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

Advantages of robot-assisted resection of large mediastinal tumors: a single-center preliminary study

Current study aims to assess the safety and efficacy of robot-assisted thoracoscopic surgery (RATS) for sizable mediastinal masses with a minimum diameter ≥6 cm, compared with video-assisted thoracoscopic surgery (VATS) and open surgery. This study enrolled 130 patients with mediastinal tumors with no less than 6 cm diameter in Zhongnan Hospital, Wuhan University, including 33 patients who underwent RATS, 52 patients who underwent VATS and 45 patients who underwent open surgery. After classifying based on mass size and whether it has invaded or not, we compared their clinical characteristics and perioperative outcomes. There was no significant difference in age, gender, mass size, myasthenia gravis, mass location, pathological types (p > 0.05) in three groups. Patients undergoing open surgery typically presenting at a more advanced stage (p < 0.05). No obvious difference was discovered in the average postoperative length of stay, operation duration, chest tube duration and average postoperative day 1 drainage output between RATS group and VATS group (p > 0.05), while intraoperative blood loss in RATS group was significantly lower than VATS group (p = 0.046). Moreover, the postoperative length of stay, operation duration, chest tube duration and intraoperative blood loss in RATS group were significantly lower than open surgery group (p < 0.001). RATS is a secure and efficient approach for removing large mediastinal masses at early postoperative period. In comparison with VATS, RATS is associated with lower intraoperative blood loss. Compared with open surgery, RATS is also associated with shorter postoperative length of stay, operation duration, chest tube duration and intraoperative blood loss.

Ergonomic Assessment of Robotic versus Thoracoscopic Thymectomy

Introduction: Robotic and thoracoscopic surgery are being increasingly adopted as minimally invasive alternatives to open sternotomy for complete thymectomy. The superior maneuverability range and three-dimensional magnified vision are potential ergonomical advantages of robotic surgery. To compare the ergonomic characteristics of robotic versus thoracoscopic thymectomy, a previously developed scoring system based on impartial findings was employed. The relationship between ergonomic scores and perioperative endpoints was also analyzed. Methods: Perioperative data of patients undergoing robotic or thoracoscopic complete thymectomy between January 2014 and December 2022 at three institutions were retrospectively retrieved. Surgical procedures were divided into four standardized surgical steps: lower-horns, upper-horns, thymic veins and peri-thymic fat dissection. Three ergonomic domains including maneuverability, exposure and instrumentation were scored as excellent(score-3), satisfactory(score-2) and unsatisfactory(score-1) by three independent reviewers. Propensity score matching (2:1) was performed, including anterior mediastinal tumors only. The primary endpoint was the total maneuverability score. Secondary endpoints included the other ergonomic domain scores, intraoperative adverse events, conversion to sternotomy, operative time, post-operative complications and residual disease. Results: A total of 68 robotic and 34 thoracoscopic thymectomies were included after propensity score matching. The robotic group had a higher total maneuverability score (p = 0.039), particularly in the peri-thymic fat dissection (p = 0.003) and peri-thymic fat exposure score (p = 0.027). Moreover, the robotic group had lower intraoperative adverse events (p = 0.02). No differences were found in residual disease. Conclusions: Robotic thymectomy has shown better ergonomic maneuverability compared to thoracoscopy, leading to fewer intraoperative adverse events and comparable early oncological results.

Outcomes of robot-assisted versus video-assisted mediastinal mass resection during the initial learning curve

To compare the learning curve of mediastinal mass resection between robot-assisted surgery and thoracoscopic surgery. Retrospective perioperative data were collected from 160 mediastinal mass resection cases. Data included 80 initial consecutive video-assisted thoracoscopic surgery (VATS) resection cases performed from February 2018 to February 2020 and 80 initial consecutive robotic-assisted thoracic surgery (RATS) resection cases performed from March 2020 to March 2023. All cases were operated on by a thoracic surgeon. The clinical characteristics and perioperative outcomes of the two groups were compared. The operation time in both the RATS group and VATS group was analyzed using the cumulative sum (CUSUM) method. Based on this method, the learning curves of both groups were divided into a learning period and mastery period. The VATS group and the RATS group crossed the inflection point in the 27th and 21st case, respectively. Subsequently, we found that the learning period was longer than the mastery period with statistically significant differences in terms of the operating time, and postoperative hospital stay in the VATS group and the RATS group. A certain amount of VATS experience can shorten the learning curve for RATS.

