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Subxiphoid and subcostal arch versus unilateral video-assisted thoracic surgery approaches to thymectomy for myasthenia gravis. Surg Today 2023; 53:12-21. [PMID: 35776206 DOI: 10.1007/s00595-022-02533-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 04/24/2022] [Indexed: 01/11/2023]
Abstract
PURPOSE Thymectomy is an important treatment for myasthenia gravis (MG). We conducted this study to compare the clinical outcomes of the recently introduced subxiphoid and subcostal arch thymectomy (SASAT) approach with those of the standard unilateral video-assisted thoracoscopic surgery (VATS). METHODS We analyzed, retrospectively, the perioperative, and long-term outcomes of 179 consecutive MG patients (age 18-65 years), who underwent SASAT or unilateral VATS-extended thymectomy between July, 2012 and May, 2019. RESULTS All demographic and clinical characteristics were comparable in the two groups. The median surgical time, estimated blood loss, thoracotomy conversion rate, total and chest drainage, and complications did not differ significantly between the groups. The visual analog scale (VAS) score was significantly lower in the SASAT group. Complete stable remission (CSR) was achieved in a significantly larger proportion of the SASAT group patients and was significantly higher in women than in men. The Quantitative MG score was significantly lower in the SASAT group. Patients in the MG Foundation of America Clinical Classification groups I and II achieved better remission rates than those in groups III-V. CONCLUSIONS SASAT is a safe and feasible MG treatment, which may yield better outcomes than unilateral VATS and improve the quality of treatment.
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Lin J, Lin N, Li X, Lai F. Transareolar uniportal thoracoscopic extended thymectomy for patients with myasthenia gravis. Front Surg 2022; 9:914677. [PMID: 36303858 PMCID: PMC9592845 DOI: 10.3389/fsurg.2022.914677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 09/20/2022] [Indexed: 11/07/2022] Open
Abstract
Background Transareolar uniportal thoracoscopic extended thymectomy (TUTET) has not been previously reported. We attempted to assess the feasibility and safety of TUTET for male myasthenia gravis (MG) patients. Patients and methods From February 2013 to February 2020, 46 men with MG underwent TUTET. All patients were followed up for 12–84 months postoperatively by clinic visits or telephone/e-mail interviews. Results All surgeries were completed successfully, with an average operation time of 72.6 min. The mean length of transareolar uniportal incision was 3.0 ± 0.4 cm, and the mean postoperative cosmetic score was 3.1 ± 0.5 at discharge. Three months postoperatively, no patients had an apparent surgical scar on the chest wall or complained of postoperative pain. Substantial amelioration of the disease was achieved in a short period, and several benefits were clear. At the 1-year follow-up, all patients showed a good cosmetic effect and high satisfaction. Conclusions TUTET is an effective and safe way for men with MG. The uniportal incision is hidden in the areola with sound cosmetic effects. We believe that TUTET is an acceptable procedure for extended thymectomy.
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Affiliation(s)
- Jianbo Lin
- Department of Thoracic Surgery, Palmar Hyperhidrosis Research Institute, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China,Correspondence: Jianbo Lin Fancai Lai
| | - Nanlong Lin
- Department of Thoracic Surgery, Palmar Hyperhidrosis Research Institute, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Xu Li
- Department of Thoracic Surgery, Palmar Hyperhidrosis Research Institute, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China,Fujian Key Laboratory of Precision Medicine for Cancer, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Fancai Lai
- Department of Thoracic Surgery, Palmar Hyperhidrosis Research Institute, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China,Correspondence: Jianbo Lin Fancai Lai
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Li J, Qi G, Liu Y, Zheng X, Zhang X. Meta-analysis of subxiphoid approach versus lateral approach for thoracoscopic Thymectomy. J Cardiothorac Surg 2020; 15:89. [PMID: 32398115 PMCID: PMC7216611 DOI: 10.1186/s13019-020-01135-w] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Accepted: 05/04/2020] [Indexed: 11/22/2022] Open
Abstract
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.
