Subxiphoid versus intercostal video-assisted thoracic surgery for lung resection: a meta-analysis

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.

Surgical removal of bilateral lung metastases from Wilms tumor via subxiphoid approach video-assisted thoracic surgery: a case report

BACKGROUND

Lung is the most common site of metastasis in pediatric patients with Wilms tumor (WT). For such patients, neoadjuvant chemotherapy before nephrectomy is recommended now. A considerable proportion of metastases will shrink in size after the chemotherapy. However, there are still some of them that are not sensitive to chemotherapy and require subsequent surgical resection. For pediatric patients with bilateral lung metastases from WT which are not sensitive to chemotherapy, the simultaneous surgical removal of bilateral lung tumors via one-stage surgery is problematic. These children typically require 2 separate surgeries to remove the bilateral lung metastases and improve their 5-year event-free survival (EFS) rate. There is no precedent in pediatric thoracic surgery for one-stage, bilateral, lung wedge resection via subxiphoid approach video-assisted thoracic surgery (SA-VATS).

CASE DESCRIPTION

In this article, we report on a successful SA-VATS performed on an 8-year-old boy whereby all of the bilateral lung metastases were completely resected. The operation was performed through 3 incisions under the xiphoid process and costal arch. No complications occurred after surgery. The patient's intraoperative blood loss was approximately 20 mL. Drainage tubes were indwelled in both pleural cavities which were removed on post-operative day (POD) 5 and POD 6. There was no recurrence at follow-up of about 4 months.

CONCLUSIONS

This case presents a new option for thoracoscopic surgery which is safe and less invasive for patients with bilateral lung metastases from WT. Similar patients may benefit from the shorter time frame between the operation and other postoperative treatment.

Modified subxiphoid approach for surgical resection of a retrosternal goiter

Backgrounds

Unilateral Video-Assisted Thorascopic Surgery (VATS) is a traditional minimally invasive transthoracic approach for the surgical resection of a subxiphoid goiter. Recently, the subxiphoid approach was recommended for an anterior mediastinal mass. This study aims to investigate the feasibility and efficacy of a modified subxiphoid VATS for the resection of a retrosternal goiter as an alternative transthoracic approach.

Methods

We retrospectively collected all patients who underwent subxiphoid VATS for the resection of a retrosternal goiter from June 2017 to June 2021 in the Zhongshan Hospital or the Zhongshan Hospital Xiamen branch. Ten patients were found. Patient characteristics, perioperative data, and surgical information were collected and further analyzed.

Results

In our study, all 10 patients underwent a thoracoscopic subxiphoid resection of a retrosternal goiter. The mean age was 49.4 years, and all were female. The majority of patients (70%) were asymptomatic. All patients were assessed by CT imaging before surgery. The mean postoperative hospital stay was 4.9 days. The drainage tube was removed 3 days after operation, and the average drainage volume was 73.1 ml. Postoperative pain was mild, with an average pain grade of 2.4 (measured on a scale from 0 to 10, with lower scores indicating less pain). There were no conversions or perioperative complications in these 10 patients.

Conclusions

Most retrosternal goiters can be completely resected through the modified subxiphoid approach after an adequate preoperative evaluation and careful intraoperative management. This thoracoscopic subxiphoid approach is feasible and safe for retrosternal goiter resection.