Perioperative outcomes and survival of modified subxiphoid video-assisted thoracoscopic surgery thymectomy for T2-3 thymic malignancies: A retrospective comparison study

Objective Our previous study demonstrated that modified subxiphoid VATS thymectomy (mSVT) with an auxiliary sternal retractor is feasible for locally invasive thymic malignancies. This study aimed to compare perioperative and oncological outcomes of mSVT versus median sternotomy thymectomy (MST) for locally advanced thymic malignancies. Methods In total, 221 patients of T2-3 thymic malignancies who underwent mSVT or MST between 2015 and 2020 were enrolled in our prospectively maintained database. A 1:1 propensity score-matching analysis was performed to balance the bias. Surgical difficulty was evaluated by a modified resection index. Perioperative and oncological results were compared between mSVT and MST groups. Results There were 72 patients in each group in the final analysis. Our results showed that the mSVT group had a shorter operative duration (98 vs. 129 min, P<0.001), less blood loss (40 vs.100 mL, P<0.001), shorter drainage duration (3 vs. 5 days, P<0.001), shorter length of hospital stay (5 vs. 6 days, P<0.001) and fewer postoperative complications (5.6% vs. 23.6%; P=0.005). No significant difference was detected in complete resection (98.6% vs. 98.6%, P =0.001) between the two groups. Conversion occurred in 5/106 (4.7%). Survival analyses indicated similar recurrence-free survival (HR=0.94; 95% CI: 0.40-2.20; p=0.883) and overall survival (HR=0.52; 95% CI: 0.05-5.02; p=0.590) between the two groups. Conclusion The mSVT was safe and effective for T2-3 thymic malignancies and could be an alternative for selected patients with locally advanced thymic diseases. Further prospective studies are needed to evaluate the long-term survival of modified subxiphoid approach thoracoscopic thymectomy.