Subxiphoid and subcostal arch thoracoscopic versus median sternotomy enlarged thymectomy for the treatment of myasthenia gravis complicated with thymoma: A propensity score matching study_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

YIN Xunliang ¹ , ZHAO Zhengwei ¹ , CHENG Shaoyi ¹ , FENG Zheng ¹ , GUO Yize ¹ , ZHANG Tianyi ¹ ,  XUE Sha ² ,  ZHOU Yong'an ¹

1. Department of Thoracic Surgery, Tangdu Hospital of the Air Force Military Medical University, Xi’an, 710038, P. R. China;
2. Department of Anesthesiology, The Second Affiliated Hospital of Xi’an Medical College, Xi’an, 710038, P. R. China;

Corresponding author：

XUE Sha, Email: xuesha1228@126.com; ZHOU Yong'an, Email: zhou.yongan@163.com

Keywords：

Myasthenia gravis; thymoma; video-assisted surgery; subxiphoid approach; median sternotomy

DOI：

10.7507/1007-4848.202301003

Video：

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Objective To compare clinical effects of enlarged thymectomy for the treatment of myasthenia gravis (MG) complicated with thymoma via subxiphoid and subcostal arch thoracoscopic resection versus median sternotomy resection. Methods We retrospectively analyzed the clinical data of patients with MG complicated with thymoma admitted in Tangdu Hospital of the Air Force Military Medical University between December 2011 and December 2021. Patients who underwent subxiphoid and subcostal arch thoracoscopic enlarged thymectomy were allocated to a SR group, and patients who underwent median sternotomy enlarged thymectomy were allocated to a MR group. Perioperative outcomes were compared between the two groups. Results A total of 456 patients were collected. There were 51 patients in the MR group, including 30 males and 21 females aged 23-66 (49.5±11.8) years. There were 405 patients in the SR group, among whom 51 patients were matched to the MR group by propensity score matching, including 28 males and 23 females aged 26-70 (47.2±12.2) years. The operations were accomplished successfully in all patients, and no conversion to thoracotomy occurred in the SR group. The SR group had advantages in the operation time, intraoperative blood loss, chest drainage duration, hospital stay time, patients’ satisfaction level, pain score and complications (all P<0.05). No statistical difference was found in the number of intraoperative lymph node dissection stations, number of intraoperative lymph nodes dissected or remission of MG between the two groups (P>0.05). Conclusion Subxiphoid and subcostal arch thoracoscopic enlarged thymectomy and lymphadenectomy is a safe, effective and feasible minimally invasive procedure for the treatment of MG complicated with thymoma.

Citation： YIN Xunliang, ZHAO Zhengwei, CHENG Shaoyi, FENG Zheng, GUO Yize, ZHANG Tianyi, XUE Sha, ZHOU Yong'an. Subxiphoid and subcostal arch thoracoscopic versus median sternotomy enlarged thymectomy for the treatment of myasthenia gravis complicated with thymoma: A propensity score matching study. Chinese Journal of Clinical Thoracic and Cardiovascular Surgery, 2023, 30(6): 824-829. doi: 10.7507/1007-4848.202301003 Copy

1.	李柱一, 常婷. 重症肌无力的诊断与治疗. 中华神经科杂志, 2022, 55(3): 238-247.
2.	Blalock A, Mason MF, Morgan HJ, et al. Myasthenia gravis and tumors of the thymic region: Report of a case in which the tumor was removed. Ann Surg, 1939, 110(4): 544-561.
3.	Narayanaswami P, Sanders DB, Wolfe G, et al. International consensus guidance for management of myasthenia gravis: 2020 update. Neurology, 2021, 96(3): 114-122.
4.	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.
5.	卢强, 李小飞, 赵晋波, 等. "三孔式" 经剑突肋缘下胸腺切除治疗重症肌无力. 中华胸部外科电子杂志, 2016, 3(2): 95-99.
6.	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.
7.	Zhao J, Wang J, Zhao Z, et al. Subxiphoid and subcostal arch thoracoscopic extended thymectomy: A safe and feasible minimally invasive procedure for selective stage Ⅲ thymomas. J Thorac Dis, 2016, 8(Suppl 3): S258-S264.
8.	Lu Q, Zhao J, Wang J, et al. Subxiphoid and subcostal arch "three ports" thoracoscopic extended thymectomy for myasthenia gravis. J Thorac Dis, 2018, 10(3): 1711-1720.
9.	Bhora FY, Chen DJ, Detterbeck FC, et al. The ITMIG/IASLC Thymic Epithelial Tumors Staging Project: A proposed lymph node map for thymic epithelial tumors in the forthcoming 8th edition of the TNM Classification of Malignant Tumors. J Thorac Oncol, 2014, 9(9 Suppl 2): S88-S96.
10.	Wolfe GI, Kaminski HJ, Aban IB, et al. Randomized trial of thymectomy in myasthenia gravis. N Engl J Med, 2016, 375(6): 511-522.
11.	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.
12.	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.
13.	Sonett JR, Jaretzki A. Thymectomy for nonthymomatous myasthenia gravis: A critical analysis. Ann N Y Acad Sci, 2008, 1132: 315-328.
14.	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.
15.	赵正维, 尹逊亮, 周勇安. 超声刀在剑突肋缘下前纵隔病变微创切除术中的临床应用. 中国胸心血管外科临床杂志, 2018, 25(1): 23-27.
16.	张天翼, 程少毅, 赵正维, 等. 剑突肋缘下前纵隔病变切除术后不留置胸腔引流管的安全性研究. 中华胸心血管外科杂志, 2020, 36(11): 668-671.
17.	Weksler B, Holden A, Sullivan JL. Impact of positive nodal metastases in patients with thymic carcinoma and thymic neuroendocrine tumors. J Thorac Oncol, 2015, 10(11): 1642-1647.
18.	Kondo K, Monden Y. Lymphogenous and hematogenous metastasis of thymic epithelial tumors. Ann Thorac Surg, 2003, 76(6): 1859-1865.
19.	Fang W, Wang Y, Pang L, et al. Lymph node metastasis in thymic malignancies: A Chinese multicenter prospective observational study. J Thorac Cardiovasc Surg, 2018, 156(2): 824-833.
20.	Weksler B, Pennathur A, Sullivan JL, et al. Resection of thymoma should include nodal sampling. J Thorac Cardiovasc Surg, 2015, 149(3): 737-742.
21.	Hwang Y, Kang CH, Park S, et al. Impact of lymph node dissection on thymic malignancies: Multi-institutional propensity score matched analysis. J Thorac Oncol, 2018, 13(12): 1949-1957.
22.	Park IK, Kim YT, Jeon JH, et al. Importance of lymph node dissection in thymic carcinoma. Ann Thorac Surg, 2013, 96(3): 1025-1032.

