Thoracoscopic Thymectomy Using a Subxiphoid Approach for Anterior Mediastinal Tumors

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.

Risk factors for diaphragmatic injury in subxiphoid video-assisted thoracoscopic surgery

BACKGROUND

Subxiphoid video-assisted thoracoscopic surgery (VATS) is considered a safe and feasible operation for anterior mediastinal mass resection. However, diaphragmatic injury, presented as tearing or puncturing, may occur during subxiphoid VATS despite of low incidence. This study aims to explore risk factors for diaphragmatic injury in subxiphoid VATS, as well as strategies to reduce occurrence of the injury.

METHODS

We retrospectively reviewed clinical records of 44 consecutive adult patients who underwent subxiphoid VATS. These patients were divided into two groups: diaphragmatic injury group and non-injury group. Perioperative outcomes and anatomic features derived from 3D CT reconstructions were compared between the two groups.

RESULTS

Significant differences were observed in operation time (223.25 ± 92.57 vs. 136.28 ± 53.05, P = 0.006), xiphoid length (6.47 ± 0.85 vs. 4.79 ± 1.04, P = 0.001) and length of the xiphoid below the attachment point on the diaphragm (24.86 ± 12.02 vs. 14.61 ± 9.25, P = 0.029). Odds ratio for the length of the xiphoid below the attachment point on the diaphragm was 1.09 (1.001-1.186), P = 0.048 by binary logistic regression analysis.

CONCLUSIONS

We identified the length of the xiphoid below the attachment point on the diaphragm as an independent risk factor for diaphragm injury during subxiphoid VATS. Prior to subxiphoid VATS, a 3D chest CT reconstruction is recommended to assess the patients' anatomic variations within the xiphoid process. For patients with longer xiphoid process, a higher incision at the middle and upper part of the xiphoid process, and partial xiphoid process resection or xiphoidectomy is preferred.

A Propensity Score-Matching Analysis: Robotic Thymectomy Through the Subxiphoid Has Advantages Over Video-Assisted Thymectomy Surgery

Objective: The purpose of this article is to evaluate the security and effectiveness of subxiphoid and subcostal robot-assisted thoracoscopic thymectomy (S-RATT) and compare it with subxiphoid and subcostal video-assisted thoracoscopic thymectomy (S-VATT) in terms of short-term perioperative results and costs. Methods: A retrospective study was carried out on 62 individuals who had undergone successful complete thymectomy for anterior mediastinal disease using subxiphoid and subcostal arch approaches. Propensity score-matching analysis was utilized between the two groups, and the perioperative outcomes were compared. Results: The S-RATT group exhibited less intraoperative blood loss (20 ± 15.35 versus 69.55 ± 69.54, P < .001), lower levels of C-reactive protein (112.38 ± 68.08 versus 72.58 ± 42.62, P = .027), and lower postoperative pain scores (2.09 ± 1.54 versus 4.27 ± 1.28, P < .001). However, the hospitalization costs of patients in the S-VATT group were found to be lower than those in the S-RATT group (33,802.41 ± 8785.05 versus 49,977.53 ± 20,221.79, P < .001). Conclusions: S-RATT appears to be a viable and secure method for managing anterior mediastinal tumors.

The Value of Postoperative Radiotherapy in Thymoma Patients with Myasthenia Gravis

INTRODUCTION

Surgery is the first-line treatment for patients with thymoma associated with myasthenia gravis (MG); however, the value of radiotherapy among these patients remains debatable. Herein, we examined the impact of postoperative radiotherapy (PORT) on the efficacy and prognosis of patients with thymoma and MG.

METHODS

This retrospective cohort study included 126 patients with thymoma and MG who were enrolled in the Xiangya Hospital clinical database between 2011 and 2021. Demographic and clinical data were collected including sex, age, histologic subtype, Masaoka-Koga staging, primary tumor, lymph node, metastasis (TNM) staging, and therapeutic modalities. To evaluate short-term MG symptom improvement following PORT, we examined changes in the quantitative myasthenia gravis (QMG) scores within 3 months post-treatment. Minimal manifestation status (MMS) was the main endpoint for assessing long-term improvement in MG symptoms. Overall survival (OS) and disease-free survival (DFS) were primary endpoints to determine the impact of PORT on prognosis.

