Impact of the surgical approach to thymectomy upon complete stable remission rates in myasthenia gravis: a meta-analysis

Objectives: To determine whether any of the available operative techniques
confer variable chances for complete stable remission (CSR) in myasthenia
gravis (MG), we performed a meta-analysis of all comparative studies of
surgical approaches. Methods: Meta-analysis of all studies providing
comparative data on thymectomy approaches, with CSR reported and minimum 3
years mean follow-up. Results: 12 cohort studies and one randomized
clinical trial, containing 1598 patients, met entry criteria. At 3 years,
CSR from MG was similar following VATS extended vs. both basic (RR 1.00,
p=1.00, 95% CI 0.39-2.58) and extended (RR 0.96, p=0.74, CI: 0.72-1.27)
transsternal approaches. CSR at 3 years was also similar following
extended transsternal vs. combined transcervical-subxiphoid (RR 1.08,
p=0.62, 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, p=0.05, CI: 0.99-2.30).  The only
significant difference in CSR rate between a traditionally open and a
minimally invasive approach was seen at 10 years when comparing the
now-abandoned basic (non-sternum-lifting) transcervical approach and the
extended transsternal approach (RR 0.4, p=0.01, CI: 0.2-0.8). Conclusions:
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 equivalent CSR rates to extended
transsternal approaches and are therefore appropriate in the hands of
experienced surgeons.