1. 李柱一, 常婷. 重症肌无力的诊断与治疗. 中华神经科杂志, 2022, 55(3): 238-247.
2. Blalock A, Mason MF, Morgan HJ, et al. Myasthenia gravis and tumors of the thymic region: Report of a case in which the tumor was removed. Ann Surg, 1939, 110(4): 544-561.
3. Narayanaswami P, Sanders DB, Wolfe G, et al. International consensus guidance for management of myasthenia gravis: 2020 update. Neurology, 2021, 96(3): 114-122.
4. 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.
5. 卢强, 李小飞, 赵晋波, 等. "三孔式" 经剑突肋缘下胸腺切除治疗重症肌无力. 中华胸部外科电子杂志, 2016, 3(2): 95-99.
6. 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.
7. Zhao J, Wang J, Zhao Z, et al. Subxiphoid and subcostal arch thoracoscopic extended thymectomy: A safe and feasible minimally invasive procedure for selective stage Ⅲ thymomas. J Thorac Dis, 2016, 8(Suppl 3): S258-S264.
8. Lu Q, Zhao J, Wang J, et al. Subxiphoid and subcostal arch "three ports" thoracoscopic extended thymectomy for myasthenia gravis. J Thorac Dis, 2018, 10(3): 1711-1720.
9. Bhora FY, Chen DJ, Detterbeck FC, et al. The ITMIG/IASLC Thymic Epithelial Tumors Staging Project: A proposed lymph node map for thymic epithelial tumors in the forthcoming 8th edition of the TNM Classification of Malignant Tumors. J Thorac Oncol, 2014, 9(9 Suppl 2): S88-S96.
10. Wolfe GI, Kaminski HJ, Aban IB, et al. Randomized trial of thymectomy in myasthenia gravis. N Engl J Med, 2016, 375(6): 511-522.
11. 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.
12. 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.
13. Sonett JR, Jaretzki A. Thymectomy for nonthymomatous myasthenia gravis: A critical analysis. Ann N Y Acad Sci, 2008, 1132: 315-328.
14. 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.
15. 赵正维, 尹逊亮, 周勇安. 超声刀在剑突肋缘下前纵隔病变微创切除术中的临床应用. 中国胸心血管外科临床杂志, 2018, 25(1): 23-27.
16. 张天翼, 程少毅, 赵正维, 等. 剑突肋缘下前纵隔病变切除术后不留置胸腔引流管的安全性研究. 中华胸心血管外科杂志, 2020, 36(11): 668-671.
17. Weksler B, Holden A, Sullivan JL. Impact of positive nodal metastases in patients with thymic carcinoma and thymic neuroendocrine tumors. J Thorac Oncol, 2015, 10(11): 1642-1647.
18. Kondo K, Monden Y. Lymphogenous and hematogenous metastasis of thymic epithelial tumors. Ann Thorac Surg, 2003, 76(6): 1859-1865.
19. Fang W, Wang Y, Pang L, et al. Lymph node metastasis in thymic malignancies: A Chinese multicenter prospective observational study. J Thorac Cardiovasc Surg, 2018, 156(2): 824-833.
20. Weksler B, Pennathur A, Sullivan JL, et al. Resection of thymoma should include nodal sampling. J Thorac Cardiovasc Surg, 2015, 149(3): 737-742.
21. Hwang Y, Kang CH, Park S, et al. Impact of lymph node dissection on thymic malignancies: Multi-institutional propensity score matched analysis. J Thorac Oncol, 2018, 13(12): 1949-1957.
22. Park IK, Kim YT, Jeon JH, et al. Importance of lymph node dissection in thymic carcinoma. Ann Thorac Surg, 2013, 96(3): 1025-1032.

Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Subxiphoid and subcostal arch thoracoscopic versus median sternotomy enlarged thymectomy for the treatment of myasthenia gravis complicated with thymoma: A propensity score matching study

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