Which is the best surgical approaches for thymectomy: RATS, VATS, TORA or SPT? A network meta-analysis

Abstract

Purpose T hymectomy is indicated in the presence of primary thymic diseases such as thymoma. However, there is no clear conclusion which is the best surgical approaches for thymectomy. We performed this network meta-analysis (NMA) to explore and compare the outcomes of different surgical approaches for thymectomy. Methods An exhaustive search of PubMed, EMBASE, Web of Science and the Cochrane Central Register of Controlled Trials (CENTRAL) was conducted to identify relevant studies from inception to December 1, 2023. Direct and indirect evidence was combined to calculate the odds radios (ORs) and 95% confidence intervals (CIs), as well as to plot the surface under the cumulative ranking (SUCRA) curves. Cluster analyses were adopted to compare the outcomes of different surgical approaches according to the similarity of 2 variables. Publication bias were detected by comparison-adjusted funnel plots. Results Fifty-eight studies were enrolled in this NMA, including 4 surgical approaches: thoracotomy (TORA), robot-assisted thoracoscopic surgery (RATS), video-assisted thoracoscopic surgery (VATS) and subxiphoid video-assisted thoracoscopic surgery (SPT). The results indicated that in terms of blood loss, RATS was the least, and TORA had more blood loss than VATS and SPT. For pleural drainage duration, TORA had longer pleural drainage duration than RATS. As for pleural drainage volume, TORA had more pleural drainage volume than VATS and SPT. For duration of hospital stay, VATS had longer duration of hospital stay than SPT. In terms of VAS score, VATS and TORA had higher VAS scores than SPT. However, the operative time, ICU stay and postoperative complications of all surgical approaches had no differences. Conclusion SPT has faster postoperative recovery, less postoperative pain and better quality of life, and other perioperative outcomes are not inferior to other surgical approaches. RATS is safer and has certain clinical advantages. We look forward to more large-sample, high-quality randomized controlled studies published in the future.