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Affiliation(s)
- Jiaduo Li
- Center of Treatment of Myasthenia Gravis Hebei Province, First Hospital of Shijiazhuang, Fangbei road No. 9, Shijiazhuang, 050011, Hebei Province, China
| | - Guoyan Qi
- Center of Treatment of Myasthenia Gravis Hebei Province, First Hospital of Shijiazhuang, Fangbei road No. 9, Shijiazhuang, 050011, Hebei Province, China.
| | - Yaling Liu
- Department of Gastroenterology, First Hospital of Shijiazhuang, Shijiazhuang, China
| | - Xuguang Zheng
- Center of Treatment of Myasthenia Gravis Hebei Province, First Hospital of Shijiazhuang, Fangbei road No. 9, Shijiazhuang, 050011, Hebei Province, China
| | - Xiaohe Zhang
- Center of Treatment of Myasthenia Gravis Hebei Province, First Hospital of Shijiazhuang, Fangbei road No. 9, Shijiazhuang, 050011, Hebei Province, China
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Qiu Z, Chen L, Lin Q, Wu H, Sun H, Zhou X, Hu Y, Peng L, Liu Y, Xu Q. Perioperative outcomes and mid-term effects in performing video-assisted thoracoscopic extended thymectomy for myasthenia gravis: subxiphoid versus right thoracic approaches. J Thorac Dis 2020; 12:1529-1539. [PMID: 32395290 PMCID: PMC7212138 DOI: 10.21037/jtd.2020.03.43] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Background Approaches of thoracoscopic thymectomy for myasthenia gravis (MG) are debatable. The subxiphoid approach is widely utilized recent years for its better visualization of the anterior mediastinum. In the present study, we compared perioperative outcomes and mid-term effects of the extended thymectomy for MG between the subxiphoid approach and the routine right-thoracic approach. Methods One hundred and thirty-one MG patients treated with thoracoscopic extended thymectomy were analyzed. Among them, 68 patients were operated on via the subxiphoid approach and the other 63 via the conventional right-side unilateral approach. The patient outcomes were retrospectively reviewed and evaluated. Mid-term clinical outcome was assessed according to the classification system proposed by the Myasthenia Gravis Foundation of America (MGFA). Clinical efficacy and variables influencing outcome were evaluated by the Kaplan-Meier method and Cox proportional hazards regression analysis. Results Compared with the right thoracic approach, the duration of the procedure via the subxiphoid approach was significantly shorter (P=0.035), the rates of total thymectomy were higher (P=0.028), and the pain scores on postoperative days 1, 3, and 7 were significantly lower (P<0.001, P<0.001, and P=0.03, respectively). A total of 112 patients with MG were followed up. The subxiphoid approach group reported higher rates of complete stable remission (CSR) and effective treatment of MG, although these differences were not statistically significant (Z=−0.484, P=0.627). By multivariate Cox proportional hazards modes analysis, the chance of CSR was significantly increased when age <40 (OR: 2.623, 95% CI: 1.150–5.983, P=0.022), non-thymomatous MG (OR: 1.078, 95% CI: 1.101–3.316, P=0.021) and MGFA clinical classification (OR: 2.024, 95%:1.164–3.523, P=0.013). Conclusions The subxiphoid approach has shorter operation time, higher rates of total thymectomy and better quality of life compared with the lateral thoracoscopic approach. Preoperative age, pathological diagnoses and MGFA Clinical Classification are the independent risk factors for non-complete stable remission (NCSR) after thymectomy.
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Affiliation(s)
- Zhihong Qiu
- Department of Cardiothoracic Surgery, Jiangxi Provincial People's Hospital Affiliated to Nanchang University, Nanchang 330006, China
| | - Liru Chen
- Department of Cardiothoracic Surgery, Jiangxi Provincial People's Hospital Affiliated to Nanchang University, Nanchang 330006, China
| | - Qin Lin
- Department of Cardiothoracic Surgery, Jiangxi Provincial People's Hospital Affiliated to Nanchang University, Nanchang 330006, China
| | - Hao Wu
- Department of Cardiothoracic Surgery, Jiangxi Provincial People's Hospital Affiliated to Nanchang University, Nanchang 330006, China
| | - Huangtao Sun
- Department of Cardiothoracic Surgery, Jiangxi Provincial People's Hospital Affiliated to Nanchang University, Nanchang 330006, China
| | - Xin Zhou
- Department of Cardiothoracic Surgery, Jiangxi Provincial People's Hospital Affiliated to Nanchang University, Nanchang 330006, China
| | - Yeji Hu
- Department of Cardiothoracic Surgery, Jiangxi Provincial People's Hospital Affiliated to Nanchang University, Nanchang 330006, China
| | - Lei Peng
- Department of Cardiothoracic Surgery, Jiangxi Provincial People's Hospital Affiliated to Nanchang University, Nanchang 330006, China
| | - Yangchun Liu
- Department of Cardiothoracic Surgery, Jiangxi Provincial People's Hospital Affiliated to Nanchang University, Nanchang 330006, China
| | - Quan Xu
- Department of Cardiothoracic Surgery, Jiangxi Provincial People's Hospital Affiliated to Nanchang University, Nanchang 330006, China
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Chiu CH, Chao YK, Liu YH. Subxiphoid approach for video-assisted thoracoscopic surgery: an update. J Thorac Dis 2018; 10:S1662-S1665. [PMID: 30034832 DOI: 10.21037/jtd.2018.04.01] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
The transthoracic video-assisted thoracoscopic surgery (VATS) is considered as standard operation for various thoracic diseases. With the development of single-incision VATS, the thoracic surgery becomes less traumatic. However, chronic chest wound pain still an issue despite the less invasive approach. Therefore, subxiphoid VATS was proposed to overcome this problem. In this article, we review current applications, pros and cons, and potential developments of VATS through subxiphoid approach.
