Subxiphoid versus intercostal video-assisted thoracoscopic extended thymectomy for myasthenia gravis: A retrospective cohort study_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

ZHENG Wenlong , ZHANG Miao , WU Wenbin , ZHANG Hui ,  ZHANG Xinhui

Affiliated Xuzhou Clinical College of Xuzhou Medical University, Xuzhou Central Hospital, Xuzhou, 221009, Jiangsu, P. R. China;

Corresponding author：

ZHANG Xinhui, Email: zhangxhdoc@hotmail.com

Keywords：

Subxiphoid; video-assisted thoracoscopic surgery; extended thymectomy; myasthenia gravis

DOI：

10.7507/1007-4848.202203010

Video：

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Objective To compare the clinical efficacy of subxiphoid video-assisted thoracoscopic surgery (XVATS) and conventional intercostal VATS (CVATS) extended thymectomy for myasthenia gravis (MG). Methods The clinical data of MG patients who underwent extended thymectomy in the Department of Thoracic Surgery of Xuzhou Central Hospital from October 2016 to October 2021 and finished the follow-up were retrospectively reviewed. They were divided into an XVATS group and a CVATS group according to the procedure. The perioperative variables and clinical efficacy of the two groups were compared. Results A total of 84 patients were collected, including 43 males and 41 females, with a mean age of 52.3 years. There were 41 patients in the XVATS group and 43 patients in the CVATS group. There was no mortality, cardiopulmonary thrombosis, prolonged air leak, or mediastinal infection. Additionally, the CVATS group recorded 5 (11.6%) patients of conversion to open thoracotomy, 1 (2.3%) patient of postoperative MG crisis, 1 (2.3%) patient of bleeding in thorax, and 1 (2.3%) patient of chylothorax. The operation time (127.4±50.4 min vs. 122.9±38.6 min), intraoperative bleeding [46.9 (25.7, 79.2) mL vs. 45.7 (21.9, 92.1) mL], incidence of complications [0 vs. 7.0% (3/43)], chest tube duration (4.3±1.9 d vs. 4.8±2.8 d), follow-up time (19.1±8.5 months vs. 22.5±13.7 months), the proportion of residual mediastinal fat tissue [12.2% (5/41) vs. 4.7% (2/43)], and total MG remission rate [29.3% (12/41) vs. 51.2% (22/43)] were not statistically different between the two groups (P>0.05). However, the two groups showed significantly different incidence of conversion to open thoracotomy [0 vs. 11.6% (5/43), P=0.024], postoperative hospital stay time (8.2±3.3 d vs. 11.4±5.8 d, P=0.003) and total drainage volume [396.7 (173.8, 542.5) mL vs. 218.8 (102.1, 430.0) mL, P=0.038]. Conclusion XVATS extended thymectomy is technically safe and feasible; however, more evidence is warranted before the recommendation of this approach for the treatment of MG.

Citation： ZHENG Wenlong, ZHANG Miao, WU Wenbin, ZHANG Hui, ZHANG Xinhui. Subxiphoid versus intercostal video-assisted thoracoscopic extended thymectomy for myasthenia gravis: A retrospective cohort study. Chinese Journal of Clinical Thoracic and Cardiovascular Surgery, 2023, 30(6): 835-841. doi: 10.7507/1007-4848.202203010 Copy

