Department of Thoracic Surgery, the Second Hospital of Jilin University, Jilin, China.
Jilin Provincial Key Laboratory on Molecular and Chemical Genetics, Kun Zhang, The Second Hospital of Jilin University, 130041, Changchun, Jilin, China.
BMC Cancer. 2024 Jan 17;24(1):92. doi: 10.1186/s12885-024-11832-7.
The efficacy and safety of subxiphoid thoracoscopic thymectomy (SVATS) for early thymoma are unknown. The purposes of this meta-analysis were to evaluate the effectiveness and safety of SVATS for early thymoma, to compare it with unilateral intercostal approach video thoracoscopic surgery (IVATS) thymectomy, and to investigate the clinical efficacy of modified subxiphoid thoracoscopic thymectomy (MSVATS) for early anterior mediastinal thymoma.
Original articles describing subxiphoid and unilateral intercostal approaches for thoracoscopic thymectomy to treat early thymoma published up to March 2023 were searched from PubMed, Embase, and the Cochrane Library. Standardized mean differences (SMDs) and 95% confidence intervals (CIs) were calculated and analyzed for heterogeneity. Clinical data were retrospectively collected from all Masaoka stage I and II thymoma patients who underwent modified subxiphoid and unilateral intercostal approach thoracoscopic thymectomies between September 2020 and March 2023. The operative time, intraoperative bleeding, postoperative drainage, extubation time, postoperative hospital stay, postoperative visual analog pain score (VAS), and postoperative complications were compared, and the clinical advantages of the modified subxiphoid approach for early-stage anterior mediastinal thymoma were analyzed.
A total of 1607 cases were included in the seven studies in this paper. Of these, 591 cases underwent SVATS thymectomies, and 1016 cases underwent IVATS thymectomies. SVATS thymectomy was compared with IVATS thymectomy in terms of age (SMD = - 0.09, 95% CI: -0.20 to - 0.03, I = 20%, p = 0.13), body mass index (BMI; SMD = - 0.10, 95% CI: -0.21 to - 0.01, I = 0%, p = 0.08), thymoma size (SMD = - 0.01, 95% CI: -0.01, I = 0%, p = 0.08), operative time (SMD = - 0.70, 95% CI: -1.43-0.03, I = 97%, p = 0.06), intraoperative bleeding (SMD = - 0.30. 95% CI: -0.66-0.06, I = 89%, p = 0.10), time to extubation (SMD = - 0.34, 95%CI: -0.73-0.05, I = 91%, p = 0.09), postoperative hospital stay (SMD = - 0.40, 95% CI: -0.93-0.12, I = 93%, p = 0.13), and postoperative complications (odds ratio [OR] = 0.94, 95% CI: 0.42-2.12, I = 57%, p = 0.88), which were not statistically significantly different between the SVATS and IVATS groups. However, the postoperative drainage in the SVATS group was less than that in the IVATS group (SMD = - 0.43, 95%CI: -0.84 to - 0.02, I = 88%, p = 0.04), and the difference was statistically significant. More importantly, the postoperative VAS was lower in the SVATS group on days 1 (SMD = - 1.73, 95%CI: -2.27 to - 1.19, I = 93%, p < 0.00001), 3 (SMD = - 1.88, 95%CI: -2.84 to - 0.81, I = 97%, p = 0.0005), and 7 (SMD = - 1.18, 95%CI: -2.28 to - 0.08, I = 97%, p = 0.04) than in the IVATS group, and these differences were statistically significant. A total of 117 patients undergoing thoracoscopic thymectomy for early thymoma in the Department of Thoracic Surgery of the Second Hospital of Jilin University were retrospectively collected and included in the analysis, for which a modified subxiphoid approach was used in 42 cases and a unilateral intercostal approach was used in 75 cases. The differences between the two groups (MSVATS vs. IVATS) in general clinical characteristics such as age, sex, tumor diameter, Masaoka stage, Word Health Organization (WHO) stage, and intraoperative and postoperative conditions, including operative time, postoperative drainage, extubation time, postoperative hospital stay, and postoperative complication rates, were not statistically significant (p > 0.05), while BMI, intraoperative bleeding, and VAS on postoperative days 1, 3, and 7 were all statistically significant (p < 0.05) in the MSVATS group compared with the IVATS group.
