VATS Resection of Anterior Mediastinal Disease: Superiority of Subxiphoid Approach Comparing to Lateral Intercostal Approach

Abstract Background & Aim: Optimal approaches for video-assisted thoracoscopic surgery (VATS) resection of anterior mediastinal diseases remain controversial. The present study was designed to compare subxiphoid approach with lateral intercostal approach, together with perioperative indices.Methods: Patients diagnosed with anterior mediastinal diseases between January 1, 2018 and October 31, 2019 were prospectively randomly assigned to two groups, to receive lateral intercostal approach vs. subxiphoid approach for VATS resection. Intraoperation PaCO2, SaO2, PaO2 and circulation changes were recorded. Perioperative outcomes, including clinical and surgical parameters such as operation time and blood loss, postoperative complication, neutrophil-to-lymphocyte ratio, and postoperative pain scores were compared. Results: A total 59 patients diagnosed with anterior mediastinal tumors or myasthenia gravis underwent VATS resection. 31 patients treated with subxiphoid approach and 28 patients treated with lateral intercostal approach had comparable baseline characteristics. Intraoperation PaCO2 was increased significantly whereas SaO2 remained stable in subxiphoid group. By contrast, PaCO2 was increased significantly whereas SaO2 was decreased in lateral intercostal group, and operations were more frequently interrupted due to hypoxia or circulation disturbance during thymus dissection in the lateral intercostal approach. Compared with lateral intercostal group, patients in subxiphoid group experienced less inflammation reaction, while yielded lower pain scores and shorter postoperative hospital stay. There were no significant differences in postoperative complications between the two groups. All these patients recovered well when discharged. There were no perioperative deaths. Conclusion: Subxiphoid approach may influence pulmonary and circulation lesser than lateral intercostal approach. Procedure may be safer and easier for subxiphoid approach, as an ideal choice for anterior mediastinal diseases.