RESULTS

Effects of PORT on MG symptoms: QMG scores significantly differed between the non-PORT and PORT groups (χ2= 6.300, p = 0.012). The median time to achieve MMS was significantly shorter in the PORT group than that in the non-PORT group (2.0 years vs. 4.4 years; p = 0.031). Multivariate analysis revealed that radiotherapy was associated with a reduced time to achieve MMS (hazard ratio [HR] 1.971, 95% confidence interval [CI]:1.102-3.525, p = 0.022). Effects of PORT on DFS and OS: The 10-year OS rate of the entire cohort was 90.5%, whereas OS rates for the PORT and non-PORT groups were 94.4 and 85.1%, respectively. The 5-year DFS rates for the whole cohort, PORT group, and non-PORT group were 89.7, 95.8, and 81.5%, respectively. PORT was associated with improved DFS (HR 0.139, 95% CI: 0.037-0.533, p = 0.004). In the high-risk histologic subgroup (type B2, B3), patients who received PORT had better OS (p = 0.015) and DFS (p = 0.0053) than those who did not receive PORT. PORT was associated with improved DFS (HR 0.232, 95% CI: 0.069-0.782, p = 0.018) in Masaoka-Koga stages II, III, and IV disease.

CONCLUSIONS

Overall, our findings indicate that PORT positively impacts thymoma patients with MG, particularly those with a higher histologic subtype and Masaoka-Koga staging.

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.

[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.

Thoracoscopy-assisted treatment for mediastinal metastasis of thyroid cancer: a case report

Advanced thyroid cancer with upper mediastinal lymph node metastasis is not rare in the clinical setting. For patients with severe metastasis, a thoracocervical incision is usually performed for dissection of lymph nodes. However, the difficult operation of three-port thoracoscopy to support performance of a cervical incision in the treatment of upper mediastinal lymph node metastasis has rarely been reported to date. We herein describe a case involving the treatment of thyroid cancer with upper mediastinal lymph node metastasis. The lymph node metastasis was severe, closely adhered to the innominate vein, and fused into a mass. Thoracoscopy with a cervical incision was performed and proved to be a highly difficult surgical maneuver. The patient recovered quickly after the operation. Repeat computed tomography showed no swollen metastatic lymph nodes, indicating that the dissection was thorough. Thoracoscopy with a neck incision is more difficult than conventional longitudinal split sternotomy in the treatment of upper mediastinal lymph node metastasis, but its advantages are less severe trauma and faster recovery. This procedure may be performed by surgeons with proficient skill in cervical surgery and thoracoscopy techniques.

Minimally invasive thymectomy for myasthenia gravis: a 7-year retrospective study

BACKGROUND

Thymectomy has been identified as an effective strategy for patients with myasthenia gravis (MG) and thymic masses. However, the best surgical approach remains a matter of debate. The aim of the present study was to compare the surgical and neurological outcomes of video-assisted thoracoscopic thymectomy with a modified subxiphoid and bilateral approach in patients with MG and thymic masses.

METHODS

From August 2013 to April 2018, 68 patients who were diagnosed with MG and thymic masses and underwent video-assisted thoracoscopic thymectomy with a modified subxiphoid (44 patients) or bilateral (24 patients) approach were included in this retrospective study. The surgical and neurological results were analyzed with propensity score matching.