1.	Wolfe GI, Kaminski HJ, Aban IB, et al. Long-term effect of thymectomy plus prednisone versus prednisone alone in patients with non-thymomatous myasthenia gravis: 2-year extension of the MGTX randomised trial. Lancet Neurol, 2019, 18(3): 259-268.
2.	Gronseth GS, Barohn R, Narayanaswami P. Practice advisory: Thymectomy for myasthenia gravis (practice parameter update): Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology. Neurology, 2020, 94(16): 705-709.
3.	Solis-Pazmino P, Baiu I, Lincango-Naranjo E, et al. Impact of the surgical approach to thymectomy upon complete stable remission rates in myasthenia gravis: A meta-analysis. Neurology, 2021, 97(4): e357-e368.
4.	徐朋亮, 陈刚, 朱勇俊, 等. 胸腔镜胸腺切除术剑突下入路与侧胸入路的病例对照研究. 中国胸心血管外科临床杂志, 2018, 25(9): 799-803.
5.	刘政呈, 杨如松. 经剑突下单孔胸腔镜胸腺切除术临床应用的倾向性评分匹配研究. 中国胸心血管外科临床杂志, 2020, 27(3): 318-322.
6.	Li J, Qi G, Liu Y, et al. Meta-analysis of subxiphoid approach versus lateral approach for thoracoscopic thymectomy. J Cardiothorac Surg, 2020, 15(1): 89.
7.	Qiu Z, Chen L, Lin Q, et al. 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(4): 1529-1539.
8.	赵训杰, 邓勇军, 刘焕鹏. 胸腔镜下右胸入路与剑突下入路胸腺扩大切除术治疗重症肌无力疗效比较的Meta分析. 基层医学论坛, 2021, 25(25): 3583-3586.
9.	刘冬, 张淼, 杨敦鹏, 等. 单孔与三孔剑突下胸腔镜全胸腺切除术的回顾性队列研究. 中国胸心血管外科临床杂志, 2020, 27(5): 539-543.
10.	尹逊亮, 薛沙, 赵正维, 等. 胸腔镜剑突肋缘下与单侧胸腔镜胸腺扩大切除术治疗重症肌无力疗效对比的倾向性评分匹配分析. 中国胸心血管外科临床杂志, 2021, 28(4): 473-478.
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12.	Ipe TS, Davis AR, Raval JS. Therapeutic plasma exchange in myasthenia gravis: A systematic literature review and meta-analysis of comparative evidence. Front Neurol, 2021, 12: 662856.
13.	Zhang J, Chen Y, Zhang H, et al. Effects of thymectomy on late-onset non-thymomatous myasthenia gravis: Systematic review and meta-analysis. Orphanet J Rare Dis, 2021, 16(1): 232.
14.	Haoshuai Z, Jianyong Z, Lei Y, et al. Factors affecting improvement of neurologic status evaluated by quantitative myasthenia gravis score for patients with thymomatous myasthenia gravis after extended thymectomy. J Transl Med, 2021, 19(1): 413.
15.	Narayanaswami P, Sanders DB, Wolfe G, et al. International consensus guidance for management of myasthenia gravis: 2020 update. Neurology, 2021, 96(3): 114-122.
16.	张含露, 刘伦旭, 陈龙奇, 等. 机器人辅助经剑突下胸腺(扩大)切除手术的临床应用. 中国胸心血管外科临床杂志, 2017, 24(10): 743-747.
17.	王维, 李川, 林琳, 等. 经剑突下达芬奇机器人手术与传统胸腔镜手术治疗重症肌无力合并胸腺瘤的对比研究. 中国胸心血管外科临床杂志, 2020, 27(11): 1287-1291.
18.	中国医师协会医学机器人医师分会胸外科专业委员会筹备组, 谭群友, 陶绍霖, 等. 机器人辅助纵隔肿瘤手术中国专家共识 (2019版). 中国胸心血管外科临床杂志, 2020, 27(2): 117-125.
19.	Zielinski M, Hauer L, Hauer J, et al. Comparison of complete remission rates after 5 year follow-up of three different techniques of thymectomy for myasthenia gravis. Eur J Cardiothorac Surg, 2010, 37(5): 1137-1143.
20.	Zieliński M. Surgical approaches to myasthenia gravis: Perspective of anatomy and radicality in surgery. Thorac Surg Clin, 2019, 29(2): 159-164.
21.	Kang CH, Na KJ, Song JW, et al. The robotic thymectomy via the subxiphoid approach: Technique and early outcomes. Eur J Cardiothorac Surg, 2020, 58(Suppl_1): i39-i43.
22.	Suda T, Ishizawa H, Nagano H, et al. Early outcomes in 147 consecutive cases of subxiphoid single-port thymectomy and evaluation of learning curves. Eur J Cardiothorac Surg, 2020, 58(Suppl_1): i44-i49.
