The Outcomes of Subxiphoid Thoracoscopic Versus Video-Assisted Thoracic Surgery for Thymic Diseases

Subxiphoid versus lateral intercostal thoracoscopic thymectomy for suspected thymoma: Results of a randomized controlled trial

OBJECTIVE

This trial was to evaluate the efficacy of subxiphoid approach thoracoscopic thymectomy for postoperative pain control and length of hospital stay compared with a lateral intercostal approach thoracoscopic thymectomy.

METHODS

This multicenter, open-label, randomized clinical superiority trial enrolled 101 eligible participants clinically diagnosed with Masaoka-Koga I-II thymoma between August 15, 2021, and February 15, 2022. Each enrolled participant was randomized and underwent subxiphoid approach thoracoscopic thymectomy or lateral intercostal approach thoracoscopic thymectomy. A per-protocol analysis for each coprimary outcome was performed in addition to the main intention-to-treat analysis.

RESULTS

In the analysis for the coprimary outcomes, the pain Visual Analog Scale score area under the curve at 0 to 7 days was lower in the subxiphoid approach thoracoscopic thymectomy group than in the lateral intercostal approach thoracoscopic thymectomy group (difference, -4.82; 98.3% CI, -8.84 to -0.80). However, there was no significant difference between the 2 groups in the length of hospital stay (difference, 0.318; 98.3% CI, -0.190 to 0.825) or cumulative opioid consumption after surgery (difference, -4.630; 98.3% CI, -9.530 to 0.272). All patients underwent complete resection, and there was no significant difference (7.84% vs 8.00%, P = 1.000) in the rate of complications between the 2 groups. No recurrence or death occurred in the postoperative 6 months.

CONCLUSIONS

This study found improved pain and similar length of hospital stay associated with the subxiphoid approach compared with the lateral intercostal approach in patients with suspected Masaoka-Koga I-II thymoma.

Thymoma and Thymic Carcinoma: Surgical Resection and Multidisciplinary Treatment

Thymoma and thymic carcinoma are the most common tumors of the anterior mediastinum and a relatively rare type of thoracic cancer. The prerequisite for surgery is clinical staging and operative evaluation, both of which are based on medical imaging. The best strategy for treating a thymic epithelial tumor is surgical resection of the organ and surrounding tissue. Thymectomy modalities vary, including open surgery and minimally invasive surgery, and surgeons have used various innovations to better meet the needs of the procedure; therefore, it is critical to select the appropriate procedure based on the patient's characteristics. Evaluation of resectability is the first step of surgical resection for thymic tumors without distant metastasis. The decision regarding unresectability should be made carefully. During subsequent chemotherapy or chemoradiotherapy, reevaluation of whether an area is resectable or not remains essential. Despite numerous technological advances in the surgical treatment of thymic tumors, several contentious issues remain, including the selection of surgical approaches for difficult cases, the selection of video-assisted thoracoscopic approaches, the evaluation of resectability, minimally invasive surgery for locally advanced thymic tumors, lymphadenectomy in thymic tumors, neoadjuvant therapy for thymic tumors, debulking surgery, and salvage surgery. In solving these problems, the surgeon's judgment, surgical experience, and surgical skills are especially important.

Minimally Invasive Central Cannulation for Extracorporeal Life Support: The Uniportal and Subxiphoid Approach

OBJECTIVE

Extracorporeal life support (ECLS) for circulatory and/or respiratory failure is improving. Currently, invasive sternotomies or rib-spreading thoracotomies are used for central cannulation of the heart and great vessels. Although peripheral cannulation of the extremities is often used, this approach may result in immobility and unintentional dislodgement. Less invasive methods for central cannulation are needed to achieve long-term ECLS. The objective of this study was to develop 2 different minimally invasive approaches for central thoracic cannulation.

METHODS

Porcine hearts were positioned in a plastic thoracic model. An endoscopic camera and multiple endoscopic instruments were used. Both access points, uniportal (lateral) and subxiphoidal, were simulatively investigated. A novel cannulation method using purse string sutures, a custom-made endoscopic puncture tool, guidewires, and dilator-assisted cannulas was developed. Simulations were tested in a closed circuit regarding leak tightness.

RESULTS

The uniportal approach allowed a cannulation of the aorta, inferior vena cava, right atrium, and main pulmonary artery. Cannulation of the right branches of the pulmonary artery and vein was also possible. From the subxiphoid approach, cannulation of the aorta, main pulmonary artery, and both atria were possible. Subsequent evaluation and leakage tests revealed no damage to the surrounding structures and tightly sealed cannulation sites. The uniportal approach was also successfully performed in a human cadaver to connect the aorta and right atrium with cannulas from the subxiphoidal space.