RESULTS

After propensity score matching, the modified subxiphoid approach in video-assisted thoracoscopic thymectomy resulted in an obviously shorter operative time (P=0.00), drainage duration (P=0.00), less intraoperative blood loss (P=0.00), and shorter postoperative hospital stay (P=0.01). In terms of neurological outcomes, no significant difference was observed in the improvement in MG, with 2-year complete stable remission rates of 21.1% and 26.3% (P=0.68) and 2-year pharmacological remission rates of 31.6% and 26.3% (P=0.60) for the bilateral and subxiphoid approaches, respectively. Additionally, the approaches resulted in similar effects on the magnitudes of decrease in the prednisolone and pyridostigmine doses after 2 years, with average pyridostigmine dose reductions of 72.2% and 71.1% (P=0.78) and average prednisolone reductions of 76.8% and 71.7% (P=0.96) for the bilateral and subxiphoid approaches, respectively.

CONCLUSIONS

The modified subxiphoid approach was found to be superior to the bilateral approach in video-assisted thoracic surgery thymectomy in terms of the surgical outcomes and yielded similar neurological outcomes. Therefore, the modified subxiphoid approach is recommended as an alternative to the bilateral approach in the treatment of patients with MG and thymic masses.

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.

Non-intubated video-assisted thoracic surgery for subxiphoid anterior mediastinal tumor resection

Background

Subxiphoid approach for mediastinal tumor resection was reported to provide a better view and less postoperative pain. Non-intubated video-assisted thoracic surgery (NI-VATS) without muscle relaxant would decrease the possibility of postoperative airway collapse for anterior mediastinal mass operation. Herein, we sought to describe the use of NI-VATS through subxiphoid approach for anterior mediastinal tumor resection.

Methods

In this retrospective cohort study, patients that underwent subxiphoid VATS resection for anterior mediastinal tumor between December 2015 and September 2019 were divided into two groups: NI-VATS and intubated VATS (I-VATS). Intraoperative and postoperative variables were compared.

Results

A total of 40 patients were included. Among them, 21 patients received NI-VATS (52.5%) and 19 were treated with I-VATS (47.5%). In total, intraoperative (4/21 vs. 2/19; P=0.446) and postoperative complications (5/21 vs. 7/19; P=0.369) were similar between NI-VATS and I-VATS group. The anesthesia time (231.76 vs. 244.71 min; P=0.218), the operation time (152.35 vs. 143.64 min; P=0.980), chest tube duration (1.81 vs. 1.84 days; P=0.08), the total volume (351.95 vs. 348.00 mL; P=0.223), post-operative pain scores (2.79 vs. 2.93, P=0.413), and the length of stay (9.47 vs. 10.57 days; P=0.970) were all comparable between two groups.

Conclusions

NI-VATS for mediastinal tumor resection via subxiphoid approach is a safe and technically feasible option in selected patients, which leads to comparable perioperative clinical outcomes when compared with I-VATS via the subxiphoid approach. This technique could be used as an alteration when intubation is not available.

Management of bleeding complications during thymectomy by subxiphoid approach with double elevation of the sternum: a case report

Thymoma is the most common tumor of the anterior mediastinum and surgical resection for thymoma has been recommended as the principal treatment. Bleeding control remains as a challenging task under minimally invasive approach. Subxiphoid approach with double elevated of sternum was a novel method which might provide good surgical view and space for operating. In this study we reported a case of bleeding control with this approach after unexpected damage to innominate vein to address the advantage of bleeding control using this specific surgical approach. The case was a 66-year-old female patient with an anterior mediastinal mass incidentally detected during physical examination and was diagnosed with thymoma with a diameter of 5 cm. Injury to the joint of innominate vein and the vena cava occurred during a subxiphoid approach with double elevation of the sternum. It was well managed by controlling the bleeding site with Alice forceps and suture under thoracoscope view without conversion to median sternotomy. A 4-0 PROLENE line was used with an elbow needle holder under the thoracoscope to suture continuously. Intraoperative blood loss was 350 mL. The drainage tubes were removed on postoperative day (POD) 2, and the patient was discharged on POD 3. This case indicated that thymectomy by subxiphoid approach with double elevation of the sternum has more advantages when there is an emergency for bleeding during the operation compared with traditional intercostal approach or subxiphoid approach with carbon dioxide inflation.