The meta-analysis showed that the conventional subxiphoid approach was superior in terms of postoperative drainage and postoperative VAS pain scores compared with the unilateral intercostal approach. Moreover, the modified subxiphoid approach had significant advantages in intraoperative bleeding and postoperative VAS pain scores compared with the unilateral intercostal approach. These results indicate that MSVATS can provide more convenient operation conditions, a better pleural cavity view, and a more complete thymectomy in the treatment of early thymoma, indicating that is a safe and feasible minimally invasive surgical method.
胸腹腔镜胸腺切除术（SVATS）治疗早期胸腺瘤的疗效和安全性尚不清楚。本研究的目的是评估 SVATS 治疗早期胸腺瘤的有效性和安全性，将其与单侧肋间入路胸腔镜胸腺切除术（IVATS）进行比较，并探讨改良剑突下入路胸腔镜胸腺切除术（MSVATS）治疗前纵隔早期胸腺瘤的临床疗效。
检索截至 2023 年 3 月 PubMed、Embase 和 Cochrane 图书馆中描述使用剑突下入路和单侧肋间入路行胸腔镜胸腺切除术治疗早期胸腺瘤的原始文献。计算并分析标准化均数差（SMD）和 95%置信区间（CI），以评估异质性。回顾性收集 2020 年 9 月至 2023 年 3 月吉林大学第二医院胸外科行改良剑突下入路和单侧肋间入路胸腔镜胸腺切除术的所有 Masaoka Ⅰ和Ⅱ期胸腺瘤患者的临床资料。比较两组患者的手术时间、术中出血量、术后引流量、拔管时间、术后住院时间、术后视觉模拟疼痛评分（VAS）及术后并发症，分析改良剑突下入路治疗前纵隔早期胸腺瘤的临床优势。
本研究共纳入 7 项研究的 1607 例患者。其中 591 例行 SVATS 胸腺切除术，1016 例行 IVATS 胸腺切除术。与 IVATS 组相比，SVATS 组患者的年龄（SMD=-0.09，95%CI：-0.20 至-0.03，I²=20%，p=0.13）、体质量指数（BMI；SMD=-0.10，95%CI：-0.21 至-0.01，I²=0%，p=0.08）、胸腺瘤大小（SMD=-0.01，95%CI：-0.01，I²=0%，p=0.08）、手术时间（SMD=-0.70，95%CI：-1.43 至 0.03，I²=97%，p=0.06）、术中出血量（SMD=-0.30，95%CI：-0.66 至 0.06，I²=89%，p=0.10）、拔管时间（SMD=-0.34，95%CI：-0.73 至 0.05，I²=91%，p=0.09）、术后住院时间（SMD=-0.40，95%CI：-0.93 至 0.12，I²=93%，p=0.13）及术后并发症（比值比[OR]=0.94，95%CI：0.42 至 2.12，I²=57%，p=0.88）均无统计学差异。然而，SVATS 组患者术后引流量少于 IVATS 组（SMD=-0.43，95%CI：-0.84 至-0.02，I²=88%，p=0.04），差异有统计学意义。更重要的是，SVATS 组患者术后第 1、3 和 7 天的 VAS 评分均低于 IVATS 组（第 1 天：SMD=-1.73，95%CI：-2.27 至-1.19，I²=93%，p<0.00001；第 3 天：SMD=-1.88，95%CI：-2.84 至-0.81，I²=97%，p=0.0005；第 7 天：SMD=-1.18，95%CI：-2.28 至-0.08，I²=97%，p=0.04），差异有统计学意义。吉林大学第二医院胸外科共纳入 117 例行胸腔镜胸腺切除术的早期胸腺瘤患者，其中 42 例行改良剑突下入路，75 例行单侧肋间入路。两组患者的一般临床特征（如年龄、性别、肿瘤直径、Masaoka 分期、WHO 分期以及手术期间和术后的情况，包括手术时间、术后引流量、拔管时间、术后住院时间和术后并发症发生率）差异均无统计学意义（p>0.05），而 BMI、术中出血量和术后第 1、3 和 7 天的 VAS 评分在改良剑突下入路组与单侧肋间入路组之间差异均有统计学意义（p<0.05）。
本研究的荟萃分析显示，与单侧肋间入路相比，常规剑突下入路在术后引流和术后 VAS 疼痛评分方面具有优势。此外，改良剑突下入路在术中出血量和术后 VAS 疼痛评分方面明显优于单侧肋间入路。这些结果表明，MSVATS 可以在治疗早期胸腺瘤时提供更方便的手术条件、更好的胸腔视野和更完整的胸腺切除术，是一种安全可行的微创手术方法。
