Hybrid combination of small subxiphoid incision and thoracoscopic thymectomy for juvenile myasthenia gravis

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.

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.

Effectiveness of thymectomy in juvenile myasthenia gravis and clinical characteristics associated with better outcomes

Thymectomy is an established treatment in adult myasthenia gravis, but its exact role in juvenile myasthenia gravis (JMG) is still uncertain. Thymectomy is frequently considered in the treatment of severe, medically refractory JMG. Surgical approaches have evolved from open median sternotomy to the more cosmesis-preserving thoracoscopic approach. This paper reviews current evidence on the effectiveness of thymectomy in JMG and discusses clinical characteristics which may be associated with improved outcomes. 17 studies including 588 patients who underwent thymectomy from 1997 to 2020 were found, which either reported uncontrolled cohorts undergoing thymectomy, or compared cohorts undergoing different surgical approaches. An improvement in clinical status or reduced requirement for medical therapy following thymectomy was seen in 453 patients (77%). Complete remission was seen in 40% (n = 172/430). Thoracoscopic approaches may provide improved outcomes, fewer complications, and better cosmetic outcomes. Better surgical outcomes may be associated with early intervention, intervention after the onset of puberty, being acetylcholine receptor antibody positive, having more severe disease and the presence of hyperplastic thymic tissue. However, analysis remains hindered by the limitations of the currently available retrospective studies of small cohorts. Nonetheless, available literature suggests a role for thymectomy in JMG patients, especially those with certain clinical characteristics.

Open versus thoracoscopic thymectomy for juvenile myasthenia gravis

BACKGROUND

Juvenile myasthenia gravis (JMG) is an antibody mediated autoimmune disorder that manifests as progressive voluntary muscle weakness and fatigue. In medically refractory cases, thymectomy has been shown to abrogate symptoms and reduce glucocorticoid dependence. While transcervical or transsternal incisions have been the traditional approach, adult trends now favor thoracoscopic thymectomy. Little data exist to support this approach in children.

METHODS

A retrospective review of all patients younger than 20 years of age who underwent a thymectomy for JMG at two pediatric institutions between 2001 and 2018 was performed. Children were divided into either an open (transcervical or transsternal) or thoracoscopic group and baseline characteristics, perioperative, and postoperative outcomes were compared.

RESULTS

Thirty-four thymectomies were performed during the 18-year study period; 18 via an open and 16 via a thoracoscopic approach. The operative time was shorter for open procedures compared thoracoscopic ones (108 ± 49 and 145 ± 43 min, respectively, p = 0.025). Thoracoscopic thymectomy was associated with less intraoperative blood loss (5.5 ± 6.0 vs 55 ± 67 ml, p = 0.007), decreased duration of postoperative intravenous narcotic use (5.0 ± 1.5 vs 20 ± 23 h, p = 0.018), and a shorter length of hospitalization (1.7 ± 1.0 vs 2.7 ± 1.1 days, p = 0.009). No perioperative complication occurred in either group. Clinical improvement was reported in 94% of children in both groups.

CONCLUSIONS

Thoracoscopic thymectomy in children is a safe and effective surgical technique for the treatment of JMG. Increased acceptance of this minimally invasive approach by children, families, and referring neurologists may enable earlier surgical intervention.

TYPE OF STUDY

Clinical research paper.

LEVEL OF EVIDENCE

III.

Subxiphoid and subcostal arch "Three ports" thoracoscopic extended thymectomy for myasthenia gravis

Background

The approaches to thoracoscopic thymectomy in myasthenia gravis (MG) are debatable. We developed a novel approach via subxiphoid and subcostal arch, with a significantly shorter duration of operation and hospital stay, less estimated blood loss, and lower postoperative pain.

Methods

From December 2012 to December 2014, 77 myasthenia gravis patients with or without thymoma underwent thoracoscopic extended thymectomy at our hospital. Among them, 41 patients were operated via the subxiphoid and subcostal arch approach and the other 36 via the conventional unilateral approach. The patient outcomes were retrospectively reviewed and evaluated.

Results

The thoracoscopic extended thymectomy was performed safely via the subxiphoid and subcostal arch approach. In this approach, no drainage tube was inserted after operation except in the first two patients. Two of the 41 patients were switched to trans-sternal approach due to the tight adhesion between the thymoma and the left innominate vein. No major complications occurred. Compared with the unilateral approach, the duration of the procedure via subxiphoid and subcostal arch was significantly shorter, with less estimated blood loss, shorter hospital-stay and lower postoperative pain (P<0.001). The cosmetic scores were comparable between the two groups (P=0.369).

Conclusions

The novel subxiphoid and subcostal arch approach is technically feasible and safe. It is an acceptable alternative to conventional thoracoscopic extended thymectomy.

Minimally invasive thoracic surgery in pediatric patients: the Taiwan experience

Minimally invasive technology or laparoscopic surgery underwent a major breakthrough over the past two decades. The first experience of thoracoscopy in children was reported around 1980 for diagnosis of intrathoracic pathology and neoplasia. Up until the middle of the 1990s, the surgical community in Taiwan was still not well prepared to accept the coming era of minimally invasive surgery. In the beginning, laparoscopy was performed in only a few specialties and only relatively short or simple surgeries were considered. But now, the Taiwan's experiences over the several different clinical scenarios were dramatically increased. Therefore, we elaborated on the experience about pectus excavatum: Nuss procedure, primary spontaneous hemopneumothorax, thoracoscopic thymectomy, and empyema in Taiwan.