median sternotomy.

METHODS

Between 1982 and 2017, 164 patients with early-stage thymoma (Masaoka I and II) were operated on by median sternotomy (108 patients) or the robotic approach (56 patients). Duration of surgery, amount of blood loss, complications, duration of chest drainage, postoperative hospital stay, oncological results and total costs were retrospectively evaluated. Data were analysed also after propensity score matching.

RESULTS

Compared to the trans-sternal group, robotic thymectomy had significantly longer average operative times (P < 0.001) but less intraoperative blood loss (P = 0.01), less perioperative complications (P = 0.03), shorter time to chest drainage removal and hospital discharge (P < 0.001). The median expense for the trans-sternal approach was significantly higher than the cost of the robotic procedure (P < 0.001), mainly due to longer hospitalization. From an oncological point of view, there were no differences in thymoma recurrence, although follow-up of the trans-sternal group was significantly longer (P < 0.001). Data were confirmed after propensity score matching.

CONCLUSIONS

Robotic thymectomy for early-stage thymoma is a technically safe and feasible procedure with low complication rate and shorter hospital stay compared to the trans-sternal approach. Cost analysis revealed lower expenses for the robotic procedure due to the reduced hospital stay. The oncological outcomes seemed comparable, but longer follow-up is needed.

A systematic review of robotic versus open and video assisted thoracoscopic surgery (VATS) approaches for thymectomy

Background

Median sternotomy has been the most commonly used approach for thymectomy to date. Recent advances in video-assisted thoracoscopic surgery (VATS) and robotic access with CO₂ insufflation techniques have allowed more minimally invasive approaches. However, prior reviews have not compared robotic to both open and VATS thymectomy.

Methods

A systematic review was conducted in accordance with the PRISMA guidelines using PubMed, Embase and Scopus databases. Original research articles comparing robotic to VATS or to open thymectomy for myasthenia gravis, anterior mediastinal masses, or thymomas were included. Meta-analyses were performed for mortality, operative time, blood loss, transfusions, length of stay, conversion to open, intraoperative and postoperative complication rates, and positive/negative margin rates.

Results

Robotic thymectomy is a valid alternative to the open approach; advantages include: reduced blood loss [weighted mean difference (WMD): -173.03, 95% confidence interval (95% CI): -305.90, -40.17, P=0.01], fewer postoperative complications (odds ratio: 0.37, 95% CI: 0.22, 0.60, P<0.00001), a shorter hospital stay (WMD: -2.78, 95% CI: -3.22, -2.33, P<0.00001), and a lower positive margin rate (relative difference: -0.04, 95% CI: -0.07, -0.01, P=0.01), with comparable operative times (WMD: 6.73, 95% CI: -21.20, 34.66, P=0.64). Robotic thymectomy was comparable with the VATS approach; both have the advantage of avoiding median sternotomy.

Conclusions

While randomized controlled studies are required to make definitive conclusions, current data suggests that robotic thymectomy is superior to open surgery and comparable to a VATS approach. Long-term follow-up is required to further delineate oncological outcomes.

Hemorrhagic complication during robotic surgery in patient with thymomatous myasthenia gravis

The advantages of thymectomy as part of the treatment of myasthenia gravis has been demonstrated repeatedly in the literature. Both single-institution and multi-institution trials have shown robotic thymectomy to be safe, feasible and associated with better early clinical outcomes than the trans-sternal approach. Most reports have also documented the superiority of robotic technology in the dissection of the superior mediastinum over conventional thoracoscopy, thanks to instruments with more degrees of movement and freedom. However, in case of a vascular injury in the superior mediastinum, after an initial management with minimally invasive approach, one should not hesitate to convert to sternotomy if the bleeding control hasn't been definitely established. In this way it is possible to avoid catastrophic injuries, also in relation to the limitations that, in our opinion, the robotic surgery has once a major vascular injury occurs in the mediastinum.

Robotic Thymectomy Is Feasible for Large Thymomas: A Propensity-Matched Comparison

BACKGROUND

Robotic-assisted thymectomy (RAT) is increasingly performed for resection of thymomas. Its application for large tumors remains controversial. In this study, we evaluated the safety and feasibility of RAT for large thymomas in comparison with transsternal thymectomy (ST).