Modified Subxiphoid Thoracoscopic Thymectomy for Locally Invasive Thymoma

BACKGROUND

We explored the feasibility and safety of modified subxiphoid thoracoscopic thymectomy for patients with locally invasive thymomas.

METHODS

Subxiphoid thoracoscopic thymectomy was performed on select patients with locally invasive thymomas (Masaoka stage III) using an auxiliary sternal retractor to create a larger operative field.

RESULTS

From June 2015 to March 2019, we performed modified subxiphoid thoracoscopic thymectomy on 48 patients with locally invasive thymomas: 39 patients had pericardium or lung infiltration and received a combination of a partial pericardium or lung wedge resection, and 9 patients had left innominate vein infiltration and underwent combined resection of the left innominate vein. Thoracoscopic thymectomy was performed from the subxiphoid pathway with an auxiliary sternal retractor in all 48 patients, and there were no conversions to median sternotomy. The median tumor size was 5 cm, and the maximal tumor size was 12 cm. The median blood loss was 50 mL. The median duration of chest tube placement was 3 days, and the median hospital stay was 4.5 days after surgery. All patients achieved a good recovery after surgery, and none had serious complications during the perioperative period. All patients underwent postoperative adjuvant radiotherapy and presented no local recurrence or distant metastasis until now.

CONCLUSIONS

Modified subxiphoid thoracoscopic thymectomy with an auxiliary sternal retractor makes minimally invasive thymectomy easier and safer to perform and is an alternative approach for some patients with locally invasive thymomas.

Safety of subxiphoid uniportal video-assisted thoracoscopic surgery for anterior mediastinal tumour in obese patients

Introduction

Subxiphoid uniportal video-assisted thoracoscopic surgery (VATS) has been gradually applied for the treatment of anterior mediastinal tumour (AMT). However, whether obesity is a risk factor for subxiphoid uniportal VATS for AMT is still unknown.

Aim

To explore the safety and short-term outcome of subxiphoid uniportal VATS for AMT in obese patients.

Material and methods

The clinical data of 142 patients who received VATS via subxiphoid approach for AMT were analysed. According to body mass index (BMI), the patients were divided into an obese group (BMI ≥ 28 kg/m²) and a non-obese group (BMI < 28 kg/m²). Then, the clinical and surgical characteristics between the obese group and the non-obese group were analysed to explore the effect of obesity on VATS for AMT. The pain scores were evaluated by the Numeric Rating Scale.

Results

The operative time and tracheal intubation time using subxiphoid uniportal VATS for AMT in the obese group were longer than that in the non-obese group (p < 0.05). However, there was no obvious difference in intraoperative blood loss, chest tube drainage time, chest tube drainage volume, and length of hospital stay between the obese group and the non-obese group (p > 0.05). Moreover, there was also no significant difference in postoperative complications, including pulmonary complications, wound infection, arrhythmia, and pulmonary leak, between the obese group and the non-obese group. In addition, the pain scores in the obese group were similar to those in the non-obese group.

Conclusions

Although obesity might prolong operative time of subxiphoid uniportal VAST for AMT, it does not increase the rate of postoperative complications. An experienced centre can properly conduct VAST via subxiphoid approach when treating AMT in obese patients.

Extended thymectomy with blood vessel resection and reconstruction improves therapeutic outcome for clinical stage III thymic carcinoma patients: a real-world research

OBJECTIVES

We examine the therapeutic efficacy of extended thymectomy with blood vessel resection and reconstruction in thymic carcinoma patients with great vessel invasion.

METHODS

In total 26 patients diagnosed as clinical stage III thymic carcinoma with severe great vessel invasion were enrolled in this retrospective study. Among these patients, 14 cases received adjuvant chemo- and radiotherapy (non-operation subgroup, NOG), the other 12 patients received extended thymectomy with vessel resection and reconstruction followed by the adjuvant treatment (operation subgroup, OG).

