Three different surgical methods for large-sized anterior mediastinal tumors in real-world practice

Video-assisted thoracoscopic surgery (VATS) for a relatively large mediastinal tumor (5.0-10.0 cm) remains controversial. In addition, few studies have focused on comparing different surgical approaches for large mediastinal tumors. Therefore, this study aimed to compare the short-term outcomes between subxiphoid approach VATS, intercostal approach VATS, and traditional sternotomy for large-sized anterior mediastinal tumors.

The study consecutively enrolled 159 patients with large-sized anterior mediastinal tumors (5.0-10.0 cm) who received surgery in our hospital between January 2018 and July 2022 (subxiphoid approach VATS: 52 patients, intercostal approach VATS: 70 patients, traditional sternotomy: 37 patients). We analyzed the clinical baseline data, intraoperative and postoperative outcomes, and postoperative complications of all patients. Then the patients were further divided into two groups according to whether there was a peripheral organ (such as pericardium, lung, or left innominate vein) invasion: group A, invasion of the surrounding organ, and group B, no invasion of the surrounding organ. Intraoperative and postoperative outcomes and postoperative complications were also analyzed in group A and group B, respectively.

In all patients, there were significant differences in blood loss (subxiphoid approach: 33.1 ± 46.0 ml, intercostal approach: 36.9 ± 44.1 ml, sternotomy: 113.0 ± 84.9 ml, P < 0.001) and duration of postoperative oral analgesics (subxiphoid approach: 3.4 ± 0.9 d, intercostal approach: 3.7 ± 1.4 d, sternotomy: 4.5 ± 1.5 d, P = 0.002) among the three methods. In group A, there was a significant difference in blood loss (subxiphoid approach: 50.0 ± 67.7 ml, intercostal approach: 90.0 ± 66.6 ml, sternotomy: 157.9 ± 90.2 ml, P < 0.001) among the three methods. In group B, there were significant differences in the duration of postoperative oral analgesics (subxiphoid approach: 3.2 ± 0.8 d, intercostal approach: 3.7 ± 1.4 d, sternotomy: 4.2 ± 1.1 d, P < 0.05) and blood loss (subxiphoid approach: 22.5 ± 19.3 ml, intercostal approach: 31.9 ± 38.5 ml, sternotomy: 65.6 ± 44.9 ml, P < 0.001) between the three methods. There were no significant differences in the postoperative complications.

VATS is an effective, minimally invasive, and safe procedure for large-sized anterior mediastinal tumors (5.0-10.0 cm) without an invasion of the surrounding organs, and maybe a feasible and secure method for large-sized anterior mediastinal tumors with an invasion of the surrounding organ (such as the pericardium, lung, or left innominate vein). Subxiphoid approach VATS is a less invasive procedure than intercostal approach VATS and traditional sternotomy due to its reduced blood loss and postoperative pain.