23.	Gao L, Lu J, Shen Z, et al. A novel method of subxiphoid video-assisted thoracic surgery for thymectomy. Ann Transl Med, 2021, 9(16): 1339.
24.	Yoshida M, Yuasa M, Kondo K, et al. Evaluation of extended thymectomy approaches based on residual fat tissue. Interact Cardiovasc Thorac Surg, 2021, 32(2): 250-255.
25.	Uchiyama A, Shimizu S, Murai H, et al. Infrasternal mediastinoscopic thymectomy in myasthenia gravis: Surgical results in 23 patients. Ann Thorac Surg, 2001, 72(6): 1902-1905.
26.	Murai H, Uchiyama A, Mei FJ, et al. Long-term effects of infrasternal mediastinoscopic thymectomy in myasthenia gravis. J Neurol Sci, 2009, 287(1-2): 185-187.
27.	Shiomi K, Kitamura E, Ono M, et al. Feasible and promising modified trans-subxiphoid thoracoscopic extended thymectomy for patients with myasthenia gravis. J Thorac Dis, 2018, 10(3): 1747-1752.
28.	Ambrogi V, Tacconi F, Sellitri F, et al. Subxiphoid completion thymectomy for refractory non-thymomatous myasthenia gravis. J Thorac Dis, 2020, 12(5): 2388-2394.
29.	Liu Y, Zhang J, Wu W, et al. Subxiphoid thoracoscopic thymectomy for myasthenia gravis. Interact Cardiovasc Thorac Surg, 2022, 34(3): 482-484.
30.	Hsu CP, Chuang CY, Hsu NY, et al. Comparison between the right side and subxiphoid bilateral approaches in performing video-assisted thoracoscopic extended thymectomy for myasthenia gravis. Surg Endosc, 2004, 18(5): 821-824.
31.	柳阳春, 林庆, 章晔, 等. 剑突下入路电视胸腔镜下胸腺切除术治疗重症肌无力13例. 南昌大学学报(医学版), 2017, 57(1): 69-70.
32.	林志潮, 黄文海, 李祖媚, 等. 胸腔镜下胸腺扩大切除术治疗重症肌无力35例临床分析. 中华显微外科杂志, 2018, 41(2): 194-196.
33.	Xu H, Liu D, Li Y, et al. The outcomes of subxiphoid thoracoscopic versus video-assisted thoracic surgery for thymic diseases. J Laparoendosc Adv Surg Tech A, 2020, 30(5): 508-513.
34.	邱志宏, 陈艰, 陈立如, 等. 剑突下与双侧胸入路电视胸腔镜胸腺扩大切除治疗重症肌无力的比较. 中国微创外科杂志, 2020, 20(1): 26-30.
35.	Chen X, Ma Q, Wang X, et al. Subxiphoid and subcostal thoracoscopic surgical approach for thymectomy. Surg Endosc, 2021, 35(9): 5239-5246.
36.	孙耀光, 田文鑫, 吴青峻, 等. 剑突肋缘下入路与右侧肋间隙入路胸腔镜胸腺扩大切除治疗重症肌无力的研究. 中华老年医学杂志, 2020, 39(7): 821-824.
37.	尹逊亮, 赵正维, 程少毅, 等. 胸腔镜剑突肋缘下与纵劈胸骨手术治疗重症肌无力临床疗效对比. 中华胸心血管外科杂志, 2019, 35(4): 239-242.
38.	张典, 郎保平, 张超, 等. 剑突肋缘下胸腔镜手术治疗重症肌无力的效果及对患者应激炎性反应的影响. 中国实用医刊, 2021, 48(15): 58-61.
39.	Cataneo AJM, Felisberto G, Cataneo DC. Thymectomy in nonthymomatous myasthenia gravis—Systematic review and meta-analysis. Orphanet J Rare Dis, 2018, 13(1): 99.
40.	张淼, 武文斌, 杨敦鹏, 等. 剑突下与肋间入路胸腔镜胸腺扩大切除术的临床体会. 中华腔镜外科杂志(电子版), 2019, 12(3): 166-170.
41.	刘伦旭, 刘雪梅. 用质量控制和技术规范改善胸心血管外科临床结果—2018新春寄语. 中国胸心血管外科临床杂志, 2018, 25(2): 103-104.
42.	谷志涛, 方文涛. 胸腺肿瘤微创切除手术的基本原则与质量控制. 中国胸心血管外科临床杂志, 2019, 26(1): 29-34.
43.	中国医师协会肿瘤多学科诊疗专业委员会. 中国胸腺上皮肿瘤临床诊疗指南(2021版). 中华肿瘤杂志, 2021, 43(4): 395-404.
44.	Li F, Tao Y, Bauer G, et al. Unraveling the role of ectopic thymic tissue in patients undergoing thymectomy for myasthenia gravis. J Thorac Dis, 2019, 11(9): 4039-4048.
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1. Wolfe GI, Kaminski HJ, Aban IB, et al. Long-term effect of thymectomy plus prednisone versus prednisone alone in patients with non-thymomatous myasthenia gravis: 2-year extension of the MGTX randomised trial. Lancet Neurol, 2019, 18(3): 259-268.
