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. 重癥肌無力的診斷與治療. 中華神經科雜志, 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.
5.	盧強, 李小飛, 趙晉波, 等. "三孔式" 經劍突肋緣下胸腺切除治療重癥肌無力. 中華胸部外科電子雜志, 2016, 3(2): 95-99.
6.	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.
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.
13.	Sonett JR, Jaretzki A. Thymectomy for nonthymomatous myasthenia gravis: A critical analysis. Ann N Y Acad Sci, 2008, 1132: 315-328.
14.	谷志濤, 方文濤. 胸腺腫瘤微創切除手術的基本原則與質量控制. 中國胸心血管外科臨床雜志, 2019, 26(1): 29-34.
15.	趙正維, 尹遜亮, 周勇安. 超聲刀在劍突肋緣下前縱隔病變微創切除術中的臨床應用. 中國胸心血管外科臨床雜志, 2018, 25(1): 23-27.
16.	張天翼, 程少毅, 趙正維, 等. 劍突肋緣下前縱隔病變切除術后不留置胸腔引流管的安全性研究. 中華胸心血管外科雜志, 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. 重癥肌無力的診斷與治療. 中華神經科雜志, 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.
5. 盧強, 李小飛, 趙晉波, 等. "三孔式" 經劍突肋緣下胸腺切除治療重癥肌無力. 中華胸部外科電子雜志, 2016, 3(2): 95-99.
6. 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.
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.
13. Sonett JR, Jaretzki A. Thymectomy for nonthymomatous myasthenia gravis: A critical analysis. Ann N Y Acad Sci, 2008, 1132: 315-328.
14. 谷志濤, 方文濤. 胸腺腫瘤微創切除手術的基本原則與質量控制. 中國胸心血管外科臨床雜志, 2019, 26(1): 29-34.
15. 趙正維, 尹遜亮, 周勇安. 超聲刀在劍突肋緣下前縱隔病變微創切除術中的臨床應用. 中國胸心血管外科臨床雜志, 2018, 25(1): 23-27.
16. 張天翼, 程少毅, 趙正維, 等. 劍突肋緣下前縱隔病變切除術后不留置胸腔引流管的安全性研究. 中華胸心血管外科雜志, 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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