Transcervical-subxiphoid-videothoracoscopic “maximal” thymectomy—operative technique and early results

doi:10.1016/j.athoracsur.2004.02.021

The Annals of Thoracic Surgery

Volume 78, Issue 2, August 2004, Pages 404-409

https://doi.org/10.1016/j.athoracsur.2004.02.021 Get rights and content

Abstract

Background

The operative technique of a transcervical-subxiphoid-videothoracoscopic “maximal” thymectomy without sternotomy is described and the early results of the follow-up of patients operated on are analyzed.

Methods

One-hundred “maximal” transcervical-subxiphoid-videothoracoscopic thymectomies were performed for nonthymomatous myasthenia gravis during a recent 32-month period (from September 1, 2000 to May 8, 2003). Patient characteristics, complications, pathologic findings, and the results of follow-up were analyzed.

Results

The study group included 83 women and 17 men. The mean age was 29.8 years (range, 10–69 years). The mean preoperative duration of myasthenia was 2.73 years (range, 3 months to 17 years). The preoperative Osserman score was I–III, 27 patients were taking steroids preoperatively. Eleven operations were performed by two teams working simultaneously and 89 operations were performed by one surgeon including four combined thymectomy-thyroid operations in patients with myasthenia and thyroid nodules. The mean operative time for two-team approach thymectomies was 159.09 minutes (range, 140–170 minutes) and the mean operative time for the thymectomy performed by one surgeon was 199.41 minutes (range, 150–270 minutes) (p = 0.0004). There was a 15.0% (15 out of 100) postoperative morbidity and no mortality. Foci of ectopic thymic tissue were found in 71.0% of the patients and were most prevalent in the perithymic fat (37.0%) and in the aorta-pulmonary window (33.0%). The mean weight of the specimen was 78.4 g (range, 14.5–253.0 g). In 48 patients followed-up for 12 months, the improvement rate was 83.3%, the no improvement rate was 14.6%, and 1 patient died during the follow-up period. Complete remission rates were 18.8% and 32.0% after 1 and 2 years of follow-up, respectively.

Conclusions

We conclude that the “maximal” transcervical-subxiphoid-videothoracoscopic thymectomy is a safe operative technique, avoiding a sternotomy, performed partly in an open fashion with the extensiveness comparable with the transsternal extended and “maximal” thymectomies. The two-team approach helps to reduce the operative time. However, because of the limited time of follow-up it is too early for the final assessment of the long-term results of this method in the treatment of myasthenia gravis.

Section snippets

Material and methods

One-hundred consecutive patients were operated on for nonthymomatous myasthenia gravis with a “maximal” transcervical-subxiphoid-videothoracoscopic thymectomy between September 1, 2000 and May 8, 2003. Our method of thymectomy was approved by the local Bioethical Committee and by the Institutional Review Board. Informed consent was obtained from all patients. No patient was excluded because of any other previous surgery, obesity, or for any other reason. Over the same period the patients

Results

There were 83 women and 17 men. The mean age was 29.8 years (range, 10–69 years). The mean duration of the symptoms of myasthenia gravis before an operation was 2.73 years (range, 3 months to 17 years). There were 3 patients in stage I, 33 patients in stage IIa, 54 patients in stage IIb, 10 patients in stage III, and none in stage IV according to Osserman classification. Twenty-seven patients were taking steroids preoperatively. Eleven operations were performed by two teams working

Comment

The thymectomy has a proven valuable in the treatment of myasthenia, but the extent of the operation is a matter of debate. According to Jaretzki, operative approaches involve the simple transcervical thymectomy, the simple transthoracic thymectomy (through partial or complete median sternotomy or lateral thoracotomy), the extended transcervical thymectomy, the videothoracoscopic thymectomy performed unilaterally from the right or left side or the video-assisted extended thymectomy, the

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Cited by (104)