RESULTS

All surgical procedures went smoothly with no perioperative death. R0 resection was obtained in all surgical cases, and we also observed a lymph node metastasis rate of 38.8%. The overall survival (OS) was 34 months for the whole cohort, 48 and 26 months for the OG and NOG respectively (p = 0.013). The median disease metastasis free survival (DMFS) was 47 months for the OG and 18 months for the NOG (p = 0.019).

CONCLUSION

Extended thymectomy with vessel resection is feasible for patients with clinical stage III thymic carcinoma. Surgery significantly improves the overall survival and the prognosis of clinical stage III thymic carcinoma.

Management of bleeding complications during thoracoscopic thymectomy

Video-assisted thoracoscopic thymectomy is increasingly performed for thymic disorders. However, intraoperative bleeding, especially from the innominate vein, is often inevitable, and is the major reason for conversion. Successful control under thoracoscopic thymectomy is crucial for the safety of the patient. We hereby report two cases of intraoperative bleeding and strategies for safe and effective bleeding control during the conventional three-port video-assisted thoracoscopic thymectomy. The first case was an 80-year-old male patient diagnosed with cystic thymoma, and injury to a thymic vein below the left innominate vein occurred during a right thoracoscopic thymectomy. It was well managed by endovascular clips under video-assisted thoracoscopic thymectomy. The intraoperative blood loss was 50 mL. The second case was a 73-year-old female patient diagnosed with thymoma. Massive bleeding from the left innominate vein occurred due to inadvertent injury during a left approach thoracoscopic thymectomy. But it was successfully controlled via endoscopic stapler. Intraoperative blood loss was 300 mL and the patient did not receive any blood transfusion. Postoperative courses of both two cases were uneventful. Our experience shows that endoscopic clipping or stapling respectively can provide safe, quick, and effective control of different types of bleedings under video-assisted thoracoscopic thymectomy. This technique is helpful to ensure the safety and success of minimally invasive surgery for thymic diseases.

Inframammary approach for addressing anterior mediastinal tumours: initial experience

Background

Anterior mediastinal tumours account for 50% of all mediastinal masses. Surgical intervention is the standard approach for their diagnosis or treatment. Minimally invasive techniques have gained significant popularity in the last few decades due to the obvious advantages that they offer. We will describe a series composed of the first 20 patients who were submitted to a new minimally invasive video-assisted technique, which uses an inframammary incision approach involving a Thoratrak rib spreader and a Rultract Skyhook retractor.

Methods

A retrospective study was undertaken, involving all the patients in our department who were submitted to a resection of their anterior mediastinal masses by inframammary incision, using a Thoratrak rib spreader, a Rultract Skyhook retractor and video assistance.

Results

A total of 20 patients were included, with a mean age of 52.6. The mean surgery duration was 47 minutes, with an intraoperative blood loss of 70 mL. The mean period of hospitalisation was 2.9 days. No patients underwent conversion to open surgery, and there were no major complications. The mean size of the masses that were excised was 13.9 cm, with a mean weight of 77.3 g. The surgical margins were all free of tumour tissue, and no early recurrence was observed during the postoperative follow-up period.

Conclusions

Video-assisted thoracoscopic surgery (VATS) and robot assisted thoracic surgery (RATS) account for most of the minimally invasive procedures. However, VATS has certain limitations in terms of deep perception and manoeuvrability, and RATS has the disadvantage of lacking tactile and force feedback for the surgeon. The inframammary technique allows for safe direct dissection around the vascular and nervous structures, ensuring a complete observation of the anterior mediastinum and its structures. The findings in the present study suggest that this technique is useful. We had good surgical results, short surgery times and very low blood loss, and all tumours were totally resected, with tumour-free surgical margins. The size and the right lateralisation of the mass did not present any contraindications, and the learning curve and investment were minimal. In conclusion, the inframammary approach could be a safe and useful approach for treating anterior mediastinal pathology.