CONCLUSIONS

Both uniportal and subxiphoid central cannulation of potential sites for ECLS were feasible. This study encourages further investigation and potential clinical translation of minimally invasive central organ support.

Subxiphoid-subcostal versus transthoracic thoracoscopic thymectomy: A safe and feasible approach

Objective

Subxiphoid-subcostal thoracoscopic thymectomy (ST) is an emerging alternative to transthoracic thoracoscopic thymectomy. Potential advantages of ST are the avoidance of intercostal incisions and visualization of both phrenic nerves in their entirety. We describe our experience with ST and compare our results to our previous experience with transthoracic thoracoscopic thymectomy.

Methods

We conducted an institutional review board-exempt retrospective review of all patients who had a minimally invasive thymectomy from August 2008 to October 2021. We excluded patients with a previous sternotomy or radiological evidence of invasion into major vasculature. The ST approach involved 1 subxiphoid port for initial access, 2 subcostal ports on each side, and carbon dioxide insufflation. We used descriptive and comparative statistics on demographic, operative, and postoperative data.

Results

We performed ST in 40 patients and transthoracic thoracoscopic thymectomy in 16 patients. The median age was higher in the ST group (58 years vs 34 years; P = .02). Operative data showed no significant differences in operative times, blood loss, or tumor characteristics. In the ST group, we had 2 emergency conversions for bleeding; 1 ministernotomy, and 1 sternotomy. Postoperative data showed that the ST group had fewer days with a chest tube (1 day vs 2.5 days; P = .02). There were no differences in median length of stay, tumor characteristics, final margins, major complication rate, and opioid requirements between the groups. There has been no incidence of diaphragmatic hernia and no phrenic nerve injuries or mortality in either group.

Conclusions

ST is safe and has similar outcomes compared with transthoracic thoracoscopic thymectomy.

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.

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/.

Robotic subxiphoid thymectomy versus lateral thymectomy: A propensity-score-matched comparison

OBJECTIVES

This study aims to compare the surgical outcomes between conventional robotic lateral thymectomy and recently introduced robotic subxiphoid thymectomy for the surgical treatment of anterior mediastinal tumors.

METHODS

Between May 2008 and July 2020, the patients who underwent robotic thymectomy were included in the study. Because robotic subxiphoid thymectomy were more frequently performed in the tumors with advanced stages and located in the upper mediastinum abutting the brachiocephalic vein, we conducted propensity score matching to minimize selection bias.

RESULTS

A total of 389 patients (subxiphoid and lateral thymectomy in 188 and 200 patients, respectively) underwent robotic thymectomy, and 141 matched pairs in each group were included in the analysis. After the matching process, both methods showed comparable demographic features, pathological diagnoses, and pathologic stages. Robotic subxiphoid thymectomy was performed more frequently for mediastinal masses abutting the brachiocephalic vein (p < 0.01). The proportion of simultaneous resection of adjacent structures, including the lung, pericardium, and phrenic nerve, was similar between the two groups; however, the proportion of brachiocephalic vein resection was significantly higher in the robotic subxiphoid thymectomy (p < 0.01). Although both groups showed comparable complication rates (p = 0.80), robotic subxiphoid thymectomy was associated with shorter hospital stays (2.4 (2.4) vs 3.1 (2.4) days; p = 0.03) and a lower pain score in the immediate and early postoperative periods.

CONCLUSIONS

Robotic subxiphoid thymectomy could be performed safely in complex upper mediastinal tumors abutting the brachiocephalic vein and showed better early outcomes with shorter hospital stays and lesser postoperative pain than robotic lateral thymectomy.

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.

[Single-versus Two-port Video-assisted Thoracic Surgery in Thymoma: A Propensity-matched Study]

BACKGROUND

In recent years, with the advancement of minimally invasive techniques, thoracoscopic thymoma resection has experienced a development process from three-port video-assisted thoracic surgery (VATS) to two-port (TP) and single-port (SP) variants. However, the feasibility and safety of SP-VATS have not been generally recognized. This study intends to explore the safety and feasibility of SP-VATS in thymoma resection, in order to provide a reference for clinical surgicalselection.

METHODS

The clinical data of 197 patients who underwent thoracoscopic thymoma resection in Beijing Tongren Hospital from January 2018 to September 2021 were retrospectively analyzed. The patients were divided into SP-VATS group (n=42) and TP-VATS group (n=155). After matching propensity scores, there is no statistically significant difference in preoperative baseline data between SP-VATS group and TP-VATS group. Among them, there were 17 males and 25 females with an average age of 28-72 (48.00±9.43) years in the SP-VATS group, and 20 males and 22 females with an average age of 30-75 (50.38±9.83) years in TP-VATS group. The clinical effects of the two groups were compared.

