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Though advancements have been made in the pharmacologic treatment of myasthenia gravis (MG), surgical resection is not only an option as a last line of defense for those patients who do not respond to medical therapy but also remains vital for those with thymic epithelial tumors (TET). While prior studies have shown the potential superiority of minimally invasive approaches via robotic- and video-assisted thoracoscopic surgery (RATS/VATS) for thymectomy compared to open surgery, in the setting of malignancies, this outcome delineation is controversial. As RATS/VATS may be associated with less post-operative complications in the treatment of TET, some surgeons argue that the open approach is necessary for complete resection (R0 resection) and to prevent potential seeding of the malignancy. In this review article, we will compare the efficacy and implications of the different surgical approaches and techniques themselves in performing a thymectomy for autoimmune and oncologic pathologies.

BackgroundEsophagectomy, an esophageal cancer treatment mainstay, is a highly morbid procedure. Prolonged operative time, only partially predetermined by case complexity, may be uniquely harmful to minimally-invasive esophagectomy (MIE) patients for numerous reasons, including anastomotic leak, tenuous conduit perfusion and protracted single-lung ventilation, but the impact is unknown. This multi-center retrospective cohort study sought to characterize the relationship between MIE operative time and post-operative outcomes.MethodsWe abstracted multi-center data on esophageal cancer patients who underwent MIE from 2010 to 2021. Predictor variables included age, sex, comorbidities, body mass index, prior cardiothoracic surgery, stage, and neoadjuvant therapy. Outcomes included complications, readmissions, and mortality. Association analysis evaluated the relationship between predictor variables and operative time. Multivariate logistic regression characterized the influence of potential predictor variables and operative time on post-operative outcomes. Subgroup analysis evaluated the association between MIE >4 h vs. ≤4 h and complications, readmissions and survival.ResultsFor the 297 esophageal cancer patients who underwent MIE between 2010 and 2021, the median operative duration was 4.8 h [IQR: 3.7–6.3]. For patients with anastomotic leak (5.1%) and 1-year mortality, operative duration was elevated above the median at 6.3 h [IQR: 4.8–8.6], p = 0.008) and 5.3 h [IQR: 4.4–6.8], p = 0.04), respectively. In multivariate logistic regression, each additional hour of operative time increased the odds of anastomotic leak and 1-year mortality by 39% and 19%, respectively.ConclusionsEsophageal cancer is a poor prognosis disease, even with optimal treatment. Operative efficiency, a modifiable surgical variable, may be an important target to improve MIE patient outcomes.