剑突下与肋间入路行胸腺扩大切除术治疗重症肌无力的单中心回顾性队列研究

Extended thymectomy for myasthenia gravis via subxiphoid versus intercostal approaches:A retrospective cohort study in a single center

目的分析不同手术入路行胸腺扩大切除术治疗重症肌无力(myasthenia gravis,MG)的疗效,探讨影响MG预后的因素。方法回顾性纳入2014年1月—2021年3月于首都医科大学宣武医院行胸腺扩大切除术患者。根据入路方式,将患者分为剑突下入路组和肋间入路组,比较两组患者的疗效。良好结局定义为完全稳定缓解(complete stable remission,CSR)、药物缓解(pharmacological remission,PR)或微小表现状态(minimal manifestations state,MMS),不良结局定义为比MMS更差的结局。采用单因素和多因素logistic回归分析,探讨MG预后的影响因素。结果共纳入187例MG患者,其中男82例、女105例,中位年龄50.0(36.0,60.0)岁。肋间入路组134例,剑突下入路组53例。与肋间入路组相比,剑突下入路组虽然手术时间更长[200.0(172.0,232.0)min vs.141.0(118.0,169.0)min,P<0.001],但术中出血量更少[10.0(10.0,20.0)mL vs.20.0(10.0,50.0)mL,P<0.001],术后住院时间更短[3.0(2.5,4.0)d vs.5.0(3.0,7.0)d,P<0.001],并发症发生率更低[1(1.9%)vs.26(19.4%),P=0.001]。159例(85.0%)患者进行了随访,中位随访时间46(13,99)个月,良好结局率为90.6%,其中CSR率为33.3%。剑突下入路组的PR、MMS和总良好结局率与肋间入路组相比,差异无统计学意义(P>0.05)。多因素logistic回归分析显示,年龄≤50岁是MG患者预后良好的独立预测因素。结论剑突下入路胸腺扩大切除术治疗MG是一种安全可行且有效的手术方式。

Objective To analyze the clinical outcomes of extended thymectomy for myasthenia gravis(MG)patients under different surgical approaches,and to determine the factors affecting the prognosis of MG.Methods The MG patients who underwent extended thymectomy from January 2014 to March 2021 in our hospital were retrospectively collected.According to the surgical approach,they were divided into a subxiphoid group and an intercostal group,and the perioperative results and prognosis were compared between the two groups.A“good outcome”was defined as complete stable remission(CSR),pharmacological remission(PR)or minimal manifestations state(MMS);a“poor outcome”was defined as outcomes worse than MMS.Univariate and multivariate logistic regression analyses were performed to assess the factors associated with the good outcomes.Results A total of 187 MG patients were included in the study,including 82 males and 105 females,with a median age of 50(36,60)years.There were 134 patients in the intercostal group and 53 patients in the subxiphoid group.Compared with the intercostal group,although the operation time of the subxiphoid group was longer[200.0(172.0,232.0)min vs.141.0(118.0,169.0)min,P<0.001],the intraoperative blood loss was less[10.0(10.0,20.0)mL vs.20.0(10.0,50.0)mL,P<0.001],the postoperative hospital stay was shorter[3.0(2.5,4.0)d vs.5.0(3.0,7.0)d,P<0.001],and the incidence of complications was lower[1(1.9%)vs.26(19.4%),P=0.001].A total of 159(85.0%)patients were followed up for a median period of 46(13,99)months,with a good outcome rate of 90.6%and CSR rate of 33.3%.There were no statistical differences in PR,MMS or overall good outcome rates between the two groups(P>0.05).Multivariate logistic analysis showed that age≤50 years was an independent predictor for"good outcome"of MG patients.Conclusion Extended thymectomy via subxiphoid for MG is a safe,feasible and effective surgical approach.