Clinical efficacy of anterior mediastinal tumor resection by thoracoscopic subcostal approach versus classic subxiphoid approach: A retrospective cohort study_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

LIAO Zefei , CHEN Fengyu , LIN Yonglong , WANG Ronghua , WANG Gengjie , ZHANG Le ,  MA Liangyun

Department of Thoracic Surgery, The 910th Hospital of Joint Logistics Support Force, Quanzhou, 362000, Fujian, P. R. China;

Corresponding?author：

MA Liangyun, Email: maliangyun1972@qq.com

Keywords：

Anterior mediastinal tumor; classic subxiphoid approach; modified subxiphoid approach; thoracoscopic surgery

DOI：

10.7507/1007-4848.202402035

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Objective To explore the clinical efficacy of two procedures in thoracoscopic anterior mediastinal tumor resection. Methods A retrospective study was conducted on patients who underwent thoracoscopic anterior mediastinal tumor resection at the Department of Thoracic Surgery, the 910th Hospital of Joint Logistics Support Force from October 2016 to January 2024. Patients were divided into two groups according to the surgical approach: a modified approach group (bilateral intercostal ports+two subcostal ports) and a classic subxiphoid approach group (one subxiphoid port+two subcostal ports). Perioperative data and postoperative improvement of myasthenia gravis (MG) subgroup were compared between the two groups. Results A total of 55 patients were included, including 27 males and 28 females with a mean age of (49.4±15.1) years. There were 23 patients in the modified approach group and 32 patients in the classic subxiphoid approach group. The modified approach group had shorter operation time [(129.0±20.5) min vs. (148.9±16.7) min, P<0.001], less intraoperative blood loss [(63.0±16.6) mL vs. (75.0±10.8) mL, P<0.001], shorter postoperative drainage tube removal time [(3.1±0.4) d vs. (3.9±0.6) d, P<0.001] and shorter postoperative hospital stay [(4.2±0.4) d vs. (5.0±0.6) d, P<0.001), and lower proportion of intraoperative cardiac dysfunction [4 (17.4%) vs. 14 (43.8%), P=0.040]. There was no statistical difference in maximum diameter of tumor resected [(4.5±1.7) cm vs. (4.0±0.9) cm, P=0.193] and postoperative drainage volume [(396.4±121.5) mL vs. (399.9±161.3) mL, P=0.932]. There was 1 patient of perioperative collateral injury in the modified approach group (pericardial injury), and 6 patients in the classic subxiphoid approach group (1 patient of diaphragm injury, 1 patient of liver contusion, 4 patients of pericardial injury). There was no statistical difference in pain scores at 24 h, 48 h and 72 h after surgery (P>0.05). The postoperative improvement of MG symptoms in the modified approach group was better than that in the classic subxiphoid approach group at 1 year after surgery (complete stable remission rate: 77.8% vs. 50.0%; effective rate: 100.0% vs. 91.6%). No conversion to open chest surgery occurred in either group, and there were no postoperative rehospitalizations or deaths related to surgery within 30 days after surgery in both groups. Conclusion The modified approach is safe and controllable with more open surgical field and more reliable complete resection range than the classic subxiphoid approach group.

Citation： LIAO Zefei, CHEN Fengyu, LIN Yonglong, WANG Ronghua, WANG Gengjie, ZHANG Le, MA Liangyun. Clinical efficacy of anterior mediastinal tumor resection by thoracoscopic subcostal approach versus classic subxiphoid approach: A retrospective cohort study. Chinese Journal of Clinical Thoracic and Cardiovascular Surgery, 2024, 31(12): 1781-1787. doi: 10.7507/1007-4848.202402035 Copy

