Subxiphoid uniportal approach using a double sternum retractor versus subxiphoid and subcostal arch approach of video-assisted thoracoscopic surgery thymectomy for thymoma treatment: A retrospective cohort study_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

ZHAO Jinlan ¹ , CHEN Weiyang ² , LIN Lin ² , WANG Lei ² , LI Jie ² , MA Lin ² , CHEN Longqi ² ,  CHEN Hong ³ ,  TIAN Dong ²

1. West China School of Nursing, Sichuan University/Operating Room, Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, 610041, P. R. China;
2. Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, 610041, P. R. China;
3. West China Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu, 610041, P. R. China;

Corresponding author：

CHEN Hong, Email: 22tiandong@wchscu.cn; TIAN Dong, Email: 1366109878@qq.com

Keywords：

Thymoma; thymectomy; thoracoscopic surgery; subxiphoid uniportal; double sternum retractor

DOI：

10.7507/1007-4848.202409009

Video：

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Objective To compare the efficacy and safety of video-assisted thoracoscopic surgery (VATS) thymectomy for the treatment of thymoma through subxiphoid uniportal approach using a double sternum retractor and subxiphoid and subcostal arch approach. Methods We retrospectively analyzed the clinical data of the patients diagnosed with thymoma who underwent VATS thymectomy from June 2023 to June 2024 in West China Hospital. Patients were categorized based on the surgical approach into two groups: a subxiphoid uniportal VATS thymectomy (SUVT) group and a subxiphoid and subcostal arch VATS thymectomy (SASAT) group. Comparisons were made between the two groups regarding surgical duration, intraoperative blood loss, postoperative drainage, thymoma size and location, and postoperative pain assessed using the visual analogue scale (VAS). Results The SUVT group consisted of 20 patients, including 11 males and 9 females, with an average age of (51.5±14.3) years. The SASAT group comprised 40 patients, with 26 males and 14 females, with an average age of (50.0±13.0) years. Compared to the SASAT group, the SUVT group had significantly larger thymomas [ (5.9±2.7) cm vs. (4.2±2.1) cm, P=0.010] and a higher proportion of neoplasms located in the superior mediastinum (30.0% vs. 2.5%, P=0.007). Additionally, the VAS pain scores on postoperative days 3, 7, and 30 were significantly lower in the SUVT group compared to the SASAT group (P<0.05). There were no statistical differences between the two groups in demographic characteristics, operative time, intraoperative blood loss, duration and volume of postoperative drainage, length of postoperative hospital stay, or the VAS pain score on the first postoperative day. Conclusion Subxiphoid uniportal VATS thymectomy using a double sternum retractor significantly reduces postoperative pain and provides superior efficacy in the resection of larger thymomas or those situated in the superior mediastinum.

