Clinical Outcomes and Technical Approach of Thymectomy in the Veterans Health Administration

• Published in: The Annals of thoracic surgery Vol. 113; no. 5; pp. 1648 - 1655
• Main Authors: Holleran, Timothy J., Napolitano, Michael A., Crowder, Hannah R., Sparks, Andrew D., Antevil, Jared L., Trachiotis, Gregory D.
• Format: Journal Article
• Language: English
• Published: Netherlands Elsevier Inc 01-05-2022
• Subjects: Humans; Retrospective Studies; Thoracic Surgery, Video-Assisted - methods; Thymectomy - methods; Thymus Neoplasms - surgery; Treatment Outcome; Veterans Health; CHF; LOS; VATS; aOR; CI; ICD; VA; VASQIP; VHA
• ISSN: 0003-4975; 1552-6259
• DOI: 10.1016/j.athoracsur.2021.05.020

Thymectomy is traditionally performed through a transsternal incision, but less invasive modalities have emerged, including transcervical, thoracoscopic, and robotic approaches. Despite the advantages of video-assisted thoracoscopic surgery (VATS) over thoracotomy, most thymectomies are performed through sternotomy. This study compared the use and 30-day postoperative outcomes of transsternal, transcervical, and VATS thymectomy in the Veterans Health Administration.
This was a retrospective review of veterans who underwent thymectomy through the Veterans Affairs Surgical Quality Improvement Program. Their 30-day outcomes were compared among techniques, by adjusting for confounding covariates. Temporal trends were analyzed using the Spearman’ rank correlation coefficient, rho(ρ).
From 2008 to 2019, 594 thymectomies were performed: 376 (63.3%) transsternal, 113 (19.0%) VATS (including robotic approaches), and 105 (17.7%) transcervical cases. VATS use increased from 0% in 2008 to 61% of case volume in 2019. Relative to the transsternal technique, VATS thymectomy was associated with decreased odds of pulmonary complications (adjusted odds ratio, 0.06; P = .028) and shorter hospital stay (2.9 ± 0.4 days shorter; P < .001). No difference in outcomes was detected between VATS and transcervical thymectomy. The postoperative complication rate decreased from 17.7% in 2008 to 5.6% in 2019 (ρ = −0.101; P = .014). Length of stay decreased from median 4 days in 2008 to 3 days in 2019 (ρ = −0.093; P = .026). In thymic cancer, VATS 5-year overall survival was noninferior to the transsternal approach (71.3% vs 74.6%; P = .54).
The transsternal approach comprised most thymectomy cases in veterans, whereas VATS thymectomy use increased over time and was associated with favorable outcomes. The 30-day outcomes after thymectomy improved over time, which may reflect a trend toward wider use of less invasive approaches. Future studies should examine long-term outcomes.
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