1.	莫安勝, 關漢斌, 馮志強, 等. 劍突及肋弓下三切口胸腔鏡手術技術及改進. 中華腔鏡外科雜志(電子版), 2021, 14(3): 187-192.Mo AS, Guan HB, Feng ZQ, et al. Improvement of the technique of subxiphoid approach for thoracoscopic surgery. Chin J Laparoscop Surg (Electronic Edition), 2021, 14(3): 187-192.
2.	瞿翼琛, 黃鑫, 趙德平, 等. 劍突下單孔胸腔鏡手術中特殊情況的處理對策. 中華胸心血管外科雜志, 2019, 35(11): 659-663.Qu YC, Huang X, Zhao DP, et al. Summary and treatment of special situations in subxiphoid uniportal VATS surgery. Chin J Thorac Cardiovasc Surg, 2019, 35(11): 659-663.
3.	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.Liu D, Zhang M, Yang DP, et al. Uniportal versus three-port subxiphoid video-assisted thoracoscopic extended thymectomy: A retrospective cohort study. Chin J Clin Thorac Cardiovasc Surg, 2020, 27(5): 539-543.
4.	張程程, 吳亮, 范江. 治療重癥肌無力的新術式: 劍突下雙拉鉤胸腔鏡下胸腺擴大切除術. 中國臨床新醫學, 2023, 16(6): 547-551.Zhang CC, Wu L, Fan J. A new surgical procedure for the treatment of myasthenia gravis—Thoracoscopic extended thymectomy with double retractors subxiphoid. Chin J New Clin Med, 2023, 16(6): 547-551.
5.	Jaretzki A 3rd, Barohn RJ, Ernstoff RM, et al. Myasthenia gravis: Recommendations for clinical research standards. Task Force of the Medical Scientific Advisory Board of the Myasthenia Gravis Foundation of America. Ann Thorac Surg. 2000, 70(1): 327-334.
6.	Numanami H, Yano M, Yamaji M et al. Thoracoscopic thymectomyusing a subxiphoid approach for anterior mediastinal tumors. Ann Thorac Cardiovasc Surg, 2018, 24(2): 65-72.
7.	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.
8.	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.Zhang M, Wu WB, Yang DP, et al. A clinical analysis on subxiphoid and intercostal video-assisted thoracoscopic extended thymectomy. Chin J Laparoscop Surg (Electronic Edition), 2019, 12(3): 166-170.
9.	劉宗昂, 張蘇寧. 人工氣胸胸腔鏡在胸腺瘤切除術中的應用. 中國醫科大學學報, 2019, 48(5): 461-463.Liu ZA, Zhang SN. Application of video-assisted thoracoscopic surgery in combination with artificial pneumothorax in the treatment of thymoma. J China Med Univ, 2019, 48(5): 461-463.
10.	Shi Y, Sun F, Jin Y, et al. Subxiphoid approach with sternum retractor for mediastinal tumor cephalad to brachiocephalic vein. J Thorac Dis, 2018, 10(6): E473-E475.
11.	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.Liu ZC, Yang RS. Clinical application of subxiphoid uni-portal thoracoscopic thymectomy: A propensity score matching study. Chin J Clin Thorac Cardiovasc Surg, 2020, 27(3): 318-322.
12.	周燕武, 李昕, 高陽, 等. 機器人輔助胸腺瘤擴大切除術治療重癥肌無力一例報道. 機器人外科學雜志, 2023, 4(4): 371-375.Zhou YW, Li X, Gao Y, et al. Robot-assisted expanded thymectomy for myasthenia gravis: A case report. Chin J Robot Surg, 2023, 4(4): 371-375.
13.	龐景灼, 葉敏, 龐文廣, 等. 胸腔鏡經劍突下和經肋間入路胸腺擴大切除治療重癥肌無力的近期效果對比. 中國醫學創新, 2021, 18(12): 29-31.Pang JZ, Ye M, Pang WG, et al. Comparison of short-term efficacy of video-assisted thoracoscopic extended thymectomy treating myasthenia gravis by subxiphoid and intercostal approach. Med Innov China, 2021, 18(12): 29-31.
14.	Infante M, Benato C, Giovannetti R, et al. VATS thymectomy for early stage thymoma and myasthenia gravis: Combined right-sided uniportal and left-sided three-portal approach. J Vis Surg, 2017, 3: 144.
15.	伍治強, 王洪, 曾小飛, 等. 充氣式劍突下單孔胸腔鏡手術治療胸腺腫瘤. 中國微創外科雜志, 2022, 22(1): 59-62.Wu ZQ, Wang H, Zeng XF, et al. Inflatable subxiphoid single-port video-assisted thoracoscopic surgery for thymal tumors. Chin J Minim Invasive Surg, 2022, 22(1): 59-62.