1.	Travis WD, Brambilla E, Burke AP, et al. Introduction to the 2015 World Health Organization classification of tumors of the lung, pleura, thymus, and heart. J Thorac Oncol, 2015, 10(9): 1240-1242.
2.	Álvarez-Velasco R, Gutiérrez-Gutiérrez G, Trujillo JC, et al. Clinical characteristics and outcomes of thymoma-associated myasthenia gravis. Eur J Neurol, 2021, 28(6): 2083-2091.
3.	Scorsetti M, Leo F, Trama A, et al. Thymoma and thymic carcinomas. Crit Rev Oncol Hematol, 2016, 99: 332-50.99-332.
4.	Predina JD, Keating J, Newton A, et al. A clinical trial of intraoperative near-infrared imaging to assess tumor extent and identify residual disease during anterior mediastinal tumor resection. Cancer, 2019, 125(5): 807-817.
5.	Dhamija A, Kakuturu J, Hayanga JWA, et al. Difficult decisions in minimally invasive surgery of the thymus. Cancers (Basel), 2021, 13(23): 5887.
6.	Raza A, Woo E. Video-assisted thoracoscopic surgery versus sternotomy in thymectomy for thymoma and myasthenia gravis. Ann Cardiothorac Surg, 2016, 5(1): 33-37.
7.	Nakagiri T, Inoue M, Shintani Y, et al. Improved procedures and comparative results for video-assisted thoracoscopic extended thymectomy for myasthenia gravis. Surg Endosc, 2015, 29(9): 2859-2865.
8.	赵金兰, 陈蔚洋, 何春梅, 等. “天平拉钩抬高胸骨法”在经剑突下单孔胸腔镜辅助前纵隔肿物切除术中的应用. 中国胸心血管外科临床杂志, 2024: 1-5.Zhao JL, Chen WY, He CM, et al. Application of "balance-shaped sternal elevation device" in the subxiphoid uniportalvideo-assisted thoracoscopic surgery for anterior mediastinal masses resection. Chin J Clin Thorac Cardiovasc Surg, 2024: 1-5.
9.	Chen X, Ma Q, Wang X, et al. Subxiphoid and subcostal thoracoscopic surgical approach for thymectomy. Surg Endosc, 2021, 35(9): 5239-5246.
10.	唐焕雨, 黄桁, 姜凯元, 等. 胸腺上皮性肿瘤手术治疗研究进展. 国际肿瘤学杂志, 2020, 47(11): 691-694.Tang HY, Huang H, Jiang KY, et al. Research progress in the surgical treatment of thymic epithelial tumors. Int J Oncol, 2020, 47(11): 691-694.
11.	梁少杰, 李德冰, 路遥, 等. 剑突下与侧胸入路胸腔镜手术治疗胸腺瘤效果的Meta分析. 安徽医药, 2021, 25(9): 1701-1707.Liang SJ, Li DB, Lu Y, et al. Meta-analysis of the efficacy of subxiphoid and lateral thoracoscopic surgery for thymoma. Anhui Med Pharm J, 2021, 25(9): 1701-1707.
12.	Zhang L, Li M, Jiang F, et al. Subxiphoid versus lateral intercostal approaches thoracoscopic thymectomy for non-myasthenic early-stage thymoma: A propensity score -matched analysis. Int J Surg, 2019, 67: 13-17.
13.	Kido T, Hazama K, Inoue Y, et al. Resection of anterior mediastinal masses through an infrasternal approach. Ann Thorac Surg, 1999, 67(1): 263-265.
14.	Suda T. Single-port thymectomy using a subxiphoid approach-surgical technique. Ann Cardiothorac Surg, 2016, 5(1): 56-58.
15.	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.
16.	Ren Y, Zhu X, Yan H, et al. Cardiorespiratory impact of intrathoracic pressure overshoot during artificial carbon dioxide pneumothorax: A randomized controlled study. BMC Anesthesiol, 2022, 22(1): 76.
17.	Mas A, Saura P, Joseph D, et al. Effect of acute moderate changes in PaCO₂ on global hemodynamics and gastric perfusion. Crit Care Med, 2000, 28(2): 360-365.
18.	Zielinski M, Czajkowski W, Gwozdz P, et al. Resection of thymomas with use of the new minimally-invasive technique of extended thymectomy performed through the subxiphoid-right video-thoracoscopic approach with double elevation of the sternum. Eur J Cardiothorac Surg, 2013, 44(2): e113-e119.
19.	Song N, Li Q, Aramini B, et al. Double sternal elevation subxiphoid versus uniportal thoracoscopic thymectomy associated with superior clearance for stage Ⅰ-Ⅱ thymic epithelial tumors: Subxiphoid thymectomy compared with VATS. Surgery, 2022, 172(1): 371-378.
20.	张程程, 吴亮, 范江. 治疗重症肌无力的新术式—剑突下双拉钩胸腔镜下胸腺扩大切除术. 中国临床新医学, 2023, 16(6): 547-551.Zhang CC, Wu L, Fan J, et al. A new surgical approach for myasthenia gravis: Subxiphoid double-hook thoracoscopic extended thymectomy. China Clin New Med, 2023, 16(6): 547-551.
21.	de Perrot M, McRae K. Evidence for thymectomy in myasthenia gravis: Getting stronger? J Thorac Cardiovasc Surg, 2017, 154(1): 314-316.
22.	Tian W, Li X, Tong H, et al. Surgical effect and prognostic factors of myasthenia gravis with thymomas. Thorac Cancer, 2020, 11(5): 1288-1296.