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Affiliation(s)
- Chien-Hung Chiu
- Division of Thoracic Surgery, Chang Gung Memorial Hospital-Linko, Chang Gung University, Taoyuan
| | - Yin-Kai Chao
- Division of Thoracic Surgery, Chang Gung Memorial Hospital-Linko, Chang Gung University, Taoyuan
| | - Yun-Hen Liu
- Division of Thoracic Surgery, Chang Gung Memorial Hospital-Linko, Chang Gung University, Taoyuan
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Mineo TC, Ambrogi V. A glance at the history of uniportal video-assisted thoracic surgery. J Vis Surg 2017; 3:157. [PMID: 29302433 DOI: 10.21037/jovs.2017.10.11] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Accepted: 04/03/2017] [Indexed: 01/26/2023]
Abstract
In the history of thoracic surgery, the advent of video-assisted thoracic surgery (VATS) had on effect equivalent to that provoked by a true revolution. VATS successfully allowed minor, major and complex procedures for various lung and mediastinal pathologies with small incision instead of the traditional accesses. These small incisions abolished ugly scars, generated less acute and chronic pain, reduced hospital stay and costs, allowed faster return to normal day life activities. Conventional VATS was initially performed through 3-4 ports and rapidly evolved to uniportal or single portal access [uniportal video-assisted thoracic surgery (uniVATS)]. First uniportal procedures were published in 2000. In 2010, uniportal technique for lobectomy was described. Focused experimental courses, live surgery events, the internet media favored the rapid diffusion of this technique over the world. Major and complex uniVATS lung resections involving segmentectomy, pneumonectomy, bronchoplasty and vascular reconstruction, redo VATS, en bloc chest wall resections have been accomplished with satisfactory outcomes. Interestingly, different uniportal approaches and techniques are emerging from a number of VATS centers particularly experienced in the mini-invasive thoracic surgery. As confidence grew, in 2014, the first uniVATS left upper lobectomy via the subxiphoid approach was reported. This novel technique is quite challenging but appropriate patient selection as well as availability of dedicated instruments allowed to perform procedures safely. The diffusion of uniVATS paralleled with the development of nonintubated awake anesthesia technique. In 2007 the first nonintubated lobectomy was described. In 2014 the first single port VATS lobectomy in a nonintubated patient with lung cancer of the right middle lobe was accomplished. The nonintubated uniVATS represents an intriguing technique, so that very experienced thoracoscopic surgeons may enroll to surgery elderly and high risk patients. Decreased postoperative pain and hospitalization, faster access to the radio-chemotherapy and diminished inflammatory response are important benefits of the modern approach to the thoracic pathologies. The history of uniVATS documented a constant and irresistible progress. This technique may further provide unthinkable surprises in next future.
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Affiliation(s)
- Tommaso Claudio Mineo
- Department of Surgery and Experimental Medicine, Official Group of Awake Thoracic Surgery Research, Policlinico Tor Vergata University, Rome, Italy
| | - Vincenzo Ambrogi
- Department of Surgery and Experimental Medicine, Official Group of Awake Thoracic Surgery Research, Policlinico Tor Vergata University, Rome, Italy.,Thoracic Surgery, Official Group of Awake Thoracic Surgery Research, Policlinico Tor Vergata University, Rome, Italy
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