Subxiphoid Versus Unilateral Video-assisted Thoracoscopic Surgery Thymectomy for Thymomas: A Propensity Score Matching Analysis
2022, Annals of Thoracic Surgery
Citation Excerpt :
The subxiphoid approach to thymectomy was first reported in 1999.15 After that, subxiphoid VATS thymectomy with or without a transcervical incision has been reported that allows the surgeon to visualize both phrenic nerves very clearly and reach high into the anterior mediastinum under direct vision.3,13,16 We began to perform this technique in 2015, using the subxiphoid and subcostal arch incisions described by Zhou and colleagues.17
The appropriate approach for video-assisted thoracoscopic surgery for early stage thymoma remains unclear. The present study aimed to explore the safety and feasibility of subxiphoid and subcostal arch thoracoscopic thymectomy in comparison with unilateral thoracoscopic thymectomy for treatment of early stage thymoma.
The outcomes of 237 patients without myasthenia gravis who had undergone thoracoscopic thymectomy for Masaoka stage I and II thymoma from January 2015 to May 2019 at our center were retrospectively evaluated (subxiphoid and subcostal arch approach, 39; unilateral video-assisted thoracoscopic surgery approach, 198). A propensity score matching analysis was generated to control for selection bias due to nonrandom group assignment in a 1:1 manner.
There was no surgery-related mortality in included patients. Matching of patients according to propensity score resulted in a cohort that consisted of 39 patients in both groups. Patients had similar clinical characteristics in both groups. Compared with patients in the unilateral group, patients in the subxiphoid group yielded lower pain scores at 24 and 72 hours after operation, respectively (P < .01). In addition, the operation time was longer in the subxiphoid group (147.5 ± 43.6 vs 93.2 ± 33.8 minutes, P < .01). There were no significant differences in blood loss, total volume and time of drainage, complications, or postoperative hospital stays between the two groups.
Subxiphoid and subcostal arch thoracoscopic thymectomy for early stage thymoma appears to be a safe and feasible procedure. It is considered to be less invasive as it may cause minimal postoperative pain compared with the unilateral video-assisted thoracoscopic surgery approach.
Modified Subxiphoid Thoracoscopic Thymectomy for Locally Invasive Thymoma
2021, Annals of Thoracic Surgery
We explored the feasibility and safety of modified subxiphoid thoracoscopic thymectomy for patients with locally invasive thymomas.
Subxiphoid thoracoscopic thymectomy was performed on select patients with locally invasive thymomas (Masaoka stage III) using an auxiliary sternal retractor to create a larger operative field.
From June 2015 to March 2019, we performed modified subxiphoid thoracoscopic thymectomy on 48 patients with locally invasive thymomas: 39 patients had pericardium or lung infiltration and received a combination of a partial pericardium or lung wedge resection, and 9 patients had left innominate vein infiltration and underwent combined resection of the left innominate vein. Thoracoscopic thymectomy was performed from the subxiphoid pathway with an auxiliary sternal retractor in all 48 patients, and there were no conversions to median sternotomy. The median tumor size was 5 cm, and the maximal tumor size was 12 cm. The median blood loss was 50 mL. The median duration of chest tube placement was 3 days, and the median hospital stay was 4.5 days after surgery. All patients achieved a good recovery after surgery, and none had serious complications during the perioperative period. All patients underwent postoperative adjuvant radiotherapy and presented no local recurrence or distant metastasis until now.
Modified subxiphoid thoracoscopic thymectomy with an auxiliary sternal retractor makes minimally invasive thymectomy easier and safer to perform and is an alternative approach for some patients with locally invasive thymomas.
Management of Brachiocephalic Vein Injury During Tubeless Subxiphoid Thoracoscopic Thymectomy
2021, Annals of Thoracic Surgery
We have reported the usefulness of the subxiphoid video-assisted thoracoscopic surgery approach in thymectomy. However, such a new method may have unknown complications that rarely occur. The brachiocephalic vein has been considered to be the vessel that is most frequently injured when performing thymectomy because of the skeletal anatomy. We herein report a case of intraoperative injury of brachiocephalic vein using tubeless subxiphoid thoracoscopic thymectomy. No additional complications have been found in the 3 months since the operation. Though subxiphoid video-assisted thoracoscopic surgery thymectomy is a safe and less invasive operation, intraoperative complications are possible, and surgeons should express caution.
Open versus thoracoscopic thymectomy for juvenile myasthenia gravis
2020, Journal of Pediatric Surgery
Juvenile myasthenia gravis (JMG) is an antibody mediated autoimmune disorder that manifests as progressive voluntary muscle weakness and fatigue. In medically refractory cases, thymectomy has been shown to abrogate symptoms and reduce glucocorticoid dependence. While transcervical or transsternal incisions have been the traditional approach, adult trends now favor thoracoscopic thymectomy. Little data exist to support this approach in children.
A retrospective review of all patients younger than 20 years of age who underwent a thymectomy for JMG at two pediatric institutions between 2001 and 2018 was performed. Children were divided into either an open (transcervical or transsternal) or thoracoscopic group and baseline characteristics, perioperative, and postoperative outcomes were compared.
Thirty-four thymectomies were performed during the 18-year study period; 18 via an open and 16 via a thoracoscopic approach. The operative time was shorter for open procedures compared thoracoscopic ones (108 ± 49 and 145 ± 43 min, respectively, p = 0.025). Thoracoscopic thymectomy was associated with less intraoperative blood loss (5.5 ± 6.0 vs 55 ± 67 ml, p = 0.007), decreased duration of postoperative intravenous narcotic use (5.0 ± 1.5 vs 20 ± 23 h, p = 0.018), and a shorter length of hospitalization (1.7 ± 1.0 vs 2.7 ± 1.1 days, p = 0.009). No perioperative complication occurred in either group. Clinical improvement was reported in 94% of children in both groups.
Thoracoscopic thymectomy in children is a safe and effective surgical technique for the treatment of JMG. Increased acceptance of this minimally invasive approach by children, families, and referring neurologists may enable earlier surgical intervention.
Clinical research paper.
III
Clinical study of thoracoscopic assisted different surgical approaches for early thymoma: a meta-analysis
2024, BMC Cancer
Are the minimally invasive techniques the new gold standard in thymus surgery for myasthenia gravis? Experience of a reference single-site in VATS thymectomy
2024, Frontiers in Neurology

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Original article: general thoracicTranscervical-subxiphoid-videothoracoscopic “maximal” thymectomy—operative technique and early results

Abstract

Background

Methods

Results

Conclusions

Section snippets

Material and methods

Results

Comment

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

Ann Thorac Surg

Chest

Ann Thorac Surg

Ann Thorac Surg

Ann Thorac Surg

Ann Thorac Surg

Original article: general thoracic
Transcervical-subxiphoid-videothoracoscopic “maximal” thymectomy—operative technique and early results