RESULTS

The operation was successfully completed in both groups, and there was no conversion to thoracotomy or increased surgical incisions. Compared with the TP-VATS group, the chest drainage time and hospital stay in the SP-VATS group were shorter [(2.95±0.76) d vs (3.33±0.85) d; (4.57±0.83) d vs (5.07±1.13) d], and the visual pain score at 24 h and 72 h after surgery were lower [(3.64±0.85) points vs (4.05±0.66) points; (2.33±0.75) points vs (3.07±0.68) points] (P<0.05). There was no statistically significant difference between the two groups in operation time [(130.00±26.23) min vs (135.24±27.03) min], intraoperative blood loss [(69.52±22.73) mL vs (82.38±49.23) mL] (P>0.05).

CONCLUSIONS

SP-VATS in thymoma is a safe, feasible, and less invasive procedure, with less postoperative pain and faster recovery than multi-port VATS.

Robot-assisted thoracic surgery versus video-assisted thoracic surgery for treatment of patients with thymoma: A systematic review and meta-analysis

Background

Surgical resection of the thymus is indicated in the presence of primary thymic diseases such as thymoma. Video‐assisted thoracoscopic surgery (VATS) and robot‐assisted thoracic surgery (RATS) offer a minimally invasive approach to thymectomy. However, there is no clear conclusion whether RATS can achieve an equal or even better surgical effect when compared with VATS in treatment of thymoma. We performed this meta‐analysis to explore and compare the outcomes of RATS versus VATS for thymectomy in patients with thymoma.

Methods

PubMed, Cochrane Library, EMBASE, China National Knowledge Infrastructure (CNKI), Medline, and Web of Science databases were searched for full‐text literature citations. The quality of the articles was evaluated using the Newcastle–Ottawa Scale and the data analyzed using Review Manager 5.3 software. Fixed or random effect models were applied according to heterogeneity. Subgroup analysis was conducted.

Results

A total of 11 studies with 1418 patients, of whom 688 patients were in the RATS group and 730 in the VATS group, were involved in the analysis. Compared with VATS, RATS was associated with less blood loss in operation, lower volume of drainage, fewer postoperative pleural drainage days, shorter postoperative hospital stay, and fewer postoperative complications. There was no significant difference in operative time and patients with or without myasthenia gravis between the two groups.

Conclusions

RATS has more advantages over VATS, indicating that RATS is better than VATS in terms of postoperative recovery. We look forward to more large‐sample, high‐quality randomized controlled studies published in the future.

A novel method of subxiphoid video-assisted thoracic surgery for thymectomy

Background

With advances in thoracoscopic surgical instruments and techniques, subxiphoid video-assisted thoracic surgery (S-VATS) has become the main approach for anterior mediastinal tumor resection under thoracoscopy. However, the drawbacks of S-VATS, including it being a relatively unfixed surgical procedure, make it complicated and difficult for unexperienced surgeons to master.

Methods

This study retrospectively reviewed and analyzed consecutive patients with anterior mediastinal tumor or myasthenia gravis (MG) who underwent S-VATS at the Fujian Medical University Union Hospital, China, between March 2015 and April 2019.Patients were divided into the conventional group and the “four-zone one-way” group. Intraoperative and postoperative variables were compared between the groups. Cumulative sum (CUSUM) analysis was applied to determine the operation time (OT)-learning curve of the S-VATS “four-zone one-way” method.

Results

A total of 82 patients were included in this analysis, of which, 40 patients underwent the conventional method of S-VATS and 42 patients underwent the “four-zone one-way” method. Patients in the “four-zone one-way” group had significantly shorter OT (138.50±29.43 and 118.00±28.18 minutes, respectively; P=0.002) and significantly less blood loss (36.00±20.16 and 23.92±14.96 mL, respectively; P=0.003) compared with patients in the conventional group. Our data indicated that there was no difference of the efficacy of MG treatment between the 2 groups. The difference in the preoperative and postoperative quantitative MG scoring system score (QMG-score) and the dose reduction of cholinesterase inhibitors was comparable between patients in the 2 groups. According to the CUSUM analysis curve, after a steady improvement over phase I (cases 1–12 for the traditional method and cases 1–5 for the “four-zone one-way” method), the surgical procedure could be mastered. Phase III occurred after case 26 in the traditional group and case 28 in the “four-zone one-way” group, and is characterized by rapid improvements.

Conclusions

Compared with the conventional method of S-VATS, the “four-zone one-way” method significantly decreased OT and estimated blood loss. These results demonstrated the feasibility and safety of the “four-zone one-way” method of S-VATS.

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.