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The short and long-term effects of open vs minimally invasive thymectomy in myasthenia gravis patients: a systematic review and meta-analysis

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Abstract

Objective

Thymectomy has been utilized as a treatment for Myasthenia Gravis (MG) for many decades, with both open and minimally invasive surgical (MIS) techniques currently used. Although MIS has shown improved short-term results, long-term effects remain uncertain. This systematic review and meta-analysis aim to compare the post-operative and long-term outcomes of MIS versus open thymectomy in MG patients.

Methods

MEDLINE, EMBASE and CENTRAL databases were searched from inception till January 2022 for keywords related to MG and open or MIS thymectomy. Primary outcome was complete stable remission (CSR), and secondary outcomes were clinical improvement, complications, length of stay, operation time, and blood loss. Grading of recommendations, assessment, development, and evaluation was used to assess the certainty of evidence.

Results

26 studies with 3588 patients were included in the analysis. At 1, 3 and 5 years, there was no statistical difference noted in CSR between open versus MIS thymectomy. However, CSR was improved at 1 year for MIS thymectomy in non-thymomatous MG (P = 0.03). There was no significant difference in rates of partial clinical improvement between techniques at 1-year. Although analyses on length of hospital stay and blood loss showed improvement following MIS thymectomy, operative time was shorter for open thymectomy.

Conclusion

This is the first systematic review and meta-analysis assessing long-term effects of MIS versus open thymectomy in MG patients. Given the lack of significant differences noted, either MIS or open thymectomy can be performed, based on surgeon preference. Further high-level, long-term research should be conducted to determine the benefit of each technique.

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Authors and Affiliations

  1. Department of General Surgery, McMaster University, Hamilton, ON, Canada

    Yung Lee & Tyler McKechnie

  2. Department of Thoracic Surgery, McMaster University, Hamilton, ON, Canada

    Yasith Samarasinghe, Janhavi Patel, Christian Finley, Wael Hanna, Yaron Shargall & John Agzarian

  3. Faculty of Medicine, University of Toronto, Toronto, ON, Canada

    Adree Khondker

  4. Department of General Surgery, University of British Columbia, Vancouver, BC, Canada

    Nadeesha Samarasinghe

  5. Division of Thoracic Surgery, Department of Surgery, McMaster University, 50 Charlton Avenue East T-2105, Hamilton, ON, L8N 4A6, Canada

    John Agzarian

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Yung Lee, Yasith Samarasinghe, Janhavi Patel, Adree Khondker, Tyler McKechnie, Nadeesha Samarasinghe, Christian Finley, Wael Hanna, Yaron Shargall, and John Agzarian have no conflicts of interest or financial ties to disclose.

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Supplementary file1 (DOCX 13 KB)

464_2022_9757_MOESM2_ESM.jpg

Supplementary Figure 1: Subgroup analysis of 5-year complete stable remission with non thymomatous only population. (JPG 164 KB)

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Supplementary Figure 2: (A) Forest plot illustrating subgroup analysis of 1-year clinical improvement with non thymomatous only population (B) Forest plot illustrating unchanged or worsened disease status with non-thymomatous only population. (JPG 320 KB)

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Supplementary Figure 3: Forest plot illustrating random effects meta-analysis of the mean difference in hospital length of stay (days) between minimally invasive surgery and open thymectomy. (JPG 410 KB)

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Supplementary Figure 4: Forest plot illustrating random effects meta-analysis of the mean difference in blood loss (mL) between minimally invasive surgery and open thymectomy. (JPG 333 KB)

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Supplementary Figure 5: Forest plot illustrating random effects meta-analysis of the mean difference in operation time (minutes) between minimally invasive surgery and open thymectomy. (JPG 460 KB)

464_2022_9757_MOESM7_ESM.jpg

Supplementary Figure 6: Forest plot illustrating subgroup analysis of the mean difference in hospital length of stay (days) between minimally invasive surgery and open thymectomy separated by thymomatous only, and non-thymomatous only population. (JPG 402 KB)

464_2022_9757_MOESM8_ESM.jpg

Supplementary Figure 7: Forest plot illustrating subgroup analysis of the mean difference in blood loss (mL) between minimally invasive surgery and open thymectomy separated by thymomatous only, and non-thymomatous only population. (JPG 390 KB)

464_2022_9757_MOESM9_ESM.jpg

Supplementary Figure 8: Forest plot illustrating subgroup analysis of the mean difference in operation time (minutes) between minimally invasive surgery and open thymectomy separated by thymomatous only, and non-thymomatous only population. (JPG 463 KB)

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Supplementary Figure 9: Forest plot illustrating random effects meta-analysis comparing the incidence of operative or post-operative complications in minimally invasive surgery versus open thymectomy. (JPG 276 KB)

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Supplementary Figure 10: Forest plot illustrating random effects meta-analysis comparing the incidence of operative or post-operative complications in minimally invasive surgery versus open thymectomy with non-thymomatous only population (JPG 186 KB)

Supplementary file12 (DOCX 60 KB)

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Lee, Y., Samarasinghe, Y., Patel, J. et al. The short and long-term effects of open vs minimally invasive thymectomy in myasthenia gravis patients: a systematic review and meta-analysis. Surg Endosc 37, 3321–3339 (2023). https://doi.org/10.1007/s00464-022-09757-y

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