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

BACKGROUND

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.

METHODS

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).

RESULTS

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).

CONCLUSIONS

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.