1. 莫安勝, 關漢斌, 馮志強, 等. 劍突及肋弓下三切口胸腔鏡手術技術及改進. 中華腔鏡外科雜志(電子版), 2021, 14(3): 187-192.Mo AS, Guan HB, Feng ZQ, et al. Improvement of the technique of subxiphoid approach for thoracoscopic surgery. Chin J Laparoscop Surg (Electronic Edition), 2021, 14(3): 187-192.
2. 瞿翼琛, 黃鑫, 趙德平, 等. 劍突下單孔胸腔鏡手術中特殊情況的處理對策. 中華胸心血管外科雜志, 2019, 35(11): 659-663.Qu YC, Huang X, Zhao DP, et al. Summary and treatment of special situations in subxiphoid uniportal VATS surgery. Chin J Thorac Cardiovasc Surg, 2019, 35(11): 659-663.
3. 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.Liu D, Zhang M, Yang DP, et al. Uniportal versus three-port subxiphoid video-assisted thoracoscopic extended thymectomy: A retrospective cohort study. Chin J Clin Thorac Cardiovasc Surg, 2020, 27(5): 539-543.
4. 張程程, 吳亮, 范江. 治療重癥肌無力的新術式: 劍突下雙拉鉤胸腔鏡下胸腺擴大切除術. 中國臨床新醫學, 2023, 16(6): 547-551.Zhang CC, Wu L, Fan J. A new surgical procedure for the treatment of myasthenia gravis—Thoracoscopic extended thymectomy with double retractors subxiphoid. Chin J New Clin Med, 2023, 16(6): 547-551.
5. Jaretzki A 3rd, Barohn RJ, Ernstoff RM, et al. Myasthenia gravis: Recommendations for clinical research standards. Task Force of the Medical Scientific Advisory Board of the Myasthenia Gravis Foundation of America. Ann Thorac Surg. 2000, 70(1): 327-334.
6. Numanami H, Yano M, Yamaji M et al. Thoracoscopic thymectomyusing a subxiphoid approach for anterior mediastinal tumors. Ann Thorac Cardiovasc Surg, 2018, 24(2): 65-72.
7. 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.
8. 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.Zhang M, Wu WB, Yang DP, et al. A clinical analysis on subxiphoid and intercostal video-assisted thoracoscopic extended thymectomy. Chin J Laparoscop Surg (Electronic Edition), 2019, 12(3): 166-170.
9. 劉宗昂, 張蘇寧. 人工氣胸胸腔鏡在胸腺瘤切除術中的應用. 中國醫科大學學報, 2019, 48(5): 461-463.Liu ZA, Zhang SN. Application of video-assisted thoracoscopic surgery in combination with artificial pneumothorax in the treatment of thymoma. J China Med Univ, 2019, 48(5): 461-463.
10. Shi Y, Sun F, Jin Y, et al. Subxiphoid approach with sternum retractor for mediastinal tumor cephalad to brachiocephalic vein. J Thorac Dis, 2018, 10(6): E473-E475.
11. 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.Liu ZC, Yang RS. Clinical application of subxiphoid uni-portal thoracoscopic thymectomy: A propensity score matching study. Chin J Clin Thorac Cardiovasc Surg, 2020, 27(3): 318-322.
12. 周燕武, 李昕, 高陽, 等. 機器人輔助胸腺瘤擴大切除術治療重癥肌無力一例報道. 機器人外科學雜志, 2023, 4(4): 371-375.Zhou YW, Li X, Gao Y, et al. Robot-assisted expanded thymectomy for myasthenia gravis: A case report. Chin J Robot Surg, 2023, 4(4): 371-375.
13. 龐景灼, 葉敏, 龐文廣, 等. 胸腔鏡經劍突下和經肋間入路胸腺擴大切除治療重癥肌無力的近期效果對比. 中國醫學創新, 2021, 18(12): 29-31.Pang JZ, Ye M, Pang WG, et al. Comparison of short-term efficacy of video-assisted thoracoscopic extended thymectomy treating myasthenia gravis by subxiphoid and intercostal approach. Med Innov China, 2021, 18(12): 29-31.
14. Infante M, Benato C, Giovannetti R, et al. VATS thymectomy for early stage thymoma and myasthenia gravis: Combined right-sided uniportal and left-sided three-portal approach. J Vis Surg, 2017, 3: 144.
15. 伍治強, 王洪, 曾小飛, 等. 充氣式劍突下單孔胸腔鏡手術治療胸腺腫瘤. 中國微創外科雜志, 2022, 22(1): 59-62.Wu ZQ, Wang H, Zeng XF, et al. Inflatable subxiphoid single-port video-assisted thoracoscopic surgery for thymal tumors. Chin J Minim Invasive Surg, 2022, 22(1): 59-62.

Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Clinical efficacy of anterior mediastinal tumor resection by thoracoscopic subcostal approach versus classic subxiphoid approach: A retrospective cohort study

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