Clinical study of thoracoscopic assisted different surgical approaches for early thymoma: a meta-analysis

OBJECTIVE

The efficacy and safety of subxiphoid thoracoscopic thymectomy (SVATS) for early thymoma are unknown. The purposes of this meta-analysis were to evaluate the effectiveness and safety of SVATS for early thymoma, to compare it with unilateral intercostal approach video thoracoscopic surgery (IVATS) thymectomy, and to investigate the clinical efficacy of modified subxiphoid thoracoscopic thymectomy (MSVATS) for early anterior mediastinal thymoma.

METHODS

Original articles describing subxiphoid and unilateral intercostal approaches for thoracoscopic thymectomy to treat early thymoma published up to March 2023 were searched from PubMed, Embase, and the Cochrane Library. Standardized mean differences (SMDs) and 95% confidence intervals (CIs) were calculated and analyzed for heterogeneity. Clinical data were retrospectively collected from all Masaoka stage I and II thymoma patients who underwent modified subxiphoid and unilateral intercostal approach thoracoscopic thymectomies between September 2020 and March 2023. The operative time, intraoperative bleeding, postoperative drainage, extubation time, postoperative hospital stay, postoperative visual analog pain score (VAS), and postoperative complications were compared, and the clinical advantages of the modified subxiphoid approach for early-stage anterior mediastinal thymoma were analyzed.

RESULTS

A total of 1607 cases were included in the seven studies in this paper. Of these, 591 cases underwent SVATS thymectomies, and 1016 cases underwent IVATS thymectomies. SVATS thymectomy was compared with IVATS thymectomy in terms of age (SMD = - 0.09, 95% CI: -0.20 to - 0.03, I2 = 20%, p = 0.13), body mass index (BMI; SMD = - 0.10, 95% CI: -0.21 to - 0.01, I2 = 0%, p = 0.08), thymoma size (SMD = - 0.01, 95% CI: -0.01, I2 = 0%, p = 0.08), operative time (SMD = - 0.70, 95% CI: -1.43-0.03, I2 = 97%, p = 0.06), intraoperative bleeding (SMD = - 0.30. 95% CI: -0.66-0.06, I2 = 89%, p = 0.10), time to extubation (SMD = - 0.34, 95%CI: -0.73-0.05, I2 = 91%, p = 0.09), postoperative hospital stay (SMD = - 0.40, 95% CI: -0.93-0.12, I2 = 93%, p = 0.13), and postoperative complications (odds ratio [OR] = 0.94, 95% CI: 0.42-2.12, I2 = 57%, p = 0.88), which were not statistically significantly different between the SVATS and IVATS groups. However, the postoperative drainage in the SVATS group was less than that in the IVATS group (SMD = - 0.43, 95%CI: -0.84 to - 0.02, I2 = 88%, p = 0.04), and the difference was statistically significant. More importantly, the postoperative VAS was lower in the SVATS group on days 1 (SMD = - 1.73, 95%CI: -2.27 to - 1.19, I2 = 93%, p < 0.00001), 3 (SMD = - 1.88, 95%CI: -2.84 to - 0.81, I2 = 97%, p = 0.0005), and 7 (SMD = - 1.18, 95%CI: -2.28 to - 0.08, I2 = 97%, p = 0.04) than in the IVATS group, and these differences were statistically significant. A total of 117 patients undergoing thoracoscopic thymectomy for early thymoma in the Department of Thoracic Surgery of the Second Hospital of Jilin University were retrospectively collected and included in the analysis, for which a modified subxiphoid approach was used in 42 cases and a unilateral intercostal approach was used in 75 cases. The differences between the two groups (MSVATS vs. IVATS) in general clinical characteristics such as age, sex, tumor diameter, Masaoka stage, Word Health Organization (WHO) stage, and intraoperative and postoperative conditions, including operative time, postoperative drainage, extubation time, postoperative hospital stay, and postoperative complication rates, were not statistically significant (p > 0.05), while BMI, intraoperative bleeding, and VAS on postoperative days 1, 3, and 7 were all statistically significant (p < 0.05) in the MSVATS group compared with the IVATS group.