METHODS

A single institution database was reviewed for patients who underwent RAT for thymoma of 4 cm or larger between 2004 and 2016. Propensity scores were applied to match RAT with ST patients, based on age, sex, tumor size, and Masaoka stage. Perioperative outcomes were compared.

RESULTS

Twenty patients (15 women and 5 men, median age 59 years) underwent RAT for a large thymoma (median size 6.0 cm). A right-sided approach was used in 14 patients (70%). A control group of 34 ST patients (median size 6.7 cm) had similar Masaoka staging (p = 0.64). Combined resection of adjacent structures, including pericardium, lung, and phrenic nerve, were frequently performed in both groups (50% RAT versus 47% ST, p = 0.83). RAT patients had lower blood loss (25 mL versus 150 mL, p = 0.001), were more frequently managed with a single chest tube (85% versus 56%, p = 0.027), and had a shorter median length of stay (3 days versus 4 days, p = 0.034). There were no perioperative deaths and no major vascular injuries. Three RAT patients (15%) were converted to open approach. Overall complication rates were similar between RAT and ST patients (15% versus 24%, p = 0.45). No difference was seen in R0 resection rates (90% versus 85%, p = 0.62).

CONCLUSIONS

RAT can be performed safely and effectively in a radical fashion for large thymomas. Future studies are necessary to determine long-term oncologic outcomes.

Robotically assisted thymectomy: a review of the literature

The aim of this literature review is to see where the robotic thymectomy stands nowadays. A thorough search of the PubMed revealed eighty-two related articles which reviewed comprehensively. The zero intraoperative mortality, the minimal intraoperative morbidity, as well as the recorded recurrence rate of 0-11.1% and complete stable remission rate of 0-40% suggests that the robotic-assisted thymectomy is a feasible, safe and an upcoming procedure. However, the lack of prospective randomized controlled trials prevents this technique to become the standard approach for the nonce.

Robot-assisted thoracic surgery for complex procedures

Background

As an option for minimally invasive thoracic surgery, robot-assisted thoracic surgery (RATS) has shown comparable perioperative outcomes to those achieved by traditional video-assisted thoracic surgery (VATS). It is unknown whether RATS might have any potential benefits in more complex thoracic surgical procedures, which usually require open surgery instead of VATS. The current study presents a preliminary result regarding the use of RATS in complex thoracic operations in an attempt to address this unresolved question.

Methods

Data from a prospectively collected and maintained surgical database were collected on patients who underwent RATS between February 2012 and August 2014. We defined complex RATS as those operations involving difficult dissections, complex sutures or excision of very large tumors (>8 cm) which would have required open surgery in our hospital before the introduction of RATS. The characteristics and peri-operative outcomes of patients receiving complex RATS were reviewed.

Results

Of the 120 patients undergoing RATS, 30 of them were classified as having undergone complex RATS, 21 to remove lung tumors and 9 to remove mediastinal tumors. The indications for complex RATS included 21 difficult dissections, 10 complex sutures, and 7 very large tumors (8 patients had two indications). There are three conversions to thoracotomy for pulmonary arterial bleeding. There was one mortality resulted from post-pneumonectomy pulmonary hypertension and sepsis. Patients with difficult dissection had longer operative time and hospital stay, and more bleeding and postoperative morbidity.

Conclusions

RATS for complex thoracic procedures is feasible, especially for complex suturing and excision of very large mediastinal tumors, but more attention is needed for patients needing difficult dissections. Advanced preparation for conversion is necessary during this difficult operation.

Thymectomy via open surgery or robotic video assisted thoracic surgery: Can a recommendation already be made?

BACKGROUND

Robot-assisted minimally invasive surgery (RVATS) is a relatively new technique applied for thymectomies. Only few studies directly compare RVATS to the mainstay therapy, open surgery (sternotomy).

METHODS

A systematic search of the literature was performed in October 2016. The meta-analysis includes studies comparing robotassisted and open thymectomy regarding operation time, length of hospitalization, intraoperative blood loss, and chest-in-tube days, postoperative complications, reoperation, arrhythmic events, pleural effusion, and postoperative bleeding.

