胸腔镜与胸骨劈开胸腺切除术治疗重症肌无力荟萃分析

Meta-analysis of thoracoscopic versus transsternal thymectomy for myasthenia gravis

目的 通过荟萃分析的方法评价胸腔镜胸腺切除术与胸骨劈开胸腺切除术治疗重症肌无力（MG）的效果.方法 检索Pubmed、Embase、Web of Science和OVID-EBMR数据库从建库到2014年3月有关胸腔镜胸腺切除术与胸骨劈开胸腺切除术治疗MG的对比性研究文献,使用RevMan 5.2软件对其中的手术时间、术中出血量、胸腔引流管引流时间、术后住院时间、肌无力危象发生率、术后总并发症、远期疗效等数据进行荟萃分析.结果 共15篇文献纳入本研究,其中随机对照研究2篇,非随机对照研究13篇.纳入病例1 215例,其中胸腔镜组642例,胸骨劈开组573例.胸腔镜组在术中出血量（WMD=-87.68,95％ CI：-116.05 ～-59.30,P＜0.01）、术后住院时间（WMD=-1.74,95％ CI：-3.08～-0.39,P=0.01）、肌无力危象发生率（OR=0.54,95％ CI：0.30～0.97,P=0.04）方面更有优势;而胸骨劈开组在手术时间（WMD=26.40,95％ CI：21.09～31.71,P＜0.01）、胸管引流时间（WMD=0.21,95％ CI：0.03～ 0.40,P=0.02）方面更有优势;两组在术后总并发症（OR=0.95,95％ CI：0.47～1.92,P=0.88）、MG完全稳定缓解率（OR=0.89,95％ CI：0.66～1.19,P=0.42）和MG改善率（OR=1.38,95％ CI：0.88～2.16,P=0.16）方面的差异无统计学意义.亚组分析显示,完成35例以上的胸腔镜组手术时间与胸骨劈开组相当.合并胸腺瘤虽然增加了胸腔镜手术时间,但胸腔镜手术有利于减少术后肌无力危象的发生.单侧胸腔镜手术以右侧入路为主,在手术时间和术后引流时间方面优于双侧入路且未影响远期疗效.结论 胸腔镜胸腺切除术安全可行,具有术中出血少、术后住院时间短和肌无力危象发生率低的优点,并能达到与胸骨劈开胸腺切除术相同的远期治疗效果.

Objective To assess the efficacy of thoracoscopic thymectomy versus transsternal thymectomy for myasthenia gravis（MG）.Methods Comparative studies of thoracoscopic thymectomy and transsternal thymectomy for MG were collected from Pubmed,Embase,Web of Science and OVID-EBMR databases up to March 2014.The dates of operative duration,blood loss during operation,duration of chest tube drainage,postoperative hospital stay,incidence of myasthenic crisis,overall post-operative morbidity and long-term outcome were analyzed.Meta-analysis was conducted with RevMan 5.2 software.Results Fifteen studies（2 randomized controlled trials and 13 non-randomized studies） were included.These studies included a total of 1215 patients：642 patients were treated with thoracoscopic approach,and 573 patients were treated with transsternal approach.Thoracoscopic group was associated with less blood loss during operation （WMD =-87.68,95% CI：-116.05 to -59.30,P 〈 0.01）,shorter postoperative hospital stay（WMD =-1.74,95% CI：-3.08 to-0.39,P =0.01）,and lower incidence of myasthenic crisis（OR =0.54,95% CI：0.30 to 0.97,P =0.04）.Transsternal group was associated with a shorter operative duration（WMD=26.40,95%CI：21.09to31.71,P〈0.01） and a shorter duration of chest tube drainage （WMD =0.21,95% CI：0.03 to 0.40,P =0.02）.There were no significant differences between the two groups for overall postoperative morbidity（OR =0.95, 95% CI： 0.47 to 1.92, P =0.88）, complete stable remission of MG（OR =0.89, 95% CI：0.66 to 1.19, P =0.42）, improvement of MG（OR =1.38, 95% CI： 0.88 to 2.16, P =0.16）.Subgroup analysis demonstrated that the difference of operative duration between thoracoscopic and transsternal group was not significant in studies with thoracoscopic cases more than 35.Operative duration was longer with the presence of thymoma in thoracoscopic group, but patients benefited in term of myasthenic crisis.Unilateral thoracoscopic surgery, mainly performed by right-side approach, was superior to bilateral approach in terms of operative duration and postoperative drainage time without affecting long-term results.Conclusion As a safe and practical procedure with less blood loss during operation, shorter postoperative hospitalization and lower incidence of myasthenic crisis, thoracoscopic thymectomy also offer satisfactory long-term outcomes comparable to those of conventional transsternal approach.A learning curve for thoracoscopic thymectomy exist in this series, and the surgeon become more proficient after about 35 cases and is able to perform the procedure with decreased operative time.