CONCLUSION

The meta-analysis showed that the conventional subxiphoid approach was superior in terms of postoperative drainage and postoperative VAS pain scores compared with the unilateral intercostal approach. Moreover, the modified subxiphoid approach had significant advantages in intraoperative bleeding and postoperative VAS pain scores compared with the unilateral intercostal approach. These results indicate that MSVATS can provide more convenient operation conditions, a better pleural cavity view, and a more complete thymectomy in the treatment of early thymoma, indicating that is a safe and feasible minimally invasive surgical method.

Effect of ultrasound-guided thoracic paravertebral block on perioperative analgesia in elderly patients undergoing video-assisted thoracic lobectomy in China: An interventional clinical randomized controlled trial

BACKGROUND

The aim of this study was to investigate the analgesic effect and safety of ultrasound-guided thoracic paravertebral block (UG-TPVB) in Chinese elderly patients undergoing video-assisted thoracic lobectomy (VATL) and to study the influence of aging factors on these effects.

METHODS

This study was a single-center, single-blind, prospective, randomized, controlled trial. A total of 300 patients scheduled for VATL were recruited and randomly divided into the UG-TPVB group (T group) and conventional anesthesia group (C group) according to the recruitment order, and subgroups were set up according to whether the age was ≥65 years old or not. The postoperative 12, 24, and 48 h static/dynamic visual analog scale (VAS) scores, intraoperative fentanyl consumption, postoperative extubation time, post-anesthesia care unit (PACU) stay time, hospitalization days, postoperative complications, and other indicators were compared between the two groups.

RESULTS

The postoperative 12, 24, and 48 h static/dynamic VAS scores of the T group were significantly lower than those of the C group. The intraoperative fentanyl consumption, postoperative extubation time, PACU stay time, and postoperative hospitalization days were significantly lower than those of the C group. The incidence of postoperative 48 h urinary retention in the T group was significantly lower than that in the C group. These advantages showed no significant difference or slight difference between elderly patients and nonelderly patients, indicating that UG-TPVB did not influence the analgesic effect and safety of VATL patients by age or age difference.

CONCLUSION

UG-TPVB is an effective and safe perioperative analgesia method for elderly VATL patients. Its application improves the quality of life and prognosis of elderly VATL patients.

A chest tube after robotic thymectomy is unnecessary

Objective

Chest tubes are frequently placed after thymectomy, without data to support this common practice. We report our experience in eliminating them after robotic thymectomy.

Methods

This is a retrospective database review of patients who underwent robotic thymectomy performed by a single surgeon in which intraoperative chest tube insertion was not planned. Patient characteristics and postoperative outcomes are presented.

Results

Between January 2018 and October 2022, 75 patients underwent robotic thymectomy performed by a single surgeon. Of those, 64 (85.3%) underwent a left-sided thoracic approach. The most common indication for resection was a suspicious anterior mediastinal mass. There were no conversions to an open operation. The median operative time was 72 minutes (range, 38-164 minutes), and the median estimated blood loss was 20 cc (range, 10-60 cc). Ten patients (13.3%) went home on the day of surgery, and all others (86.7%) were discharged on postoperative day 1. A chest tube was placed in 1 patient at time of closure because of a persistent air leak after extensive adhesiolysis from a prior thoracotomy; the tube was removed on the day of surgery after resolution of the air leak. No other patient required chest tube placement intraoperatively, immediately postoperatively, or within 60 days postoperation. Two patients underwent outpatient thoracentesis within 1 month postoperation for effusions. There were no 30- or 90-day mortality and no major morbidities.