RESULTS

Of 626 studies preliminary screened, 7 articles were included. There were no significant differences in comparison of operation time (-3.19 minutes [95% confidence interval, 95% CI -112.43 to 106.05]; P = .94), but patients undergoing RVATS spent significantly less time in hospital (-4.06 days [95% CI -7.98 to -0.13], P = .046). There were fewer chests-in-tube days (-2.50 days [95% CI -15.01 to 10.01]; P = .24) and less intraoperative blood loss (-256.84 mL [95% CI -627.47 to 113.80]; P = .10) observed in the RVATS group; due to a small number of studies, these results were not statistically significant. There were also less post-operative complications in the RVATS group (12 complications in 209 patients vs 51 complications in 259 patients); however, this difference was not statistical significant (odds ratio 0.27, 95% CI 0.07-1.12; P = .06).

CONCLUSIONS

Patients undergoing RVATS spent less time in hospital than patients treated by open surgery (sternotomy). These patients tended to have less postoperative complications, less intraoperative blood loss, and fewer chest-in-tube days. We found evidence for the safety and feasibility of RVATS compared with open surgery, which has to be further confirmed in randomised controlled trials.

Robotic Resection of 3 cm and Larger Thymomas Is Associated With Low Perioperative Morbidity and Mortality

OBJECTIVE

The approach to thymoma resection has usually been determined by tumor size, although established guidelines do not exist. Minimally invasive approaches have been limited to tumors smaller than 5 cm, although 3 cm has been the suggested cutoff for performing an adequate oncologic procedure. No study has compared the perioperative outcomes of patients with 3 cm or larger tumors resected robotically versus sternotomy.

METHODS

We reviewed patients who underwent resection of 3 cm or larger thymomas from 2004 to 2014. Patients were divided based on approach: robotic and open thymectomy/thymomectomy.

RESULTS

Forty patients with tumors ranging from 3 to 13 cm were evaluated, 23 robotic and 17 open. Patient and tumor characteristics were similar. An R0 resection was primarily achieved: robotic, 91% (21/23); and open, 88% (15/17); P = 0.832. Adjuvant radiation rates were statistically equivalent: robotic, 17% (4/23) versus open, 41% (7/17); P = 0.191. Major postoperative complications were comparable: robotic, 4% (1/23) versus open, 29% (4/17); P = 0.184. Median chest tube duration was shorter for robotic (1 day) versus open (3 days); P = 0.001. The robotic approach had a shorter median intensive care unit stay compared to open (0 days vs 1 day); P = 0.024. The median hospital stay was shorter for robotic (2 days) versus open (5 days); P < 0.001.

CONCLUSIONS

In 3 cm or larger thymomas, robotic thymectomy is feasible based on the ability to achieve a complete resection with similar adjuvant radiation therapy rates. Perioperatively, robotic thymectomy is associated with lower morbidity; and shorter chest tube duration, intensive care unit stay, and hospital stay compared to open. However, oncologic outcomes are immature and require prolonged surveillance.

Surgical and oncological outcomes of thoracoscopic thymectomy for thymoma

Thymoma remains the most common primary anterior mediastinal neoplasm. Surgical resection remains central to the treatment of thymoma, with thoracoscopic thymectomy (TT) being increasingly performed. This present review article aimed to summarize current studies comparing TT and open thymectomy (OT). Recently, most patients with Masaoka stage I-II thymoma have been receiving TT. This procedure is associated with a significantly shorter post-operative hospital stay, decreased intraoperative blood loss, and fewer complications compared with OT. Recurrence rates of thymoma after TT range from 0% to 6.7%, and the 5-year disease-free survival (DFS) ranges from 83.3% to 96%. The oncological outcomes of TT are comparable to that of OT. Masaoka stage and the World Health Organization (WHO) type classification are valuable predictors of the prognosis of thymoma; hence, the optimal treatment for thymoma should be performed according to these two. TT is less invasive, with equivalent oncological outcomes, when compared with the OT. Minimally invasive surgery including TT for stage I-II thymomas is becoming the mainstay of therapy.

