Minimally Invasive Thymectomy and Open Thymectomy: Outcome Analysis of 263 Patients

doi:10.1016/j.athoracsur.2012.04.097

The Annals of Thoracic Surgery

Volume 94, Issue 3, September 2012, Pages 974-982

Presented at the Forty-eighth Annual Meeting of The Society of Thoracic Surgeons, Fort Lauderdale, FL, Jan 28–Feb 1, 2012.

https://doi.org/10.1016/j.athoracsur.2012.04.097 Get rights and content

Background

An open thymectomy is a morbid procedure. If a minimally invasive thymectomy is performed without compromising the tenets of thymic surgery, it has the potential for decreasing morbidity and may offer similar clinical and oncologic results.

Methods

This is an institutional review board–approved, retrospective study of a single center's experience with both open (transsternal) and minimally invasive (video-assisted thoracoscopic surgery) thymectomy. Survival estimates and statistical comparisons were calculated using standard software.

Results

From 2000 to 2011, 263 patients (93 men; median age, 49 years; interquartile range, 37 to 60 years) underwent thymectomy for indications including myasthenia gravis (n = 139) and mediastinal mass (n = 108). Seventy-seven thymectomies were performed by minimally invasive approach. Both groups were equally stratified by sex, body mass index, World Health Organization and Masaoka-Koga staging, incidence of myasthenia gravis, and comorbidities except hyperlipidemia and diabetes. The minimally invasive thymectomy cohort had significantly shorter hospital (p < 0.01) and intensive care unit lengths of stay (p < 0.01) and a lower estimated blood loss (p < 0.01). There was an insignificant difference in postoperative cardiac and respiratory complication rates as well as vocal cord paralysis (p = 0.60). There was no difference in terms of operative room times (p = 0.88) or volume of blood products transfused (p = 0.16) between the two groups. Higher estimated blood loss was associated with higher intensive care unit admission rates (p < 0.01). All minimally invasive thymoma resections were complete, with negative margins.

Conclusions

Minimally invasive thymectomy is safe and achieves a comparable resection and postoperative complication profile when used selectively for all indications, including myasthenia gravis and small thymomas without vascular invasion.

Section snippets

Material and Methods

This is a single-center, institutional review board–approved, retrospective study of all the adult patients who underwent a thymectomy from January 2000 through December 2011.

Patient Characteristics

Of the 263 patients (median age, 49 years; interquartile range, 37 to 60 years) included in the study, 93 (35%) were men. An OT was performed in 186 patients (71%), including 6 conversions from minimally invasive to an open technique. The OT and MIT cohorts were equally stratified in terms of sex (p = 0.36), body mass index (p = 0.77), World Health Organization and Masaoka-Koga staging (p = 0.50), and incidence of myasthenia gravis (p = 0.78). A comparison of all patients demonstrated a female

Comment

Although a century has passed since the first reported thymectomy, there is still equipoise regarding one standard technique for the removal of the thymus gland. Minimally invasive procedures have gained in popularity for patients with nonthymomatous myasthenia gravis. However, the adoption of this approach as the mainstay of therapy in patients with a suspicious mediastinal mass has yet to be widely accepted. It is generally believed that an open sternotomy is required to treat malignant

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We retrospectively included patients who underwent extended resection of locally advanced, nonmetastatic thymic malignancies at our institution. Patients were deemed eligible for resection by a multidisciplinary team. During surgery, priority was given to achieving complete resection rather than to sparing organs.
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In an expert center, extended resection targeting complete resection rather than organ preservation provided good outcomes in patients with locally advanced thymic malignancies. The risk/benefit ratio of surgery should be assessed with special care in patients who are elderly or have myasthenia gravis.
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Mature mediastinal teratomas can rarely become symptomatic after a compression of surrounding organs and a rupture and are often treated with an emergency open approach such as median sternotomy. Clinical significance of thoracoscopic approach as elective setting is unknown.
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Surgical, Radiation, and Systemic Treatments of Patients With Thymic Epithelial Tumors: A Systematic Review
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A total of 106 studies were included, mainly from observational studies. There was an overall survival benefit with postoperative radiotherapy for patients with thymic carcinoma (hazard ratio = 0.65, 95% confidence interval: 0.47–0.89) and for patients with thymoma (hazard ratio = 0.70, 95% confidence interval: 0.59–0.82), especially for those with a high risk for mortality. Patients with thymic carcinoma or thymoma had a response to chemotherapy. Selection bias affected the results for studies that evaluated neoadjuvant chemotherapy or minimally invasive surgical techniques. Furthermore, the overall survival benefit found for adjuvant chemotherapy may have been confounded by the administration of postoperative radiotherapy.
For patients with thymoma or thymic carcinoma, the literature is of low quality and subject to bias. There were overall survival benefits with postoperative radiotherapy. The results of this systematic review were used to inform treatment recommendations in a clinical practice guideline. Future large-scale prospective studies that control for confounders are needed.
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Subxiphoid-subcostal thoracoscopic thymectomy (ST) is an emerging alternative to transthoracic thoracoscopic thymectomy. Potential advantages of ST are the avoidance of intercostal incisions and visualization of both phrenic nerves in their entirety. We describe our experience with ST and compare our results to our previous experience with transthoracic thoracoscopic thymectomy.
We conducted an institutional review board-exempt retrospective review of all patients who had a minimally invasive thymectomy from August 2008 to October 2021. We excluded patients with a previous sternotomy or radiological evidence of invasion into major vasculature. The ST approach involved 1 subxiphoid port for initial access, 2 subcostal ports on each side, and carbon dioxide insufflation. We used descriptive and comparative statistics on demographic, operative, and postoperative data.
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Original articleGeneral thoracicMinimally Invasive Thymectomy and Open Thymectomy: Outcome Analysis of 263 Patients

Background

Methods

Results

Conclusions

Section snippets

Material and Methods

Patient Characteristics

Comment

J Thorac Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

Myasthenia gravis and tumors of the thymic region: report of a case in which the tumor was removed

Ann Surg

The treatment of myasthenia gravis by removal of the thymus gland

JAMA

The surgery of the thymus gland

Br J Surg

Thymectomy for nonthymomatous myasthenia gravis: a critical analysis

Ann N Y Acad Sci

Thymectomy in myasthenia gravisResults of 662 cases operated upon in 15 years

Eur J Cardiothorac Surg

Follow-up comparison of suprasternal versus transsternal method for thymectomy in myasthenia gravis

Ann N Y Acad Sci

Thymoma and thymic carcinoma

Gen Thorac Cardiovasc Surg

Original article
General thoracic
Minimally Invasive Thymectomy and Open Thymectomy: Outcome Analysis of 263 Patients