Conclusions

A chest tube after robotic thymectomy is not necessary in almost all patients and can be safely omitted. The dogmatic routine practice of chest tube placement should be questioned.

Robot versus video-assisted thoracoscopic thymectomy for large thymic epithelial tumors: a propensity-matched analysis

BACKGROUND

Both video-assisted thoracoscopic surgery (VATS) thymectomy and robot-assisted thoracoscopic surgery (RATS) thymectomy have been suggested as technically sound approaches for early-stage thymic epithelial tumors. However, the choice of VATS or RATS thymectomy for large and advanced thymic epithelial tumors remains controversial. In this study, the perioperative outcomes of VATS and RATS thymectomy were compared in patients with large thymic epithelial tumors (size ≥5.0 cm).

METHODS

A total of 113 patients with large thymic epithelial tumors who underwent minimally invasive surgery were included. Sixty-three patients underwent RATS, and 50 patients underwent VATS. Patient characteristics and perioperative variables were compared.

RESULTS

Compared with the VATS group, the RATS group experienced a shorter operation time (median: 110 min vs.130 min; P < 0.001) and less blood loss (30.00 ml vs. 100.00 ml, P < 0.001). No patients in the RATS group needed conversion to open surgery, but in the VATS series, five patients required conversion to open procedures (0% vs. 14.29%, P = 0.054). The rate of concomitant resection in the RATS group was similar to that in the VATS group (11.43% vs. 5.71%; P = 0.673). There was no significant difference between the two groups in the duration of chest tube (P = 0.587), postoperative complications (P = 1.000), and the duration of postoperative hospital stay (P = 0.141).

CONCLUSION

For large thymic epithelial tumors, RATS thymectomy can be performed safely and effectively in a radical fashion. Due to the advanced optics and precise instrument control, concomitant resections can be easily achieved in larger thymic epithelial tumors using the robotic approach.

Early Postoperative Results after Thymectomy for Thymic Cancer: A Single-Institution Experience

BACKGROUND

Surgery for thymic cancers is considered the key of curative treatment. Preoperative patients' characteristics and intraoperative features might influence postoperative outcome. We aim to verify short-term outcomes and possible risk factors for complications after thymectomy.

METHODS

We retrospectively investigated patients undergoing surgery for thymoma or thymic carcinoma in the period between January 1, 2008, and December 31, 2021, in our department. Preoperative features, surgical technique (open, bilateral VATS, RATS), intraoperative characteristics and incidence of postoperative complications (PC) were analyzed.

RESULTS

We included in the study 138 patients. Open surgery was performed in 76 patients (55.1%), in 36 VATS (26.1%) and in 26 RATS (36.1%). Resection of one or more adjacent organs due to neoplastic infiltration was required in 25 patients. PC appeared in 25 patients (52% Clavien-Dindo grade I, 12% grade IVa). Open surgery had a higher incidence of PC (p < 0.001), longer postoperative in-hospital stay (p = 0.045) and larger neoplasm (p = 0.006). PC were significant related to pulmonary resection (p = 0.006), phrenic nerve resection (p = 0.029), resection of more than one organ (p = 0.009) and open surgery (p = 0.001), but only extended surgery of more organs was confirmed as independent prognostic factor for PC (p = 0.0013). Patients with preoperative myasthenia symptoms have a trend toward stage IVa complications (p = 0.065). No differences were observed between outcomes of VATS and RATS.

CONCLUSIONS

Extended resections are related to a higher incidence of PC, while VATS and RATS guarantee a lower incidence of PC and shorter postoperative stay even in patients that require extended resections. Symptomatic myasthenia patients might have a higher risk toward more severe complications.

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.

Rare thoracic cancers: a comprehensive overview of diagnosis and management of small cell lung cancer, malignant pleural mesothelioma and thymic epithelial tumours

Despite the progress in outcomes seen with immunotherapy in various malignancies, including nonsmall cell lung cancer, the benefits are less in small cell lung cancer, malignant pleural mesothelioma and thymic epithelial tumours. New effective treatment options are needed, guided via more in-depth insights into the pathophysiology of these rare malignancies. This review comprehensively presents an overview of the clinical presentation, diagnostic tools, staging systems, pathophysiology and treatment options for these rare thoracic cancers. In addition, opportunities for further improvement of therapies are discussed.