1. Travis WD, Brambilla E, Burke AP, et al. Introduction to the 2015 World Health Organization classification of tumors of the lung, pleura, thymus, and heart. J Thorac Oncol, 2015, 10(9): 1240-1242.
2. Álvarez-Velasco R, Gutiérrez-Gutiérrez G, Trujillo JC, et al. Clinical characteristics and outcomes of thymoma-associated myasthenia gravis. Eur J Neurol, 2021, 28(6): 2083-2091.
3. Scorsetti M, Leo F, Trama A, et al. Thymoma and thymic carcinomas. Crit Rev Oncol Hematol, 2016, 99: 332-50.99-332.
4. Predina JD, Keating J, Newton A, et al. A clinical trial of intraoperative near-infrared imaging to assess tumor extent and identify residual disease during anterior mediastinal tumor resection. Cancer, 2019, 125(5): 807-817.
5. Dhamija A, Kakuturu J, Hayanga JWA, et al. Difficult decisions in minimally invasive surgery of the thymus. Cancers (Basel), 2021, 13(23): 5887.
6. Raza A, Woo E. Video-assisted thoracoscopic surgery versus sternotomy in thymectomy for thymoma and myasthenia gravis. Ann Cardiothorac Surg, 2016, 5(1): 33-37.
7. Nakagiri T, Inoue M, Shintani Y, et al. Improved procedures and comparative results for video-assisted thoracoscopic extended thymectomy for myasthenia gravis. Surg Endosc, 2015, 29(9): 2859-2865.
8. 赵金兰, 陈蔚洋, 何春梅, 等. “天平拉钩抬高胸骨法”在经剑突下单孔胸腔镜辅助前纵隔肿物切除术中的应用. 中国胸心血管外科临床杂志, 2024: 1-5.Zhao JL, Chen WY, He CM, et al. Application of "balance-shaped sternal elevation device" in the subxiphoid uniportalvideo-assisted thoracoscopic surgery for anterior mediastinal masses resection. Chin J Clin Thorac Cardiovasc Surg, 2024: 1-5.
9. Chen X, Ma Q, Wang X, et al. Subxiphoid and subcostal thoracoscopic surgical approach for thymectomy. Surg Endosc, 2021, 35(9): 5239-5246.
10. 唐焕雨, 黄桁, 姜凯元, 等. 胸腺上皮性肿瘤手术治疗研究进展. 国际肿瘤学杂志, 2020, 47(11): 691-694.Tang HY, Huang H, Jiang KY, et al. Research progress in the surgical treatment of thymic epithelial tumors. Int J Oncol, 2020, 47(11): 691-694.
11. 梁少杰, 李德冰, 路遥, 等. 剑突下与侧胸入路胸腔镜手术治疗胸腺瘤效果的Meta分析. 安徽医药, 2021, 25(9): 1701-1707.Liang SJ, Li DB, Lu Y, et al. Meta-analysis of the efficacy of subxiphoid and lateral thoracoscopic surgery for thymoma. Anhui Med Pharm J, 2021, 25(9): 1701-1707.
12. Zhang L, Li M, Jiang F, et al. Subxiphoid versus lateral intercostal approaches thoracoscopic thymectomy for non-myasthenic early-stage thymoma: A propensity score -matched analysis. Int J Surg, 2019, 67: 13-17.
13. Kido T, Hazama K, Inoue Y, et al. Resection of anterior mediastinal masses through an infrasternal approach. Ann Thorac Surg, 1999, 67(1): 263-265.
14. Suda T. Single-port thymectomy using a subxiphoid approach-surgical technique. Ann Cardiothorac Surg, 2016, 5(1): 56-58.
15. 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.
16. Ren Y, Zhu X, Yan H, et al. Cardiorespiratory impact of intrathoracic pressure overshoot during artificial carbon dioxide pneumothorax: A randomized controlled study. BMC Anesthesiol, 2022, 22(1): 76.
17. Mas A, Saura P, Joseph D, et al. Effect of acute moderate changes in PaCO₂ on global hemodynamics and gastric perfusion. Crit Care Med, 2000, 28(2): 360-365.
18. Zielinski M, Czajkowski W, Gwozdz P, et al. Resection of thymomas with use of the new minimally-invasive technique of extended thymectomy performed through the subxiphoid-right video-thoracoscopic approach with double elevation of the sternum. Eur J Cardiothorac Surg, 2013, 44(2): e113-e119.
19. Song N, Li Q, Aramini B, et al. Double sternal elevation subxiphoid versus uniportal thoracoscopic thymectomy associated with superior clearance for stage Ⅰ-Ⅱ thymic epithelial tumors: Subxiphoid thymectomy compared with VATS. Surgery, 2022, 172(1): 371-378.
20. 张程程, 吴亮, 范江. 治疗重症肌无力的新术式—剑突下双拉钩胸腔镜下胸腺扩大切除术. 中国临床新医学, 2023, 16(6): 547-551.Zhang CC, Wu L, Fan J, et al. A new surgical approach for myasthenia gravis: Subxiphoid double-hook thoracoscopic extended thymectomy. China Clin New Med, 2023, 16(6): 547-551.
21. de Perrot M, McRae K. Evidence for thymectomy in myasthenia gravis: Getting stronger? J Thorac Cardiovasc Surg, 2017, 154(1): 314-316.
22. Tian W, Li X, Tong H, et al. Surgical effect and prognostic factors of myasthenia gravis with thymomas. Thorac Cancer, 2020, 11(5): 1288-1296.

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