Thoracoscopic Thymectomy for Large Thymic Cyst: Myasthenia Gravis With Thymoma Concealed by Thymic Cyst

We herein report a case of myasthenia gravis (MG) in which thoracoscopic thymectomy was performed for a large thymic cystic lesion using a subxiphoid approach. We have previously suggested the usefulness of the subxiphoid approach in thymectomy. The indications of thoracoscopic thymectomy were recently expanded to include large thymic cystic lesions without intraoperative rupture of the lesions. The pathologic diagnosis of the lesion in the present case was multilocular thymic cyst with type A thymoma and micronodular thymoma. The postoperative complications were minimal without MG crisis. Thoracoscopic thymectomy using a subxiphoid approach seems to be an ideal procedure, even for large thymic cystic lesions. In addition, early-onset MG with a large thymic cystic lesion may suggest the presence of a small thymoma even if the lesion is not detected on a preoperative radiologic examination.

Subxiphoid thymectomy with a double sternum retractor: a pilot study

Background

Our study aims to describe the experience of a single team in terms of the potential and benefits of subxiphoid thymectomy using a double sternum hook retractor.

Methods

From November 2016 to July 2018, 34 patients have been undergone subxiphoid thymectomy at our Department. Twenty patients were diagnosed with Masaoka Stage I-III thymomas, 12 with thymic hyperplasia or cysts of the thymus, 2 with thymic tumors. All patients underwent a chest computed tomography (CT) with enhancement. 18-Fludeoxyglucose positron emission tomography (¹⁸FDG-PET) was performed when recurrence was suspected. Neurological examinations were set. Patients underwent video-assisted thoracoscopic surgery (VATS) subxiphoid thymectomy with a double sternum retractor. A retrospective analysis of clinical, perioperative data, and follow-up was performed. Incidence rates for death or recurrence were calculated. Average pain score (NRS scale), average mental health, and physical health scores (SF-12) were analyzed.

Results

Thirty-four patients (mean age 54; 12 men and 22 women) with thymic neoformation (from 1.0 cm × 1.0 cm × 1.0 cm to 14.0 cm × 9.0 cm × 4.5 cm) were enrolled. All patients underwent subxiphoid thymectomy. No mortality or recurrence was observed. Median follow-up time was 17.9 months (range, 2.2-23.3 months). The morbidity rate was 9.7 events per 100 person-years. Average pain scores after surgery and after follow-up were 1.7±0.4 and 0.1±0.4, respectively; average mental health and physical health scores on the SF-12 scale were 45.6±2.4 and 33.6±2.4, respectively.

Conclusions

Subxiphoid thymectomy is a high satisfaction approach with positive aesthetic outcomes and low pain. Double sternum retractors are especially useful for creating space during thymectomy. However, the qualified experience is needed.

The safety of thymic vein sealing with ultrasonic energy in video-assisted thoracoscopic surgery thymectomy

Background

The key for conducting thymectomy by thoracoscope is the treatment of thymic veins, as they are the most common source of bleeding. The traditional treatment is to cut off the distal and proximal vessels after Ham-Lock clamping. Our team found that it is safe and reliable to use ultrasonic energy to cut off thymic veins in previous open operations. This study aimed to investigate the feasibility and safety of thymic vein sealing with ultrasonic energy in video-assisted thoracoscopic surgery (VATS) thymectomy.

Methods

A total of 169 patients with or without thymic tumors who underwent thymectomy by thoracoscope were enrolled in the study. Among them, group A, with 89 patients, underwent thoracoscopic thymic vein resection by Ham-Lock, and group B, with 80 patients, did so by ultrasonic energy. The groups were compared in terms of the characteristics of patients, tumors, and perioperative period.

Results

There were no significant differences in patients' characteristics between the two groups (P>0.05). There was no significant difference between the two groups in blood transfusion, operation time, drainage, and hospitalization (P>0.05). There were no deaths, secondary operation and post-operative blood transfusion, and no serious complications leading to prolonged hospitalization. One patient in group A was converted to thoracotomy due to left anonymous venous hemorrhage, and one patient in group B had thymic venous hemorrhage, but the hemorrhage was successfully stopped under thoracoscope.