2. Gronseth GS, Barohn R, Narayanaswami P. Practice advisory: Thymectomy for myasthenia gravis (practice parameter update): Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology. Neurology, 2020, 94(16): 705-709.
3. Solis-Pazmino P, Baiu I, Lincango-Naranjo E, et al. Impact of the surgical approach to thymectomy upon complete stable remission rates in myasthenia gravis: A meta-analysis. Neurology, 2021, 97(4): e357-e368.
4. 徐朋亮, 陈刚, 朱勇俊, 等. 胸腔镜胸腺切除术剑突下入路与侧胸入路的病例对照研究. 中国胸心血管外科临床杂志, 2018, 25(9): 799-803.
5. 刘政呈, 杨如松. 经剑突下单孔胸腔镜胸腺切除术临床应用的倾向性评分匹配研究. 中国胸心血管外科临床杂志, 2020, 27(3): 318-322.
6. Li J, Qi G, Liu Y, et al. Meta-analysis of subxiphoid approach versus lateral approach for thoracoscopic thymectomy. J Cardiothorac Surg, 2020, 15(1): 89.
7. Qiu Z, Chen L, Lin Q, et al. 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(4): 1529-1539.
8. 赵训杰, 邓勇军, 刘焕鹏. 胸腔镜下右胸入路与剑突下入路胸腺扩大切除术治疗重症肌无力疗效比较的Meta分析. 基层医学论坛, 2021, 25(25): 3583-3586.
9. 刘冬, 张淼, 杨敦鹏, 等. 单孔与三孔剑突下胸腔镜全胸腺切除术的回顾性队列研究. 中国胸心血管外科临床杂志, 2020, 27(5): 539-543.
10. 尹逊亮, 薛沙, 赵正维, 等. 胸腔镜剑突肋缘下与单侧胸腔镜胸腺扩大切除术治疗重症肌无力疗效对比的倾向性评分匹配分析. 中国胸心血管外科临床杂志, 2021, 28(4): 473-478.
11. 中国免疫学会神经免疫分会. 中国重症肌无力诊断和治疗指南(2020版). 中国神经免疫学和神经病学杂志, 2021, 28(1): 1-12.
12. Ipe TS, Davis AR, Raval JS. Therapeutic plasma exchange in myasthenia gravis: A systematic literature review and meta-analysis of comparative evidence. Front Neurol, 2021, 12: 662856.
13. Zhang J, Chen Y, Zhang H, et al. Effects of thymectomy on late-onset non-thymomatous myasthenia gravis: Systematic review and meta-analysis. Orphanet J Rare Dis, 2021, 16(1): 232.
14. Haoshuai Z, Jianyong Z, Lei Y, et al. Factors affecting improvement of neurologic status evaluated by quantitative myasthenia gravis score for patients with thymomatous myasthenia gravis after extended thymectomy. J Transl Med, 2021, 19(1): 413.
15. Narayanaswami P, Sanders DB, Wolfe G, et al. International consensus guidance for management of myasthenia gravis: 2020 update. Neurology, 2021, 96(3): 114-122.
16. 张含露, 刘伦旭, 陈龙奇, 等. 机器人辅助经剑突下胸腺(扩大)切除手术的临床应用. 中国胸心血管外科临床杂志, 2017, 24(10): 743-747.
17. 王维, 李川, 林琳, 等. 经剑突下达芬奇机器人手术与传统胸腔镜手术治疗重症肌无力合并胸腺瘤的对比研究. 中国胸心血管外科临床杂志, 2020, 27(11): 1287-1291.
18. 中国医师协会医学机器人医师分会胸外科专业委员会筹备组, 谭群友, 陶绍霖, 等. 机器人辅助纵隔肿瘤手术中国专家共识 (2019版). 中国胸心血管外科临床杂志, 2020, 27(2): 117-125.
19. Zielinski M, Hauer L, Hauer J, et al. Comparison of complete remission rates after 5 year follow-up of three different techniques of thymectomy for myasthenia gravis. Eur J Cardiothorac Surg, 2010, 37(5): 1137-1143.
20. Zieliński M. Surgical approaches to myasthenia gravis: Perspective of anatomy and radicality in surgery. Thorac Surg Clin, 2019, 29(2): 159-164.
21. Kang CH, Na KJ, Song JW, et al. The robotic thymectomy via the subxiphoid approach: Technique and early outcomes. Eur J Cardiothorac Surg, 2020, 58(Suppl_1): i39-i43.
22. Suda T, Ishizawa H, Nagano H, et al. Early outcomes in 147 consecutive cases of subxiphoid single-port thymectomy and evaluation of learning curves. Eur J Cardiothorac Surg, 2020, 58(Suppl_1): i44-i49.
