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, 陳剛, 朱勇俊, 等. 胸腔鏡胸腺切除術劍突下入路與側胸入路的病例對照研究. 中國胸心血管外科臨床雜志, 2018, 25(9): 799-803.
5.	劉政呈, 楊如松. 經劍突下單孔胸腔鏡胸腺切除術臨床應用的傾向性評分匹配研究. 中國胸心血管外科臨床雜志, 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.	趙訓杰, 鄧勇軍, 劉煥鵬. 胸腔鏡下右胸入路與劍突下入路胸腺擴大切除術治療重癥肌無力療效比較的Meta分析. 基層醫學論壇, 2021, 25(25): 3583-3586.
9.	劉冬, 張淼, 楊敦鵬, 等. 單孔與三孔劍突下胸腔鏡全胸腺切除術的回顧性隊列研究. 中國胸心血管外科臨床雜志, 2020, 27(5): 539-543.
10.	尹遜亮, 薛沙, 趙正維, 等. 胸腔鏡劍突肋緣下與單側胸腔鏡胸腺擴大切除術治療重癥肌無力療效對比的傾向性評分匹配分析. 中國胸心血管外科臨床雜志, 2021, 28(4): 473-478.
11.	中國免疫學會神經免疫分會. 中國重癥肌無力診斷和治療指南(2020版). 中國神經免疫學和神經病學雜志, 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.	張含露, 劉倫旭, 陳龍奇, 等. 機器人輔助經劍突下胸腺(擴大)切除手術的臨床應用. 中國胸心血管外科臨床雜志, 2017, 24(10): 743-747.
17.	王維, 李川, 林琳, 等. 經劍突下達芬奇機器人手術與傳統胸腔鏡手術治療重癥肌無力合并胸腺瘤的對比研究. 中國胸心血管外科臨床雜志, 2020, 27(11): 1287-1291.
18.	中國醫師協會醫學機器人醫師分會胸外科專業委員會籌備組, 譚群友, 陶紹霖, 等. 機器人輔助縱隔腫瘤手術中國專家共識 (2019版). 中國胸心血管外科臨床雜志, 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.	柳陽春, 林慶, 章曄, 等. 劍突下入路電視胸腔鏡下胸腺切除術治療重癥肌無力13例. 南昌大學學報(醫學版), 2017, 57(1): 69-70.
32.	林志潮, 黃文海, 李祖媚, 等. 胸腔鏡下胸腺擴大切除術治療重癥肌無力35例臨床分析. 中華顯微外科雜志, 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, 陳艱, 陳立如, 等. 劍突下與雙側胸入路電視胸腔鏡胸腺擴大切除治療重癥肌無力的比較. 中國微創外科雜志, 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.	孫耀光, 田文鑫, 吳青峻, 等. 劍突肋緣下入路與右側肋間隙入路胸腔鏡胸腺擴大切除治療重癥肌無力的研究. 中華老年醫學雜志, 2020, 39(7): 821-824.
37.	尹遜亮, 趙正維, 程少毅, 等. 胸腔鏡劍突肋緣下與縱劈胸骨手術治療重癥肌無力臨床療效對比. 中華胸心血管外科雜志, 2019, 35(4): 239-242.
38.	張典, 郎保平, 張超, 等. 劍突肋緣下胸腔鏡手術治療重癥肌無力的效果及對患者應激炎性反應的影響. 中國實用醫刊, 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.	張淼, 武文斌, 楊敦鵬, 等. 劍突下與肋間入路胸腔鏡胸腺擴大切除術的臨床體會. 中華腔鏡外科雜志(電子版), 2019, 12(3): 166-170.
41.	劉倫旭, 劉雪梅. 用質量控制和技術規范改善胸心血管外科臨床結果—2018新春寄語. 中國胸心血管外科臨床雜志, 2018, 25(2): 103-104.
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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, 陳剛, 朱勇俊, 等. 胸腔鏡胸腺切除術劍突下入路與側胸入路的病例對照研究. 中國胸心血管外科臨床雜志, 2018, 25(9): 799-803.
5. 劉政呈, 楊如松. 經劍突下單孔胸腔鏡胸腺切除術臨床應用的傾向性評分匹配研究. 中國胸心血管外科臨床雜志, 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. 趙訓杰, 鄧勇軍, 劉煥鵬. 胸腔鏡下右胸入路與劍突下入路胸腺擴大切除術治療重癥肌無力療效比較的Meta分析. 基層醫學論壇, 2021, 25(25): 3583-3586.
9. 劉冬, 張淼, 楊敦鵬, 等. 單孔與三孔劍突下胸腔鏡全胸腺切除術的回顧性隊列研究. 中國胸心血管外科臨床雜志, 2020, 27(5): 539-543.
10. 尹遜亮, 薛沙, 趙正維, 等. 胸腔鏡劍突肋緣下與單側胸腔鏡胸腺擴大切除術治療重癥肌無力療效對比的傾向性評分匹配分析. 中國胸心血管外科臨床雜志, 2021, 28(4): 473-478.
11. 中國免疫學會神經免疫分會. 中國重癥肌無力診斷和治療指南(2020版). 中國神經免疫學和神經病學雜志, 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. 張含露, 劉倫旭, 陳龍奇, 等. 機器人輔助經劍突下胸腺(擴大)切除手術的臨床應用. 中國胸心血管外科臨床雜志, 2017, 24(10): 743-747.
17. 王維, 李川, 林琳, 等. 經劍突下達芬奇機器人手術與傳統胸腔鏡手術治療重癥肌無力合并胸腺瘤的對比研究. 中國胸心血管外科臨床雜志, 2020, 27(11): 1287-1291.
18. 中國醫師協會醫學機器人醫師分會胸外科專業委員會籌備組, 譚群友, 陶紹霖, 等. 機器人輔助縱隔腫瘤手術中國專家共識 (2019版). 中國胸心血管外科臨床雜志, 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. 柳陽春, 林慶, 章曄, 等. 劍突下入路電視胸腔鏡下胸腺切除術治療重癥肌無力13例. 南昌大學學報(醫學版), 2017, 57(1): 69-70.
32. 林志潮, 黃文海, 李祖媚, 等. 胸腔鏡下胸腺擴大切除術治療重癥肌無力35例臨床分析. 中華顯微外科雜志, 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, 陳艱, 陳立如, 等. 劍突下與雙側胸入路電視胸腔鏡胸腺擴大切除治療重癥肌無力的比較. 中國微創外科雜志, 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. 孫耀光, 田文鑫, 吳青峻, 等. 劍突肋緣下入路與右側肋間隙入路胸腔鏡胸腺擴大切除治療重癥肌無力的研究. 中華老年醫學雜志, 2020, 39(7): 821-824.
37. 尹遜亮, 趙正維, 程少毅, 等. 胸腔鏡劍突肋緣下與縱劈胸骨手術治療重癥肌無力臨床療效對比. 中華胸心血管外科雜志, 2019, 35(4): 239-242.
38. 張典, 郎保平, 張超, 等. 劍突肋緣下胸腔鏡手術治療重癥肌無力的效果及對患者應激炎性反應的影響. 中國實用醫刊, 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. 張淼, 武文斌, 楊敦鵬, 等. 劍突下與肋間入路胸腔鏡胸腺擴大切除術的臨床體會. 中華腔鏡外科雜志(電子版), 2019, 12(3): 166-170.
41. 劉倫旭, 劉雪梅. 用質量控制和技術規范改善胸心血管外科臨床結果—2018新春寄語. 中國胸心血管外科臨床雜志, 2018, 25(2): 103-104.
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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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