Changes and significance of serum AchR-Ab and CAE-Ab in patients with thymoma after thoracoscopic surgery

To probe into the changes and significance of serum acetylcholine receptor antibody (AchR-Ab) and citric acid extractive antibody (CAE-Ab) in patients with thymoma after thoracoscopic surgery (TS). The data of 50 patients with thymoma receiving TS in our hospital from February 2017 to February 2021 were selected for retrospective analysis. Serological testing was performed before and after surgery to determine serum AchR-Ab and CAE-Ab levels, the therapeutic effect was evaluated and the trend of serum AchR-Ab and CAE-Ab changes and their meanings were analyzed. Among 50 patients with thymoma after TS, 15 (30.0%) were in remission, 25 (50.0%) had improvement and 10 (20.0%) had no response to treatment. After treatment, the serum AchR-Ab and CAE-Ab levels of patients, which were remarkably lower than those before treatment (P < 0.001), were remarkably lower in the remission group than in the improvement group (P < 0.001) and remarkably lower in the improvement group than in the ineffective group (P < 0.001). The ordinal logistic regression analysis concluded that the levels of AchR-Ab and CAE-Ab were related to therapeutic effect, i.e. the lower the serum AchR-Ab and CAE-Ab levels, the better the therapeutic effect. TS can reduce the serum AchR-Ab and CAE-Ab levels in patients with thymoma, and serum AchR-Ab and CAE-Ab levels can reflect the therapeutic effect, providing reference value.

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.

Continuing challenges of primary neuroendocrine tumours of the thymus: A concisereview

Primary neuroendocrine tumours of the thymus (NETTs) are exceedingly rare tumours, usually presenting around mid-life, which have a propensity towards males and smokers. They are seen more often in those with MEN-1, but multiple different genetic mutations have been found to be involved in the tumorigenesis of NETTs. Histologically, NETTs are classified according to number of mitoses, the presence of necrosis, and the presence or absence of small cell features. NETTs display a wide spectrum of behavior, and they can be incidentally found on chest imaging, on screening in MEN-1, or present with symptoms of local compression. Advanced disease and paraneoplastic syndromes are common. CT-, PET/CT-, MRI-scans, and somatostatin receptor scintigraphy are the imaging modalities of choice both for the initial assessment as well as for monitoring after treatment. For patients with localized disease, complete surgical resection with lymphadenectomy provides the best chance of long-term, disease-free survival, and can be achieved through either an open or thoracoscopic approach. While chemotherapy-regimens based on platinum, taxane, and temozolomide are used most often, the optimum chemotherapy regimen in the adjuvant and palliative settings remains unclear, as does the role of radiotherapy. Ongoing research on the most effective use of somatostatin analogues, peptide receptor radionuclide therapy (PPRT), kinase inhibitors and immunotherapy in patients with other types of advanced neuroendocrine tumours may lead to further treatment options for NETTs in the future.

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.

Robotic Mediastinal Tumor Resections: Position and Port Placement

This study aimed to determine the optimal position and port placement during robotic resection for various mediastinal tumors. For anterior mediastinal tumors, total or extended thymectomy is commonly performed in the supine position using the lateral or subxiphoid approach. Although it is unclear which approach is better during robotic thymectomy, technical advantages of subxiphoid approach are beneficial for patients with myasthenia who require extended thymectomy. Partial thymectomy is performed in the supine position using a lateral approach. Superior, middle, and posterior mediastinal tumors are resected in the decubitus position using the lateral approach, whereas dumbbell tumor resection, which requires a posterior approach, can be performed in the prone position. The position and port placement should be chosen depending on the size, location, and aggressiveness of the tumor. In this study, we describe how to choose which of these different robotic approaches can be used based on our experience and previous reports.