Robotic-assisted thymectomy: current perspectives

Thymectomy is the cornerstone in the treatment of thymic tumors and an accepted option for the management of myasthenia gravis. Different surgical approaches have been described, but the gold standard is represented by median sternotomy. In the last two decades, the development of minimally invasive surgery has led to an increased acceptance of thymectomy, especially for benign diseases. Robotic thymectomy seems a further step in the development and evolution of minimally invasive approaches. Since its introduction, different authors described their experience with robotic thymectomy, both for nonthymomatous myasthenia gravis and for thymic tumors. Available data show that robotic thymectomy may be considered a safe and feasible operation. In patients with nonthymomatous myasthenia, robotic thymectomy is effective and the long-term results are encouraging. The role of robotic thymectomy in patients affected by thymoma is still under evaluation, but the intermediate results seem promising both in terms of surgical and oncologic outcomes.

Minimally invasive versus open thymectomy: a systematic review of surgical techniques, patient demographics, and perioperative outcomes

BACKGROUND

Thymectomy is the mainstay of treatment for thymoma and other anterior mediastinal tumors, and is often utilized in the management of patients with myasthenia gravis (MG). While traditionally approached through a median sternotomy, minimally invasive approaches to thymectomy have increasingly emerged. The present systematic review was conducted to compare perioperative and clinical outcomes following minimally invasive thymectomy (MIT) and open thymectomy (OT).

METHODS

Articles were obtained through a PubMed literature search. Comparative studies reporting clinical outcomes following MIT and OT were eligible for inclusion. We selected studies with full text availability, written in the English language, published after 2005 and with at least 15 patients in each arm. A descriptive analysis was performed.

RESULTS

Twenty studies were included, involving a total of 2,068 patients undergoing either MIT (n=838) or OT (n=1,230). Within individual studies, MIT and OT cohorts were well matched with regards to patient age and gender, but there was considerable variation across studies. Resected thymomas were consistently larger in OT groups, with mean diameter significantly larger in five studies (MIT, 29-52 mm; OT, 31-77 mm). MIT was consistently associated with a lower estimated blood loss (MIT, 20-200 mL; OT, 86-466 mL), chest tube duration (MIT, 1.3-4.1 days; OT, 2.4-5.3 days), and hospital length of stay (MIT, 1-10.6 days; OT, 4-14.6 days). There were no consistent differences in rates of perioperative complications, thymoma recurrence, MG complete stable remission, or 5-year survival.

CONCLUSIONS

In appropriately selected patients, MIT may reduce blood loss, chest tube duration, and hospital length of stay, with comparable clinical outcomes compared to OT via median sternotomy.

Multi-institutional European experience of robotic thymectomy for thymoma

BACKGROUND

Robotic thymectomy for early-stage thymomas has been recently suggested as a technically sound and safe approach. However, due to a lack of data on long term results, controversy still exists regarding its oncological efficacy. In this multi-institutional series collected from four European Centres with high volumes of robotic procedures, we evaluate the results after robot-assisted thoracoscopic thymectomy for thymoma.

METHODS

Between 2002 and 2014, 134 patients (61 males and 73 females, median age 59 years) with a clinical diagnosis of thymoma were operated on using a left-sided (38%), right-sided (59.8%) or bilateral (2.2%) robotic approach. Seventy (52%) patients had associated myasthenia gravis (MG).

RESULTS

The average operative time was 146 minutes (range, 60-353 minutes). Twelve (8.9%) patients needed open conversion: in one case, a standard thoracoscopy was performed after robotic system breakdown, and in six cases, an additional access was required. Neither vascular and nerve injuries, nor perioperative mortality occurred. A total of 23 (17.1%) patients experienced postoperative complications. Median hospital stay was 4 days (range, 2-35 days). Mean diameter of resected tumors was 4.4 cm (range, 1-10 cm), Masaoka stage was I in 46 (34.4%) patients, II in 71 (52.9%), III in 11 (8.3%) and IVa/b in 6 (4.4%) cases. At last follow up, 131 patients were alive, three died (all from non-thymoma related causes) with a 5-year survival rate of 97%. One (0.7%) patient experienced a pleural recurrence.

CONCLUSIONS

Our data suggest that robotic thymectomy for thymoma is a technically feasible and safe procedure with low complication rates and short hospital stays. Oncological outcome appears to be good, particularly for early-stage tumors, but a longer follow-up period and more cases are necessary in order to consider this as a standard approach. Indications for robotic thymectomy for stage III or IVa thymomas are rare and should be carefully evaluated.