From the Division of Thoracic Surgery (P.S.-P., J.B., W.T., J.B.S.), Department of Cardiothoracic Surgery, Stanford University School of Medicine, CA; Knowledge and Evaluation Research Unit (P.S.-P., E.L.-N., L.P., O.J.P.), Mayo Clinic, Rochester, MN; Universidad Central (E.L.-N.), Medical School, Quito, Ecuador; Unidad de Conocimiento y Evidencia (O.J.P.), Universidad Peruana Cayetano Heredia, Lima, Perú; and Department of Surgery (J.B.S.), Veterans Affair Palo Alto Health Care System, CA.
Neurology. 2021 Jul 27;97(4):e357-e368. doi: 10.1212/WNL.0000000000012153. Epub 2021 May 4.
To determine whether the available operative techniques for thymectomy in myasthenia gravis (MG) confer variable chances for achieving complete stable remission (CSR), we performed a meta-analysis of comparative studies of surgical approaches to thymectomy.
Meta-analysis was done of all studies providing comparative data on thymectomy approaches, with CSR reported and minimum 3-year mean follow-up.
Twelve cohort studies and 1 randomized clinical trial, containing 1,598 patients, met entry criteria. At 3 years, CSR from MG was similar after video-assisted thoracoscopic (VATS) extended vs both basic (relative risk [RR] 1.00, = 1.00, 95% confidence interval [CI] 0.39-2.58) and extended (RR 0.96, = 0.74, 95% CI 0.72-1.27) transsternal approaches. CSR at 3 years was also similar after extended transsternal vs combined transcervical-subxiphoid (RR 1.08, = 0.62, 95% CI 0.8-1.44) approaches. VATS extended approaches remained statistically equivalent to extended transsternal approaches through 9 years of follow-up (RR 1.51, = 0.05, 95% CI 0.99-2.30). The only significant difference in CSR rate between a traditional open and a minimally invasive approach was seen at 10 years when the now-abandoned basic (non-sternum-lifting) transcervical approach was compared to the extended transsternal approach (RR 0.4, = 0.01, 95% CI 0.2-0.8).
A significant difference in the rate of CSR among various surgical approaches for thymectomy in MG was identified only at long-term follow-up and only between what might be considered the most aggressive approach (extended transsternal thymectomy) and the least aggressive approach (basic transcervical thymectomy). Extended minimally invasive approaches appear to have CSR rates equivalent to those of extended transsternal approaches and are therefore appropriate in the hands of experienced surgeons.
为了确定重症肌无力（MG）胸腺切除术的现有手术技术是否会导致完全稳定缓解（CSR）的机会不同，我们对胸腺切除术手术方法的比较研究进行了荟萃分析。
对所有提供了关于胸腺切除术方法的比较数据并报告了 CSR 且随访时间至少为 3 年的研究进行了荟萃分析。
符合纳入标准的有 12 项队列研究和 1 项随机临床试验，共包含 1598 例患者。3 年时，视频辅助胸腔镜（VATS）扩大与基本（相对风险 [RR] 1.00， = 1.00，95%置信区间 [CI] 0.39-2.58）和扩大（RR 0.96， = 0.74，95% CI 0.72-1.27）经胸骨胸腺切除术相比，CSR 相似。3 年时，扩大经胸骨胸腺切除术与经颈锁骨下联合（RR 1.08， = 0.62，95% CI 0.8-1.44）方法相比，CSR 也相似。通过 9 年的随访，VATS 扩大方法与经胸骨扩大方法在统计学上仍然等效（RR 1.51， = 0.05，95% CI 0.99-2.30）。在长达 10 年的随访中，传统开放与微创方法在 CSR 率方面的唯一显著差异是在现在已被放弃的基本（非胸骨提升）经颈方法与扩大经胸骨方法相比时观察到的（RR 0.4， = 0.01，95% CI 0.2-0.8）。
仅在长期随访中并且仅在最具侵袭性的方法（扩大经胸骨胸腺切除术）和侵袭性最小的方法（基本经颈胸腺切除术）之间，才能确定重症肌无力患者胸腺切除术各种手术方法之间 CSR 率的显著差异。扩展的微创手术方法似乎具有与扩展经胸骨方法相当的 CSR 率，因此在经验丰富的外科医生手中是合适的。