23. Gao L, Lu J, Shen Z, et al. A novel method of subxiphoid video-assisted thoracic surgery for thymectomy. Ann Transl Med, 2021, 9(16): 1339.
24. Yoshida M, Yuasa M, Kondo K, et al. Evaluation of extended thymectomy approaches based on residual fat tissue. Interact Cardiovasc Thorac Surg, 2021, 32(2): 250-255.
25. Uchiyama A, Shimizu S, Murai H, et al. Infrasternal mediastinoscopic thymectomy in myasthenia gravis: Surgical results in 23 patients. Ann Thorac Surg, 2001, 72(6): 1902-1905.
26. Murai H, Uchiyama A, Mei FJ, et al. Long-term effects of infrasternal mediastinoscopic thymectomy in myasthenia gravis. J Neurol Sci, 2009, 287(1-2): 185-187.
27. Shiomi K, Kitamura E, Ono M, et al. Feasible and promising modified trans-subxiphoid thoracoscopic extended thymectomy for patients with myasthenia gravis. J Thorac Dis, 2018, 10(3): 1747-1752.
28. Ambrogi V, Tacconi F, Sellitri F, et al. Subxiphoid completion thymectomy for refractory non-thymomatous myasthenia gravis. J Thorac Dis, 2020, 12(5): 2388-2394.
29. Liu Y, Zhang J, Wu W, et al. Subxiphoid thoracoscopic thymectomy for myasthenia gravis. Interact Cardiovasc Thorac Surg, 2022, 34(3): 482-484.
30. Hsu CP, Chuang CY, Hsu NY, et al. Comparison between the right side and subxiphoid bilateral approaches in performing video-assisted thoracoscopic extended thymectomy for myasthenia gravis. Surg Endosc, 2004, 18(5): 821-824.
31. 柳阳春, 林庆, 章晔, 等. 剑突下入路电视胸腔镜下胸腺切除术治疗重症肌无力13例. 南昌大学学报(医学版), 2017, 57(1): 69-70.
32. 林志潮, 黄文海, 李祖媚, 等. 胸腔镜下胸腺扩大切除术治疗重症肌无力35例临床分析. 中华显微外科杂志, 2018, 41(2): 194-196.
33. Xu H, Liu D, Li Y, et al. The outcomes of subxiphoid thoracoscopic versus video-assisted thoracic surgery for thymic diseases. J Laparoendosc Adv Surg Tech A, 2020, 30(5): 508-513.
34. 邱志宏, 陈艰, 陈立如, 等. 剑突下与双侧胸入路电视胸腔镜胸腺扩大切除治疗重症肌无力的比较. 中国微创外科杂志, 2020, 20(1): 26-30.
35. Chen X, Ma Q, Wang X, et al. Subxiphoid and subcostal thoracoscopic surgical approach for thymectomy. Surg Endosc, 2021, 35(9): 5239-5246.
36. 孙耀光, 田文鑫, 吴青峻, 等. 剑突肋缘下入路与右侧肋间隙入路胸腔镜胸腺扩大切除治疗重症肌无力的研究. 中华老年医学杂志, 2020, 39(7): 821-824.
37. 尹逊亮, 赵正维, 程少毅, 等. 胸腔镜剑突肋缘下与纵劈胸骨手术治疗重症肌无力临床疗效对比. 中华胸心血管外科杂志, 2019, 35(4): 239-242.
38. 张典, 郎保平, 张超, 等. 剑突肋缘下胸腔镜手术治疗重症肌无力的效果及对患者应激炎性反应的影响. 中国实用医刊, 2021, 48(15): 58-61.
39. Cataneo AJM, Felisberto G, Cataneo DC. Thymectomy in nonthymomatous myasthenia gravis—Systematic review and meta-analysis. Orphanet J Rare Dis, 2018, 13(1): 99.
40. 张淼, 武文斌, 杨敦鹏, 等. 剑突下与肋间入路胸腔镜胸腺扩大切除术的临床体会. 中华腔镜外科杂志(电子版), 2019, 12(3): 166-170.
41. 刘伦旭, 刘雪梅. 用质量控制和技术规范改善胸心血管外科临床结果—2018新春寄语. 中国胸心血管外科临床杂志, 2018, 25(2): 103-104.
42. 谷志涛, 方文涛. 胸腺肿瘤微创切除手术的基本原则与质量控制. 中国胸心血管外科临床杂志, 2019, 26(1): 29-34.
43. 中国医师协会肿瘤多学科诊疗专业委员会. 中国胸腺上皮肿瘤临床诊疗指南(2021版). 中华肿瘤杂志, 2021, 43(4): 395-404.
44. Li F, Tao Y, Bauer G, et al. Unraveling the role of ectopic thymic tissue in patients undergoing thymectomy for myasthenia gravis. J Thorac Dis, 2019, 11(9): 4039-4048.
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Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Subxiphoid versus intercostal video-assisted thoracoscopic extended thymectomy for myasthenia gravis: A retrospective cohort study

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