Conclusions

In VATS thymectomy (with or without thymic tumors), there is no significant difference in the treatment of thymic veins between Ham-Lock clipping and ultrasonic energy in conversion to open surgery in regards to thymic venous hemorrhage, postoperative drainage, blood transfusion, operation time, drainage, and hospital stay. Use of ultrasonic energy is a safe and reliable method for thymic vein disconnection.

Subxiphoid versus lateral intercostal approaches thoracoscopic thymectomy for non-myasthenic early-stage thymoma: A propensity score -matched analysis

BACKGROUND

Thymectomy is increasingly being performed via minimally invasive approaches. The present study aimed to assess the safety and feasibility of the subxiphoid approach to video-assisted thoracic surgery (VATS) compared with the lateral intercostal approach VATS.

METHODS

Patients who underwent VATS thymectomy via subxiphoid and lateral intercostal approaches in our hospital between 2015 and 2018 were retrospectively analyzed. A series of perioperative outcomes, including clinical and surgical results, postoperative pain scores and cosmetic results, was compared in a propensity score matching analysis.

RESULTS

A total of 98 patients diagnosed with non-myasthenic early-stage thymoma underwent complete thymectomy by VATS. Propensity score analysis revealed that 28 patients treated with the subxiphoid approach and 28 patients treated with the lateral intercostal approach had the same baseline characteristics. Compared with those in the lateral intercostal approach group, patients in the subxiphoidapproach group yielded lower pain scores and shorter postoperative hospital stays. Other advantages of the subxiphoid approach included decreased inflammatory cytokine response and superior cosmesis. There were no significant differences in postoperative complications between the two groups. All these patients recovered well when discharged. There were no perioperative deaths.

CONCLUSIONS

Our data suggest that subxiphoid and subcostal arch thoracoscopic radical thymectomy is a less invasive procedure for the treatment of non-myasthenic early-stage thymoma and provides a satisfactory cosmetic effect. Owing to the limitation ofour retrospective study, further prospective studies are needed to evaluate long-term and oncologic outcomes of subxiphoid approach VATS thymectomy.

Value of Adjuvant Radiotherapy for Thymoma with Myasthenia Gravis after Extended Thymectomy

Background:

The co-existence of myasthenia gravis (MG) and thymoma makes the surgical treatment more complicated and adjuvant radiation more controversial. The aim of this study was to investigate adjuvant radiotherapy for thymoma with MG after extended thymectomy.

Methods:

A total of 181 patients with both MG and thymoma were recruited between 2003 and 2014 at Tongren Hospital, China. Among all the patients, 157 patients received radiation therapy after surgery (Group A); whereas the other 24 patients did not receive radiation therapy (Group B). According to the time that patients started mediastinal radiation therapy, we subdivided the 157 patients in Group A into subgroups (1-month subgroup, n = 98; 2-month subgroup, n = 7; and 3-month subgroup, n = 52). We then compared the effect of the mediastinal radiation therapy across these different groups using the survival rate, the rate of postoperative myasthenic crisis, and the complete stable remission (CSR) rate as the primary endpoints.

Results:

There was a significant difference in the occurrence of postoperative myasthenic crisis between 1-month subgroup and Group B (χ² = 4.631, P = 0.031). The rates of reaching CSR were 32.6% in 1-month subgroup, 25% in 3-month subgroup, and 22.7% in Group B, respectively. The overall survival rates of 1-month subgroup, 3-month subgroup, and Group B were 88.8%, 83.3%, and 77.3%, respectively. Analysis on the Kaplan-Meier survival curves demonstrated that within 8 years after surgery, there was no significant difference in aspects of overall survival and disease-free survival between 1-month subgroup and Group B, and between 3-month subgroup and Group B; over 8 years after surgery, the disease-free survival rates in 1-month subgroup, 3-month subgroup and Group B were 79.4%, 70.6%, and 55.3%, respectively.

Conclusions:

Adjuvant radiation within 1 month after extended thymectomy may be helpful in controlling postoperative MG, such as decreasing the possibility of postoperative myasthenic crisis, and raising cumulative probabilities of reaching CSR.